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Home My WebLink AboutKyoto Steak House 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:. LONG XING LIN Whose place of business is: LR KYOTO, INC.C/B/A KYOTO JAPANESE STEAK HOUSE 242 CHAUNCY STREET PERSON(S) IN CHARGE: LONG XING LIN Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-40 BOARD OF HEALTH Michae(.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: LONG XING LIN having a place of business at: Town of Mansfield 6 Park Row Mansfield, MA 02048 LR KYOTO, INC.C/B/A KYOTO JAPANESE STEAK HOUSE 242 CHAUNCY 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-40 Board of Health MlchaeCMCCfean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred ,os CONSULTING ass®cam (BOSTON OFFICE) 65 HARRISON AVE, BOSTON, MA 02111 PHONEIFAX 617-422-0098 CELL 781-267-6590 To Whom It May Concern: (WATERTOWN O I64 SUMMER ST, PHONE/FAX 617-' Food Safety Manager Training Program This Letter is to verify that 1 " l N . Al ✓M has Training Program and also finished the examination of the program on The results of the examination will be available approximately 2-3 week - have any questions concerning the certificate feel free to call me any tim /45c) fits ///_s lz�e )r /1 [,n(�>cTY Respectfiilly Yours Test Administrator/Trainer National Registry of Food Safety Professional MA 02472 Of the Food Safety after the test. If you during business hours. 7cIv5 2o4wz /fS zv� 46 t d 8900-66b-LL9 1 0ue1401 0 FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-40 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name LR KYOTO, INC C/B/A KYOTO JAPANESE STEAK HOUSE 2) Establishment Address 242 CHAUNCY STREET = 3 3) Establishment Mailing Address (if different) 242 CHAUNCY STREET MANSFIELD, MA 02048 a 4) Establishment Telephone No (508) 339-8822 5) Applicant Name & Title: LONG XING LIN, OWNER 6) Applicant Address 1 NFI€tB MA 87a08— 1 7) Applicant Telephone No.: (626) 236-0690 24 Hour Emergency No.: (670)677-020 8) Owners Name & Title LONG XING LIN 9) Owner Address (If different from applicant) Owner's telephone number 646-608-6988 11) If a corporation or partnership, give name, title, and home address of officers 10) Establishment Owned By: !An Association or partner. I) 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: (LONG XING LIN Address: 1242 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: I(646) 508-6988 FAX: I(508) 339-8885 E-mail: ADALLINds-11 C Alt E-Mail: 24 Hour Emergency No: (570) 677-0210 13) District Or Regional Supervisor (if applicable) Name & Title 'LONG XING LIN i Address: 1242 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: �(646) 508-6988 24 Hour Emergency No. (570) 677-0210 FAX: (508) 339 8885 E-mail. KYOTOMANSFIELD@YAHOO.COM 04 Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN -- --- DEP Public Water Supply No (If applicable) 16) No. of Food Employees 4 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: LONG XING LIN 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: [] Permanent Location 22) Establishment Type F-1 Mobile Mobile Start Date: I _I Retail ( S Ft) Mobile End Date: Moblie Comments: 21) Length of Permit: (J Annual Seasonal Seasonal Dates: f—I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: q E/] 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) ❑ Caterer $25.00 U 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 23) Food Operations Definitions:PHF- Potentially hazardous food (timelemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Nan-PHFs ❑d PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- - --- --- ❑ Sale of Commercially Pre -Packaged PHFs -� ------ [� Preparation of PHFs For Hot And for More Than a Single Meal Service ---------------— ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ------------- --- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility [ ] Reheating of Commercially _ to be Prepared by Consumer -- - ---_-- ❑ Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours 1=j Customer Self Service of Non PHF and Non- --- - ------ i ]Customer Seif-Service V Use of Process Requiring di Variance ' and/or HACCP Plan (including bare hand Perishable Foods Only --_--�- _-_-- _ Ice Manufactured and Packaged for contact alternative time as a public health Elcontrol Preparation of Non-PHFs Retail Sale ) _ __— Other Food Operations l.,-.] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin Offers RTE PHF in Bulk QuantitWs 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 Total 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 CHAR 50.00 -andlhe federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury 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: 46-7232734 26) Signature of Individual or Corporate Name: c��k/ Town of Mansfield Town o f 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: LR KYOTO, INC.C/B/A KYOTO JAPANESE STEAK HOUSE ADDRESS: 242 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8822 FAX NUMBER: (508) 339-8885 OWNER OF BUSINESS: LONG XING LIN TELEPHONE OF OWNER: 646-508-6988 FEDERAL IDISS NUMBER: 46-1232734 FEE: $10.00 PERMIT NUMBER: FS-40 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. ,c- Signature of Individual or Corporate Name By: Corporate Offic Y (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:\Hm1thVane's DoeumentAPERMTr APPLICATIONS\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress street, Suite 100 Boston, MA 021I4-2017 lug www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses, TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Business/Organization Address: Are you an employer? Check thew propriate box: 1. 