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HomeMy WebLinkAboutCheng Du 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:. TI (SONNY) TANG, PRESIDENT Whose place of business is: TANG SZ, INC., dba CHENG DU RESTAURANT 249 NORTH MAIN STREET PERSON(S) IN CHARGE: TI (SONNY) TANG Permit Expires: December31,2018 Food Fee: $125.00 License Number: FS-86 BOARD OF HEALTH Michaet`McCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: TI (SONNY) TANG, PRESIDENT having a place of business at: TANG SZ, INC., dba CHENG DU RESTAURANT 249 NORTH MAIN 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-86 Board of Health .Michael-%&CCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-86 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name TANG SZ, INC., dba CHENG DU RESTAURANT 2) Establishment Address 249 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 249 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (608) 339-5946 5) Applicant Name &Title; TI (SONNY) TANG 6) Applicant Address 6 JUSTIN DRIVE, MANSFIELD, MA 02048 !, 7) Applicant Telephone No.: (508) 337-8659 CELL (508) 451- 24 Hour Emergency No.: (508) 337-8659 (508) 451-6387 CELL 6387 8) Owners Name & Title TI (SONNY) TANG, PRESIDENT 9) Owner Address (If different from applicant) 6 JUSTIN DRIVE, MANSFIELD, MA 02048 Owner's telephone number (508) 337-8659 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation NameI -� TitleAddressAddress An Individual '�_ t,�,,7 S'��i9it%�7_ A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'TI (SONNY) TANG Address: 6 JUSTIN DRIVE, MANSFIELD, MA 02048 Telephone No: (508) 339-5946 24 Hour Emergency No: (508) 337.8659 (508) 451.6387 CELL FAX (508) 451-6387 — n E-mail: r?-1 Alt E-Mail. 13) District Or Regional Supervisor (if applicable) Name & Title: p cl ct/Jia Y T ti/H 744) Address: I6 JUSTIN DRIVE, MANSFIELD, MA 02048 Telephone No L(508) 24@=@i4q� 24 Hour Emergency No. FAX IE-mail, �) Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-THURS 11:30 AM-10 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 8 FRI 11:30 AM-11 PM SAT 12 PM-11 PM SUN 4 PM-10 PM 18) Name of Person In Charge Certified in Food Protection Management: Tt TANG If more than 3 individuals are certified, complete list is on file. '.. Required as of 101112001 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) IV! 20) Location: Permanent Location 122) Establishment Type -_! Moblie Moblie Start Date: ir_. J Retail ( Sq. Ft) Moblie End Date: Imo] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21 Length of Permit: i i.Food Service up to 101 -200 1 Annual or up to 25' PHF display $150.00 --. Seasonal 1 J Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: Temporary _.. Food Service -Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: I I Caterer $25.00 1 ] Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer _ J Pushcart $25.00 # of Pushcarts: 0 -1 Residential Kitchen $100.00 Retail Food $100.00 J 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 time/temperature controls required) (Check all that apply): '�, RTE - mady-to-eat foods (Ex. sandwiches, salads, muffins which need no turtherprocessing) Sale of Commercially Pre -Packaged Non PHFs IJI PHFCooked To Order ' I Hot PHF Cooked and Cooled or Hot Held ---- -- -= ---- -- --- Sale of Commercially Pre Packaged PHFs VI Preparation of PHFs For Hot And for More Than a Single Meal Service -_- --. - - --- —j Cold Holding For Single Meal Service IV] Delivery of Packaged PHFs L I PHF and RTE Foods Prepared For Highly -- -.- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility .-. r] Reheating of Commercially to be Prepared by Consumer ( ]Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours --_ --_ - - Customer Self -Service of Non PHF and Non- d Customer Self Service Use of Process Variance as (includingbare Iy,-coont o Perishable Foods Only Manufactured and Packaged for my [] IMRetail If I i ct alternative, time public l Preparation Non Sale - -.... Other Food Operations I. J Juice Manufactured and Packaged for',', Offers Raw Or Undercooked Food Of ., Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities IVI Prepares Food/Single Meals for i 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: $125.00' Payment is due with application I 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 CfolI 590.000ra9d the federal Food Code, 24) Signature of Applicant: f%e 66f2 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2655616 31 26) Signature of Individual or Corporate Name: r. that I, to my best knowledge and belief, have filed all state tax returns 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 December 31st of each year. NAME OF BUSINESS: TANG SZ, INC., dba