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HomeMy WebLinkAboutQuan's Kitchen 12/31/2018A Commonwealth 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:. ERIC QUAN, PRESIDENT Whose place of business is: QUAN'S KITCHEN 30 CHAUNCY STREET PERSON(S) IN CHARGE: JULIE QUAN/JAMES QUAN Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-78 BOARD OF HEALTH MichaeCwlcCCean, Chairman Milk & Cream O Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: ERIC QUAN, PRESIDENT having a place of business at: QUAN'S KITCHEN 30 CHAUNCY 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 1213112016 License No.: FS-78 Board of Health MichaeCMcCCean, 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-78 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name QUAN'S KITCHEN 2) Establishment Address 30 CHAUNCY STREET !' 3) Establishment Mailing Address (if different) 30 CHAUNCY STREET t F' 1Fd MANSFIELD, MA 02048 4) Establishment Telephone No -- — ---- (508)339-5906 5) Applicant Name & Title: ERIC QUAN, PRESIDENT 6) Applicant Address 171 LAWNDALE ROAD, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 699-5906 24 Hour Emergency No.: (917) 378-3723 8) Owners Name & Title ERIC QUAN, PRESIDENT 9) Owner Address (If different from applicant) 171 LAWNDALE ROAD, MANSFIELD, MA 02048 Owner's telephone number (508) 699-7826 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1--i An Association or partner. LI A Corporation Name Title Address 1 An Individual ❑ A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 1JULIE QUANIJAMES QUAN Address: i171 LAWNDALE ROAD, MANSFIELD, MA 02048 Telephone No: I(917) 378-3723 24 Hour Emergency No: (917) 378.3723 FAX: (508) 261-7831 E-mail: QUANSKITCHEN(aDYAHOO.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: 'IJULIE QUAN Address: 171 LAWNDALE ROAD, MANSFIELD, MA 02048 Telephone No: (917) 378 3723 24 Hour Emergency No: (917) 378.3723 LQUANSKITCHEN@YAHOO.COM FAX (781) 826-8898 E-mail: )WATER SOURCE. TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18-20 17) DAYS/HOURS: MON-SUN 10 AM-12 AM 18) Name of Person In Charge Certified in Food Protection Management: 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): ❑ 20) Location: 1J Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: [1 Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) [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 $275.00 ❑ Food Service - Institution ( Meals/Day) JULIE W. QUAN ❑ Caterer $25.00 L] Milk & Cream $10,00 ❑ Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer (-. ] Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: r-----_.._ __.. _.---------------— 23) Food Operations Definitions PHF- Potentially hazardous food(fimelemperature controls required) Non-PHFs non -potentially hazardous food(no time/femperalure controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) _.__ ... _.. I _._. __ _______ _— __— ❑ Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs [] Delivery of Packaged PHFs 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 Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer Customer Self -Service 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 Vacuum Packaging! Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin r Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for - ____ _. Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health -----— —— Tota Permit Fee: $125.00 Payment is due, with application [:]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 CMR 590.000 and the federal Food Code. �.--- 24) Signature of Applicant: Pursuant to MOIL Ch.62C, sec. 49A, I certify under the penalties �e> ury 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: 04-3286820 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 December 31st of each year. NAME OF BUSINESS: QUAN'S KITCHEN ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-5906 FAX NUMBER: OWNER OF BUSINESS: (508)261-7831 ERIC QUAN, PRESIDENT TELEPHONE OF OWNER: (508) 699-7826 FEDERAL ID/SS NUMBER: 04-3288820 FEE$10.00 PERMIT NUMBER: FS-78 f. y SIGNATURE: DATE: ! L I S 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 By: Corporate Officer (Mandatory, if Applicable) A S2 "Social Security No. (Voluntary) or Federal Identification Number v *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:\HmIthVa e's Docmnents\PERMPP APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PER YMTING AUTHORITY. Applicant Information PIea Business/Organization {N�amie: �✓ r r �. .� ' Address: E~ t k i Ar you an employer? Check the appropriate box: L I am a employer with employees (full and/ or part-time).* 2: I am a sole proprietor or partnership and have no employees working forme 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.] Phone /I € Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/Bating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11. ❑ Health Care 12.