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Home My WebLink AboutLonghorn Steakhouse 12/31/2018I 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 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:. RUAIRI BYRNE, MANAGING PARTNER Whose place of business is: LONGHORN STEAKHOUSE #5296 390 WEST STREET PERSON(S) IN CHARGE: RUAIRI BYRNE, MANAGING PARTNER Permit Expires: December 31, 2018 Food Fee: $150.00 License Number: FS-39 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. RUAIRI BYRNE, MANAGING PARTNER having a place of business at. - LONGHORN STEAKHOUSE #5296 390 WEST 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-39 Board of Health MichaeCMcCCean, Chai"nan POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-39 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name LONGHORN STEAKHOUSE #5296 2) Establishment Address 390 WEST STREET F` 3) Establishment Mailing Address (if different) P.O. BOX 695016 ORLANDO, FL 32869-5016 4) Establishment Telephone No 261-8810 5) Applicant Name & Title: RARE HOSPITALITY INTERNATIONAL, INC. 6) Applicant Address P.O. BOX 695016, ORLANDO, FL 32859-3330 7) Applicant Telephone No.: (800) 248.4918 x6787 24 Hour Emergency No.: (401) 886-4525 (401) 3744953 S.SCOTT CELL (781) 733-2511 8) Owners Name & Title RUAIRI BYRNE, MANAGING PARTNER 9) Owner Address (If different from applicant) 3595 POST ROAD 20-102, WARWICK, RI 02886 Owner's telephone number 401-626-6060 10) Establishment Owned By: ❑ An Association 1/1 A Corporation ❑ An Individual ❑ A Partnership 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name erg, / Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: RUAIRI BYRNE, MANAGING PARTNER Address: 3595 POST ROAD 20-102, WARWICK, RI 02886 Telephone No:__ o: (401) 626-6060 24 Hour Emergency No: (401) 896.4525 (401) 374.4953 s.sco7r _...... CELL (781) 733.2511 FAX: (407)872-3775 E-mail. RHAYWARD@DARDEN.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: STEPHEN SCOTT Address: 11000 DARDEN CENTER DRIVE, ORLANDO, FL 32837 Telephone No: 1(407) 245-4000 24 Hour Emergency NO: (800) 248.4918 x6787 1 FAX: (407) 872-3768 E-mail: RHAYWARD@DARDEN.COM 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 17) DAYS/HOURS: SUN-THURS 11 AM-10 PM FRI-SAT 11 AM-11 PM 18) Name of Person In Charge Certified in Food Protection Management: Tur-. ER-LAP�i-UME— 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 certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): L] 20) Location: ❑d Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: [] Retail ( Sq. Ft) Mobile End Date: [-j Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit fir•] Annual L.] Seasonal Seasonal Dates: Temporary Temporary Start Date Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): i] 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 EV] Milk & Cream $10.00 Ej Mobile Food & Consession $75.00 ❑ 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 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Nan-PHFs - non -potentially hazardous tood(no tlme/temperature controls required) RTE - ready -to -eat roods (Ex. sandwiches, salads, muffins which need no furtherprocessing) LJ Sale of Commercially Pre Packaged Non-PHFs [ ] Sale of Commercially Pre -Packaged PHFs [ -] Delivery of Packaged PHFs 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 k PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer Customer Self -Service 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 Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities I ❑ Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service i or Reconditioned Food I 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 comp with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtai conies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I 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: 58 1498312 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 December 31st of each year. NAME OF BUSINESS: LONGHORN STEAKHOUSE #5296 ADDRESS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 261-8810 FAX NUMBER: (508) 261-8812 OWNER OF BUSINESS: RUAIRI BYRNE, MANAGING PARTNER TELEPHONE OF OWNER: 401-626-6060 FEDERAL ID/SS NUMBER: 58-1498312 FEE: $%00 PERMIT NUMBER: FS-39 SIGNATURE: c� / DATE: CQ1dS_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 By: Car orate Officer (Mandatory, if Applicable) G1Jee^ !M'ken�Y SrSlz. A'y /q-- �3I;- *"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. R\Hm1thVane's Documents\PERMnT APPLICATIONS\TAX CERTIFICATION FORM.doc 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 Applicant Information Please Print Legibly Business/Organization Name: RARE Hospitality International Inc. dba LongHorn Steakhouse #5296 Address: 390 West Street City/State/Zip: Mansfield. MA 02048 Phone #: 508-261-8810 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 58 employees (full and/ 5. ❑ Retail or part-time).