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Home My WebLink AboutWalgreens #19941 -12/31/2020f�(VT30-0r(��q�t�� j0 FOR BOARD OF HEALTH USE ONLY Permit # Issued r,Y A4j FOOD ESTABLISHMENT PERMIT APPLICATION µ ------- ("A p ation must be submitted at least 30 days before the planned opening date) Establishment Name WALGREENS #19441 Establishment Address 243 CHAUNCY ST.,MANSFIELD , MA 02048 -1247 Establishment Mailing Address (if different) License Administration Walgreen Eastern CO., Inc. MS 3215 / PO Box 901 Deerfield, IL 60015 Establishment Telephone No (508) 337-8800 Applicant Name & Title: Raylynn Be Los Santos License Specialist, License Administration Walgreen Eastern CO., Inc. Applicant Address MS 3215 / PO Box 901 Deerfield, IL 60015 Applicant Telephone No.: (847)-315-3376 24 Hour Emergency No.: (800) 695-9904 Applicant Email taxlicenserenewals@walgreens.com Owner Name & Title (If different from applicant) Walgreen Eastern CO., Inc. Owner Address MS 3216 / PO Box 901 Deerfield, IL 60015 Owner telephone number (847)-315-3376 taxlicenserenewals @ walgreens.com Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or I An Association partner. X7 A Corporation Name Title Address 17 An Individual Please see attached F-1 A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: William Pereira(Manager) Address: 243 Chauncy St., Mansfield, MA 02048-1247 Telephone No: (508) 337-8800 24 Hour Emergency No: (800) 695-9904 FAX: (508) 337-6193 E-mail: taxlicenserenewals@walgreens.com Alt E-Mail:mgr.19441@store.walgreens.com District Or Regional Supervisor (if applicable) Name & Title: Director, Pharmacy and Retail Operations - Michael Christie Address: 62 Forest St., Ste. 120 Marlborough, MA 01752 Telephone No: (774) 843-7520 24 Hour Emergency No: (800) 695-9904 FAX: (508) 337.6193 E-mail: taxlicenserenewals@walgreens.com License Automation Page 1 of 1 License Automation License Search Check Request C'lwck I list3ry New Locations St,te Sales "I' t iuense as I'yne Federal ID Dist Account Change 11) Notifications License Search Results Location Location City ST License G Lic Mult License Renewal License License Address Type Ind Lic. Exp Due Renew Amt 19441- 243 S* CHAUNCY MANSFIELD MA FOOD L 0 12/31/1911/20/19 12/18/18 $125.00 ST 19441- 243 S* CHAUNCY MANSFIELD MA MILK L 0 12/31/1911/30/19 10/29/18 $10.00 ST Results: 2 Total $135 21684256 Hay 10.22.19 Please mail licenses to: License Administration Walgreen CO. MS 3216 / PO Box 901 Deerfield, IL 60016 Haylynn De Los Santos License Specialist, PHONE # (847)-315-3376 FAX # (847)-368-6525 *I will be out of the office on Fridays' taxlicenserenewals@walgreens.com Sent Payments to: Public Health Department Town Hall, 1st floor 6 Park Row Mansfield, MA 02048 http://licenseautomation.walgreens.com/LicenseAutomation/serviet/walgreens.ii... 10/22/2019 Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 17 DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. 1-1 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: X Annual (X•] Retail Food $125.00 ❑ Mobile Food Consession Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 �..-J Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 _ $25.00/freezer Temporary End Date: [] Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: LJ Supermarkets $400 n Residential Kitchen $100.00 Rain Date: IL Milk &Cream $10.00 1. J Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(fimertemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous/ood(no fime/tempereture controls required) RTE - ready-lo-eatfoods (Ex. sandwiches, salads, muffins which need no further processing) IX] Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service 0 Delivery of Packaged PHFs Cold Holding For Single Meal Service rY PHF and RTE Foods Prepared For Highly Susceptible Population Facility n Reheating of Commercially El Sale of Raw Animal