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Home My WebLink AboutJimmy's Pub 12/31/2016a Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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, 2016 License Number: FS -29 Food Fee: $75.00 Milk & Cream V BOARD OF HEALTH Michael-VcClean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: GEORGE D. PANTOS having a place of business at: JIMMY'S PUB AND RESTAURANT 141 NORTH MAIN STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 12131/2016 License No.: FS -29 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Date received: FOR BOARD�OF HEALTH USE ONLY Date Inspected: Approved By: Permit # Issued FS -29 I J, FOOD ESTABLISHMENT PERMIT APPLICATION vicai►on m�bsubmiaec-Taweasia0 days e e pine opening�cate)— 1) Establishment Name JIMMY'S PUB AND RESTAURANT 2) Establishment Address 141 NORTH MAIN STREET 3) Establishment Mailing Address (if different) P.O. BOX 515 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-7167 5) Applicant Name & Title: GEORGE D. PANTOS, PRESIDENT 6) Applicant Address 23 FREEDOM TRAIL, NORFOLK, MA 7) Applicant Telephone No.: (508) 384-1448 24 Hour Emergency No.: 508-384-6448 c 508-451-55 75 8) Owners Name & Title GEORGE D. PANTOS MA 9) Owner Address (If different from applicant) 23 FREEDOM TRAIL, NORFOLK, Owner's telephone number (508) 384-6448 -- 10) Establishment Owned By: 11) If a corporation or partnership give name, title, and home address of officers ❑ An Association or partner. L% -]*A Corporation Name Title Address ❑ An Individual ---- ❑ A Partnership L1 Other Other legal Entity -- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name —& - Title: GEORGE D. PANTOS Address: !23 FREEDOM TRAIL, NORFOLK, MA Telephone No: (508) 451-5575 FAX: ](508)__339-5982 E-mail: IGDPANTOS1523@GMAIL.COM -_ .0 --- - Alt E -Mail: 13) District Or Regional Supervisor (if applicable) -------------- ' Name & Title: 1 Address: Telephone No: E-mail: 2.4 Hour Emergency No: 508-384-6448 C 508-451-5575 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOW DEP Public Water Supply No: (If applicable) 16) No. of Food Employees 17) DAYS/HOURS: 7 DAYS 11 AM -12 AM 18) Name of Person In Charge Certified in Food Protection Management: JEAN E. FAULKNER 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 certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0 20) Location: Permanent Location ❑ Moblie Moblie Start Date: i Moblie End Date: Moblie Comments: 21) Length of Permit: Annual j ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $62.50 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 W 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 -PRFs ❑ 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 W PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service ] Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative; time as a public health control) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin -- — — — — — F] Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities 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: $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 Vith 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how too in c 105 CMR 590.000 and the federal Food Code. 24) Signature of Applican Pursuant to MGL Ch.62C, se . 1 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. 25) Social Security Number or Federal ID: 010-52-3843 4 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: JIMMY'S PUB AND RESTAURANT ADDRESS: 141 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-7167 FAX NUMBER: OWNER OF BUSINESS: (508) 339-5982 GEORGE D. PANTOS TELEPHONE OF OWNER: (508) 384-6448 FEDERAL IDISS NUMBER: 010-52-3843 04-2796618 FEE: $5.00 PERMIT NUMBER: FS -29 *,SIGNATURE: DATE: 41) 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: Corporate Officer (Mandatory, if applicable) 010.57- -Jzgg3 ** 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. �df The Commonwealth 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 Business/Organization Name: Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with employees (full and/ or part-time),* 2, ❑ 1 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.] Phone #: 4C�� Business Type (required): 5. ❑ Retail 6, ❑ Restaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (incl. real estate, auto, etc,) 8. ❑ Non-profit 9, ❑ Entertainment 10.0 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins, Lic. page (showing the policy num 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,Bl br insurance coverage verification. I do hereby penalties of perjury that the information provided above is true and correct nate.. 5-/z3r« 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 #: M W 5W, TAW WWWA The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - hq://,www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 