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Home My WebLink AboutDollar General Store #20417 - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit# Issued: FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date)9 , lean., Establishment Name Dollar General Store# 20417 Establishment Address 65 Copeland Dr. Mansfield MA 02048 Establishment Mailing Address (if different) Attn: Tax Dept-100 Mission Ridge Goodlettsville, TN 37072 Establishment Telephone No 5 0 8 - 9 6 4 - 2 3 7 0 Applicant Name &Title: DG Retail, LLC Applicant Address same as mailing Applicant Telephone No.: 6 15 - 8 5 5 - 4 0 0 0 24 Hour Emergency No.: (615)517-8717 Applicant Email tax-beerandwinelicense@dollargeneral.com Owner Name & Title (If different from applicant) Owner Address same as applicant Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. O A Corporation Name Title Address ❑ An Individual see attached !7 A Partnership EIX Other legal Entity LLC Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: Stephen Burgess, Store Mgr Address: Telephone No: 401-529-4789 24 Hour Emergency No: 615-517-8717 FAX: 877-364-4130 E-mail: tax-beerandwinelicense@dollargeneral.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name&Title: HUMBERTO RODRIGUEZ, DIST MGR Address: Telephone No: 615-517-8717 24 Hour Emergency No: 615-517-8717 FAX:877-364-4130 E-mail: tax-beerandwinelicense@dollargeneral.com Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: n/a DAYS/HOURS: 8:00am-9:00pm daily Name of Person(s) In Charge Certified in Food Protection Management: n/a Name of Person(s) In Charge Certified in Allergen Awareness Training n/a I 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. []Yes n/a Does this establishment require a FOG permit? n/a If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [X Annual [X Retail Food $125.00 ❑ Mobile Food Consession Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream ❑ 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: Supermarkets $400 ❑ p ❑Residential Kitchen $100.00 Rain Date: X Milk & Cream $10.00 [ ❑Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(notime/lemperature contacts required) RTE - ready -to -eat foods (Ex, sandwiches, salads, mums which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order (, I Hot PHF Cooked and Cooled or Hot Held [X Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared. For Highly I_l Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours ❑ Customer Self -Service and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only [X Ice Manufactured and Packaged for control) [_I Preparation of Non-PHFs Retail Sale p [-I Offers Raw Or Undercooked Food Of IiX Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging / Cook Chili ❑ Offers RTE PHF In Bulk Quantities ❑ 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 been Instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: KSt., 1///; VA,LI' Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 3 6— 4 5 7 7 2 4 2 I, to my best knowledge and belief, have filed all state tax returns 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: Corporate Officer (Mandatory, if Applicable) 36-45772472 *"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. Q\UscB\sleite\Desktop\Scotps Doeuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth nf',M11a srrchrrsetls Deli m•tmenl of Irfrlrrstricrl ficer'Fleuts' tlj'Ilce of'III1'emigationx 600 I1 a kington Street LiFutnn, 111A 02111 tlt'it'N'. ftrFlS'1',I; el f+f1lfrr Workers' Comp wisolion lasurance Affidavit, General 'linsinesses Applicant information Please Print Legibly E3usiness.+Orgtu,izsttiun Nimle; DG Retail, LLCI Dollar General Store# 2.0417 Addr.w Attn: Tax Dept- 100 Mission Ridge CitylStatci7_.ip: Goodlettsville, TN 37072 1'Juntc ?;: 615.855-4000 Are. rr,lt all employer'! C'ttock ncv apprnpriato hnx: iiushtess Type (required): I:Q lalm;tcntpiny'cr,.vhh 1,000+ cmployee's(lullondi 5. QRettlil Or pall -time),° 6. ® RestauranuIbi-Irating rstmUkshmcni 21 1 am a.sule proptietor or pm Intrship and have, no 7. ❑ Olicc 1111l 'or S afo% (incl, r d vslale, auto, cic,) employees working for file in imy capacity. [No workors' comp, insnrallec requilvd] 8. ONoir,prolrt 3F] tb'e me a corpolhticm a rd ilsoit;s=sirs have cstircised 9. Q E:utcriminmenl their right rdexcnlplion per c. 152. § t(S), and the lnn'c I IL[] h7inulhituriog. _ fill employees. tNn workor:s' comp. insninmc rogUiMilt' <4. t4'etrr It eau rrhiu ctn,nitv:iiot.sla(t'od by trdumacrs, I L[] Health Cone 1 r with no cinplovecN. JNo t}orkors' corup- illauranee rry.] 12z:J Othor btn W