❑ Other *Any. . °Any applicant that checks box#I must also fill out the section below showing their Workers' compensation policy infortna6on. **If the corporate officers have cxcmptcd thcrosclvos, but the empora6on bas other employees, a workers compensation policy is required and such an organization should check box #I. I am an employer that isproviding workers' compensation insurance for my gnployees. Below is thepolicy information. Insurance Insurer's City/State/Zip: Policy # or Self -ins, Lic, #- iX k ,( W� L, 6'-J Attach a copy of the workers' compensation policy CJ4't Expiration Dater III ( n 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 insuance coverage verification. I do hereby certify, under ko pgF and penalties of perjury that the information provided)rbove q 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: Phone AccWhP CERTIFICATE OF LIABILITY INSURANCE �/ DATE (MMIDdYVYY) 10 26 17 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chan Insurance Agency, Inc. 220 Harrison Avenue Boston, MA 02111 CNTACNAME: T Eddie Mui 1-6733 FAX No: (617) 451-6735 R.E.noosesservice@chaninsurance.com INSURE S AFFORDING COVERAGE NAIC q INSURER A: Travelers Insurance INSURED INSURERB:Guard Insurance Grou Quan's Kitchen, Inc. INSURERC: 30 Chauncy Street INSURER D: _ Mansfield, MA 02048-1958 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHSTANDING 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 LTR TYPE OF INSURANCE AWL INSR Stan WVD POLICY NUMBER POLICY EFF MM/DOIY POLICY EXP MM/DD1YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CIAIMSAIADE OCCUR 6804681B6791642 10/17/17 10/17/18 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ed ce $ 300DDD MEDEXP(An/onepersm) $ 5,000 PERSONAL& ADVINJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER POLICY PRO- XCTLOC PRODUCTS - COMP/OP AGO $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS (Ea accident) DIN L LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE eraccident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE S AGGREGATE $ DED RETENTION $ $ D MRKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEPoEXECUTIVE YIN OFFICERMIEMBER EXCLUDED? N (Mandatory In NH) If Yes, tlesvibe under DESCRIPTION OF OPERATIONS below NIA QUWC895496 10/19/17 10/19/18 WC STATU- X OTH- E.L. EACHAca MNT $ 500 000 EL DISEASE EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is m ldred) Restaurant located at: 30 Chauncy Street, Mansfield, MA 02048 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS, 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Frank C. Chan �z!gz" © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(NPAIDD'YYYY) 10/26 17 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s . PROWLER Chan Insurance Agency, Inc. 220 Harrison Avenue Boston, MA 02111 NAME: Eddie Mui PHONE 617 451-6733 AA No: (617) 451-6735 IAAIL ADDRESS: service@chaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: Travelers Insurance INSURED INSURERS:Guard Insurance Group Quan's Kitchen, Inc. INSURER C: 30 Chauncy Street Mansfield, MA 02048-1958 INSURERD: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. ILTR TYPEOFINSURANCE AODL 1 SUBft POLICY NUMBER PO ICY EFF MMIW/Y POLICY EXP MM/ODIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY Cl-AIMS-MADE OoCCUR 6804681B6791642 10/17/17 10/17/18 EACHOCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 300,000 MED EXP(Ary ore Person) $ 5 000 PERSONAL& ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2 000 000 GENTAGGREGATEUMITAPPLIES POLICY PER PRO- 'ECTLOC PRODUCTS-OOMP/OP AGO $ 2 000 000 $ AUTOMOBILE LIABILITY ANY AUTO ALLOWPED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS Ce aEE IINED SFN LE LIMIT $ BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) -PROPERTY $ DPMAGE eracdtlent $ $ UMBRELLA LIAB EXCESS LIAB F OCCUR CLAIMS -MACE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIRARTNERIEXECUTPoE = OFFICEWMEMBER EXCLUDED? (Mandatary In NH) If yes, Uesuiba under DESCRIPTION OF OPERATIONS below NIA QUWC895496 10/19/17 10/19/18OTH- M E.L. EACH ACO OE $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Renaft Schedule, If more spare is mqd red) Restaurant located at: 30 Chauncy Street, Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 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 C. Chan © 1988.2010 ACORD CORPOF ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: 7 a F a NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALSO CERTIFIES JULIE W QUAN HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE ISSUE DATE: APRIL 22, 201 4 EXPIRATION DATE: APRIL 22, 2019 CERTIFICATE No: 20970986 TEST FORM: EZC 12 This eerlifaate is net valid for neon Ibnn five yen. from dale ar Issne National Registry of Food Safety Pr CERTIFIED FOOD SAFETY M JULIE W QUAN JULIE W QUAN 871 WASHINGTON ST HANOVER, MA 02339 d) certificate Issue Date:A Expiration Date: A 550 1 Orlaodo, FL 32819 I Phone: 407.352.3830 I Fax: 407.352.36 .� w u