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HomeMy WebLinkAboutShaw's Supermarkets, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health to Operate a Food Service E 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:. SHAW'S SUPERMARKET INC. Whose place of business is: SHAW'S SUPERMARKET #431 390 WEST STREET License Number: FS -67 Permit Expires: December 31, 2019 BOARD OF HEALTH Food Fee: $400.00 Milk & Cream AichaeCHeaCey, Chairman Permit for the Sale of 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: SHAW'S SUPERMARKET #431 390 WEST STREET License Number FS -67 Permit Expires: December 31, 2019 BOARD OF HEALTH NichaeCHeaCey, Chairman X U rl !y'v FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: Shaw's #431, Establishment Address: 390 West St., Mansfield, MA 02048 Establishment Mailing Address(if different): PO Box 29096, MS#6531 OV 13 201 Phoenix, AZ 85038-9096 Establishment Telephone No.: 508-339-3987 EKY._ Applicant Name & Title: Shaw's Supermarkets, Inc. Applicant Address: zso PG—1 C Lc X51 df 43<ise� f D E'37a Applicant Telephone No.: 800-379-2967 24 Hour Emergency No.: 800-379-2967 Applicant E-mail: nasc.tax@safeway.com Owner Name & Title (If different from applicant): Shaw's Supermarkets. Inc. Owner Address: Z?-, j'r+�.E ce...�-Lc.,- b'lvaf.f Js'o7S�� (P Owner Telephone No.: 623-869-4326 Owner E-mail: Nasc.tax@s-afeway-.com Establishment Owned By If a corporation or partnership, give name, title, and home address of officers or O An Association partner. X A Corporation Noma Title Address O An Individual 0 A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Lisa Coash Address: `�6 (4,F,f sr�. A 0z0y,4 Telephone No: 508-339-3987 24 Hour Emergency No: 800-379-2967 FAX: 623-869-1445 E-mail: nasc.tax@safeway.com Alt E -Mail: william.wagner@albertsons.com District Or Regional Supervisor (if applicable) Name & Title: Mike Goulart Address: 750 W. Center St., West Bridgewater, MA 02379 Telephone No: 508-897-8866 24 Hour Emergency No: 800-379-2967 FAX: 623-869-1445 E-mail: nase.tax@safeway.com - Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 117 DAYS/HOURS: Mon -Sat 7am-10pm / Sun 7am-9pm Name of Person In Charge Certified in Food Protection Management Lisa Coash If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: (W Permanent Location Establishment Type ®Moblie Moblie Start Date: Retail ( Sq. Ft) Moblie End Date: LJFood Service up to 100 INCLUDING Moblie Comments: FOOD TRUCKS $175.00 Length of Permit: ❑® Annual ❑r�Q Seasonal Seasonal Dates: ❑d Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Food Service up to 101 -200 $250.00 - I [J Food Service up to 201 + $300.00 ❑a Supermarkets $400 L� Caterer $35.00 Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ® Pushcart $50.00 # of Pushcarts: i❑_= Residential Kitchen $100.00 Retail Food $125.00 Ell Retail Snack Food $50.00 0 Tobacco Products $150.00 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous lood(no time/temperature controls required) RTE -ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑® Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order ❑® Hot PHF Cooked and Cooled or Hot Held a ❑i Sale of Commercially Pre -Packaged PHFs 0 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 - ❑� Sale of Raw Animal Foods Intended Susceptible Population Facility © Reheating of Commercially to be Prepared by Consumer I❑.' Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ------ - ----- 0 Customer Self Service of Non PHF and Non- -- ---- --- 0 Customer Self -Service 0 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only- _.. — - 0 Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _-- Otters RTE PHF in Bulk Quantities --_----- [.2 Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date - ----- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application H waived 1, 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 copiesof 1Q5 CMR 590.000 and the federal Food Code. Signature of Applicant t_Aj'!v"tTr;.