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HomeMy WebLinkAboutJimmy's Pub - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD ESTABLILSHMENT 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:. GEORGE D. PANTOS Whose place of business is: JIMMY'S PUB AND RESTAURANT 141 NORTH MAIN STREET PERSON(S) IN CHARGE: GEORGE D. PANTOS Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS -37 BOARD OF HEALTH MichaeCHeaCey, Chairman I Milk & Cream I FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: V /r17 M o Establishment Address: } mG>u�✓� inR d Establishment Mailing Address(if different): � �� l�i Establishment Telephone No.: Applicant Name & Title: G eor- e_ PQ r) -to Applicant Address: Applicant Telephone No.: 24 Hour Emergency No.: Applicant E-mail: CiJp�v�}OS�S23((a/Jlc�il Cpry� Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. 91 A Corporation Name p Title Address El An Individual G�or1911 1 0140 5______Qu-)nty A Partnership E] Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: G eGrcl-t?, Pani -DS ownp r -- Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: QC)Pan-t- 5 (S 21 9 C5mat L Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti Choking Procedures (if -2 -5 -Seats or more): 0 Location: permanent Location Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: G.Annual Q Seasonal Seasonal Dates: Q Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type Retail ( Sq. Ft) Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 Q Food Service up to 201 + $300.00 Q Supermarkets $400 Caterer $35.00 F o Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Dessertslice Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 Retail Food $125.00 Retail Snack Food $50.00 Food Operations Definitions:PHF - Potentially hazardous food(timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no (ime/temperature controls required) ;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) E] Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held El Sale of Commercially Pre -Packaged PHFs I] Preparation of PHFs For Hot And for More Than a Single Meal Service ----- - ------------- Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly E] Delivery of Packaged PHFs _-.- - _ Susceptible Population Facility -- ----- --- ---- ------ Sale of Raw Animal Foods Intended _ E] Reheating of Commercially to be Prepared by Consumer Q Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours — - -ce, ----- Customer Self -Service of Non PHF and Non- Perishable Foods Only --- ------ ' Customer Self-Service U Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control g -f -- `Ice Manufactured and Packa ed for Retail Sale Preparation of Non-PHFs -....._...._."_ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations i] Juice Manufactured and Packaged for Retail Sale Prepares Food/Single Meals for Catered Events or Institutional Food Service Q Offers RTE PHF in Bulk Quantities or Reconditioned Food To be completed by the Board of Health ""-"" _--- Total Permit Fee: Payment is due with application E] 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. 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. Signature of Individual or Corporate Name: Social Security Number or Federal ID: Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: 1 'i I �) 1M G 1 y] ��+ B City/State/Zip: I i yy��r� l Q_.n,S F'l P,Lfj O Phone #: SO R 339 '7/G, � Are you an employer? Check the appropriate box: Business Type (required): 1. [9' I am a employer with S 2, employees (full and/ 5. ❑ Retail or part-time).* 6.[E22estaurant/Bar/EatingEstablishment 2. ❑ I 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, Ej 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]* 4. ❑ We by 111-1HealthCare are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.] I 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 exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box C. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: WA Qcc o , 1, m er C I -t G n iS Insurer's Address: PO )acy -");FA 1 City/State/Zip: ©2 I S3 i Policy # or Self -ins. Lic. # O ) y boD c, o a I °1 I I Expiration Date: I O L Ly 12 '.01 (� 4\ 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 verification. I do hereby cpift,, ym*r the pains and penalties ofperjury that the information provided above is true and correct. le 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.gov/die 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. )9 Signature of Individual or Corporate Name Social Security Number (Voluntary) or Federal Identification Number" By: Corporate Officer (Mandatory, IF Applicable) 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. A CERTIFICATE OF LIABILITY INSURANCE DATE (MM/OD/Y zi THIS CERTIFICATE i::NOT !i: AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES CERTIFICATE F INS RANVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES S BELOW THIS CERTIFICATE UC 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 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 this certificate does not confer rights to the certificate holder in lieu of such endorsementtst ODUCER Connolly Insurance Agency, Inc 85 Main Street North Easton, MA 02356 Jimmy's Pub Mr. George Pantos 141 N. Main Street Mansfield, MA 02048 A: uoerly Mutual Insurance Cc B: Norfolk & Dedham Group -Cc c: Cove Risk Services LLC - - - • yr nll' wNce LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED. NO ANVREQ TAIN, T NE, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCEAFFORDED 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. R i TYPE OF [NSURANCR _- MGKCIAL GENERAL LIABILITY CLAIMS -MAGE II OCCUR LAGGREGATE LIMITAPPLIES ER: I I BKS55980008 I 02/05/18 I 02/05/19 P POLICY PRO- ❑ E]ECT OC �ESCRIP770N OF OPERATIONS /LOCATIONS f VEHICLES (ACORD 101, Additional Romania Schedule, may be attached If more space is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 tt 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Richard P. Connolly (CORD 25 (2016/03)©1988. 015 The ACORD name and logo are registered marks of ACORD ANYAUTO CO DINED SINGLE LIMIT $ B OWNED AUTOS ONLY SCHEDULED AUTOS BA91313326A BODILY INJURY(Perpercon) $ HIRED AUTOS ONLY NON -OWNED AUTOS ONLY 02114/18 02/14/19 BODILY INJURY( eraccitlenU $ PROPERTY DAMAGE Per accident S UMBRELLA LIAR OCCUR $ EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE S DED RETENTION$ AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS•LIABILITY $ ANY PROPRIETOR/PARTNEWEXECUTIVE YIN EXCLUDED? ❑ N/A C OFFICER/ME(Mandatory 01400050219211$ X PER STATUTE ERR in NER IAlandato.o NH) If Y--. 01/01/18 01(01/19 EL EACHACCIDENT IPTI Nunder DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYEE $ Liquor Liability E.L. DISEASE -POLICY LIMIT 5 D BKS55980008Limit 02/05/18 02105/19 �ESCRIP770N OF OPERATIONS /LOCATIONS f VEHICLES (ACORD 101, Additional Romania Schedule, may be attached If more space is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 tt 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Richard P. Connolly (CORD 25 (2016/03)©1988. 015 The ACORD name and logo are registered marks of ACORD INFORMATION PAGE Insurer: MA Retail Meichants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: DGP & Sons, Inc. Jimmy's Pub Mailing Address: 141 North Main Street Mansfield, MA 02048 Other workplaces not shown above: NO OTHER WORKPLACES FOR THIS POLICY RENEWAL AGREEMENT PRODUCER: Agent# 652 R. P. Connolly Insurance Agency, I 85 Main Street North Easton, MA 02356 Carrier Policy #: 014000502192118 Carrier Prior Policy #: 014000502192117 Fein: 042796618 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1 Ol 2018 to 12:01 a.m. on 1/01/2019 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each - state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1.000.000 each accident Bodily Injury by Disease $ 1.000.000 policy limit Bodily Injury by Disease $ 1.000.000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000414(07/90) WC000422B(O1/15) WC200102(01/14) WC200301(04/84) WC200302A(09/08) WC200303D(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis No. Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 3,539.00 Minimum Premium $ 292.00 Expense Constant $ Rate Per Estimated $100 of Annual Remuneration Premium 00 Deposit Premium $ .00 ry W U I w W v µc 0 O N 00 0 0 rr W 2 7� z w CO `z W o m �• a Z � u. X K u c Q � O O E N w LO � X r N a C LO 0 Cl • c _0 W E 0 V° On Me-' 50 FS