HomeMy WebLinkAboutJimmy's 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 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, 2018
Food Fee: $150.00
License Number: FS-36
BOARD OF HEALTH
Michael .McClean, Chairman
Milk & Cream ❑O
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:
GEORGE D. PANTOS
having a place of business at.
JIMMY'S PUB AND RESTAURANT
141 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 1213112018 , unless previous to that time is suspended or revoked.
Expires 1213112018
License No.: FS-36
Board of Health
Michae(McCCean, 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 FS-36
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
j 1) Establishment Name
i 2) Establishment Address
JIMMY'S PUB AND RESTAURANT
141 NORTH MAIN STREET
3) Establishment Mailing Address (if different) P.O. BOX 515
MANSFIELD, MA 02048
4) Establishment Telephone No _ (508) 339-7167
6) Applicant Name & Title: GEORGE D. PANTOS, PRESIDENT
6) Applicant Address 23 FREEDOM TRAIL, NORFOLK, MA
7) Applicant Telephone No.: (508) 3846448 24 Hour Emergency No.:
8) Owners Name & Title
608.384.6448 C 608-461-5676
GEORGE D. PANTOS
9) Owner Address (If different from applicant) 23 FREEDOM TRAIL, NORFOLK, MA
Owner's telephone number (608) 384-6448 OR (608) 451-5575
10) Establishment Owned By: Flo
1) If a corporation or partnership, give name, title, and home address of officers
1—i An Association -r partner.
i; A Corporation Name Title Address
l An Individual ;
-- --
A Partnership
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title. IGEORGE D. PANTOS
i
Address: 123 FREEDOM TRAIL, NORFOLK, MA
Telephone No (508) 451 5575
FAX (508) 339 5982
E-mail: IGDPANTOS1623OGMAIL.0 OM
Alt E Mail:
13) District Or Regional Supervisor (if applicable)
Name &Title;
Address:
Telephone No:
FAX: LE -mail:
24 Hour Emergency No: 508.384-6448 C 508-451.5575
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
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:
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): W
20) Location: IJ] Permanent Location
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
(yl Annual
Seasonal
Seasonal Dates:_ _
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
[ Retail ( Sq. Ft)
l Food Service up to 100 or
up to 10' PHF display $125.00
IyJ Food Service up to 101 -200
or up to 25' PHF display $160.00
[:I Food Service up to 201 +
or 25'+ PHF display $275.00
❑ Food Service - Institution
( Meals/Day)
JEAN E.FAULKNER
El Caterer $25.00
IJi Milk & Cream $10.00
(_1 Mobile Food & Consession $75.00
LI Manufacture Frozen Dessertsllce Cream
$26,00/freezer
❑ Pushcart $25.00 # of Pushcarts: 0
i Residential Kitchen $100.00
Retail Food $100,00
❑ Retail Snack Food $25.00
❑ Tobacco Products $25.00
23) Food Operations PHF- Potentially hazardous food (tfine/femperalum controls required)
Non-PHFs non -potentially hazardousfood(nottmartemperature controls required)
(Check all that apply): I RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
i_
i Sale of Commercially Pre -Packaged Non-PHFs
F] Sale of Commercially Pre -Packaged PHFs
rl Delivery of Packaged PHFs
jdl Reheating of Commercially
Processed Foods for Service Within 4 Hours
(-"j Customer Self -Service of Non PHF and Non
Perishable Foods Only
W PHFCooked To Order
aration of PHFs For Hot And
Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer b'eu-Service
for
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 I Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
contact alternative, time as a public health
j Preparation of Non-PHFs _ Retail Sale 001101 i
Other Food Operations n Juice Manufactured and Packaged for (] Offers Raw Or Undercooked Food Of
Retail Sale Animal Ongin _
1 Offers RTE PHF in Bulk Q'
uantities
_� Prepares Food/Single Meals for
Catered Events or Institutional Food Service
I I Retail Sale of Salvage, out -Of -Date --. - --- ---- ------=
or Reconditioned Food r To be completed by the Board of Health j
-"--------"""----------"I Total Permit Fee: $160.00
i. Payment Is due with application L1 waived
I, the undersigned, attest to the accuracy of the information provided In this application and affirm that the food
establishment operation will comply 105 CMR 690,000 and all other applicable law. I have been Instructed by the
board of health on how to obtai pie cf 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: NT1
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have Flied all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 010-52-3843 04-2 —0 l�p ?
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 31 st of each year.
NAME OF BUSINESS: JIMMY'S PUB AND RESTAURANT
ADDRESS: 141 NORTH MAIN STREET
TELEPHONE AT LOCATION: (508) 339-7167
FAX NUMBER: (508) 339-5982
OWNER OF BUSINESS: GEORGE D. PANTOS
TELEPHONE OF OWNER: (508) 384-6448;OR (508) 451-5675
FEDERAL ID/SS NUMBER: 010-52-3843 04-2796618
FEE: $1000 "
PERMIT NUMBER: FS-36
SIGNATURE:
DATE:
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.
4L
Signature of Individual or Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
Qk
By: orpo ffieer (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 IthUane's WoutnentAPERMIT APPLICATIONSUAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Departrnent ofTndrish ial Accidents
1 Congress street, Suite 100
Boston, AM 02114-2017
k1ri . www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED'WWEI THE PERMITTING AUTHORITY.
