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Home My WebLink AboutMansfield Xtra Mart - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. DRAKE PETROLEUM COMPANY, INC. Whose place of business is: MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET Permit Expires December 31, 2019 License Number: RF-8 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH MichaeCHeaCey, Chairman Permit for the Sale Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET License Number RF-8 Permit Expires December 31, 2019 BOARD OF HEALTH Michae(HeaCey, Chairman 0 IFOR BOARD OF HEALTH USE ONLY Permit #Issued I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planneq EineM J, Establishment Name: NOY 13 2018 Establishment Address: e?oT 3L"'� I" kvA'('4 !S71kce7 Establishment Mailing Address(if different): Establishment Telephone No.: j d t -- ,t& Applicant Name & Title: '+al 44, C_ Applicant Address: S-xT, 3 Applicant Telephone No.: j- 3e4t, qo i, 1 24 Hour Emergency No.: Applicant E-mail: IT qctsvok-Are�EL � P , r'x, t"'k Owner Name & Title (if different from applicant): "'Smv'n�' CAS a'Vw'f"z_ Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or E9 An Association partner. " Corporation Name Title Address H An Individual f (k,SK, c (_t-OL r k� d 0 A Partnership 9 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: j VK -i�s k 'Z� `e- �"k -kq'z r Address: qD1-'3-&-rk:o+ VV01-10A 'MA - Telephone No: Jo - a yl 24 Hour Emergency No: /-/,Dl — (L-"5 FAX: E-mail: 'j:WrVK-4 S C' q 16 C�'_C'Wj J Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: V1 Address: Telephone No: -p (OCI 24 Hour Emergency No: 4b i 4r FAX: E-mail: Food Establishment Information WATER SOURCE ,,. fD LAJA SEWAGE DISPOSAL: Ls ti o No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: % d Cfk em 'U -e C. e- :; kok' € " [ , Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (if 25 Seats or more): El Location: "Permanent Location Establishment Type caterer$35.00 QMobMobile Start Date: [ 2etall ( Sq. Ft) r L;�lie Milk & Cream $10.00 Mobile End Date: 0 Food Service up to 100 INCLUDING Eil Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Q Food Service up to 101 -200 $250.00 Food Service up to 201 + $300.00 Supermarkets $400 [94,anufacture Frozen Desserts/Ice Cream $25.00/freezer Ell Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 R°Retail Food $125.00 0 Retail Snack Food $50.00 Length of Permit: pE/,ArNnnual [ Seasonal Seasonal Dates: Q Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF- Potentially hazardous food(h'me/temperatum controls required) Non-PHFs - non-potentialy hazardous food(no 6'me/tempereture controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I( Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer ri Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Vacuum Packaging / Cook Chill 0 Use of Process Requiring di Variance andlor HACCP Plan (including bare hand contact alternative, time as a public health control) Gi Customer Self -Service of Non PHF and Non- Perishable Foods Only Customer Self -Service (] Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin ED Offers RTE PHF in Bulk Quantities Ej Prepares Food/Single Meals for Catered Events or Institutional Food Service I] Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due vrith application H 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 of 105 CMR 590.000 and the federal Food Code. Signature of Applicant:_ Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of pefjury in I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. By signing this application, I declare that I have read the regulation and am responsible for tobacco product sales regarding federal, state and local laws. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: kly0 _ - �J t � L i) ._ AA Ze4vu, vtrk v_ - n LOCATION OF SALE OF TOBACCO PRODUCTS: TELEPHONE AT LOCATION: jc 1 LC � OWNER OF BUSINESS: -6 . A'V d yR AZ c 'e €,k V Q ew-o'47pj a kt c'__ ADDRESS OF OWNER: cep yt, �. it -- =yt . j� } _ t,Z k"I1 r§ Vv�, • ,tk TELEPHONE OF OWNER: t,-_ %l q & Q I FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: ° SIGNATURE/--�7�% DATE: " ir`Q, d - cm Letter to: L0739248768 011 Department aofRevenMaeA9nchusotta Notice Date: September 24, 2018 Q6r"' Christopher C. Harding, Commissioner Acemem ID: CRL I1154405.072 n'r or4 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO trbir4hd��rr�lrrrlll�l�"grhr4�gndur�l�lllr��dtlrlu� DRAKE PETROLEUM CO INC MILLBURY XTRA MART 15 NE INDUSTRIAL RD BRANCORD CT 06405-2844 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE 6 4As5A rE� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T + �8¢ Retailer License for Sale of Cigars and Smoking Tobacco Sy�`7Vpzl� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CRL- 11154405-072 MANSFIELD XTRA MART Location ID: 11154405-0204 905 S MAIN ST License Number: 486008832 MANSFIELD MA 02048-3149 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 Fysnr�t!