HomeMy WebLinkAboutFlynn's Irish Pub 12/31/2016Commonwealth 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 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
Permit Expires: December 31, 2016
License Number: FS -3
Food Fee: $75.00
Milk & Cream 91
BOARD OF HEALTH
MichaeCMcClean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Sell Milk and Cream
This is to certify that:
JOHN DOWNES
having a place of business at:
FLYNN'S IRISH PUB
219 NORTH MAIN 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 12/3112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -3
Scott Leite, Heaah .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE ONLY �
1 Date received: Date Inspected: Approved By: Permit # Issued j
FOOD ESTABLISHMENT PERMIT APPLICATION
-- plica ion mus esu m7tted—a-vleast-30-cva-ys before the planned opening date)
1) Establishment Name FLYNN'S IRISH PUB
2) Establishment Address 219 NORTH MAIN STREET
3) Establishment Mailing Address (if different) P.O. BOX 446
SANDWICH, MA 02563
4) Establishment Telephone No
5) Applicant Name & Title: JOHN DOWNES, OWNER
6) Applicant Address P.O. BOX 446, SANDWICH, MA 02563
7) Applicant Telephone No.: 24 Hour Emergency No.: (508) 360-4187 (401) 787-2448
8) Owners Name & Title JOHN DOWNES
9) Owner Address (If different from applicant) P.O. BOX 446, SANDWICH, MA 02563
Owner's telephone number (508) 360-4187
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
W A Corporation Name Title Address
❑ An Individual
❑ A Partnership
❑ Other legal Entity j
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager, etc )
Name &Title: �EATHER BUCK
Address: 11972 VILLAGE GREEN S APT. D RIVERSIDE, RI 02915
Telephone No: 1(401) 787-2448 24 Hour Emergency No: (508) 360-4187 (401) 787-2448
j
Y_
FAX: --
E-mail: IHBUCK24(cD_AOL COM
Alt E -Mail: JTDOWNES99(&-GMAIL COM
13) District Or Regional Supervisor (if applicable)
(Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment,lnformation
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS: MON-THURS 3:30 PM - 1 AM FRI-SUN 11:30 AM - 1 AM
18) Name of Person In Charge Certified in Food Protection Management: MATT DOWNES
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of MARY ANNE CHIPMAN
certificate HEATHER BUCK JOHN 1
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0
20) Location: Permanent LocationF22),,Establishment Type
Moblie Moblie Start Date: tail ( Sq. Ft)
Moblie End Date: i ❑ Food Service up to 100 or
Moblie Comments: up to 10' PHF display $62.50
21) Length of Permit:
Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
❑ Caterer $12.50
Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts:
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sale of Commercially Pre -Packaged PHFs
❑ Delivery of Packaged PHFs
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order❑
Hot PHF Cooked and Cooled or Hot Held
---- — -- —
- for More Than a Single Meal Service
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
—Susceptible
Population Facility
�____ -
-
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
------ - — - --
❑ Use of Process Requiring A Variance
❑ Customer Self -Service
and/or HACCP Plan (including bare hand
❑ Ice Manufactured and Packaged for
contact alternative, time as a public health
Retail Sale
control)
❑ Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
— -- _— _- ❑ Prepares Food/Single Meals for
Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
Retail
Out-Of-Date
Reconditioned Food orTO be completed by the Board of Health
- -- Total Permit Fee: $75.00
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 CMO 590.000 and the federal Food Code,
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify andhe penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. 1
25) Social Security Number or Federal ID: 463661110
26) Signature of Individual or Corporate Name:
Town of Mansfield
Town of 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 June 1st of each year.
NAME OF BUSINESS: FLYNN'S IRISH PUB
ADDRESS: 219 NORTH MAIN STREET
TELEPHONE AT LOCATION: % ' 33
FAX NUMBER:
OWNER OF BUSINESS: JOHN DOWNES
TELEPHONE OF OWNER: (508) 360-4187
FEDERAL ID/SS NUMBER: 463661110
FEE: $5.00
PERMIT NUMBER: FS -3
SIGNATURE:
DATE: I ��I
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 (Mandatory)
By: Corporatk Officer
(Mandat , if applicable)
�b-� G �\\\`O
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonf0ealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
,Applicant Information Please Print Legibly
Business/Organization Name:
Address:
C�2 1_\ V_
�� Phone #:
Are you an employer? Checkthe appropriate box:
I. F -1I 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.]
S-6 E3 — 3_ I ),%vim
Business Type (required):
5, ❑ Retail
6. P 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 # 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. #.
Expiration 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.
Ido hereby certify, under the pains and penalties 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:
www, mass, gov/dia
Phone
98 (Policy Provisions: WC 00 00 00 B)
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: 10448
Company Code: 5
POLICY NUMBER: 102 WEC CS5798
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 MAINNN ST
MANSFIELD MA 02048
2. Policy Period: From 02/21/16 To 02/21/17
12:01 a.m., Standard time at the insured's mailing address.
Producers Name: THE EGIS GROUP
PO BOX 603377
PROVIDENCE, RI 02906
Producers Code: 090249
Issuing Office: THE HARTFORD
301 WOODS PARK DRIVE
CLINTON NY 13323
(800) 962-6170
Total Estimated Annual Premium: $2,193
Deposit Premium:
HE
HARTFORD
O'i
Suffix
LARS RENEWAL
01
Policy Minimum Premium: $266 MA (INCLUDES INCREASED LIMIT MIN. PREM.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
J uII� 1 G�tizry
Countersigned by 01/02/16
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 01/02/16 Policy Expiration Date: 02/21/17
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 ITEIy1 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 41,800 .08 33
CLERICAL OFFICE EMPLOYEES NOC
9079
RESTAURANT NOC
182,900 1.15 2,103
NLA RATE DEVIATION PREMIUM CREDIT (.20) (903 7)
INCREASED LIMITS PART TWO (9807) 1.00 PERCENT
TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848)
TOTAL PREMIUM SUBJECT TO EXPERIENCE IODIFICATION
NiA - Iti'IERIT RATING CREDIT (9885)
PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM
EXPENSE CONSTANT (0900)
MASSACHUSETTS DIA ASSESSMENT 5.750 PERCENT
TERRORISM (9740) 224,700 .030
TOTAL ESTIMATED ANNUAL PREMIUM
-427
17
33
1,759
.950
1,671
1,671
338
117
67
2,193
Total Estimated Annual Premium: $2,193
Deposit Premium:
Policy Minimum Premium: $266 MA (INCLUDES INCREASED LIMIT MIN. PREM.)
Interstate/Intrastate Identification Number:
NAICS:
Labor Contractors Policy Number: SIC: 5812
UIN:
NO. OF EMP: 000015
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 01/02/16 Policy Expiration Date: 02/21/17
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Naine of ReClplellt: HEATHER BUCK
Certificate Number: 2343195
Date of Completion: 5/23/2016
Date of Expiration: 512112021
7J.re aho >e-nara .d person is h •rehy issued this cc tifrcate
f r eomple ing are allergen awareness training proArnm
rerognized 19, tlrc Alassacbmetts Department ofPublie Health
in accordance witli 10.5 CHR 590.009(G)(3)(a).
This certificate trill he valid forfrve (5.) pears from/ date ofcomplction.
Issued By:
MRR NATIONAL
�- RESTAURANT
ASSOCIATION„
MnssachusettsRestnurantAssociation 800.765.2122
333 Tivnpike Road, Suite 102 umw.restaurant.org
Southborough; MA 01772
508-303-9905
NAim:marestaurantassoc.org
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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 Industrial 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 -MASSA -FE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05