Business/Organization
City/State/Zip: /`i/G4Z��s( %�L (� Phone 56,5- s �q
Are you on employer? Check the appropriate box:
Business Type (required):
I. Q I a employer with employees (full and/
S. ❑ Retail
or part-time).*
6, estaurant/BadEating Establishment
2:L] 1 am a sole proprietor or partnership and have no
7, Q Office and/or Sales (incl. real estate, auto, etc.)
employees workingfor me in any capacity.
S. ❑ Non-profit
[No workers' comp, insurance required]
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. El manufacturing
no employees, [No workers' comp, insurance required]*
11.❑ Htalth Care
4. ❑ We are a non-profit organization, staffed by volunteers,
1211 Other
with no employees, iNo workers' comp, insurance req.]
*Any applicant that cheoks'box #1 must also fill out the section below showing Heir workers' compensation policy Wbrmstiou.
**If the corpoaf officers have exempted themselves, but the corporation has other employscs, a worker:' compensation pDUcy is roquucd and such an
organization should cheek box#l.
fain an employer that is prov(d(ng workers' conrpensadon insurance for my employees. Below is the policy inforrnatioA.
Insurance
Insurer's
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby e(er a s and penalties ofpei jwy that the (nfornradon provided above is true and correct.
Si aturo Date:
Phone #�UcC✓ ��� ' f ��
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. BuildingDepartonent 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phon e
1�t iJvuoVl lxPU DLU414 1DVO6DO I Z01 Udltll 16/11/ll '1'ltuat 16:D1 vm rage: ua/ua
CERTIFICATE OF LIABILITY INSURANCE DAT1211111fYYYY)
2/11l17
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($(, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
I PORTANM If the certificate holder is an ADDITIONAL INSURED, the pohcy(ies) must have ADDITIONAL INSURED provisions or be 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 endorsement(s). '
PRODUCER
E:
Connolly Insurance Agency, Inc
85 Main Street
v NEE , SOB438.8778 ac No : 508-238-7281
ADDRESS:
North Easton, MA 02356
INSURERIS)AFFORDING COVERAGE
NAICN
INSURERA: Liberty Mutual Insurance Co
INSURED
INSURER e; Norfolk & Dedham Group -Corn
Jimmy's Pub
INSURER C; Cove Risk Services LLC
Mr. George. Pantos
141 N. Main Street
INSURER D:
INSURER E:
Mansfield, MA 02048
INSURER P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER'
THIS IS TO CERTIFY T'HATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDASOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR
TYPE OF INSURANCE
INSOUVDPOLICY
NUMBER
IMMIDDIYYYYI
l(MM[bomm
LIMITS
A
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE Q OCCUR
SKS1855980008
02105117
02/06118
EACH OCCURRENCE
S 1,000000-
PREMISES Be oecunonco
S
MED EXP (Any OnoPerm)
_3_00,000
$ 15,000
PERSONAL a ADV INJURY
S 1,000,00D
GEN'L AGGREGATE LIMIT APPLIES PER:
X PRO. ❑ LOC
POLICY ❑ JECT
OTHER:
GENERALAGGREGATE
y 2,000,000
PRODUCTS COMP/OPAGG
S 2,000,000
S
B
AUTOMOBILE
LIABILITY
ANYAUTD
OWNED
AUTOS ONLY AUTOSULED
HIRED ED
AUTOS ONLY AUTO$ONLYY
BA91313326A
02114117
02114118
DI D LMIT
F.a denl
S
BOUIIV INJURY IPer peraon)
S 600,000
BODILY INJURY(Par auldenq
S 500,000
Pe eFcike I A
S 100,000
9
UMBRELLA LIAR
EXCESS LIAR
HOCCUR
CLAIMS -MADE
EACH OCCURRENCE
S
AGGREGATE
3
DED I I RETENTIONS
S
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANYIPROPRIET9ENEXCN JE?ECUTIVE❑
IMandaloly In NH)
11&$ dowlii a under
DE8CRIPTION OF OPERATIONS below
NIA
014000502192118
01101/18
01/01119
X1. T1TE [2I1
E.L. EACHACCIDENT
$ 1,000,000
E.L DISEASE - EA EMPLOYEE
S 1,000.000
61,0ISEASE-POLICV1.IMIT
S 1,00D,000
D
Liquor Liability
BKS1855960008
02/06117
02I05118
Limit
1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllunal Remadte Schedule, may be aaached II morn apace IS required)
Town of Mansfield
6 Park Row
Mansfield. MA 02048
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Richard P. Connolly
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
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TOWN OF MANSFIELD
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER
Department: BOARD OF HEALTH -- - - Date: �12-13-2017
Schedule: JED121317
GEORGE PANTOS JIMMY'S PUB
10,00
The above is a detailed list of moneys collected by me, amounting In the aggregate to:
$loop 4or the period endino 112-13-201
DEC 1 3 2912
Bank k
PktB
Town of Mansfield �- Board of Health 6Pa k R wansfleld
Mansfield, NIA 02048
Application or 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: 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. PAN'TOS
TELEPHONE OF OWNER: (508) 384-6448 OR (608) 451-5575
FEDERAL ID/SS NUMBER: 010-52-3843 04-2796618
FEE: $10:00'
PERMIT NUMBER: FS-36
SIGNATURE:
TOWN OF MANSFIELD
PAID DATE:
DEC 1., ^3l 20V
AMT..._-_.-..�/-'ems