HomeMy WebLinkAboutFlynn's Irish 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 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:.
JOHN DOWNES
Whose place of business is:
FLYNN'S IRISH PUB
219 NORTH MAIN STREET
PERSON(S) IN CHARGE:
HEATHER BUCK, GM
Permit Expires: December 31, 2019
Food Fee: $250.00
License Number: FS-29
BOARD OF HEALTH
'vlichaeCHeatey, Chairman
Milk & Cream
FOR BOARD OF HEALTH USE ONLY Permit # p 'ed
FOOD ESTABLISHMENT PERMIT APPLICATIO .
(Application must be submitted at least 30 days before the planned opening`daie}----_
Establishment Name:
Establishment Address: t`1NW S `
Establishment Mailing Address(if different): +Dc "VA 6
�A130w:cJ lVAN 6yS63
Establishment Telephone No.: S'j 2 3-3'1 - a 10u
Applicant Name & Title: '37Z�-\44^` Dawa v¢'
Applicant Address: �.5 A,,y,"j f"4o,r+.cld;Jv1 u1S:3
Applicant Telephone No.: 5-6 t - 3 `' \ 81 24 Hour Emergency No.: —
Applicant E-mail: FCU `07 SO'4O IRMNNS, ca N
Owner Name & Title (If different from applicant):AR ftQ.-IQ
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
El An Association partner.
O A Corporation Name Title Address
El An Individual +r-kA. k �N, I Aa.'A CA��\�
❑A Partnership gup,,yrVr 4253a
---
Other legal Entity'
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: t3v d',l G-M
Address: 2(4 N0 f� 51 /✓�ArySFe1D
Telephone No: yJ . 7 t�i- a 44 B 24 Hour Emergency No: —
FAX:
E-mail: ir1Fv JD
Alt E-Mail: �
District Or Regional Supervisor (if applicable)
Name & Title: NIA
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS: tl,)Ai041 . A_Yo" `�3' 4a�. 'FR,'k-SPPr 14,1,A' S+wOM� Ivnr
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 25 Seats or more): ❑
J
Location: .:. Permanent Location
Establishment Type
❑ Caterer $35.00
[-]Mobile Moblie Start Date:
❑ Retail ( Sq. Ft)
❑ Milk & Cream $10.00
Moblie End Date:
❑ Food Service up to 100 INCLUDING
❑ Mobile Food Consession
Moblie Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Length of Permit:
Food Service up to 101 -200 $250.00
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Annual
❑ Food Service up to 201 + $300.00
❑ Pushcart $50.00 # of Pushcarts:
Seasonal
❑ Residential Kitchen $100.00
Seasonal Dates:
Supermarkets $400
❑ Retail Food $125.00
❑Retail Snack Food $50.00
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
-"""--____--
-__-
Food Operations Definitions:PHF- Potentially hazardous food(time/temperature 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 furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
[ 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
— ------
ID Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service
❑ 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 ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Oriqin
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:
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 CMW0.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A,
and paid state taxes required under
under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
Signature of Individual or Corporate Name:
Social Security Number or Federal ID: U
g63GGfit o
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.
�A 'a s%r RCSg�rry�" 6y-�•.p - - -
Signature of Individual or Corporate Name By: Corpor t 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.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
U'ro
Boston, MA 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information n o Please Print LeEibly
Business/Organization Name:
Address: C�,Nq t'l , MN1 °' !9
City/State/Zip: l`!Fl^ISFi�D/MA- Phone#: S:it ^ 337
Are yyoo an employer? Cheek the appropriate box:
Business Type (required):
,Zan
t am a employer with Ci employees (full and/
5. ❑Retail
or part-time).*
6. �staurant/Bar/Eating 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. ❑ We are a corporation and its officers have exercised
9. ❑ Entertaimnent
thew right of exemption per c. 152, § 1(4), and we have
I0. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
I L ❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12,0 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 workerscompensation policy is required and such an
organization should check box #i.
I am aii employer that is provitlittg 1vorkers'�ccompensatimr insurmrce for my employees. Below is the policy inforuuaion.
Insurance Company Name: �/J�AtG 1 i;"
Insurer's Address: /' �L•� Ord, 1 L✓Y"
City/State/Zip:
Policy # or Self -ins. Lie. # d 7. bra 1E G L' S 97 9 Expiration
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 certify, unrlerr the pains and penalties of peijmy that the information provided above is true and correct.
o -U e -1-o e-1
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/dia
98 (Policy Provisions: WC 00 00 00 C)
57
CS INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: HARTFORD ACCIDENT AND INDEMNITY COMPANY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 10498
Company Code: 5
Suffix
LARS RENEWAL
POLICY NUMBER: 102 WEC CS5798 03
Previous Policy Number: 102 WEC CS5798
HOUSING CODE: SB
1. Named Insured and Mailing Address: FLYNNS RESTAURANT GROUP INC
(No., Street, Town, State, Zip Code) FLYNN'S IRISH PUB
FEIN Number: 999000000
State Identification Number(s):
UIN:
219 N MAIN ST
MANSFIELD, MA 02048
The Named Insured is: CORPORATION
Business of Named Insured: RESTAURANT - FULL SERVICE (WAI
Other workplaces not shown above: 219 N MAIN ST
MANSFIELD MA 02048
2. Policy Period: From 02/21/18 TO 02/21/19
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: THE EGIS GROUP
81 SOUTH ANGELL STREET
PROVIDENCE, RI 02906
Producer's Code: 090249
Issuing Office: THE HARTFORD
301 WOODS PARK DRIVE
CLINTON NY 13323
(800) 962-6170
Total Estimated Annual Premium: $2, 234
Deposit Premium:
Policy Minimum Premium: $267 MA (INCLUDES INCREASED LIMIT MIN. PREM. )
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Ciu®ten CI z Z �
Countersigned by 01/06/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 01/06/18 Policy Expiration Date: 02/21/19
INFORMATION PAGE (Continued)
Policy Number: 02 WEC CS5798
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 $500, 000 each accident
Bodily injury by Disease $500, 000 policy limit
Bodily injury by Disease $500, 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND
STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
WC 00 04 03 WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14
WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A
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.
