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HomeMy WebLinkAboutAce Sushi @ S&S 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment; Type: FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. ASIANA MANAGEMENT GROUP Whose place of business is: ACE SUSHI @ STOP & SHOP #007 377 CHAUNCY STREET PERSON(S) IN CHARGE: ASIANA MANAGEMENT GROUP Permit Expires: December 31, 2016 License Number: FS -76 Food Fee: $62.50 BOARD OF HEALTH NichaeCvlcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -76 FOOD ESTABLISHMENT PERMIT APPLICATION - -- - - ---- --- - - �ica�ion mu�su�6m��easi-�0 ays before fh-e—pFannecTopen�ng dafe7 1) Establishment Name ACE SUSHI @ STOP & SHOP #007 2) Establishment Address 377 CHAUNCY STREET 3) Establishment Mailing Address (if different) 1447 W.178TH STREET STE #303 GARDENA, CA 90248 4) Establishment Telephone No (508) 337-9450 5) Applicant Name & Title: ASIANA MANAGEMENT GROUP 6) Applicant Address 1447 W.178TH STREET STE #303, GARDENA, CA 90248 C7) Applicant Telephone No.: (310) 327-zzz3 24 Hour Emergency No.: 1 8) Owners Name & Title ASIANA MANAGEMENT GROUP 9) Owner Address (If different from applicant) 1447 W.178TH STREET STE #303, GARDENA, CA 90248 Owner's telephone number 3103272223 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. V A Corporation Name Title Address ❑ An Individual ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ASIANA MANAGEMENT GROUP {I ! Address: 1447 W.178TH STREET STE #303, GARDENA, CA 90248 Telephone No: o (310) 327-2223 24 Hour Emergency No: C& _&p3 FAX:- (310) 327-9193 --- - - - �- - - - � E-mail 5 � --- v� --- �s�►1-, -c_® - - -- Alt -E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title no U®l - 1®tiler + -- - -- - _ -- - - ! --- - ------ --- - - - - - - --- Address: 11447 W.178TH STREET STE #303, GARDENA, CA 90248 ' hone p No � (310) 327-2223 24 Hour Emergency No: 0&0) Tele - -- FAX: i-(310) 327-9193 - 1 E-mail: - - -- -- - --- -- - - - - Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 8 Ann - 5 PM -1 ckas 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 1 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: Permanent Location 122) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: 0 Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: V Annual ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Seasonal ❑ Food Service up to 201 + or 25'+ PHF display $137.50 Seasonal Dates: ----- ----- --- -" ❑ Food Service - Institution ❑ Temporary I Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: ❑ Caterer $12.50 ❑ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: 0 ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations - I Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) !(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 1 ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order - ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service -- --- ---- --- -- -- �❑ Sale of Commercially Pre -Packaged PHFs -- -- -- F1 Preparation of PHFs For Hot And__- Highly - -- - -- - Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For ❑ Delivery of Packaged PHFs�❑ - --- - - _____ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially !I to be PreP ared by Consumer i ❑ Vacuum Packaging ! Cook Chill Processed Foods for Service Within 4 Hours --- -------- Customer Self -Service of Non PHF and Non- -----_---- -- - -- I❑ Customer Self -Service W Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Onlyf-_- . _ - --- -- __-- ❑ Ice Manufactured and Packaged for contact alternative, time as a public health -_- ___------_.-_— -----_-_.-- ❑ Preparation of Non-PHFs Retail Sale- control) -----___----_ --- - L]Juice Manufactured and Packaged for, j ❑ Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal PREPARE AND PACKAGE ON SITE FRESH �❑ Offers RTE PHF in Bulk Quantities ❑ Prepa essrigin Food/Single Meals for 1 -____-_-______ Catered vInstitutional or Food Service Retail Sale of Salvage Out -Of -Date ❑g _ or Reconditioned Food To be completed by the Board of Health l Total Permit Fee: $62.50 Payment is due with application ❑ waived 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 toai opies of C 590.000 and the federal Food Code. �2;105 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 41-207-4147 „'A1 ^G1�L�A 151 t li ACS C7 , 26) Signature of Individual or Corporate Name: t71� tai F� 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 (Mandatory) By: rporate Officer (Mandatory, if applicable) Al ®-.®-7 d ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: AQE, a Address: t4iikl W- 1-18' Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with — employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees, [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp, insurance req.] Business Type (required): 5. t5l Retail 6. Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc,) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing U. Health Care 12.❑ Other *Any applicant that checks box # 1 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 Name: Insurer's Address: City/State/Zip: Policy # or Self -ins, Lic, 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, Ido hereby certify, under the pains andpenalties ofperjury that the information provided �above _is true and correct Ira 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other 11 Contact Person: Phone #: 11 www.mass.gov/dia AC40R" ®r✓ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/12/2015 PRODUCER (949) 679-3700 FAX: (949) 679-3701 IQ Risk Insurance Services, LLC 4 Executive Circle Suite 280 Irvine CA 92614 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED Asiana Management 1447 W. 178th St. Gardena Group Ste 303 CA 90248 INSURER A: Travelers Property Casualty 25674 INSURER B: INSURER C: INSURER D: INSURER E: THE POLICES 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 OFSUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD'L IYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXDATE PIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 51000 A X I CLAIMS MADE ® OCCUR 630837ORBIO 10/5/2015 10/5/2016 PERSONAL$ ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY CO LIMIT $ 11000,000 ANY AUTO INGLV (Ea accident) BODILY INJURY $ A X ALL OWNED AUTOS BA8370RBIO 10/5/2015 10/5/2016 (Per person) SCHEDULED AUTOS BODILY INJURY $ X HIRED AUTOS X (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/ UMBRELLA LIABILITY EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 X1 OCCUR CLAIMS MADE $ A XDEDUCTIBLE CUPS370RBIO 10/5/2015 10/5/2016 RETENTION $$ A WORKERS COMPENSATION X WC STATU- 0TH- ER— AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE a E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYE $ 11000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) B8417RS24 10/5/2015 10/'5%2016° E.L. DISEASE -POLICY LIMIT $ 11000,000 If yes, describe under SPECIAL PROVISIONS below A OTHERBuS1neSS Property 6308370R810 10/5/2015 10/5/2016 Limit: $355,000 Including Theft DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *10 Days Notice of Cancellation for Non -Payment of Premium. AHOLD USA Companies, Inc. its parent, subsidiary, and affiliated companies are named as Additional Insured. Vendor #24907 CERTIFICATE HOLDER UAr4%,CLLNI IV1Y SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL AHOLD USA, Inc. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR MAC Risk Management, Inc. 136 S. Main Street, 3rd FloorREPRESENTATIVES. Assonet, MA 02702 AUTHORIZED REPRESENTATIVE Bobby Truong/BOBBY ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. TMc Arr1Dr1 nnma and Innn arp rpaistpred marks of ACORD \ E £ 3 \ / \ @ 0 R 4 5 O N � O � CD j § § j 0 4 0 ,0 O (NI � O (.0 O $ \ j 0 { 0 S � )o.guo @ A m Y as � N Cl) O i1 N �O +4 1-4 G h P ,^ a3 O 93 o C� Q El Cd u '.Q U O W m as I.z �O G h P ,^ � 4 ,h m Information and Instructions Massachusetts General Laws. chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer," MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantwho has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary), A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05