HomeMy WebLinkAboutTahana Restaurant 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment
Type: FOOD SERVICE 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, 2018
Food Fee: $150.00
License Number: FS-85
BOARD OF HEALTH
.MichaeCMcCCean, Chairman
Milk & Cream W
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 1213112018 , unless previous to that time is suspended or revoked.
Expires 1213112018
License No.: FS-85
Board of Health
Michae(McCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE ONLY Pe
- _ - — — ---- _
FOOD ESTABLISHMENT PERMIT APPLICA
(Application must be submitted at least 30 days before the planr
1) Establishment Name 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
7) Applicant Telephone No.:
107 WINTHROP ROAD, BROOKLINE, MA 02445
2 1 aft
date)
(617)738-0543 24 Hour Emergency No.: (617)736-0543
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
L1 An Association or partner.
A Corporation i Name c r' Title Address
❑ An Individual f { 1_ K_• I C�IPI5.(�Ct�L_�I_(�l Ti 0
IA A Partnership
LL 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
Telephone No 1(617) 738-0543 24 Hour Emergency No: (617) 738.0543
FAX: I,(508) 337-6593 _
E-mail:
Alt E-Mail: I ( Cho D Re co' h6 e 1--o -a 1 • t ev„_
13) District Or Regional Supervisor (if applicable)
Name & Title:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) li 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:
If more than 3 individuals are certified, complete list is on file.
WILLIAM CHAN
Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
L19) Person Trained in Anti Choking Procedures (If 25 Seats or more) I_
20) Location: I;e Permanent Location r 22) Establishment Type ❑Caterer $25.00
❑ Moblie Moblie Start Date: I 1 Retail ( Sq. Ft) lj;� Milk & Cream $10.00
Moblie End Date:
Moblie Comments:
21) Length of Permit:
%j Annual
❑, Seasonal
Seasonal Dates:
I Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
I_. j Food Service up to 100 or
up to 10' PHF display $125.00
Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $276.00
-_. Food Service - Institution
( Meals/Day)
] Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
❑ Pushcart $25.00 # of P
Residential Kitchen $100.00
J Retail Food $100.00
❑ Retail Snack Food $25,00
❑ Tobacco Products $25.00
Rain Date:
23) Food Operations Definitions:PHF - Potentially hazardous food(timeRemperature controls required)
Non-PHFs - non -potentially hazardous food(no timeRemperature controls required)
(Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
i Sale of Commercially Pre Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
i Customer Self -Service of Non PHF and Non -
Perishable Foods Only
❑ Preparation of Non-PHFs
Other Food Operations
I, the undersigned, attest to the ace
establishment operation will comply
board of health on how to obtain col
24) Signature of
Idi PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
,] Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer
Ice Manufactured and Packaged for
Retail Sale
❑ 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
_J Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
L I Juice Manufactured and Packaged for [_] Offers Raw Or Undercooked Food Of
Retail Sale , Animal Origin
Offers RTTEE PHF
--nBulk—Quant-_""""ities— - ❑ Prepares Food/Single Meals for
PHFii
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 $150.00
Payment is due with application 1 _1 waived
the information prove d i� this application and affirm that the food
i CMR 5�p .000 and II et er applicable law. I have been instructed by the
)5 CMFV/5.90.000 apey, a federal Food Code.
Pursuant to MGL Ch.62C,'sec. 49A, I certify under the g
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-2905244
26) Signature of Individual or Corporate Name:
of perjury that I, to my best knowledge and belief, have filed all state tax returns
Town of Mansfield
Town of'Mansf eld - 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 December 31st 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 $10.00
PERMIT NUMBER: FS-85
SIGNATURE: X
DATE
1I— 20 w- zol'")
E
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.
By: Corporate Officer (Mandatory, if Applicable)
04- �-9Oszq-`f
"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.
R: HwItWane's Docu ants\PERMIT APPLICATIONS\TAX CERTIFICATION PORM.doc
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Or'ganizationName: TA AN A QCS (AU KAA
Address: (O� CJ�k�-A/�t�•
City/State/Zip: NAN,;F1E—L-*Pbyo4hone#: -E-ag" 3 3 1
Are yop an employer? Check the appropriate box:
Business Type (required):
1. Nr I am a employer with _ employees (foil and/
5. ❑ Retail
or part-time).*
6. CRestaurantBar/Hating Establishment
2. ❑ 1 am a sole proprietor or partnership and have no
7, 0 Office and/or Sales (incl. real estate, auto, etc.)
employees working forme in any capacity.
8• ❑ Non-profit
[No workers' comp. insurance required]
3, ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
I I.❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12, ❑ Other
with no employees. [No workers' comp, insurance req.]
*Any applicant that checks box #1 must also fill out the section below showing theirworkms' compensation policy information.
**If the corporate officers have exempted themselves, but [be corporation bay otber employees, a workers' compensation poBry is required and such an
organization should cbeck box #1.
I am an employer that is providing workers'compensation insurancefor my employees. Below is thepolley informadoh.
insurance Company Name:.D��K7t '1'7r%�r"�T'a 1/�WA I 5r-UI tL}�� JA-<; i RA/4 C-& 2W
insurer's Address:P-013WA-6 t%.S t,(/V�6;K !� TrVV LKE-S'-MRI( E- IPA fo D-3
City/State/Zip: V V ( `9 ES BAPKE ; PA IS ! D 3
Policy #or Self -ins, Lie.#-TANC921 7L Expiration Date:3`�5— �o
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 r insurance coverage veri�ca]ion.
I do hereby
Signature:
Phone #: S0 ` 7S 5 1 — O -�' 0�
under the pains �^d peyrz{a�ltiesAf/orjury that the information provided above is true and corre-c't7.
(`mil% 0,-, Date: f ( `�f% ZCJ / ct /
Official use only. Do not write in this area, to be completed by city or town offolal.
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#:
wvrx.mass.gov/dia
From Lorefla Lee FaxID: Page 2 of 2 Dat'e: 11/1,420'17 10'55 AM P'age..2 of
a
!Berkshire Hathaway
Insurance
Ps,► GUARD RD Companies
Wgrker's Como'en'satio'n and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Co.
Policy Number TAWC821576
Renewal of NEW
NCCI No. [25844]
Policy Information Page
1jNamed Insured and Mailing Address
Tahana Inc
60 Oakland St
Mansfield, MA 02048
Federal Employer's ID 04-2905244
Additional Names of Insured
(N2) Tahana Chinese Restaurant
Agency
RICHARD SOO HOO INSURANCE AGENCY, INC.
1148 Washington Street
Boston, MA 02118
Agency Code: MARIS010
Insured is Corporation
[2] Policy Period
From March 25, 2017 to March 25, 2018,12:01 AM, standcud time at the insured's mailing address.
[3] Coverage
/
A. Workers' Compensation Insulanco - Part O'ne of this policy applies to the Workers' Compensation
Law of the following states: Mxsrichusetts
B. Employer's Liability Insurance Prot Two of this policy applies to work in each of th'e states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of Nor.f Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endor'so rents and schedule-,:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore th,? premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating PI . r:. All required infoiination is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium
Total Surcharges/Assessments
� 1,12z
45.00
INTERNAL USE _ IF Page - 1 - Information Page
MGA : TAWC821576-=. WC 000G01A
Date : 03/17/2017
MANOTE
Issuing Office: P.O. Box A-H, 16 S. Pivcr Street, willrtes-nor're, PA 18703-OOZO • www.guard.com
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