HomeMy WebLinkAboutTahana 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:.
PETER K. Y. CHAN
Whose place of business is:
TAHANA RESTAURANT
60 OAKLAND STREET
PERSON(S) IN CHARGE:
PETER CHAN OWNER/MANAGER
Permit Expires: December 31, 2016
License Number: FS -62
Food Fee: $75.00
Milk & Cream V
BOARD OF HEALTH
AichaeCMcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
PETER K. Y. CHAN
having a place of business at:
TAHANA RESTAURANT
60 OAKLAND STREET
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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 1213112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -62
Scott Leite, Heaah Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
Date received:
1) Establishment Name
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By: Permit # Issued
FS -62
FOOD ESTABLISHMENT PERMIT APPLICATION
��a ►on mus e submii> eas s e p�ne�enmg dam
TAHANA RESTAURANT
2) Establishment Address 60 OAKLAND STREET
3) Establishment Mailing Address (if different) 60 OAKLAND STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 337-8500
5) Applicant Name & Title: PETER K. Y. CHAN, OWNER & PRESIDENT
6) Applicant Address 107 WINTHROP ROAD, BROOKLINE, MA 02445
j 7) Applicant Telephone No.: (617) 738-0543 24 Hour Emergency No.
(617) 738-0543
8) Owners Name & Title PETER K. Y. CHAN
9) Owner Address (If different from applicant) 107 WINTHROP ROAD, BROOKLINE, MA 02445
Owner's telephone number
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: PETER CHAN OWNER/MANAGER
Address: 107 WINTHROP ROAD, BROOKLINE, MA 02445
I Telephone No: 617) 738-0543 24 Hour Emergency No: (517) 738-0543
- — - -
FAX: (508) 337-6593
E-mail ---_— _- _--- - -I
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No
FAX: E-mail:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) i 16) No. of Food Employees: 7
17) DAYS/HOURS: MON-SUN 3:00 PM - 1:00 AM
18) Name of Person In Charge Certified in Food Protection Management: WILLIAM CHAN
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 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: ❑ Food Service up to 100 or
Moblie Comments: up to 10' PHF display $62.50
21) Length of Permit:
Annual
❑ Seasonal
Seasonal Dates:
U Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
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
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
Definitions: PHF Potentially hazardous food (time/temperature controls required)
p Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
i(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
❑ Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
i ❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non -
Perishable Foods Only
❑ Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
23 Food Operations
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
- ❑ Use of Process Requiring A Variance
❑ Customer Self -Service and/or HACCP Plan (including bare hand
— - ----
Ice Manufactured and Packaged for contact alternative, time as a public health
❑ �
Retail Sale control)
�_
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale I Animal Origin
- - —
❑ Offers RTE PHF in Bulk Quantities j [_1 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
- - _— - — -1 Total Permit Fee: $75.00
f�
L Payment is due with application ❑ waived
I, the undersigned, attest to the acc racy f the information providgin fhis( application and affirm that the food
establishment operation will comply it 105 CMR 50.000 and all�ber applicable law. I have been instructed by the
board of health on how to obtain cd sof 1�8"CMR 590.000 an +�e`federal Food Code.
l
24) Signature of Applicant: !�f
Pursuant to MGL Ch.62C, se . 4 A, I certify under the penaltie of erjury that I, to my best knowle e apd belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-2905244 % r
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: TAHANA RESTAURANT
ADDRESS: 60 OAKLAND STREET
TELEPHONE AT LOCATION: (508) 337-8500
FAX NUMBER: (508) 337-6593
OWNER OF BUSINESS: PETER K. Y. CHAN
TELEPHONE OF OWNER:
FEDERAL ID/SS NUMBER: 04-2905244
FEE: $5.00
PERMIT NUMBER: FS -62
0'/
SIGNATURE-
_
DATE:
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.
* Sigture of IndMduaF6r t
Cor orate Name (Mandato
By: Corporate Officer
(Mandatory, if applicable)
04(- 2, qo 15-2 q�
** 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 �j /, Please Print Legibly
Business/Organization Name: t A ffA N�f f�E` T/A (A k f/ff
Address: k L AN -D
City/State/Zip: V 0 Phone #: S O R_ ' — RS -0 y
Are you an employer? Check th oppropriate box:
1. Cel am a employer with _ employees (full and/
or part-time).*
2. ❑ l 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. ❑ Retail
6. VRestaurant/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 #I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: � G Lj C xS-6_ �Vr(,C T f�S U 1r 4' `I C C-0 •
Insurer's Address: C/�t � PAKk /� ut /\t E -W yoKr— l � i ®o 16
City/State/Zip:
Policy # or Self -ins. Lic. #, V V C, 0 1& Expiration Date: `'T yl ®_�-o 1
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 aaj�nst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiizations of the DrAyfor insurance coverageker titration.
I do hereby certify,r�,nder the
G �/
Phone
that the information 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 Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
www,mass.gov/dia
Phone #:
Public Service Insurance Company
One Park Avenue
New York, NY 10016-5807
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
INFORMATION PAGE
NCCI Company No: 16152 Prior Policy Number: WC 038029 15 91
RENEWAL Policy Number: WC 038029 16
1. Named Insured and Mailing Address:
Tahana, Inc. dba Tahana Chinese Restaurant
60 Oakland St
Mansfield, MA 02048-1411
The Insured: Corporation
Other workplaces not shown above:
Producer and Mailing Address:
Richard Soo Hoo Insurance Agency, Inc.
1148 Washington Street
Boston, MA 02118
Tel. (617) 338-8168
Named Insured: Tahana, Inc. dba Tahana Chinese Restaurant
2. The policy period is from 4/1/2016 to 4/1/2017 12:01 A.M. Standard Time at your mailing address shown above.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the
states listed here: Massachusetts
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 $ 100,900 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 100.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes the following 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.
Premium Basis Rate Per Estimated
Loc. Code Total Estimated $100 of Annual
Classifications St. No. No. Annual Remuneration Remuneration Premium
See Extension of Information Page $1,541
Loss Constant: $0 Expense Constant Charge: $338
Minimum Premium $ 219 Deposit Premium $1,879 Total Estimated Annual Premium: $1,879
Premium Adjustment Period: Annually
Servicing Office: New England Branch
Countersigned 3/7/2016 at New York, N.Y. by""r
Authorized Representative
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY.
Edition 10/97 Page 1 of 5
Copyright, 1987 National Council on Compensation Insurance
Richard Soo Hoo Insurance Agency, Inc.
INSURED COPY
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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 cavy 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 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