1?1 I am a employer with-1_ employees (full and/ or part-time).* 2: 0 1 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.] Q- Business Type (required): 5. ❑ Retail 6. 1/1 Restaurant/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 #I must also fill out the section below showing thcirworken:' compensation policy information. xxlf the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should cbecic box M. am an employer that is providing workers' compensation yinssurance for my employees. Below is the policy informadoh. Insurance Company Name: 6�{�� \l "0CO(i� )0u) \1 Insurer's Address: r . o , ]S uA A " City/State/Zip: \QA "S -. DD 2'�) . Policy# or Self -ins, Lic. #- ) g"m NO _�� O Dhl- Expiradon Date: u< Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex iration 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. [do hereby certify, under the pains and penaldes of perjury 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: Phone www.mass.goWma NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above -mentioned chapter by insuring with: NorGUARD Insurance Company NAME OF INSURANCE COMPANY P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY LRWC888045 01/31/2017 01/31/2018 POLICY NUMBER 220 Harrison Avenue EFFECTIVE DATES CHAN INSURANCE AGENCY Boston, MA 02111 617-451-6733 NAME OF INSURANCE AGENT ADDRESS PHONE # LR Kyoto Inc. 242 Chauncy St. Ste 1 Mansfield, MA 02048 EMPLOYER ADDRESS 12/27/2016 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER `From: Chan and Company Wax: (212) 5660580 To: -.Fax: (505) 338-8885 Page '1 of 1 11110I2017 3:14 PM DEPARTMENT-UF THE TREASURY - ,..,, �R.LINVBRN-AL:.REVENUE . SERVICE .- CINCINNATI `.OR -4rz999-0023 '. -. Date of this notice: 10-22-201� Employer Identification Number; . _ ....-.-_,•46-1232734 .... Form:_ . SS-4 LR "TCYOTO.;INC Number of s ... CP S ' this notice. �- � 7$ A" ' ._KYOTO' JAPANESE-STEAK ROUSE:`•' . ..> :. .. ,.. ... .. .. 242 CHATMCX ST. ...__ For-asslatanCe you_. may:"call us at. " MANSFIELD, -MA 02048 .`.. Al 800-82974933 .. .. - . ... ..,.,. `. IP.'.YOU..WRITIiATTACH TEE STUB'AT:THB:EN,.;D OF THIS NOTICE. • " ....-'WS ASSIGNBD .XOU AN EMPLOYER 'IDENTIFICATION NUMBER Thank you for applying for.an Employer- Identification: Number-(EIN). `We,assigned you _. _ BIN 46-1232734..This EIN will identify Y._ou , your business"accounts;-tax returns,:and :.documents,'._even if. you have -no"employees. ?.Please 'kgep.'.thip :notice.in:yeur permanent records,. .. ,- _ When filing., tax documents, payments„ and related correspondence, it is very important - that .you use your::.BIN. :and'complete name; and. address exactly as shown above. Any variation may cause- tielav, in. processing, result 'in"incorFeot igfOrmat your—'Account,....:cr_.even,..., cause y*da to be �3e67�gned.,more than gone EIN -§ If El)e> nEoi�nation =isnot correct.'as shown " above, .please make' the'c0rrection'using,the attach,0 tear off stub and return it to us. 'Based on the information received from:ycu or your representative, you :"most file `,the following form(s) by the date(s).shown. -.... ._ ... ..,.. :Form.941 - -. .._ 04/30/2013 - ....., - _ ...-:_..Form _940 ...... 01/31/2014 . Form I320 -.... i ,you have questions"about the "form (a)"or, -the due.; date(s)'shown;;.you Carl call us at . the.phone.:number or:write:to us at the: address,:shown.at.the top of this notice... If you :`•.:`- need help: -in determining your annual accounting.iperiod (tax year), see Publication 538, ....:Acenunting ;Per ode .and.:R4ethods- , ... r ._... We`assignO you a taz classif:atlon based,ou information obtained from you or'your.-.- :representatxve:•' It as not a legal:;determination` of your tax classification, and is not banding:.on the iRS. If'you want::aJagal :determination of your tax classification, you may request a"prAvate.letter ruling #ran the IRS".under the guidelines ;n. Revenue Procedure .2004 1, 2004 1 L,x,e 1";(or superseding Revenue ProcEidµre for.ahe.:year, at igsue) .-Note-.- Certain =tax-cl!sea, ication:�;elecL Qns can be,_Xeduested; by filing Fo7Cm $532,;;;6Y1t2ty =--- : -.-: Classificati.on.iElectaon ....See Form 8832 and instructions for addi Tonal information. . --IINI?ORTANT IN8OW1WTION'FQR S CORPORATION ELECTION: .: ... .- -... •.-. - If you in6end,.to.elect to file Yourreturnaa-a--i:emall..business.corporatyon, an_ ..._ __ electiott�to faLe:a",FOYm.I12o-S must be made within certain tirtteframes.and the ,.., corporation must, meet certain testa. A1l.of this infazmatxon-ip.included ln the instructions -for: Form, 2553. Election.by a.: Small'' Business. lCotporation. I I I� Ix I11U Ib I I 0 I : I � i I � � I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I r I I a� I m I (D c ® N I O N @ r I U E wi Z s co I j v a) I K N I m m N cn Z CL COo 75 al Q I O o � o . 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