CHENG DU RESTAURANT ADDRESS: 249 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-5946 FAX NUMBER: (508) 451-6387 OWNER OF BUSINESS: TI (SONNY) TANG, PRESIDENT TELEPHONE OF OWNER: (508) 337-8659 FEDERAL ID/SS NUMBER: 04-2655616 FEE: $10.00 PERMIT NUMBER: FS-86 SIGNATURE:, `S% DATE: 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 Indl'� or Co� e By: Corporate Officer (Mandatary, if Applicable) "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: HwIthVa es Docu mts\PERWF APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Lelribly Business/Organization Name: %sue PZ Z zc- ,fW C%IZI a Je, Ct sT Lr erg/) i Address: ,9 t/ C-' A�A14117 l' % City/State/Zip: /9/� S/I �Z 11A G e)4/?Phone Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. [A6staurant/Saz/Sating Establishment 2: ❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp, insurance required] ❑ 3, E 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 E] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 121-1 Other with no employees. [No workers' comp, insuranceeq.] *Any applicant that checks box #I must also fill out the section below showing theirworkers' 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 checic box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ///C— h/H //-6/f0 / /� X I, t7/eIt) 1.-�q Insurer's Address yr y City/State/Zip: >✓ /J%'%h� %%��%�0/�G n ":)2 C� Policy # or Self -ins. Lic. #- Ci 0 IA% ECCA) .3 9 5.3 Expiration Date: / - 0*1 O J Q^ Attach a copy of the workers' compensation policy declaration page (sboviing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Oficlal 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 Healtb 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone#: avwrr.mass.gowma TANGSZI-01 AKAHANOWITZ 4CORo° CERTIFICATE OF LIABILITY INSURANCE DATE 12113 /201 YY) 12I1312017 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on PRODUCER Insurance ro, MA 02760 E.m (508) 699-7511 1 (AA/c, Ne):(508) 699-7511 _. INSURER(S) AFFORDING COVERAGE _.. ,.... NAIC p. INSURED iINSURER B Tang SZ, Inc. DBA Chang Du Restaurant INSURER C 249 North Main St Mansfield, MA 02048 IN INSSUURERIE RER E INSURER F : PnvooArzcC: CCRTICICATR Jul IMRRIi• RCVIcArIl I NI IMRFR. 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 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 OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - ADDL SUER -POLICV EFF POLICY EXP L TYPE OF INSURANCE Sp POLICY NUMBER p p LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS MADE OCCUR J _ ICI DAMAGE TO RENTED PREMISES( Ea Occurrence) I$. _ MEp EXP (Any_oneperson) 5 PERSONALB_ADV INJURY $ GEN'L 1 AGGREGATE LIMIT APPLIES PER I I I GENERAL AGGREGATE _$__ _.. POLICY LOC jECT _ PRODUCTS COMP/OPAGG $ 1 OTHER'. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Eaactldmd $ ANY AUTO III BODILY INJURY(Per person) $ _ Il SCHEDULED INJURY PerawtlenQ ppggOP _ AOWNED HREDTILLY I ONLY OOND 'BODILY rr&Rq 1lIpAMAGE $O $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ I ) EXCESS LIAR _1 CLAIMSMADE (AGGREGATE_. ,$ DED RETENTION$ I WORKERS COMPENSATION DHA PER STATUTE R L.. EMPLOYERS' LIABILITY AND YIN 08WECCN2853 08/091P097 08191/2018 _, 500,000 ANY PRORI R/EXECUTIVE M9MBER EXCLUDED? EL EACH ACCIDENT I NH) (MaFnIC4a E L DISEASE- EA EMPLOYEE($ 500'000 If yes, describe under I DESCRIPTION OF OPERATIONS below 'E.L. DISEASE - POLICY LIMIT $ 500,000 I I i I DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Town of Mansfield Building Dept Mansfield, MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD u w w zy,,� !- z -4' � J w z w P4 z W w to N (, Z Q d N O O N ry U Q 0 w .N a �o N 12 W Y O Q l � � 42 PEEL HERE c-r ®rPR AED if Association, Ti (Sonny) Tang The above Individual has successfully completed the objectives and skills evaluations In accordance with the curriculum of the ARA Reansaver CPR AEO Program. Options, completed modules are those NOT marked out: 5/09/21117CPRAEO Infant CPR 5/09/M19 Issue Date Recommended Renewal Date Strike through the moduleacunsty eted. This card contains unique ures to protect agamstrgery. Training Safety Program COnsultantWIt1WMA4688 Center Name Ox a 00 TC Into wwryf,9sRclpom 500,;252-3049 Course Location Mansfield instructor Bonnie Meagher 0211229 Vd if Name g Holder's ®emeame�icen Heart Avocielbn TempednB with tM1R UNrvdl elferile eppwrerxn. 1F1B10 Enclose you will find your card for the class you have recently taken. At this time I would like to personally like to thank you for using Safety Program Consultants, Inc. for your teaching needs. I look forward to seeing you again. Sincerely, �� .. Bonnie J Meaghe Safety Program Consultants Inc. 15-1810 2/16 hT 1pC��f FC„vG'€ib°,`�! f ar('i