HomeMy WebLinkAboutSake Steakhouse (DW Wong 688, Inc.) - 12/31/2021sue/ --1��� ��
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT AP (CATION
(Application must be submitted at least 30 days before the planned
Establishment Name PW wcml ��. TvtC CSA kt Sft• itucSC >'
J e
/ /
Establishment Address ),go SG� ( �-C1�C
Establishment Mailing Address (if different) a2?0 kX 001 ciYee-k .
Establishment Telephone No
Applicant Name & Title: XlnyliuYt Lv� tW eYG� iLL lt�
J{"o4oy0vt��
-.,
Applicant Address (,� • , M/1 o,)-o �S_- 1
``%T
Applicant Telephone No.: G]j . Tp� - �(T 24 Hour Emergency No.: G
Applicant Email
Owner Name & Title (If different from applicant) }(o Ft burl wa,11
Owner Address f.� Co(c 55e_l. F04111y"9 ,, MA 010 � - /(�q4( ,
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
An Association
partner.
VA Corporation
Name Title Address
El An Individual
_—
El A Partnership(ri2N
�iyr1 1 Ulcarcct ,� /S8 Lo(o<S Se{ . S
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: vvems AA ¢'V arX:fger -//
Address: I _(, 9Co(ac S 0/1 . S i . �^c91C 00 a,,94 , AO O)r') � -
Telephone No: 06- A � )40) 24 Hour Emergency No: G j. _ 4 � •-ltj 0 7
FAX: - i : 7 .- ')} 8 -9 _
t�\��
E-mail: �tiNlctGG� ®�GlOJ , L� Y'it
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: S-io R -_ }
E-mail: 4/twe't �// & �CZ c%O , (�J�✓l
Food Establishment Information
WATER SOURCE: wW
SEWAGE DISPOSAL /0wo
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYWHOURS: MOVI _ jl)� oD
m zv 4lM
,
1
Name of Person(s) In Charge Certified in Food Protection Management:
wa� Lr'A
X1 jLr���p✓iuy VtOGta2r
Name of Person(s) In Charge Certified in
Allergen Awarelnneess Training
Te rr ., %
Name of pest control company routinely
inspecting the premises for evidence
of pests N
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. l Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
E] Retail Food $125.00
E] Mobile Food Consession
Temporary
[]Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
0 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
`Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
[] Food Service up to 201 + $300.00
E] Pushcart $50.00 # of Pushcarts:
Temporary Time:
E] Supermarkets $400
0 Residential Kitchen $100.00
Rain Date:
pT Milk &Cream $10.00
71 Caterer $35.00
Food Operations: Definitions: PHF- Potentially
hazardous food (time temperature controls required)
(Check all that apply): Non-PHFs- non-potentally hazardous food(no timeRemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Q Sale of Commercially Pre -Packaged Non-PHFs
Q PHFCooked To Order
(] Hot PHF Cooked and Cooled or Hot Held
Q Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs
Cold Holding For SinglerMeal Service
PHF and RTE Foods Prepared For Highly
0 Sale of Raw Animal Foods Intended
Susceptible Population Facility
J Reheating of Commercially
to be Prepared by Consumer
Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
O Customer Self -Service
and/or HACCP Plan (including bare hand
Q Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only
Ice Manufactured and Packaged for
control)
Q Preparation of Non-PHFs
Retail Sale
0 Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations
Retail Sale
Vacuum Packaging) Cook Chili
Offers RTE PHF in Bulk Quantities
Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMR_590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A. I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information / Please Print Legibly
'>
Business/Organization Name: (fyo V)aN U - . VtC
City/State/Zip:fOW ��'`tel,/ii, ffi Xt7 kY Phone #:
Are au an employer? Check the appropriate box:
Business Type (required):
5. ❑ Retail
1. I am a employer with employees (full and/
or part-time).*
6.❑RestaurantBar/F.atingEstablishment
2. ❑ I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
[No workers' comp, insurance required]
3.❑ We are a corporation and its officers have exercised
9. ❑Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurance required] *
I 1 ❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. [No workers' comp. insurance req.]
*My applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/Statt
Policy # or Self -ins. Lie. #J)/5 ' () Y,�_( Y 7 )-.," -,�O " 4 - 4 Expiration Date: O_� - -) '? - �-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct.
Phone #• _ a � � I -
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
t
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact
Phone
www.mass.gov/dia
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CEwrIFICATION FORM.doc
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: Pu/
Address: 2eo Sd wl �tyee -
Mailing Add
D-)o
Phone/Fax Number: Id- S � I " ) 8 /
Email: Pvawee't GG? 0 1 -
Contact Person/Title for Grease
i,,r C ! ��✓2 �. yvtL
Name of Company scheduled to pump internal grease trap(s) monthly: � �7;Vzy
Name of Company scheduled to pump external grease trap quarterly: Pa ( kky i6ei • Lam,
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
container
$50
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
Date IV / �) / / - -0
Print Name �✓iy%iA dN VJcx6'tC�
Facility Operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A'. Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday' ; pQ i7 U✓ i6vl Tuesday 1J,00hm — ld ,'q jrl Wednesday' ;'iJ�pM — /O; wrivi
Thursday t <v0 vJ "t Friday W es— „oti ?ro Saturday M1t .{rvi — 1 I �� >��
Sunday
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
3 compartment sink
Handwashing sink
'
Commercial Dishwasher
Bar sink
Mop Sink
)�
j
Garbage Disposal
Ice Making Machines
2
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? f(i.ei in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? /V Yes No
If yes, at what station/sink? ( 2 S yl �401 S61 sf�,17, a
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap 1
f
2�
Grease Trap 2
t{ {
Trap 3
t %Grease
%l 6
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
V Yes
Where is the existing outdoor GRU located?
