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Home My WebLink AboutQuan's Kitchen 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:. ERIC QUAN, PRESIDENT Whose place of business is: QUAN'S KITCHEN 30 CHAUNCY STREET PERSON(S) IN CHARGE: JULIE QUAN Permit Expires: December 31, 2016 License Number: FS -54 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH MichaecmcCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: ERIC QUAN, PRESIDENT having a place of business at: QUAN'S KITCHEN 30 CHAUNCY STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -54 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -54 FOOD ESTABLISHMENT PERMIT APPLICATION '— (Ap_p ►—Tcafionmuse —sub mi ffe d a east-3-ays e or�p anne opening --a e -- 1) Establishment Name QUAN'S KITCHEN 2) Establishment Address 30 CHAUNCY STREET 1 3) Establishment Mailing Address (if different) 30 CHAUNCY STREET MANSFIELD, MA 02048 �4) Establishment Telephone No (508) 339-5906 — 9t -- - 5) Applicant Name & Title: ERIC QUAN, PRESIDENT 6) Applicant Address 171 LAWNDALE ROAD, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 699-5906 24 Hour Emergency NO.: (917) 378-3723 ) 71 LAWNDALE ROAD MANSFIELD MA 02048 8 Owners Name & Title ERIC QUAN, PRESIDENT 9) Owner Address (If different from applicant) 1 Owner's telephone number 5086997826 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 0 A Corporation Name Title Address ❑ An Individual ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in cnarge, supervisor, maiidyei au;.) Name &--Title: JULIE QUAN Address: 1171 LAWNDALE ROAD, MANSFIELD, MA 02048 Telephone No: (917) 378-3723 FAX: (508) 261-7831 E-mail: QUANSKITCHENO-YAHOO.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: T Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: (917) 378-3723 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SUN 10 AM -12 AM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18-20 18) Name of Person In Charge Certified in Food Protection Management: JULIE W. QUAN 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: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date - 22) Establishment Type ❑ Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 ❑V_ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - 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) ❑ Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for re Than a le Meal Service ❑ -- . y 9-- — — - Cold Holding For Single Meal Service ❑ PHF aond RTE FoodsPr pared For Highly Sale of Commercial) Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And i Delivery of Packaged PHFs - -- Susceptible Population Facility -- -- - ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer E] Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only - contact alternative, time as a public health __ _ ❑ Ice Manufactured and Packaged for control E]Pre p p F1aration of Non-PHFs Retail Sale a Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of -_ Other Food Operations Retail Sale Animal -origin ❑ ❑ Food Cate ed Evens oIr Institut Institutional Food Service �I eals for Offers RTE PHF in Bulk Quantities ❑ Retail Sane of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health --- 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 to obtain copies of 105 CMR 590.000 and the fede{al Food. Code. 24) 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. 25) Social Security Number or Federal ID: 04-3288820 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: QUAN'S KITCHEN ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-5906 FAX NUMBER: (508) 261-7831 OWNER OF BUSINESS: ERIC QUAN, PRESIDENT TELEPHONE OF OWNER: 5086997826 FEDERAL ID/SS NUMBER: 04-3288820 FEE: $5.00 PERMIT NUMBER: FS -54 SIGNATURE: DATE: % z _1/6 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) b q _'30W ad ** 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 I Please Print Legibly Business/Organization Name: OW011S IZAd^AV1 ThC Address: 30 d'a.uhey City/State/Zip: ILtAvyfitid Are you an employer? Check the appropriate box: 1. L I am a employer with -- D employees (full and/ or part-time),* 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 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]* 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] Phone #: 5&� - 334^ .5 qy_6 Business Type (required): 5. 