Foods Intended toPrepared Consumer [] Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Sea rvice 17 Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale [ j Offers Raw Or Undercooked Food Of iJ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale J Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities U Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 byn ipstruq(edbyy the board of health on how to obtain copies of 105 C 590.000 and the federal Food Code. ay ynn a Os Santes Signature of Applicant: { License Specialist, License Administration 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. Social Security Number or Federal ID: 36-1924026 Signature of Individual or Corporate Name: Walgreen Eastern Co., Inc. 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. Walgreen Eastern Co., Inc. Signature of Individual or Corporate Name 36-1924026 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, 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. C:\Users\.sleite\Desktop\Scott's Doe ments\Food Establishments- Temp\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: Address: 243 CNAUNCY ST WALGREENS #19441 City/State/Zip: MANSFIELD , MA 02048 -1247 Phone #: (508) 337-8800 Are you an employer? Check the appropriate box: Business Type (required): 1.❑ I am a employer with 17 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 me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 31-1 We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I o.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 1 I .❑ Health Care with no employees. [No workers' comp. insurance req.] 121-1 Other Retail Drug & Sundries *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: Please See attached City/State/Zip: Policy # or Self -ins. Lic. Expiration 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, under thepains and penalties ofpfrjury that the information provided above is true and correct. 10/23/19 Phone #: (847)-315-3376 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: Phone #: www.mass.gov/dia WALGREEN EASTERN CO., INC. OFFICERS AND DIRECTORS TITLE NAME ADDRESS NUMBER Ownership 108 Wilmot Road President & Director Richard Ashworth Deerfield, IL 60015 (847) 914-2500 0% 108 Wilmot Road Vice President John Saylor Deerfield, IL 60015 (847) 914-2500 0% 108 Wilmot Road Vice President Alan Nielsen Deerfield, IL 60015 (847) 914-2500 0% 108 Wilmot Road Treasurer & Director Todd Heckman Deerfield, IL 60015 (847) 914-2500 0% Vice President & 108 Wilmot Road Secretary Joseph Amsbary, Jr. Deerfield, IL 60015 (847) 914-2500 0% 108 Wilmot Road Director Alexander W. Gourley Deerfield, IL 60015 (847) 914-2500 0%. 108 Wilmot Road Assistant Treasurer Susan Halliday Deerfield, IL 60015 (847) 914-2500 0% MEMORANDUM OF LIABILITY INSURANCE Current as; of, June 21 2019 PRODUCER MARSH USA INC THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO 540 W. MADISON RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM. THIS MEMORANDUM DOES NOT CHICAGO, ILLINOIS 60661 UNITED STATES OF AMERICA AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW. ANY USE, DUPLICATION OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS PROHIBITED. INSURED 4 COMPANIES AFFORDING COVERAGE NA[C# COMPANY A ZURICH AMERICAN INSURANCE COMPANY 16535 WALGREEN CO. AND SUBSIDIARIES 300 WILMOT RD., MS #3228 DEERFIELD, ILLINOIS 60015-5223 COMPANY B INDIAN HARBOR INSURANCE COMPANY 36940 COMPANY C AMERICAN ZURICH INSURANCE COMPANY 40142 UNITED STATES OF AMERICA COMPANY D SELF INSURANCE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECFTO WHICH THIS MEMORANDUM MAY BE 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. COMPANY LEITER TYPEOFINSURANCE POLICY NUMBER POLICY EPFECrIVE ;DATE POLICY .EXPIRATION DATE L1Mirs LIMITS IN USD UNLESS ATRERWISEINDICATED A GENERAL LIABILITY GILD 9310091 16 7/1/2019 7/l/2020 GENERAL