HomeMy WebLinkAboutRasoi Restaurant 10/22/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishmenj
Type: TEMPORARY FOOD PERMIT
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:.
SANJIV DHAR, PRESIDENT
Whose place of business is:
RASOI RESTAURANT - INDIAN AMERICAN ASSOCIATION OF SHARON
250 EAST STREET
PERSON(S) IN CHARGE
TUSHAR BHOPALE, RESTAURANT MANAGER
Permit Expires: October 22, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee: $25.00
License Number: T-164
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
— - -
----------
FOOD
--------FOOD ESTABLISHMENT PERMIT APPLICATION
(Application -must be suFirrtitfed at least 3(� days befo�a the planned-openirig date)
I
1) Establishment Name 9,A _(7P
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title y l�_
9) Owner Address (If different from applicant)
__....
........
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
n Association or partner.
"1 A Corporation Name Title Address
❑ An Individual
_1 A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: i c�S•,y`'/
Address: r ,�, /) j' ,-%.. t ,V% •?, . fJ�
Telephone No: E` t7 24 Hour Emergency No:
FAX,
_ f i
E-mail: v{ ✓3 r . Kny
Alt E -Mail:
i
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at leastdays before the planned opening date)
1) Establishment Name � / _ r t--
rn V r 1 1-6- I1I a- L
2) Establishment Address 20 ORO ST1!
MP1)9 020�4R�
3) Establishment Mailing Address (if different)
4) Establishment Telephone No -40 �� �5 -4 0
5) Applicant Name & Title: av�lyi
6) Applicant AddressC�(. L .-
7) Applicant Telephone No.: 24 Hour Emergency No.:
FAX:X0
8) Owners Name & Title� f' j> r -I d
9) Owner Address (If different from applicant)
Owner's telephone number D
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
11 1 Association
or partner.
Z A Corporation
Name Title Address
0 An Individual
3 ''
El A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
` -L) l 1,) a
rophLC
Address:
2�
Telephone No:
°fie 6(?�� Sr�� 24 Hour Emergency No:
J
FAX:X0
E-mail:r-
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: ®Ukp;�_2 C
15) SEWAGE DISPOSAL:
fc)6LEC .
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees:•--
i u
17) DAYS/HOURS: . DO YS
up to 10' PHF display $62.50
E]Food Service up to 101 -200
Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
18) Name of Person In Charge Certified in Food Protection Management: '1U Shff/L
E] Annual
If more than 3 individuals are certified, complete list is on file.
0 Pushcart $12.50 # of Pushcarts:
Residential Kitchen $50.00
Retail Food $50.00
F1 Seasonal
Seasonal Dates:
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
❑ Food Service - Institution
( Meals/Da Y)
certificate
Temporary
Temporary Start Date: OCT 22 , �G71C
Temporary End Date: )I t f 1 r
19) Person Trained in Anti -Cho" Procedures (If 25 Seats or more)
`j t I to t
20) Location: 21 Permanent Location
22) Establishment Type
❑ Caterer $12.50
Moblie Moblie Start Date:
Moblie End Date:
12 Retail (, Sq. Ft)
F] Food Service up to 100 or
Milk & Cream $5.00
Mobile Food & Consession $37.50
Moblie Comments:
up to 10' PHF display $62.50
E]Food Service up to 101 -200
Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
21) Length of Permit:
E] Annual
or up to 25' PHF display $75.00
Food Service up to 201 +
or 25'+ PHF display $137.50
0 Pushcart $12.50 # of Pushcarts:
Residential Kitchen $50.00
Retail Food $50.00
F1 Seasonal
Seasonal Dates:
❑ Food Service - Institution
( Meals/Da Y)
❑ Retail Snack Food $12.50
Tobacco Products $12.50
Temporary
Temporary Start Date: OCT 22 , �G71C
Temporary End Date: )I t f 1 r
Temporary Time: IP hD 12COCX4�1)
Rain Date:
23) Food Operations 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)
Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held
0 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 ❑ PHF and RTE Foods Prepared For Highly
rY g — - Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer 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 Ice Manufactured and Packaged for contact alternative, time as a public health
Preparation of Non-PHFs Retail Sale control)
Other Food OperationsI E] Juice Manufactured and Packaged for E] Offers Raw Or Undercooked Food Of
Retail Sale I Animal Origin
Offers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application El 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 P5 CMR 590.000 and Ifother applicable law. I have been instructed by the
board of health on how to obtain copie of 105 CMR 590.000 and, e.federal Food�de.
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:
26) Signature of Individual or Corporate Name:
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
;r p v .
- of % F ..._
"Social Security No. (Voluntary) or Federal
Identification Number
rf
{
By: Corporate Officer (Mandatory, if Applicable)
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
g� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: `2j '" €�C Vit'€ ���zC PU �- 02_x. �
City/State/Zip: l o Cm -j - 2 Si6 Phone #:�
Are you an employer? Check the appropriate box:
1. I am a employer with f j employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
o workers' comp. insurance required]
3a -`"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. ❑ Retail
6. [°Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11.❑ 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 #l.
