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HomeMy WebLinkAboutQuan's Kitchen - 12/31/2021FOR BOARD OF HEALTH USE ONLY - Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening k, s,edco'9 Establishment Name I "'s Pb CU cw� / �, �( Establishment Address �U CAC(- t C- GM � �`„ (j _�Y� k- v 7 y JJJ J '� t Establishment Mailing Address (if different) Establishment Telephone No 56� . -33q - O� Applicant Name & Title: y�L �v p ,� �,xRSt Applicant Address 17 0-"/vQS Applicant Telephone No.:9 J•� 26 )3a' 24 Hour Emergency No.: Applicant Emailll� Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. &A Corporation ® An Individual Name Title n Address O A Partnership- O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 50 T\"_ QV-CA-1-1 / Address: (1 ( l_aw" Acle_� I Y ICn� YV�C� D b�U Telephone No: 9 i 1 - _M - 3 7 z3 24 Hour Emergency No: Cit 3 / U 7Q — J2 7 �-3 FAX: 78 ( — 13J d E-mail:^tS Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Teo tMn SEWAGE DISPOSAL: 7-®vr1 DEP Public Water Supply No: (If applicable) No. of Food Employees: g DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: 4. Name of Person(s) In Charge Certified in Allergen Awareness Training Nameofpest control company routinely inspecting the premises for evidence of pests 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. el Yes > Does this establishment require a FOG permit? bZ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [ Annual ® Retail Food $125.00 ® Mobile Food Consession Q Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Temporary Start Date: Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up l0 201 + $300.00 El Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑r+ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 0 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(timeRemperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no time/lemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs [PHFCooked To Order H Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service ❑�- Delivery of Packaged PHFs Cold Holding For Single Meal Service [I PHF and RTE Foods Prepared For Highly Q Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer H Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 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) Preparation of Non-PHFs Retail Sale R Offers Raw Or Undercooked Food Of to Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Q 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% ano4e federal Food Code. / Signature of Pursuant to MGL Ch.62C, sec. 49A, I certify under the p6nialties 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: D LF?✓" `�� " �;Z �{— p Signature of Individual or Corporate Name: Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address: Mailing Add Phone/Fax Number:y T)6 -/% 1)1 �;' / I u-%1 .17 UA - Z-b Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: D o-m o��i ,cr�lze- 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 $50 container 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 informatio Print in these documents is true, accurate and complete. Date W (� %O 1 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): 2— Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday f1 3D D py�'\ Tuesday I0 , 3v — '1 Wednesday 10 , 3o 6r1— ( 0 Thursday �� � �- I b f /"\ Friday ) 0; Dp a�n — 10 �)(f)Saturclay f D; 3b — 1():3brv�" Sunday bh 0FW\ 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 Garbage Disposal b Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 'Dro4c� S (C-/'\� c_�) Y Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? z Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes x No Size gallons Where is the existing outdoor GRU located? 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 Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fr) Where is the grease storage unit located? How often is this grease storage unit emp Please list the vendor who removes the w 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. A I e if A I �(c L, ) C cQ i,�AIJ Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 043 Q� Hzi **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\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc Department of Industrial Accidents — — Office of Investigations 600 Washington Street _ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip: Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. E[Restaurant/Bar/Eating Establishment 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] IF] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I0.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by I I.❑ Health Care volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *Any 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. r an: an employer that is providing workers' cohrpensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: CJ, v�_ Jy V Cvy Policy # or Self -ins. Lie. # a 11, 5 ( , � -) � � ; J (� Expiration Date: () I 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 tine 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. f do hereby certify, under t/:e pains nnrl perrafties ofperjury that "fornrgtion provided Above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia Phone � 1 R6 ACTOR© CERTIFICATE OF LIABILITY INSURANCE DATE (MMlODI1'1'1'V) 10@1/20 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chan Insurance Agency, Inc. CONTAUT NAME: Eddie MUI nlcoNNo E:t:'17.451.6733 (AAIC No): 617-451.6735 FA AooaEss: service@chaninsurance.com 220 Harrison Avenue Boston, MA 02111—'-- INSURER(S)AFFORDING COVERAGE NAICM _ INSURERA: Travelers Insurance INSURED INSURER IS Guard Insurance Group INSURER C: Quan's Kitchen, Inc. 30 Chauncy Street Mansfield, MA 02048-1958 _ INSURER D INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY YYY MMIDD/Y LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR 6804681136791642 10117/20 10117/21 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 300,000 MED EXP An one person)$ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT ❑PRO- ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY - COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N� (Mandatory in NH) If yes, descdba under DESCRIPTION OF OPERATIONS below_l NIA QUWC121535 10/19/20 10119/21 PER X ERH_ E.L. EACH ACCIDENT _ $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Restaurant located at: 30 Chauncy Street, Mansfield, MA 02048 CFRTIFICATP Mru nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Frank C. Chan @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. /�1 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. I 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, emi-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 re ponsibility 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: 7-0 Applicant Name (please print clearly) I I I PROMETRIC I , aoasa JULIE QUAN I I I I FOOD MANAOER eER [I�FICATIO' k j ,. I Exam 7401 Recognized�By Conference For Food'Ro(ecilon i 009203800 04/27%M9 I I IOU 2049872 Exam Date I 1 Camp ExplresOn 04/27�24 L- - - - _ - _ _ _ _ — _ _ _ _ - J CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name 6El2e;clpi�,t VM UM Certificate Number: 2WO07 Data of ComNleYion: "r17!20+6 Date of txpiration: 11117r202+_, Aht ahoy-ua>nrd prnron !r haehy imrcd thin r a tJnvr for mnrpdatiag an allege, gWwwljgi training program rorogtri&-elly the Mnrrarhraest Depardnrwt n)'pjdlir q dth (o rurorrlgncr soith 105 0MR 590.009(0)(3)(a). 7hir rrrr rttt quill be enlul fmAo (5) yrurv)vm date oj'romp/edan. 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