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Home My WebLink AboutFlynn's Irish Pub - 12/31/2020Iq FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening dajb „ Establishment Name Establishment Address Establishment Mailing Address (if different) �; ,s � Jc 7u, Okll P, o 1 S-t63 Establishment Telephone No SrCq-, - 33 7 - 'I Applicant Name&Title: Applicant Address V Applicant Telephone No.: 24 Hour Emergency No.: So Applicant Email < v rU � F K. Ca , 3 T Jo wl e Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or F+ An Association partner. Z A Corporation Name Title Address El An Individual \F� 7 .3 - ` k f M v - El A Partnership4— El Other legal Entity 3 s 32 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 1 Address:. Telephone No: � � (`-2 �' 7. '4 '1 24 Hour Emergency No: 7 E .1 4 `e FAX: E-mail: 'tom o Dv� pie S, a t Alt E-Mail: District Or Regional Supervisor (if applicable) Nlil- Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: l �� DEP Public Water Supply No: (If applicable) No. of Food Employees: 2 DAYS/HOURS: Name of Person(s) In Charge(} Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests \� a If there is seating for 25 peo le or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. OYes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: t5gAnnual tiP Retail Food $125.00 !€d Mobile Food Consesslon El Temporary M Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream ZFood Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: FR Food Service up to 201 + $300.00 ! Pushcart $50.00 # of Pushcarts: Temporary Time: Rl Supermarkets $400 [ij Residential Kitchen $100.00 Rain Date: 19 Milk & Cream $10.00 0 Caterer $35.00 Food Operations: Definitions:PHF-Pofenliallyhazanfousfood (llmeRemperafure controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no fime/temperdture controls required) RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furfherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ED PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held I Sale of Commercially Pre -Packaged PHFs rJ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service hJ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Reheating of Commercially Susceptible Population Facility to be Prepared by Consumer Processed Foods for Service Within 4 Hours 12 Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand Customer Self-service of Non PHF and Non- 0 Customer Self -Service contact alternative, time as a public health Perishable Foods Only 0 Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale c Offers Raw Or Undercooked Food Of rm Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale a Vacuum Packaging / Cook Chill Offers RTE PHF In Bulk Quantities Prepares Food/Single Meals for P Retail Sale of Selvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided In this application and affirm that the food establishment operation will comply with 1 5 CMR 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain coples ot�5 CMR,990.k00,and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I cep, I and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 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 C& w 3461116 **Social Security No. (Voluntary) or Federal Identification Number By: Corpo ate 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. C:\Users\sleite\Desktop\Scott's Doe ments\Food Establishments- Temp\TAR CERTIFICATION FORMdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street �g Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: rtit" 5" City/State/Zip: Phone M - ?'� 7 _ _-)� 4a Are yo employer? Check the appropriate box: Business Type (required): L I am a employer with 7 1 employees (full and/ 5. Retail or part-time).* 6.,,❑Re-siaurantBar/Eating Establishment 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. [No workers' comp, insurance required] S. ❑ Non-profit 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]* 11.❑ 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 exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: l if d Insurer's Address: 6"'e" - /) 1 t zA- City/State/Zip: J-S-" Policy # or Self -ins. Lic. # cExpiration Date: 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, untler the pains and penalties ofperjury 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 # z.:, t �9l 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of hidustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Form Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: The Hartford Accident and Indemnity Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 10448 Company Code: 5 \:q15 ' �t1 Suffix LARS RENEWAL POLICY NUMBER: 02 WEC CS5798 4 Previous Policy Number: 02 WEC CS5798 1. Named Insured and Mailing Address: FLYNNS RESTAURANT GROUP INC FLYNN'S IRISH PUB (No., Street, Town, State, Zip Code) 219 N MAIN ST MANSFIELD MA 02048 FEIN Number: 99-9000000 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 2. Policy Period: From 02/21/19 To 02/21/20 ANNUAL 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: 02090249 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 853-2582 Total Estimated Annual Premium: $2,200 Deposit Premium: Policy Minimum Premium: $265 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by Authorized Representative 01/12/19 Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 01/12/19 Policy Expiration Date: 02/21/20 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 NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information