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HomeMy WebLinkAboutFlynn's Irish Pub 12/31/2018Commonwealth 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 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 Permit Expires: December 31, 2018 Food Fee: $150.00 License Number: FS-30 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W 0 Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: Ill Lei MIkiI0I0]49.1 having a place of business at: ►► G ■ 219 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-30 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS30 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name FLYNN'S IRISH PUB — - 2) Establishment Address 219 NORTH MAIN STREET a-- # r a 2bi1 --OV07 3) Establishment Mailing Address different) BOX (if P.O. 446 SANDWICH, MA 02563 4) Establishment Telephone No (508) 337-2100 5) Applicant Name & Title: JOHN DOWNES, OWNER 6) Applicant Address P.O. BOX 446, SANDWICH, MA 02563 7) Applicant Telephone No.: (508) 3604187 24 Hour Emergency No.: (608) 3604187 (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 L An Association or partner. F7 A Corporation Name Title Address ❑An Individual 0jAA%",4 Cs�l�x CIAPartnership L Other legal Entity_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title. IHEATHER BUCK Address: 1972 VILLAGE GREEN S APT. D RIVERSIDE, RI 02915 Telephone No: I(401) 787-2448 FAX E-mail: HBUCK24@AOL.COM Alt E Mail: IJTDOWNES99(cDGMA1L.COM 13) District Or Regional Supervisor (if applicable) Name & Title JOHN DOWNES, OWNER Address: Telephone No: 24 Hour Emergency No: (508) 360-4187 (401) 787.2448 .O. BOX 446, SANDWICH, MA 02563 i08) 360-4187 24 Hour Emergency No: E-mail: SAG R,4 rJ-jS', t t t" 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food 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: JOHN T. DOWNES If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of MARY ANNE CHIPMAN certificate ue ATueo of 119) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ]� 20) Location: EV] Permanent Location 22) Establishment Type [.! Mobile Mobile Start Date: [ ] Retail ( Sq. Ft) Mobile End Date: ❑ Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [/I Annual ❑ Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑./ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 [] Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 i Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 o Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions:PHF-Potentially hazardous food(timekemperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): j RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs F%el PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- -- -------------- for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs ❑ Preparation of PHFs For Hot And _------- --- ----- 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 In _ ❑ Reheating of Commercially - to be Prepared by Consumer ❑Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours i_ - - ------ -- - -____ ----- customer Self -Service of Non PHF and Non L _] - -- ----- J❑ r 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 [ 1 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 J Retail Sale of Salvage, Out -Of -Date ------- --------I or Reconditioned Food To be completed by the Board of Health -- __-- ---- - Total Permit Fee: $150.00 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 yf 105 CMR 590.Onr and the federal Food Code. 24) Signature of Applicant: a Pursuant to MGL Ch.62C, sec. 49A, I e ify 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 la . 25) Social Security Number or Federal ID: 46 3661110 _ 26) Signature of Individual or Corporate Name: �-\':A rS'J 1 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 December 31st of each year. NAME OF BUSINESS: FLYNN'S IRISH PUB ADDRESS: 219 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 337-2100 FAX NUMBER: OWNER OF BUSINESS: JOHN DOWNES TELEPHONE OF OWNER: (508) 360-4187 FEDERAL IDISS NUMBER: 46 3661110 FEE: $10.00 PERMIT NUMBER: FS-30 SIGNATURE: DATE: V [L�+ 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 36� 1IID "Social Security No. (Voluntary) or Federal Identification Number By: Corpol6je 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. R:\He 1thVane's Documents\PERMIT APPLICATIONSWAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 r www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: �yN^a sl1S�J1V Q r*a �-rLa .�f Address: -r\,�. 0. k-AN\" S .-i- �PrS`�\JJ i wv Are yp "an employer? Check th7e appropriate box: 1, l am a employer with / 7 employees (full and/ or part-time).* 2: 0 lam 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 j PhoneM 5b4 - 331 -a k6� Business Type (required): 5. ❑ Re all 6. 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 emporafion has other employces, a workers' compensation policy is required and such an organization should check box M. [am an employer that is providing workers' Sompensa�t/�ip�.n, insurance for my employees. Below is the policy informadon. Insurance Company Name: -."::_�V�``'a"'2 Insurer's Address: 'r"'����' via ` )RZ,* City/State/Zip: t }12i 2i7 I C 1 r.1 Policy #or Self-ins.Lic.#-- �-`' L"'S �7 9`3 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. I do hereby certify, 4der the pains,knd penales ofperjury that the information provided above is true and correct. \\ , 6 kk-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 S. Selectmen's Office 6.Other Contact Person: Phone#: www.maes,gowma 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: 10449 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): DIN: 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 02/21/17 To 02/21/18 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: THE EGIS GROUP Suffix LARS RENEWAL 02 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, 174 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. Countersigned by ®� ' 01/07/17 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 01/07/17 Policy Expiration Date: 02/21/18 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 Descrintion Remuneration Remuneration Premium 8810 43,700 .07 31 CLERICAL OFFICE EMPLOYEES NOC 9079 191,100 1.09 2,083 RESTAURANT NOC