* 6. ® Restaurant/Bar/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 the in any capacity. [No workers' comp. insurance required] 8. ❑ 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fill out the section below shoving 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: XL Insurance America Inc. Insurer's City/State/Zip: Policy # or Self -ins. Lic. # RGE3001137 Expiration Date: 6/1/2018 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,l(3E HQSPITALInTY INTRNFCTIONALr/INCthe information provided above is tree and correct Phone #: 800-248-4918 4787 Official use only. Do not write in this area, to be completer/ by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone www.tnass.govidia Ar ate,. k CERTIFICATE OF LIABILITY INSURANCE .... DA7E(MMMDNM) OSQ312017 THIS CERTIFICATE I$ 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 INSURED, the polieypes) 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 certificate holder In lieu of such endorsements). PaooucER Marsh USA, Inc. 3031 N. Rockyy Pam Drive West Suite 700 Tampa, Fl. 3360T Attn: cam GNipi737t)50-GAWU•17-18 VARIO DAROE INSURED Daman ROSIOUrms, Inc. GMRI, Inc. 10M Darden Center Or CA Ue.VOT - PHO E JAIC No): E•MA L'- n00RESS: S AFFORDING COVERAGE NAICA INSURER A, AProperty Insurance ODmpalry MlnsurarmComPanY INSURER e: Gnce Company 20699 22322 INSURERC: ACa,InC, 24554 INSUNER 0 : Xance CompanyOrlando, 37585 INSUREREiNSURERF: FL 321137 �,nu w uaeeen COVERAGES GCKIIr11iRIC fYVmocR: '••`•"'^"^'•' '--"-'-"'-'- BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED- NOTWITHSTANDING. ANY REQUIREMENT, AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AND CONDITIONS OF'BUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, EXCLUSIONS 19R L S. PooCC EFF PO Y E]!P TYPE tlF INSURANCE' POLICYN BER Mm0 MID LIMITS B X COMMERCUILOFNERAL LIABILITY RGE3001137-01 06/0112017 08101f1010 EACHOCCURRENCE s 1,000,000 PREMISES ERE T:o��. s, 1.000.000 CLAIMS-MADE.M OCCUR. X LIOUORLIABILITY MEOEXP(Amanopon"I S 1,0)0'000 PERSONAL& AOV INJURY S GENERAL AGGREGATE S 5.000,000 GEML AGGREGATE LIMIT APPLIES PER: 5.000,000 X ❑ LOC El JECT PRODUCT$-COMPA)PAGG S POLICY SIR s 1,000,000 OTHER: 'RAD943779601 O61OtQ017 Q6Ntl20ie CO FINED SINGLE LIMIT E ammde s__ 2:000.000 B AUTOMOBILE LIABILITY BODILYJNJURY(Parpe=) $ . X ANY AUTO ALL OWNED SCHEDULED. BODILY INJURY eCNdem) S AUITCSAUTOSPR X PERTYD AGE War m. g X AUYN SVINEP .. 5 A X UMBRF11A L1ABtC:1AIlMS-MAD0V oUR 'XOO G20123383002 O6-01 017 O6N112018 EACH OCCURRENCE S. 1,p00,0p0. AGGREGATE 5 1,000'WO EXCESSLIAB s DSD I X I RETENrlOns25 RWD300113p-01 (AOSJ 06N12017 A)11201 X PETA E Oft - WORKERS, COMPENSATION.. E.L. EACH ACCIDENT S 2'�'� AND EMPLOYERS' UABILRY YIN 'RWR3001139-01(WT. AK) 0610112017 0610112018 E.L DISEASE -EA EMPLOYE 5 2'0'0(MandatoryInNRI ANY PROPRIETORIPARTNERIEXECUTIVE Q OFfICERNEMBER ptCLUDEDT NIA 'RWE943548C01(OH, WA) 06110112017 06N12p18 untlo*SIRf.1,000.000(OH,WA)E.L. DISEASE -POLICY LIMIT 2.000 Oppnyea.douEo SDESCRIPTION [DESCRIPTION OF OPERATIONS blow OF OPERATIONS ILOCATIONS I VEHICLES (ACORD fat, Addltlodal RammAs Schedule, may he aaaehed it more apace la mANmd) RE See attached locations This ceffate Cancels and SUPemcmas all P IV1001Y Issued CanlSCales. The commonwealth of Massachusetts Office Invesdpadons 800 Washimian SEeal, 7th Street Boston, MA 02111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. of March USA mC. Momehi Mukhodea ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD Oct 2317 05:42p ml A 'i .w� c 0 c ^; E LL x W C � O � u u aa+ 0 maL V 'O 0 � LL k `o Ca U G C � o a u a � � w � o V E oz LLa a 0 a N yT i z L m c o f� r A V W p w � m c � o 'NO N R Z ii / c � ! r u WLL a c v z n a r z o m N X uu 1 L 11 W 6 ou O 0 N N U n L FLO o � Q 0 Q V� w Q W-4 0 w � � u � � � Q� z *--4 z I z �. � � T *W4 *M4 I � j ( q ! 2 7 2 ( \ \ 0 ) %2G)§ ,z �¥ 1!;2& �\ )]\k§ )a/2t �®\ ( \ //\\ t«& 6 \ \/z ± �k\ / � / N,(w--t:tr5lpuy ofFcoJ Sala; Prok;;iunsls! CERUFIED FOOD SAFETY MANAGER RUAna C BYRNE -- Cwamts NO: 20894034 Issvo Dvtc APri130,2013' 'Expi2ii0n Me: Apol30, 2018 p'd Z d dZb 90 L 6 £Z 3o0 OPPE NOOPDll1e111IY0B1E11Ngvmeljm. OPfl0ENMOOMEOTOK0 MtrBwalolkm[art MBdO1 .a Ft OLlP oftlw Capvele Olken OewWb: P.O.Bee8B9010, 0OenBe, P010 Name TXw R.M. W N,M..W P,"dv 4OI50I4.,R. 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