AGGREGATE 5,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE QX OCCUR GLO 9310184 16 (Puerto Rico) 7/1/2019 7/1/2020 PERSONAL & ADV INJURY 4 000 000 X Blanket Additional Insured EACH OCCURRENCE 4,000,00 X Per Policy FIRE DAMAGE (Any One Fire 500,00 X Blanket Contractual Liability MED EXP (Any One Person 0 X Uquor Liability A AUTOMOBILE LIABILITY BAP 9310096 16 7/1/2019 7/1/2020 X ANY AUTO BAP 9310183 16 (Puerto Rico) 7/1/2019 7/1/2020 COMBINED SINGLE LIMIT $ 5,000,000 ALL OWNED AUTOS 1 SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per Person) $ NON -OWNED AUTOS BODILY INJURY (Per Accident) $ PROPERTY DAMAGE $ B EXCESS LIABILITY US0007929SLI18A 7/1/2018 8/1/2019 PER CWM 5000000 X UMBRELLA FORM AGGREGATE 51000.00 OTHER THAN UMBRELLA FORM C A A WORKERS COMPENSATION/ EMPLOYERS LIABILITY WC 9310092 16 (ADS) WC 9310094 16 (WI) EWS 9310448 16 (MA) 7/1/2019 7/1/2020 WORKERS COMPENSATION LIMITS STATUTORY A PARTNERS/EXECUTIVE EL EACH ACCIDENT 2,000,000 A BINCL. OFFICERS ARE: EXCL EL DISEASE -POLICY LIMIT 2,000,000 EL DISEASE - EACH EMPLOYEE 2 000 000 D PRODUCT LIABILITY Self -Insured 7/1/2019 7/1/2020 EACH OCCURRENCE 21000,00 AGGREGATE 2,000,000 ADDITIONAL INFORMATION OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS, LENDERS, MORTGAGEES, GROUND LESSORS, VENDORS, CUSTOMERS, CLIENTS, AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE, CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE, CONTRACT OR OTHER WRITTEN AGREEMENT. The: Memorandum of Insurance serves solely to list Insurance, policies, limits and dates of coverage. Any modifications berate are not authorized, Town of Mansfield 6 Park Bow, Manfeld, Massachusetts 02048 Health Department Amy Donovan -Palmer, MPH, R, , Health Agent October 16, 2019 Retail Food establishment vendors: Your current food establishment permit in Mansfield will expire on December 31, 2019. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 27, 2019. Please note that ALL of these_ documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. 1. Food Establishment Permit Application (Attached) 2. Tax Certification Form (Attached) 3. Workers' Compensation Insurance Affidavit: General Business. (Attached) 4. Workers' Compensation policy declaration page The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address for all positions. As a retail food establishment, the following fees may apply: • $125 Retail Food Establishment • $10 Milk and"Cream' There are several new requirements based on the MA DPH adoption of the 2013 FDA Food Code. The following documents must be on site during inspections. Vomit and Diarrhea Clean up Procedure (example attached) Pest Control contract and/or receipts from routine inspections of the premise The Plastics Waste Reduction bylaw is now fully in effect. According to this by-law, no retail establishment shall provide thin-film, single -use plastic check-out bags. Check-out bags can only be a 100% recyclable paper bag containing at least 40% post -consumer recycled content or a reusable check-out bag. Phone (508)261-7366 Fax (508)261-7425 Emailadpalmer@mansfieldma.com Please contact the Health Department if I can be of any further assistance. Sincerely, CLI Amy Donovan -Palmer, MPH, IRS Health Agent Food Establishments Fee Caterer $35 Milk & Cream $10+ Pushcart $50 Manufacture Frozen Desserts/Ice Cream per freezer $25 Mobile Food $100 Residential Kitchen $100 Retail Snack Food, no PHF $50 Retail Food $125' HACCP review and approval $100 Restaurants Seating up to 100 $175 Restaurants Seating 101-200 $250 Restaurants Seating 201+ $300 Supermarket $400 Farmer's Market $25 Temporary (per day) $50 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) Any establishment that generates FOG and does not have FOG containment $50 Critical Violation re -inspection fee $100 Plan review $100 Tobacco and Nicotine Delivery Products $150