02185 ADDRESS OF INSURANCE COMPANY 014000502192116 1/01/2016 - 110112017 POLICY NUMBER EFFECTIVE DATES R. P. Connolly Insurance Agenc 85 Main Street North Easton, MA 02356 508-238-871 NAME OF INSURANCE AGENT ADDRESS PHONE # Jimmy's Pub 141 North Main Street Mansfield, MA 02048 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER OF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured Mailing Address INFORMATION PAGE RENEWAL AGREEMENT DGP & Sons, Inc. Jimmy's Pub 141 North Main Street Mansfield, MA 02048 Other workplaces not shown above: NO OTHER WORKPLACES FOR THIS POLICY PRODUCER: Agent# 652 R. P. Connolly Insurance Agency, I 85 Main Street North Easton, MA 02356 Carrier Policy #: 014000502192116 Carrier Prior Policy #: 014000502192115 Fein: 042796618 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1J01/2016 to 12:01 a.m. on 1/01/2017 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) WC000310(04/84) WC000414(07/90) WC000422B(01/15) WC200301(04/84) WC200302(05/86) WC200303B(07/99) 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 Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 3,061.00 Minimum Premium $ 294.00 Expense Constant .00 Deposit Premium To: 15083395982 From: 15082387281 Date: 05/20/16 Time: 7:44 AM Page: 02/02 DATE (WA/Do YYYY) ACS CERTIFICATE OF LIABILITY INSURANCE 5 20 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF 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 UR INSED, the policy(ies) must he 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 nprfificate holder in lieu of such endorsement(s)._ PROWCM Connolly Insurance Agency, Inc 85 Main Street North Easton, MA 02356 P.,�., -$7-78 _ AN,)!_(506) 238-7281 (508 8 -_..._._ ._.. ...... .............._..........-_..._.....-__......__ Irs............... uRED INSiJRER.e•Norfolk &_-Dedham Group -Com - Jimmy . Com_Jimmy' s Pub itmF Rc: Cove Risk Sesv_ices LLC Mr. George Pantos iNsuAEa o . L pert _y Mutual - ins_ _ Groff - 141 N. Main Street INSURER E: ----------- -- Mansfield, MA 02048 INSURER F: COVERAGES lint l It'llam 1 C IN U WIBGn4 BELOW HAVE BEEN ISSUED TO THE INSURED - - NAMED ABOVE FOR THE O PERIOD THIS IS TO CER71FY THAT THE POLICIES OF INSURANCE LISTED TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT H} WITH RESPECT TTQ WHICH THIS INDICATED. NOTWITHSTANDING ANY REOUREMENT, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE 113SUED OR MAY PERTAIN, AND CONDITIONS OFSUGa POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _...._......................_ ........_...-__..... ... .._. EXCLUSIONS INB._L......___.... - ADDL 8UBR� OLICY EF'� LTE TYPE OF INSURANCE I POLICY NUh�Op M, NY Di.P fMAlD vYW RE LIMITS D GENERALLIABIIITY 8X855980008 2/5/161 TT 2/5/171 EACHOCCURRENCE $— . 000, 000 DAIJAy_To R=NTED 300, 000 }� (COMtdERCIALGENEPALLtAEILiTI' PREM SES (Eaoccurrsn^^) $ MEC EXP(An)�or�aparson)_ $ CLAIMS-IAADE OCCUR -- I II I PERSONAL&ADVINHIRY $ 11000,000 GENERAL AGGREGATE $ 2 000 000 PRODUCTS - COMP!CPP.GG $ 2 000 OOD -- GE_N'LAGGREGATE LMT APPLIES PE -Ft }{ i 8 PlCv PRo- L ATOhOeILELIABIUTY I 2/14/16 2/14/17� — cieng6— I BCDil v Iri U -1y (Pei pvr0) $ 500:_000 ANYAUTO ALLOWNED SCHEDULED -_. BCDILY;P4}URY(PeI eccldent) $ 500, 000 J AUTOS AUTC^ I NOWOWNED PROPERLY DAMAGE PerecrlrY _ $ 100, 000 HREDAUTOS AUTCS $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE $ AGGPEGATE $ _ EXCESSLIAB CLAIMS -MADE V�" STA7U OTH- �y. AA TG _ C 014000502192116 1/1/16 1I'1/37 DED RETENTION $ VZiiKERS CWIPENS AT ION AND EMPLOYERS' LIABILfTY ANY PROPRIETOR/PARTNEPJEXECUTNE Y� OFRCEPRIEhEREXCiUDED^ N 1 A I E L .�l1�lf}3i if— )y�r......�1000 r_0,00 E.L.,D45E�SE _;FA,EM?LC„. _... ........ --_ QAarvlata In NH) llyyesdEsuloew�oei DESCRIPTION OF OPE NATIONS bele n El. DSEASEPOLI^'!LIMIT $ 1, 000, 000 A Liquor Liability 8XS55980008 2/5/16 2/5/17ILimit 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (Attach ACORD 101, Additional RonatkaSchedule, itmore space isrepured) w ..,wr„ •T,A �, TE SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE. POLICY PROVISIONS, 6 Park Raw - - — — Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Richard P. Connolly -- � 1988-2090 ACORD CORPORATION. All rights reserved. ' ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Fhone: Fax: E -Mail: i Q W z Q W c � R y Wo= �. Z m c U m.+ u d y i G) 4 Q a E d uCN X u 5 y u LL a O m UN O W � m N W u LOtn f C L O Q c o9a y Wo= a W-4 O W-4 Q U w d W-4 V D z z cry W z J 2 ` ZMv n Q u (A o LLttd] CQ ^v y `4 V �M kn O N t- N N I NQ� v 41 � N Q � V z U -� r, ) U 4l O `� O e� Q J 2 ` ZMv n Q u (A o LLttd] CQ a El ^v y `4 Q NQ� v � N Q � V ti •� roa`p w y V a El 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 require:d," 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 burn 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