+�rF Commonweatth ofMnssechusetts Lettern): L1283046528 Department of Revenue Notice Date: September 20, 2018 Christopher C. Harding, Commissioner Account to: CO1-11154405-069 rBgr oFs' mess.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES tb�J��nn�h��" ��IIIIIIII'I�'11�I��IIhllprdd�q�Illlhl� DRAKE PETROLEUM CO INC MILLBURY XTRA MART IS NE INDUSTRIAL RD BRANFORD CT 06405.2844 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE gll 6 SSAHt sF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m,8, Retailer License for Sale o£ Cigarettes t :Nr ot'�Q This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CGL-I 1154405-069 MANSFIELD XTRA MART Location ID: It 154405-0203 905 S MAIN ST License Number: 2048337920 MANSFIELD MA 02048-3149 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 I I Town of Town of Mansfield - Board of Health 6 Pak RoM tansfield Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board of llealth at the Town of Mansfield. In accordance with the provisions gfsection 0511 gfChapter 94 of the General Lars, as most recentlp amender/ and the regulations made thereunder, the undersigned hereby applies for a license for a WHOLE.SALEIRE7AIL manrtfacatre of frozen desserts and ice cream ntir and.subinits the,following information: Full name of applicant: 4i1+t''gS1Po-A—'-) 2. Business address - 610,"'j__- 3. /fapplicont is mh indivi(hral. Full name: 4 )ft All ' e`, f ci(L Ah CC r-y 6 bids Residence: _ �'C4 e i.n.`i`t,+ S- j; t:- J t" l L,2.i Rl-irdF �i.,✓ii - L, �a �$'s_ 3tt. !f applicant it a partnership,,firll name mud residence of all p<a huers: 3b. I!'applicant is a corporation: State of incorporation: /Y1 V} 'y S.tk C'.O , � i i S � Date of incorporation: rr} P 2-t L l RS Fall runic and address qf: Principal office: t y � i yp a_ e, President -- Treasurer: Y Clerk: 4. Location ofPlants: ! "�) Pokz-. 5. Nunes ofbrands and trade or corporation mmne, if any, under which the products are to be sold; _E, V'J VNfct-"L$co - - --- --- - 6. Nmnber and capacilp of tee=wrs and,jires, 1 Fee: ($25.00 per freezer) $ #Type! Z Is the nile purchased? `C J Ifso, limn+ whom purchased' 8. Is the nu): Pasteurized? S 9. Number ofgallons of fro=en desserts cod/or ice cream mix to be sold in Massachusetts during the licensing period I (I, Number ot'gedlons of Ji o_en desserts andror ice cream rnis .sold in rblassachusens during the previous licensing period 11. Is the plant constructed and equipped as provided in the regulations? \je 12. Ls the water supply public or not? \1 2-Y . �c, 'V) i zi.-_.. 13. Have pour received a copy of the regulations' I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under santlary conditions. I attest that the information stated in this appl dab . s bue nd accurate under thg awns and penalties ofperjury. N, 940N, rY-Iza, zaw; Cx ' t-"� j �,� ��'- �� (Cornpan�ffic signay ture) (DATE) 1,-%16e`Ls�:�', .�kCz _ �,� t%'cC,fj o_&s,t Afi (Title) (City or Town) 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 *"Social Security No. (Voluntanj) or Federal Identification Number or (Mandatonj, if Applicable) d,Xk,%. : r.� l I { �''Wy *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\ScotVs Documents\Food Establishments- Temp\TAX CERTLFICAnON FORM.doc Ofivae of III vesilgatAbus PORK ST "FILLE 1) r 60 . 0 Imas/16 0 UT C 0 AIPLE TDI LY onc fth t. in rd rw h-doft Hushless/organizatboll Name" 4z v-vv- c vo, L) Jyv-.P.IA - -'r i-k C Md*gsi. Sbi'-, 3u,klf- IFM -A-r.63,10 OP rmlplpYdi'?,Clkg4l;titdqPhi�OPPlht9;40t: 101, [m.sok.proprIe'tor or.parhlersfilBoo IAA" DO any capa6ify., 00 Avot.kersl� obinp, ih%Lrdnff0qVlI'Od) alya eDj6p, J1 sOaiiCaj tqq4irqdj Wwa-nre, a nomproritariganizatio4? swffejl,by vqIonl4ars )�U ,fn wivempl - oi, wriliat Ysprovidthg tPorkerwl 101ftodo Qoh*pY!,jmnb!: , I tj' VusInps F1 Oftibb Ej wony,-.