applicum rh:¢eheekx I:mx R1 Hlu'r nixn fill r.,,i ilwxeel inn hekm slwwing dxir m rke,x:' aompan nliun pnl::,p unfi';mierinn. "tr Ill,, anlmale ollireri lam, esempled Ihemsrhex. but rw mr,,ralian La:01110 cuSpLllixx, n sellkcrs'.uml:c li;uiu:, rc,liry li fit lnixJ;mi1.W t 1115 rz� nianinn shrndtl c6Ax'.k has 4A I am an elaptarer Oat 1'S' pr viding myrkers' elaellp"awelo r7lEYrrrYrrrf.'r! fbr Inr evrrlJfna'r. r..tiv Ifefrnv lY iho lwlle;r iu(nrmarjan. Insurance Company Norm: Ace American Insurance Company lnsurcr'sAddres»: 26 Century Blvd. City;Stafo+Zil>: Nashville, TN 37230 Policy li or Sslf-ans, Lic, iN lltfLRC$5438495 Expiration Data: 2/1012020 Alfatelt n ropy of (lie 5vorhers' cotmottkation pollcf' dechrrallou page (.showing the policy number find expiration (Into 1'ailltrC tO 3PCnregnVel'+lgC as required under Section 25A of WiL c. 152 can lead to the Imposition uforiminal perialtios of It line till In Si, tlti,f)l nnipprcmc-yc;u ioatpriSOfinlool, ns well m civil pcmdlics ul the Irrll Ora STOP WORK ORDER and a tine or up to S2517100 a day against Io violmor. Etc advised lhat o copy o1'this slatenmitI may 15e forwarded 10 the Office of Jncestigldiults of the L)lA for insurance cuvenwc vc» licatiefn. I drz here?l?ff rriilp, antler t)re paths and har]ftWes elf perjul y dlxff Ill(? 11hol-r is Il itc (raft e'.M'rwel 615-855-4000 Offirchil use orr(n Do iml olrla- in dhix lull, to he complicted 17), c rr or rnn'rr gjyidiel C Er r 01, Town: PermI(I'lecnse Issuing Atillority (circle unc): 1, Board of llelllth 2. 111411ling pepar kilonl i, City,rFown Clerk 4. Hcensing Rpurd S. Soloclmea's Office 6, Other Contact Person Irllone. Page 1 of 2 ,AcoIzof CERTIFICATE OF LIABILITY INSURANCE 14..� - DATE(MMIDDMYY) 02/11/2019 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 INSURED, the policy(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 Tennessee, Inc. Willis Century c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONED 1-877-945-7378 FAX 1-888-467-2378 A/C t Me No: EMAIL ADDRESS: certificates@willis.com Nashville, TN 372305191 USA INSURERfSJ AFFORDING COVERAGE NAICa INSURERA: ACE American Insurance Company 22667 INSURED Dollar General Corporation & Its Subsidiaries and Affiliates INSURER B: Berkley Insurance Company 32603 INSURER C: ACE Fire Underwriters Insurance Company 20702 100 Mission Ridge Drive Goodlettsville, TO 37072 INSURER D: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: W10080150 RFVISION NIIMRFP- THIS IS TO CERTIFY THAT 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 RESPECT TO WHICH THIS CERTIFICATE 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. INSR LTR TYPE OF INSURANCE ADOLSUBR ISO POLICYNUMBER POLICYEFF MMIDDNYYY) POLICYEXP tMWDDWYYI LIMITS X J COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR EACH OCCURRENCE S 500,000 DAMAGE TO HENTEO PREMISES Ea occunence $ 500,000 X MED EXP(Any one person) $ 0 A SIR $750,000 PERSONAL&ADV INJURY $ 500,000 XSL G71235282 02/10/2019 02/10/2020 DEVIL X AGGREGATE LIMIT APPLIES PER: POLICY D JECT LOG GENERALAGGREGATE $ 20,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea amdenl 5 BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per aeaden0 5 PROPERTY DAMAGE Per aoddenl 5 $ B X UMBRELLALIAB X OCCUR EACHOCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE 47-MO-303309-03 02/10/2019 02/10/2020 DEB RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNEMEXECUTIVE OFFICER/MEMBEREXDLDDED7 No (Mandatory In NH) If yes, describe under DESCRIPTIONOF OPERATIONS below NIA WLR C65438495 02/10/2019 02/10/2020 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 11000 0000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Excess Work Compensation wCU C65438574 02/10/2019 02/10/2020 E.L - Each Accident $1,000,000 Employer's Liability - E.L Disease - EA Emp $1,000,000 Per Statute E.L Disease - Pol Li $1, 000, 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) DOLGENCORP of TX, Inc. is a non -subscriber to the Workers' Compensation System in the State of Texas and as such is not afforded benefits by the Workers' Compensation policies referenced herein in Texas only. SEE ATTACHED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DG Retail LLC AUTHORIZED REPRESENTATIVE 100 Mission Ridge �f�l Goodlettsville, TN 37072 ACORD CORPORATION. All rinhts reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD an In: 17498857 ENTCR: 1063438 DG RETAIL, LLC— a Tennessee limited liability company Officer Listing Jason Reiser Chief Merchandising Officer and Secretary Larry Gatta Senior Vice President, General Merchandise Manager