MA RATE DEVIATION PREMIUM CREDIT (.20) (9037) -423 INCREASED LIMITS PART TWO (9807) 1.00 PERCENT 17 TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848) 33 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 1,741 MA - MERIT RATING CREDIT (9885) .950 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 1,654 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,654 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMENT 5.600 PERCENT 112 TERRORISM (9740) 234,800 .030 70 TOTAL ESTIMATED ANNUAL PREMIUM 2,174 Total Estimated Annual Premium: $2, 174 Deposit Premium: Policv Minimum Premium: $267 MA ( INCLUDES INCREASED LIMIT MIN. PREM. ) InterstateAntrastate 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 / 0 7 / 17 Page 2 Policy Expiration Date: 02/21/18 Policy Number 02 WEC CS5798 FLYNNS RESTAURANT GROUP INC FLYNN'S IRISH PUB 219 N MAIN ST MANSFIELD, MA 02048 Dear Hartford Insured, Policy Effective Date 02/21/17 Re: An Important Message to Workers Compensation Policyholders The control of workplace accidents and injuries should be among the highest priorities of your firm. Each accident wastes precious human and financial resources, and introduces inefficiencies into your operations. From a practical standpoint, the control of accidents, and their inevitable costs, simply makes good business sense. An effective loss prevention/loss control program can save you money and aggravation, can positively impact your loss experience (and thus your premium), and most importantly, can help you maintain solid control of your operations. As a service to you, our valued customer, the Loss Control Department of The Hartford in cooperation with your independent agent, can assist you in establishing loss control strategies. If you would like assistance, please complete and return to us the reply portion of this brochure, or contact your independent agent. Services Available The following is a description of some of the services that we provide. The types of services that may be appropriate for your business depend upon the nature and size of your operations and the specific loss control services you have requested. The cost of loss control services may or may not be a part of your insurance premium. This depends on the extent of the requested services, agreements stated in your insurance policy and program, and statutory regulations that may require us to provide loss control services. 1) Reference Materials — Information about loss control topics that can be provided or made available to you to help you to enhance your loss control program. 2) Telephone Consultation — We can hold a teleconference with you to help you to evaluate your loss control program, identify areas for improvement, and recommend ways to implement such improvements. 3) Onsite Consultation — This consists of visiting your premises and helping you to assess and remedy your loss control needs onsite. This level of service is usually only appropriate for larger, higher hazard operations. The following are examples of some of the services that could be provided onsite: Form 97485 14th Rev. Printed in U.S.A. Page 1 of 6 Process Date: 01/07/17 Policy Expiration Date: 02/21/18 POLICY NUMBER: FLBP894273 BUSINESSOWNERS BP 04 89 01 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIQUOR LIABILITY COVERAGE This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE A. Liquor Liability Aggregate Limit: $ 2,000,000 B. Each Common Cause Limit: $ 1,000,000 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Liability is amended as follows: A. The insurance provided under Paragraph A.1. Business Liability also applies to all "bodily in- jury" or "property damage" arising out of the sell- ing, serving or furnishing of alcoholic beverages. B. For the insurance provided by this endorsement only, Paragraph B. Exclusions is amended as fol- lows: 1. Paragraph 1. Applicable To Business Liabil- ity Coverages, other than Exclusions a. Ex- pected Or Intended Injury, d. Workers' Compensation And Similar Laws and e. Employer's Liability, does not apply. 2. The following exclusions are added: This insurance does not apply to: a. "Bodily injury" or "property damage" arising out of any alcoholic beverage sold, served or furnished while any required license is not in effect. b. "Bodily injury" or "property damage" arising out of "your product". This exclusion does not apply to "bodily injury" or "property dam- age" for which the insured or the insured's indemnities may be held liable by reason of: (1) Causing or contributing to the intoxica- tion of any person; (2) The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. c. Any "bodily injury" or "property damage" with respect to which other insurance is af- forded, or would be afforded but for the ex- haustion of the Limits of Insurance. This exclusion does not apply if the other insurance responds to liability for "bodily in- jury" or "property damage" imposed on the insured by reason of the selling, serving or furnishing of any alcoholic beverage. C. The following are added to Paragraph D. Liability And Medical Expenses Limits Of Insurance: D. Liability And Medical Expenses Limits Of Insurance 5. The Liquor Liability Aggregate Limit shown in the Schedule of this endorsement is the most we will pay for all "bodily injury" and "property damage" as the result of the sell- ing, serving or furnishing of alcoholic bev- erages. BP 04 89 01 10 ©Insurance Services Office, Inc., 2009 Page 1 of 2 ❑ BUSINESSOWNER'S POLICY DECLARATIONS Issued: 10/31/2017 Policy No.: FLBP894273 Effective Date: 12/05/2017 POLICY WIDE COVERAGES AND LIMITS OF INSURANCE Forgery or Alteration _.k ..__.._ '. Fungi, Wet Rot, Dry Rot & Bacteria (Mold) n k. 3 ,s Business Income/EE Number of Days 30 �:L�abiGtypvara9e.Pbbn __..'x �` `r�4p141de9Y@rage�e. . Glass Expense z i F �, kh 2 T t Actual lmss 5ustaf¢ecl ',i 4�ne11k,. �x� ...,.: Interruption of Computer Operations Liquor Liability Common Cause Limit $1,000,000 dAggCeft�t Lim�.�..nti Gross Annual Liquor Receipts $96,000 Loss by Theft of furs, fur garments, garments trimmed with fur jewels, IIT DS 01 05 Page 6 of 7 ow c w E A� �fI rm V 4 ,i q 0 0 LL. 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