�tif I QgE1 wpirpour4 11110Health Cove, VU VN- -�11 QN9161flia Lim. #_jA� ri 16 /cLiq (Euo�, .Atld-dU g copy 6 npo ou 'fine lip t0j.I.,6b0,00 the folin-of a STOP VjrOMCOXDER:npd 4fune qfperjmrop ffi(ddto Of#oful.osd Oulp, IM noforticM fills hraff, bbg coilwiffteri4v cl?(' Orfoself.q.01dNI, city'.010rall"n: Clark 6, Orthpi, CERTIFICATE, OF. LIABILITY INSURANCE 1o/1/zo19 ;ATErvvvv) 9/27/207/2018 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(les) 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 Lockton Insurance Brokers, LLC 725 S. Figueroa Street, 35th FI. CA License #OF15767 Los Angeles CA 90017 (213) 689-0065 NAMEACT FAX PHONE Exit, No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A: Liberty Mutual Fire Insurance Company 23035 INSURED 1370629 probe Petroleum Company, Inc. Global Partners, LP INSURER B:LibeY Insurance Corporation 42404 INSURER C INSURER D 800 South Street INSURER E: Waltham MA 02454 INSURER F: rnvcRnr_cc nr n9AAl CFRTIGICATF IUIIMRFR• 1SARq IAA REVISION NUMBER: XXXXXXX V 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 ADDL i D SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYV POLICY EXP MM/DDM'YY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX A AGE TOR PREMISES Ea occurrence) s XXXXXXX MED EXP(Any one person) s XXXXXXX PERSONAL &ADV INJURY s XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s XXXXXXX PRODUCTS-COMP/OP AGG $ XXXXXXX POLICY E PRO-0 LOC JECT OTHER: A AUTOMOBILE LIABILITY N N AS2-691-460066-038 10/1/2018 10/l/2019 COMBINED SINGLE LIMIT Ea accident $ 1 000 000 BODILYINJURY(Perperson) $ XXXXXXX ANY AUTO BODILYINJURY(Peraccident) $ j(XXXXXX OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY I PROPERTY DAMAGE Per accident $XXXXXXX Comp/Coll Ded. $ 1,000 UMBRELLA LIAR OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX EXCESSLIAB CLAIMS -MADE DED RETENTION$ s XXXXXXX B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIM(Mandatory In ER NH) (Mandatory In NH) N/A N WAS-69D-460066-018 10/I/201$ 10/1/2B79 X STATUTE ERH E.L. EACH ACCIDENT s 1000000 E.L. E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000.000 fyes,descr!be under DESCRIPTION OF OPERATIONS below TE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION 15683144 Commonwealth of Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Department Of IndUSh']a1 ACClderit5 P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Office of Investigations 600 Washington Street Boston MA 2111 AUTHORIZED REPR U 1988-ZU15A1_;tJKU UUKPUKAI IUN. Aii rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD DRAKE PETROLEUM COMPANY, INC. CORPORATE OFFICERS Name & Address Title Eric Slifka Director, President and Chief Executive 800 South Street Officer Waltham, MA 02454 Andrew Slifka Executive Vice President 800 South Sheet Waltham, MA 02454 Edward J. Faneuil Secretary, Executive Vice President and 800 South Street General Counsel Waltham, MA 02454 Matthew Spencer Chief Accounting Officer 800 South Street Waltham, MA 02454 Daphne Foster Chief Financial Officer 800 South Street Waltham, MA 02454 Mark Romaine Chief Operating Officer 800 South Street Waltham, MA 02454 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES JAMES BRODEUR HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE P66B SAPffy MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS _;NSs e, Suite 220, Of lando, FL 32821 (407) 352-3603 ivww:NRF59com y of Food Safety Professionals' Notification of Test Results ID#: xxx-xx- Scaled Test Score: 75 Candidate Status: Pass Test Date: April 26, 2018 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes al the address below, Preventing Contamination and Cross Contamination (Competent) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Needs review) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Needs review) Conducting Cleaning and Sanitizing (Needs review) PhysiCal Facility Design & Malmenance: Preventing & Controlling Pests (Competent) PRESIDENT: LAWRENCE J. LYNCH, CAE ISSUE DATE: APRIL 26, 2018 EXPIRATION DATE: APRIL 26, 2023 CERTIFICATE NO: 21459837 TEST FORM:EXE70 IDie cen,&me ,s not valid for more than five years from date of issue. National liegntry of Food Safety Professional CERTIFIED FOOD SAFETY MANAGER JAMESBRODEUR' JAMESBRODEUR 392 COGGES HALL ST FALL RIVER, MA 02721 Certificate No: 21459817 Issue Date: April 26, 2018 Pxpiration Date: April 26, 2023 National Registry of Food Safety Protessionalsh l 6751 Fomm Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3930 1 Fax: 407,352.3603