0 Retail 6. 0 Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales (incl, real estate, auto, etc.) 8, ❑ Non-profit 9. ❑ Entertainment 10,0 Manufacturing 11.0 Health Care 12.0 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 # I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: (' L\AV\ -av\te AG,,¢i+t4 y -c Insurer's Address: 0 144frj6vn Ave City/State/Zip: telltcv) MA egill Policy # or Self -ins. Lic, #�(��j 6 y t8 15 0 9 1-592— Expiration Date:. ►o h -I l� 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 DTA for insurance coverage verification, I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: gl�-�ab. 13191 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/oia Phone r , ® CERTIFICATE OF LIABILITY INSURANCE AC(JR® DATE (MMIDDlWW) 5/24/16 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 policy(ies) must 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 erclorsement(s). PRODUCER Chan Insurance Agency, Inc. 220 Harrison Avenue Boston, MA 02111 CONTACT NAME: Eddie Mui PONE FAX (617) 451-6735 Ext: (617) 451-6733 / No: -Ma� ADDRESS: service@chaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC3 INSURER A : Travelers Insurance 10/17/16 INSURED INSURER B : Public Service Mutual Quan' s Kitchen, Inc. INSURER C: INSURER D: 30 Chauncy Street INSURERE: Mansfield, MA 02048-1958 INSURER F rnVI7PAnFR rPPTIFIrATF N I IMRRR• 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 WrFH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSRVWD SUER POU CYNUMBER POLICY EFF (MMIMNYYY) POU CY EXP (MMIDDIYWY) LIMITS A GENERAL LIABILITY X COMMERCIALGENERALLIABILITY CLAIMS -MADE 1XI OCCUR Frank C. Chan 6804681B6791542 10/17/15 10/17/16 EACH OCCURRENCE $ 1,000,000 PREMSES E, "$ $ 300 000 MED EXP F" one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGR EGATE LIMIT APPLIES PER. POLICY IT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITYCOMB ANYAUTO ALLOWAED SCHEDULED AUTOS AUTOS HIREDAUTOS AUTOS ED INED SINGLE L IMIT (Ea acc,derf) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ jPeOrNON-OVI"adent) AMAGE $ $ UMBRELLA LIAB EXCESS LIAB [7OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ B V+ORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANYFROPRIETOR/PARTNERIEXECUTIVE YJN OFFICE R/MEMEER D(CLUDED? (Mandatory in NH) If yes, describe under DESCR [PTO N OF OPERATIONS below N / A WC004535 10/19/15 10/19/x.4 ORYLMUS X OER E.L.EACH ACCIDENT $ 500,1)1)0 EI. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS !VEHICLES (Attach ACORD 101, Additional Re nerlcs Schedde, if more space is recl ired) Restaurant located at: 30 Chauncy Street, Mansfield, MA 02048 rCRTICIrATC unI 1119:0 rAHrFl I ATInN @ 1988-2010 ACORD CORPORATION. All rights reserveo. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: 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 A UTHORIZ ED RE PRE SENTATNE Mansfield, MA 02048 Frank C. Chan @ 1988-2010 ACORD CORPORATION. All rights reserveo. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: NATIONAL RSGIST�Ry OF F000- SAFE' FSSIOI .LS® RE' iii-MENTS FOR THE HAS swccrm$FOLL�y -V F ID SXFETY M*N**M UP4 1 W-cTij*-STANDARDS FoR 1: Foon 1jil;W C-ONFEREN& LAVWMRENCE J. LYNCH, CAE APRIL 22, 20'14 19tug PATE E;X-pjf,WVION DATE: APRB. 22,2019 CFWV!FrlcATE NO: 20970986 TEST FORM: EZC 12 This 4ertintate, (v not valid for more NATiONAI. FOOD SAFF-Ty,l JULIA W ,41 HAS SUCCESSFULLY SAT - . .IS . FI;rD SHE LAWRENCg0j'. LYNCH, CAE issUF- DATE: APRIL 22, 2014 EXPIRATION DATE: APRIL 22) 2019 6 W Q V c� z z00 z w w C7 `�...`t.� �y� Ci "" � �� .�t? '`•�`'�_7 �J.r� t] Ca '`'�x� ��'�"` r3' Ca ``-ti'"L,J �.— c7 � "o O D N W 'Y M C7 `�...`t.� �y� Ci "" � �� .�t? '`•�`'�_7 �J.r� t] Ca '`'�x� ��'�"` r3' Ca ``-ti'"L,J �.— c7 � 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 pen -nit 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 permit/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 burn 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