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HomeMy WebLinkAboutFlynn's Irish Pub - 12/31/2021V yy l C r FOR BOARD OF HEALTH USE ONLYr Permit # Issued r' _ FOOD ESTABLISHMENT PERMIT APPLICATION`S (Application must be submitted at least 30 days before the planned openia Establishment Name t Establishment Address Establishment Mailing Address (if different) �(�yi �l`i �, S� y1 �lrs �QN�- Establishment Telephone No Applicant Name&Title: G-r ibf�2 Applicant Address GI U'UtS2i ceJ (fn'+•�- JS'�2 i Q Applicant Telephone No.: q6I -"1001 24 Hour Emergency No.: 7417, ;�4N Applicant Email 101 " 0-) C't A— "n 1�=vro�P G3f—i Owner Name & Title (If different from applicant) Owner Address �0 Sn��1•,u'C �� 04'sS 3 Owner telephone number V-s-- -3�" Owner email: '1 ,55 * (;D ej0`t �A-J'-_" , Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. rA Corporation Name Title Address 11 An Individualu\� ❑ A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (f cA-a4 c e- (3�-c Address: G KIt r�e CJr ee N t?Oc,m. Telephone No: L() / - 1 i- 14"t ti 24 Hour Emergency No: ,S6 •• 3-31 ) FAX: E-mail: c�D �4o�l�N�S,GDti 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: �'e `j o,Y DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: __ / � = ��� � _, Q,-• Sty`: \'7. ^\; � - � ��'" Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified(d in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests \Qs -,%-mil a If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. Yes Does this establishment require a FOG permit? f- If yes, please attach the FOG permit application. Len th of Permit: Establishment Type: '. Annual ❑ Retail Food $125.00 Mobile Food Consession Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FQOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no tfine/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Q 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 PH Fs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service contact alternative, time as a public health Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the; establishment operation will corn board of health on how to obtain Signature of Applicant: of the information provided in this application and affirm that the food 105 CMR 590.000 and all other applicable law. I have been instructed by the )4105_CMR,590.000 and the federal Food Code. Pursuant to MGL Ch.62C, sec. 43QQ., certify under the penalties of perjury that I, to my best knowledge and belief, have filed all stale tax returns and paid state taxes required and . 1w. Social Security Number or Federal ID: �' G r� 6� Signature of Individual or Corporate Name: 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. L�__ Signa ure of Individual or Corporate Name By: Cor +te 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\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Alit l.V/ILIRVIb IYGllG6/b Vf 1YL llJJlW I4 L�JGLLJ Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: � ro r'Sk S o- Q-sk Address: D lA 00 t-c-\Jk- H('> t3 City/State/Zip: IAA 0 9-&`A Phone #: Are you an employer? Check the appropriate box: L �am a employer with / employees (full and/ or part-time).* 2. ❑ I 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.] Business Type (required): 5. ❑ Retail 6._�estaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 Ln Health Care 12.❑ Other *Any applicant that checks box #I 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 an: an employer that is providing r�fjh/ers' con pensat!_on insurance for my employees. Below is the policy information. Insurance Company Name: I - 7fAAy�,�fl Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. U 1✓ Q-- 4 &t i CI .P--4) 0� A raRv� C (0 C.S S_ / 9 Expiration Date: `l P- ( )-N 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, undt the pains and penalties of perjury that the information provided above is true and correct. / 2-3 /0� S�tis 333_A+D \_�- 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 #: Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: l�" "' S Address: \ r ~ t S r Mailing Address: boot �) Sri 0tiv4 C_)JI� Phone/Fax Number: >t"c' Email `1 C6" Contact Person/Title for Grease Traps:�� r r Name of Company scheduled to pump internal grease trap(s) monthly: 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. Signed �g—= ®® Date �6 �31 �)-Z> Print 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): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday Thursday Sunday (mil Tuesday I ` (7� 4 Friday 7/C) P /" Wednesday Cf � 7 'y'~ Saturday 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 `G,RU 1 F— S 3 compartment sink N o ae O o I .rr Handwashing sink Commercial Dishwasher Bar sink Mop Sink OW E N( A- Garbage Disposal N 0 Ice Making Machines 3 N 0 Fryolators 0 Grills or Ovens © Exhaust Hoods NO Floor drains Other: How are hood vents cleaned? (ke., in three (3) bay sink, off site by privat mpan)&-- Is dinnerware pre -rinsed before being washed?f Yes No If yes, at what station/sink? 0 J" %2C A— I P-E CTLY C O n n E CAD T"b QcEKSF_+P_CL-P) 2 Grease Traps 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 G6�1 b)SNNa.S1AF_P�,0 {7J/v.y 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)? II�� Yes No Size 35 gallons / dia�crt _ Where is the existing outdoor GRU located? I CGtiTt- J t r-) h F b /Ic IG AyLrY — b C hLV1 Cl I"L�nn`S 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? O itlocated� 0 Where is the grease storage un How often is this grease storage unit emptied?_ Please list the vendor who removes the A - NIA 3 TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. Y I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. r I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature ._�. Date: Applicant Name (please print cle y) �� r"f y NATIONAL REGISTRY OF p&F00Ds� FOOD SAFETY PROFESSIONALS® A CERTIFIES ` DANIELLE MACHNIG HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER' CERTIFIED ,': UNDER THE w R CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: V LAWRENCE J. LYNCH, CAE ISSUE DATE: FEBRUARY 5, 2019 EXPIRATION DATE: FEBRUARY 5, 2024 CERTIFICATE No: 21 544880 N0656 TEST FORM: EZT17 6751 Foram Drive, Suite 220, Orlando, FL 32821 This cenlfi,me is not valid (or more P (800) 446 0257 F (407) 352 3603 wa wNRFSP.com than five years from date of issue National Registry of Food Safety Professionals' oFeooas } National Registry of Food Safety Professionals Notification Of Test Results eftm . CERTIFIED FOOD SAFETY MANAGER ID#: XXX-XX- Scaled Test Score: 75 -andidate Status: Pass Test Date: February 5, 2019 congratulations! Attached is your certificate and wallet card. Please notify he National Registry of name or address changes at the address below. 'reventing Contamination and Cross Contamination (Competent) nsuring Personal Hygiene and Employee Health (Competent) fictively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Needs review) _nsuring Product Time and Temperature (Needs review) conducting Cleaning and Sanitizing (Competent) Managing:Physical Facility Design & Maintenance: Preventing & Controlling Pests (Competent) DANIELLE MACHNIG Certificate No: 21544880 Issue Date: February 5, 2019 Expiration Date: February 5, 2024 DANIELLE MACHNIG 78 ST JOSEPH ST APT I WOONSOCKET. RI 02895 National Registry of Food Safety Professionals® 1 6751 Foram Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3930 1 Fax: 407.352.3603 0 � � � . j ° % 04 ) E q 4) E k z k z 2 B ' o E z L § Q 4) R t LU 4) k \7\\ \ \\\\ \ `\ \ \ \\�� 4\\` / � / 'W � ^V^ i� cZ3 O -> M O O UCO U) N — U O7 O = O C cn p N � Q m p a v C - N N ®UL� +� �70 -0 — (a) Q UO E ,L � U E ai •� VV Q yE U) Q 7 u U U UA z w Of zQ �W c U a`> CO 3 c CO LL L p w O w V z *moo z z w Q' w a U m o ¢ n N U W o O z ° U Q Q •l C y 1 b m `a 13, t2 p 0 E 0 O AA ON c C� 0 :0:) M t 0 U,o T 0M 0 E om .0 ti 0 ulo� —C3 o 0 Z"uw