I am an employer that is provid' g workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: l C/ + T AJI u VA -Z_ f � 6)7
Insurer's Address: ) ( i 1 Aim Fruo- NOC
Address:"
1'I-Am q— �C/-
City/State/Zip: C , Zgj -7 FUM
U C&
I NV , .
swc, III 8,110 ;
Policy # or Self -ins. Lie. # C Expiration Date:��—
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.
Ido hereby certifyunder the pai s and penalties of perjury that the information provided above is true and correct.
Qianafiira• ��+ebafl€ii `� £� xv' l7AtP.'
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
Contact Person: Phone #:
www.mass.gov/dia
Security National Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 5
INSURANCE POLICY INFORMATION PAGE
Ncci Code: 40533 RI Un. #: 0002069660
1. Insured: Policy Number: SWC1118330
Swades, Inc. }
DBA: Rasio Restaurant _� ?
727 East Ave _Individual _Partnership
Pawtucket, RI 02860-6100 _Corporation X LLC
Other workplaces not shown above: Federal Tax ID: 550900222
See Extension of Information Page
Producer: Risk Id:
AmTrust North America, Inc. Renewal of: WC 031247
c/o Insurance Leader
1237 Elmwood Avenue
Providence, RI 02907
2. The policy period is from 9/18/2016 to 9/18/2017 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 states listed here: Rhode Island
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:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$100,000 each accident $500,000 policy limit $100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and State(s) Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 10,426
STATE ASSESSMENT 0
TOTAL ESTIMATED COST 4 10,426
Minimum Premium 500
Deposit Premium 2,605
Issue Date: 7/11/2016 Countersigned by
This employer is subject to the provisions of the
of the State of Rhode Island
Workers' Compensation Insurance Company: Security National Insurance Company
Adjusting Company: Security National Insurance Company
Telephone: 1-866-272-9267 Policy Effective Date: 9/18/2016
In accordance with Rhode Island General Law §28-32-1, the employer must report to the
Director of Labor and Training every personal injury sustained by an employee if the
injury incapacitates the employee from earning full wages for at least three (3) days or
requires medical treatment, regardless of the period of incapacity. If the injury proves
fatal, the report must be filed within forty-eight (48) hours. If not fatal, the report shall be
made within ten (10) days of the injury.
An injured employee shall have the freedom to choose medical treatment initially. The
employee's first visit to any facility under contract or agreement with the employer or
insurer to provide priority care shall not be considered the employee's initial choice.
For more information about Workers' Compensation procedures and benefits, call the
Education Unit at (401) 462-8100 and press option #1 or TDD (401) 462-8006. If you
suspect fraud, contact the Fraud Prevention Unit at (401) 462-8100 and press option #7.
In accordance with Rhode Island General Law §28-29-13, this notice must be posted
and maintained in conspicuous places where workers are employed.
Fines may be imposed for noncompliance.
DWC-8 (5/2004)
z
n
z
P, �
al -
c /C asva PP98TZSTSL VV58TZ3T8L CO:TZ 9TOZ"OT"qz)O
cl
it
-N
xLO
kit
fdm
114
(T)
(a
6
(1, 10
P, �
al -
c /C asva PP98TZSTSL VV58TZ3T8L CO:TZ 9TOZ"OT"qz)O
0
<?
/ x
�
E
/ •b
\ \
.
\ \
�
2
�
&
CL§
a®®
-
to
>-
^^
}/
.G
Cot\�
E
_
%\
-
�
\ §
/
c /Z aovd VV98TZ8T8L
VV98TZST8L
4
Q
60:TZ 9TOZ'OT.4Do
oct.10.2016 21:03 7818218544 7818218544 PAGE. 1/ 3
Date: October 90th, 2096
Attention:
Scott Lelte, Public Health Consultant
Town of Mansfield, 1st floor
6 Park Row, Mansfield MA 02048
Phone: (506) 261-7$86
FAX,, (508) 261-7343
r
Blndu Wedhwa
Indian American ,Association of Sharon
PO Box 465
Sharon, MA 62067
Phone; 781-724-4506
Mr. Leite,
The Indian American Association of Sharon is scheduled to have its annual event st the Mansfield
High School on October 22, 2016. We have been using this facility since 2090.
Please find the following two documents that Denise Holmer (Mansfield High School, Buildings
and Facilities Department) has requested to be forwarded to you:
1, Food Business License
2. ServSsfa Certificate
Feel free to reach out to me with any questions @ 789-724-4506.
Thanks,
A IPA"
Bindu Wadhwa
(781-724-4506)
Email; binduwadhwaQgmaii.com
1
Jane Doucette
From: Bindu Wadhwa <bincluwadhwa@gmail.com>
Sent: Tuesday, October 11, 2016 12:08 PM
To: Jane Doucette
Subject: Re: Mansfield Food Permit
Hi Jane,
The Indian American Association of Sharon hosts the Annual 'Diwali' cultural program on October 22, 2016.
We use the school auditorium for performances by children and the cafeteria for the food.
