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Home My WebLink AboutSake Steakhouse 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:. GUANG K. SHI Whose place of business is: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 280 SCHOOL STREET PERSON(S) IN CHARGE: MICHELLE LI, MANAGER Permit Expires: December 31, 2018 Food Fee: $150.00 License Number: FS-79 BOARD OF HEALTH MichaeCMcCean, Chairman Milk & Cream O 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: GUANG K. SHI having a place of business at: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 280 SCHOOL 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-79 Board of Health -%1ichaeC-%1cCCean, 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 FSFS79 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 2) Establishment Address Y80 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-2388 5) Applicant Name & Title: GUANG K. SHI, PRESIDENT 6) Applicant Address 141 ARMSTONG AVENUE, METHUEN, MA 7) Applicant Telephone No.: (646) 410-6228 24 Hour Emergency No.: (646) 41M228 8) Owners Name & Title GUANG K. SHI 9) Owner Address (If different from applicant) 141 ARMSTRONG AVENUE, METHUEN, MA Owner's telephone number (646) 410-6228 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. vl A Corporation Name Title Address i..l An Individual A Partnership Other legal Entity, _ -;- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MICHELLE Ll, MANAGER _I Address: 111 EAST MAIN STREET, APT RIGHT, NORTON, MA Telephone No: (646)410-6228 24 Hour Emergency No: (646) 410-6228 I FAX: 1(508) 337-2328 E-mail: MICHELLELI662(WYAHOO.COM Alt E-Mall. 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: (508) 337-2328 E-mail: SAKESTEAKHOUSE_MA@HOTMAILCOM i Food Establishment Information 1 14 WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN Supply ( DEP Public Water Su No If applicable) 16) No. of Food Employees: 4 17) DAYS/HOURS: MON-SAT 11:00 AM -1:00 AM SUN 12:00 NOON - 1:00 AM 18) Name of Person In Charge Certified in Food Protection Management: JIN HUA CHEN 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): Wl 20) Location: [VI Permanent Location I 22) Establishment Type j ❑ Mobile Mobile Start Date: ❑Retail ( Sq. Ft) Moblie End Date: Ll, Food Service up to 100 or Mobile Comments: I up to 10' PHF display $125.00 21) Length of Permit: V, Food Service up to 101 -200 d. Annual or up to 25' PHF display $150.00 Seasonal Food Service up to 201 + '., or 25'+ PHF display $275.00 Seasonal Dates: Temporary i_'�, Food Service - Institution Temporary Start Date: �I, ( Meals/Day) Temporary End Date: Temporary Time: XIANG WEI ZHUO [] Caterer $25.00 - [VI Milk & Cream $10.00 L1 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 I Retail Food $100.00 Lj Retail Snack Food $25.00 [_' Tobacco Products $25.00 Rain Date 23) Food Operations Defmitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF'' non potentially hazardous food(no timeaemperatum controls required) :(Check all that apply): I 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 ./' 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 - Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 1 PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chili Customer Self -Service of Non PHF and Non- ! L', Customer Self -Service - ICI Use of Process Requiring A Variance 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 Operations r . Juice Manufactured and Packaged for _ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ! Prepares Food/Single Meals for. --_ Catered Events or Institutional Food Service i_ Retail Sale of Salvage, Out -Of -Date --- -:- _ __ -- or Reconditioned Food To be completed by the Board of Health --- - - '' Total Permit Fee: $150.00 Payment is due with application i 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 ap cable law. I have been instructed by the board of health on how to obtain copies of 105 CM_, 590.000 and the feder Fbod Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the p and paid state taxes required under law. 25) Social Security Number or Federal ID: 27-2378335 26) Signature of Individual or Corporate Name: of perjury that I, to my best knowledge and belief, have fled 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: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 337-2388 FAX NUMBER: (508) 337-2328 OWNER OF BUSINESS: GUANG K. SHI TELEPHONE OF OWNER: (646) 410-6228 FEDERAL ID/SS NUMBER: 27-2378335 FEE: $10.00 PERMIT NUMBER: FS-79 SIGNATURE: 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. ry i J ec, Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, 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: H&dth\Ja e's Doo=ents\PERMrr APPLICATIONSWAX CERTIFICATION FORM.doc :T The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 U1F . www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organiza-tion N Address: ? V 5 City/State/Zip: OV L S&. (9ZQ KPhone#: Are you an employer? Check the appropriate box: Business Type (required): 1. am a employer with employees (full and/ 5. ❑ Retail QI or part-time).* 6. E]RestauranUBar/Eatin g Establish ment 2.0 1 am a sole proprietor or partnersbip and have no y. 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. ❑ 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, ❑ with no employees. [No workers' comp. insurance req.] 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 excmptcd themselves, but the corp=60]a has other cmployces, a workers compensation policy is required and such an organization should check box 41. f am an employer that isproviding workers' compensatiolt insurance for my employees. Below is thepolicy information. Insurance Company Name: o y- e m (94 L (Y Vl V I�ULvt r oul � Insurer's Address: �- l� Y J City/State/Zip: fn /JL , rr� t��L'-- �l` 10 / Policy # or Self -ins, Lic. # N� L C 3 Expiration Date: D 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 vAification. I do hereby certify, under e pains and Qionafio— VvbA-- -z3 thatthe information provided abo a is tree 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 : Phone #: www.mass.guwwa Page 2 of 2 Date: 11282017 08:57 AM Page:2 of 2 ACORO" SASTE-1 OP If). �--- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODRYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OP 1NFORMAMOR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1112812017 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTNRCA7E OF INSURANCE GOES NOTCONS7ITUTE 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(fes) must have ADDITIONAL If SUBROGATION IS WAIVED, subject to the terms and wnditlons of tINSURED provisions or be endorsed.he policy, certain pollcles may require an endorsement. q statement on this certificate does not confer if PRODUCES ghts to the caAificate holder {n lieu of such endorsements . 61T-38B-Bf68 Richard Soo HDo InsuraneA r�SiIIPCT Richard Soo Hnn leer,......, THIS IS TO INDICATED, OR OF MERVAL GENERAL LIABILITY CLAHASMADE ® OCCUR L AGGREGATE LIMIT APPLIES PER POLICY ❑ JEC'T ED LOC I ANY AUTO OWNED SCHEDULED UUTEEOSONLY ApUN�+TIOppSVyTI�p HHA�pp FUTOSONLY gl1TOS ONLY UMBRELLA LIAR OCCUR EXCESS IIAS nemc ur. BELOW HAVE BEEN ISSUED TO THE CONDITION OF ANY CONTRACT OR 012SI20 f 7 + 14W2,W201& DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlanal .QCATIRemarks SahatlWe, mry be atbchatl 0 mare apace la nqulrNl W. 288SCHCM ST, MANSFfEl t0, MA o204e ABOVE FOR THE POLICY PERIOD r WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS, SHOULD ANY OF THEABOVEDFSCRA&WppLry MiWCgyrEXLZDJWF4=E THE EXPIRATION DATE THEREOF, NOTICE WILL BE Town of Mansfield ACCORDANCE W ITH THE POLICY PROVISIONS. DELIVERED IN 6 Park Row Mansfield, MA 02048 A1REPRESENTATIVE ;20'16103) -1TH0/�Ivdi%Af-w O 1989-2016 ACORD CORPORATION. All rights reserved: The ACORD name and logo are registered marks of ACORD