No /1 (Size gallons
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owners Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied?_
Please list the vendor who removes the waste:_
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TRAVELERS J� WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: UB-OR514723-20-42-G
NEW-20
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
A Stock Company
NCCI CO CODE: 12637
1.
INSURED:
DW WANG 688, INC
SAKE STEAKHOUSE
280 SCHOOL ST. STE-J100
MANSFIELD, MA 02048
PRODUCER:
RICHARD SOO HOO INSURANC
123 BEACH ST
BOSTON, MA 02111-2511
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-28-20 to 05-26-21 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1,000,000 Each Accident
Bodily Injury by Disease: $ 1,000,000 Policy Limit
Bodily Injury by Disease: $ 1, 000, 000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF
- EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY
DATE OFISSUE: 05-28-20 DI
OFFICE: HUDSON 126
PRODUCER: RICHARD SOO HOO INSURANC CTK20
TRAVELERS
ONE TOWER SQUARE
HARTFORD CT 06183
CLASSIFICATION SCHEDULE:
CLASSIFICATIONS CODE NO
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE v INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: UB-OR514723-20-42-G
PREMIUM BASIS
ESTIMATED
RATES ESTIMATED
TOTAL ANNUAL
PER $100 OF ANNUAL
REMUNERATION
REMUNERATION PREMIUM
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S)
SIC -CODE: 5812 NAILS: 722511
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 2712
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 338
TERRORISM 77
TOTAL ESTIMATED PREMIUM 3127
TAXES AND SURCHARGES 93
DEPOSIT AMOUNT DUE 3220MP
Minimum Premium: $ 215
EMPLOYERS LIABILITY MINIMUM: $75
DATE OFISSUE: 05-28-20 DI
OFFICE: HUDSON 126
PRODUCER: RICHARD SOO HOO INSURANC CTK20
COUNTERSIGNED -AGENT
TRAVELERSJRK
ONE TOWER SQUARE
HARTFORD CT 06183
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A)
POLICY NUMBER: UB-OR514723-20-42-G
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
INSURED-S NAME:DW WANG 688, INC
CLASSIFICATION CODE
LOCATION 001
FEIN 844936547 ENTITY CD 001 00
DW WANG 688, INC
SAKE STEAKHOUSE
280 SCHOOL ST
STE J100
MANSFIELD , MA 02048
NAICS: 722511
RESTAURANT NOC 9079
MA MANUAL PREMIUM $ 2637
12637-MA
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
REMUNERATION REMUNERATION PREMIUM
256000.00 1.03 2637
2.00% EMPL. LIAB. INCREASED LIMITS(9812) $ 53
ADD FOR INCREASED LIMITS MINIMUM 22
TOTAL PREMIUM SUBJECT TO EXPERIENCE MOD. 2712
EXPERIENCE MODIFICATION: MODIFIED PREMIUM 2712
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2712
EXPENSE CONSTANT(0900) 338
TERRORISM(9740) 77
TOTAL ESTIMATED PREMIUM 3127
3.51% DIA ASSESSMENT 93
TOTAL PREMIUM 3220
DEPOSIT AMOUNT DUE 3220
DATE OF ISSUE: 05-28-20 DI SCHEDULE NO: 1 OF 1
TRAVELERS J� WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 00 00 01 (A)
go] 4Nl'Ai IvIli•I .1 a -0.411: r
LISTING OF ENDORSEMENTS
EXTENSION OF INFO PAGE
We agree that the following listed endorsements form a part of this policy on its effective date.
WC
00
00
01
A
- 001
WC
00
00
01
A
- 001
WC
00
00
01
A
- 001
WC
00
00
01
A
- 001
WC
00
04
14
00
- 001
WC
00
04
22
B
- 001
WC
20
03
01
00
- 001
WC
20
03
02
A
- 001
WC
20
03
03
D
- 001
WC
20
04
05
00
- 001
WC
20
06
01
A
- 001
INFORMATION PAGE
INFORMATION PAGE 2
EXTENSION OF INFORMATION PAGE - SCHEDULE
ENDORSEMENT LISTING
NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
TERRORISM RISK INS PROG REAUTH ACT ENDT
MA LIMITS OF LIABILITY ENDORSEMENT
MASSACHUSETTS - ASSESMENT CHARGE
MA NOTICE TO POLICYHOLDER ENDORSEMENT
MASSACHUSETTS PREMIUM DUE DATE ENDT
MA CANCELLATION ENDORSEMENT
DATE OF ISSUE: 05-28-20 ST ASSIGN: Page 1 of 1
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
1 have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature Date: O ``/ J )v
Applicant Name (please print clearly)