We have been holding this event at Mansfield High School since 2010 when I was the President of the
association. I'm still part of the executive committee.
Please feel free to contact Denise Holmer and Bob Laconte for any additional information about the event.
Thanks,
Bindu Wadhwa
781-724-4506
Sent from my iPhone
On Oct 11, 2016, at 11:39 AM, Jane Doucette <Jdoucettegmansfieldma.com> wrote:
Hi Bindu, what is the event you will be attending at the Mansfield High School on October 22"?
Disciza i rne r
The information
Aon conlained m thiscommunication from the Town of Mansfield is confidential. It is intended solely for
use by the recipient and oillecs, authorized to receive it, If YOU are not the recipient, you are hereby notified that
any disclosure, copying, 'JisbAbution or taking action in relation of the contents of this information is strictly
prohibited and may be unlawful.
This ernail has been -,,,:armed for viruses and malware, and may have been automatically archived by Mimecast
Ltd, an innovator in Software as a Service (SaaS) for busines5. Providing a safer and more useful place for your
human generated data. Speclahzlng in; Security, archiving and compliance. To find out: more Click Here.
Jane Doucette
From:
Amy Donovan -Palmer
Sent:
Monday, October 17, 2016 3:11 PM
To:
Jane Doucette
Subject:
FW: Food Establishment Documents
Attachments:
1.pdf; 2.pdf; 3.pdf; 4.pdf; 5.pdf, 6.pdf
This should help get the permitting started and if they are missing anything, maybe it can be caught early.
Amy
From: niteshknc@gmail.com [mailto:niteshkncCa)gmail.coml On Behalf Of Nitesh Malhotra
Sent: Monday, October 17, 2016 1:35 PM
To: Amy Donovan -Palmer
Cc: bind uwadhwaCaJbgmail.com; Sandeep Bhatia; sanjiv sir
Subject: Food Establishment Documents
Good Afternoon Amy,
Attached are the signed documents which we have also mailed today by
USPS. It will be delivered to you by Wednesday.
Have a great day
Nitesh Malhotra
Restaurant Manager
Rasoi - Regional Cuisines of India
Work: 401-728-5500
Cell: 765-409-2211
Fax: 401-728-5501
Web: rasoi-restaurant.com
Jane Doucette
From:
Amy Donovan -Palmer
Sent:
Tuesday, October 18, 2016 12:17 PM
To:
Jane Doucette
Subject:
FW: Food Establishment Documents
Attachments:
tushar (1).pdf; 1(1).pdf
From: niteshknc@gmail.com [mailto:niteshknc@gmail.com] On Behalf Of Nitesh Malhotra
Sent: Tuesday, October 18, 2016 11:45 AM
To: Amy Donovan -Palmer
Cc: Nitesh Malhotra; bind uwadhwa(&gmail.com; Sandeep Bhatia; sanjiv sir; tusharknc@gmail.com
Subject: Re: Food Establishment Documents
Hello Amy,
Please find the attached corrected first page of the application form
with Mr Tushar Bhopale Servsafe certificate.
On Mon, Oct 17, 2016 at 3:12 PM, Amy Donovan -Palmer
<adpalmerkmansfieldma.com> wrote:
> Thank you so much. I've forwarded the documents to the secretary, Jane, who
> will begin the permitting process. We won't be able to finalize it until
> Wednesday when we receive the originals. If Jane catches anything that may
> need additional attention, she'll let you know.
> This is really helpful.
> Amy
> From: niteshknc2cgmail.com [mailtomiteshknckgmail.com] On Behalf Of Nitesh
> Malhotra
> Sent: Monday, October 17, 2016 1:35 PM
> To: Amy Donovan -Palmer
> Cc: binduwadhwaggmail.com; Sandeep Bhatia; sanjiv sir
> Subject: Food Establishment Documents
> Good Afternoon Amy,
> Attached are the signed documents which we have also mailed today by
I
> USPS. It will be delivered to you by Wednesday.
> Have a great day
> Nitesh Malhotra
> Restaurant Manager
> Rasoi - Regional Cuisines of India
> Work: 401-728-5500
> Cell: 765-409-2211
> Fax: 401-728-5501
> Web: rasoi-restaurant.com
> Disclaimer
> The information contained in this communication from the Town of Mansfield
> is confidential. It is intended solely for use by the recipient and others
> authorized to receive it. If you are not the recipient, you are hereby
> notified that any disclosure, copying, distribution or taking action in
> relation of the contents of this information is strictly prohibited and may
> be unlawful.
> This email has been scanned for viruses and malware, and may have been
> automatically archived by Mimecast Ltd, an innovator in Software as a
> Service (SaaS) for business. Providing a safer and more useful place for
> your human generated data. Specializing in; Security, archiving and
> compliance. To find out more Click Here.
Nitesh Malhotra
Restaurant Manager
Rasoi - Regional Cuisines of India
Work: 401-728-5500
Cell: 765-409-2211
Fax: 401-728-5501
Web: rasoi -restaurant. com
2