reauired below is subject to verification and chanae by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $2,200 Deposit Premium: Policy Minimum Premium: $265 MA (Includes Increased Limit Min. Prem.) Interstate/intrastate Identification Number: Refer to Schedule of Operations NAICS: 722110 Labor Contractors Policy Number: SIC: $1,706 $338 $77 $2,121 $79 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 01/12/19 Policy Expiration Date: 02/21/20 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number: 02 WEC CS5798 Endorsement Number: Effective Date: 02/21/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: FLYNNS RESTAURANT GROUP INC FLYNN'S IRISH PUB 219NMAIN ST MANSFIELD MA 02048 Item 3.D. of the Information Page is completed to include the following endorsements WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1 INFORMATION PAGE WC000001A.2 INFORMATION PAGE WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC200301 APPLICATION OF LIMITS OF LIABILITY ENDORSEMENT - MASS WC200302A MASSACHUSETTS -ASSESSMENT CHARGE WC200303D MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT WC200405 MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT WC200601A MASSACHUSETTS CANCELLATION ENDORSEMENT WC9900011 Signature/ Copyright WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY WC990005 SCHEDULE OF OPERATIONS WC990300D WORKERS COMPENSATION BROAD FORM ENDORSEMENT WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS Form WC 99 03 68 Printed in U.S.A. Process Date: 01/12/19 Policy Expiration Date: 02/21/20 SCHEDULE OF OPERATIONS F� This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE HARTFORD ACCIDENT AND INDEMNITY INSURANCE COMPANY Company Code: 5 Policy Number: 02 WEC CS5798 Schedule Number: 01-20-01 Effective Date: 02/21/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: FLYNNS RESTAURANT GROUP INC FLYNN'S IRISH PUB 219 N MAIN ST MANSFIELD MA 02048 FEIN:99-9000000 NAICS: 722110 SIC: 5812 NO. OF EMPL: 15 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 9079 208,700.00 1.0300 2,150 RESTAURANT NOC 8810 47,800.00 0.0700 33 CLERICAL OFFICE EMPLOYEES NOC Total State Summary Total Class Premium 2,183 Rate Deviation Premium Credit 0.2000 -437 Emp liab increased limits 0.0100 17 Employer Liability Increase Limits balance to Minimum 33 Premium Merit Rating 0.9500 -90 Total Estimated Annual Standard Premium 1,706 Expense constant 338 Terrorism Risk Insurance Program Reauthorization Act 256,500.00 0.0300 77 Disclosure Endorsement MA DIA Private/Public Assessment (CBAI 62) Surcharge 3.8300 79 Total Estimated Annual Premium 2,200 Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 01/12/19 Policy Expiration Date: 02/21/20 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: ` ,S aA Mailing Address '� � '� � ` �"� � � -� '�^?�`�z �-� � 3 Phone/Fax Number: t `" _..z,-?-? ),\ Email: Contact Person/Title for Grease Traps: Name of Company scheduled to pump Internal grease trap(s) monthly: ,2s�=t Q� �� Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date �L(-)�-(kl Print Name:>l� v Facility Operational Information Please answer all questions in this section. If an item is not applicable, Indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): I' VI u Seating Capacity (Actual Count): ! M Normal Hours of Food Preparation/Service: Monday ((per Thursday 3 l Sunday t) 3' - 12 Tuesday's°`�l( Friday'- Wednesday Saturday 11"-1'V— Please indicate the NUMBER of kitchen fixtures used In your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU ( 3 compartment sink Handwashing sink Commercial Dishwasher I Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? �6 , S\�' N Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes ,/ No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: _ Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? OV' j tA How often is this grease storage unit Please list the vendor who removes t a" nfii6 6751 Forum Drive, Suite 2 (800) 446-0257F (407) 352 National Registry of Food 0 E. l R C I' 0, Otlando, FL 32821 otification of Test R #: xxx-xx- ,aled Test Score: 75 andidate Status: Pass ,st Date: February 5, 9 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES DANIELLE MACHNIG HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS agratulations! Attached is y¢ur certificate and wallet card. Please notify : National Registry of name d� r address changes at the address below. PRESIDENT: ,-- LAWRENCE J. LYNCH, CAE :venting Contamination and ross Contamination (Competent) ne suring Personal Hygieand Employee Health (Competent) lively Managing Controls in aFood Establishment (Competent) mitering the Flow of Foods ( eeds review) suring Product Time and Tettiperature (Needs review) nducting Cleaning and Sandi ing (Competent) maging: Physical Facility Desi n & Maintenance:Preventing & Controlling Pests (Competent) ISSUE DATE: FEBRUARY 5, 2019 EXPIRATION DATE: FEBRUARY 5, 2024 CERTIFICATE No: 21544880 TEST FORM: EZT 17 This cemficate is non.lid for mare than fire years fiom date of issue. National Registry of Food Safety Professionals CERTIFIED FOOD SAFETY NIANAGER DANIELLE MACHNIG Certificate No: 21544880 Issue Date: February 5, 2019 Expiration Date: February 5, 2024 DANIELLE MACHNIG 78 ST JOSEPH ST APT 1 WOONSOCKET, RI 02895 National Registry}of Food Safety ProfessionalsR 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3830 1 Fax: 407.352.3603 / ( \\k\ /}ƒ] Tw}§ \ �\)\ [ \ v � � g � i 2 i n m m: kƒ -� .5 . 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