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
8810
CLERICAL OFFICE EMPLOYEES NOC
9079
RESTAURANT NOC
45,700 .07 32
199,700 1.09 2,177
MA RATE DEVIATION PREMIUM CREDIT (.20) (9037)
INCREASED LIMITS PART TWO (9807) 1.00 PERCENT
TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848)
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION
MA - MERIT RATING CREDIT (9885)
PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM
EXPENSE CONSTANT (0900)
MASSACHUSETTS DIA ASSESSMENT 4.560 PERCENT
TERRORISM (9740) 245,400 .030
TOTAL ESTIMATED ANNUAL PREMIUM
-442
18
32
1,817
.950
1,726
1,726
338
96
74
2,234
Total Estimated Annual Premium: $2,234
Deposit Premium:
Policy Minimum Premium: $267 MA ( INCLUDES INCREASED LIMIT MIN. PREM. )
Interstate/Intrastate Identification Number:
Labor Contractors Policy Number:
NAICS:
SIC: 5812
UIN:
NO. OF EMP: 000015
Form WC 00 00 01 A (1) Printed in U.S.A.
Process Date: 01/06/18
Page 2
Policy Expiration Date: 02/21/19
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
QUICK REFERENCE
Beginning
Beginning
on Page
on Page
INFORMATION PAGE
PART TWO - Continued
1
G.
Limits of Liability ..............................................
4
General Section................................................................
1
H.
Recovery From Others.....................................
4
A.
The Policy...............................................................
1
I.
Actions Against Us ..........................................
4
B.
Who Is Insured........................................................
1
C.
Workers Compensation Law ...................................
1
PART
THREE - OTHER STATES INSURANCE........
4
D.
State........................................................................
1
A.
How This Insurance Applies............................
4
E.
Locations.................................................................
1
B.
Notice..............................................................
5
PART
ONE- WORKERS COMPENSATION INSURANCE.......... 1
PART FOUR- YOUR DUTIES IF INJURY OCCURS ..............
5
A.
How This Insurance Applies ....................................
1
B.
We Will Pay.............................................................
1
PART
FIVE - PREMIUM ..............................................
5
C.
We Will Defend .......................................................
1
A.
Our Manuals ....................................................
5
D.
We Will Also Pay .....................................................
1
B.
Classifications.......................... ........................
5
E.
Other Insurance......................................................
2
C.
Remuneration..................................................
5
F.
Payments You Must Make ......................................
2
D.
Premium Payments .........................................
5
G.
Recovery From Others ............................................
2
E.
Final Premium................................. .................
5
H.
Statutory Provisions ................................................
2
F.
Records...........................................................
6
G.
Audit.................................................................
6
PART
TWO - EMPLOYERS LIABILITY INSURANCE .............
2
A.
How This Insurance Applies ......................... -.........
2
PART SIX - CONDITIONS .....................................
6
B.
We will Pay..............................................................
3
A.
Inspection........................................................
6
C.
Exclusions...............................................................
3
B.
Long Term Policy.............................................
6
D.
We Will Defend .......................................................
3
C.
Transfer of Your Rights and Duties .................
6
E.
We Will Also Pay .....................................................
4
D.
Cancellation.....................................................
6
F.
Other Insurance......................................................
4
E.
Sole Representative ...... -.......... ......................
6
IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does
not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for
actual contractual provisions.
PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY.
Form WC 66 01 56 B Printed in U.S.A.
Process Date: 01 / 06 / 18 . Policy Expiration Date: 0 2 / 21 / 19
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Pi NATIONAL. REGISTRY OF
FOOD SAFETY PROFESSIONAL'SO
CERTIFIES
DAI*iIELLE MACHNiG
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR TI-tE
FooWSAPEw MANAGER
UNDER THE'
PRESIDENT;
LAWRENCE J. LYNCH. CAE
;Nlotification o€Test Results
Uk xxx-xx-
kaled'fest Score: 75
,'andidate Status: Pass
Lest Date: Febeual`y 5, 2019
ongraluladons! Attached is your Certi6ate and wallet cud. Please notify
lie National Registry of name or address changes at the address below.
preventing Contamination and Cross Contamination (Competent)
mmong Personal Hygiene and Employee Health (Competent)
Actively Managing Controls in a Food Establishment (Cornpotent)
Honitoring the Flow of Foods (Needs review)
-rou ring Product Time and Temperature (Noods review)
-onducling Cleaning and Sanitizing (Competent)
Nanaging:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Competent)
ISSUE DATE: FEBRUARY 5, 2019
EXPIRATION DATE: FEBRUARY 5, 2024
CERTIFICATE No: 21 S448BO
TEST FORM: EZT 17
n: C111141C i51tUl "Ii1 �+mU+C
a1 cyan fro ll.lorimc
'DANIELLE MACIiNIG
.Cenwcatc No:21544880
lgv,E t? W rebrunry:5 ?010
Ltpi+111mi Uaw IvInea y 5?034
DANIELLE MACFINIG
78 ST ,IOSLPFi ST APT I
WOONSOCKE"r, RI 02895
National liegW y of Food Safety Profcssiunnlspn) 1 (1751 Fonun Drive, Ste 221) 1 Orlando, FL 32821 j Phan^. 407,352.:1830 1 Fax: 407,3529603