~f--- I Ly 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. Signature of Individual or Corporate Name: 5 ^ a r" S Social Security Number or Federal ID: 04-01123420 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS -80 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. 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: Shaw's #431 LOCATION OF SALE OF TOBACCO PRODUCTS: 390 West St., Mansfiels, MA 02048 ........__ TELEPHONE AT LOCATION: 508-339-3987 OWNER OF BUSINESS: Shaw's Supermarkets, Inc. ADDRESS OF OWNER: 250 Pat kcenter Blvd., Boise, ID 83706 TELEPHONE OF OWNER: 623-869-4326 FAX NUMBER: 623-869-1446 If a corporation or partnership, give name, title, and home address of officers or partner. see attached * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 CT -3T NUMBER: 129953792 FEDERAL ID/SS NUMBER: 04-01123420 I SIGNATURE:L,I,„,''L if DATE: 111 1 55s a��rF7T Commonwealth of Massachusetts Dcparhncnl of Rowena Christopher C. Harding, Commissioner ��.wr oe4 mass.gov/dor ojo Later to: LI 530344064 Notice Data: September 17, 2018 Account ID: CGL -11546651-107 RETAILER LICENSE FOR SALE OF CIGARETTES �lu�l'I�Il�hhd�IlL,ll�i�lll�lln�lll'u��lllltlnllrlll TAX DEPT SHAWS SUPERMARKET INC SRAWS SUPERMARKETS INC STORE NO 2 PO BOX 29096 MS # 6531 PHOENIX AZ 85038-9096 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 4ac'ius DEPARTMENT OF REVENUE MASSACHUSETTS DE Form CT -3T N Retailer License for Sale of Cigarettes 2 FMro<" F This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SHAWS SUPERMARKET INC Account ID: CGL -11546651-107 SHAW'S #431 Location ID: 11546651-0221 390 WEST ST STE 1 License Number: 129953792 MANSFIELD MA 02048-1170 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 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. Jl(��'fj'dit:;``��Signature of of Individual or Corporate Name By: Cp poratgf fficer (Mandatory, if Applicable) U11 --6I 1 Z /zo "Social Security No. (Voluntaq) 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. C:\Users\sleae\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION EORM.doc The Commonwealth ofMrissachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf wwwmmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant blformation Please Print Legibly Business/Organization Name: S A,�, 4"-f �Y ! Address: '-�, `l0 <04_� _57, City/State/Zip: 0-n sJ-,`cr i cl /17,4 oz uy g Phone 7 Are you an employer? Check the appropriate box: Business Type (required): 1. [9-I am a employer with t 1 7 employees (full and/ 5. [g"Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no T ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their fight of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 taw corporation has other employees, a workers' compensation policy is required and such an organization should check box 91. I a»r an errrployer that is providing workers' conrpensatioa iasljra•aace.Jm- ayneneployees. Below is fire policy information. ,. Insurance Company Name: Ace Aa.a�:ec�n tlnlu✓'< Ce Insurer's Address: 5-60a U+. b'3 'i b��o r� >v:l`� /1'c<) City/State/Zip: Policy # or Self -ins. Lic. uc.eC --sY>La6z-3 Expiration Date: &/; I < ? 6 f ? 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 eer tiff,, ander the pains and penalties a/peijmry that the information provided above is true and correct 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia ao .4C0/ZO I"07/27/2018 OF LIABILITY INSURANCE DATE(MWDDIYYYY) D7,27I2D,B 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 Aon Risk Services Central, Inc. Minneapolis MN Office 5600 West 83rd street 8200 Tower, Suite 1100 CONTACT NAME: PHONE INC FAX No.EXt); (866) 283-7122 AIC.No.: 1800) 363-0105 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAG $ Minneapolis MN 55437 USA INSURED INSURERA: ACE American Insurance Company 22667 New Albertsons L.P. Including All Affiliated subsidiaries & Associated Companies 250 E. Parl(center Blvd. Boise ID 83706 USA INSURER B: ACE Property & Casualty Insurance CO. 20699 INSURER C: INSURER D: NSURER E: Liquor Llabilay Included INSURER F: AUTOMOBILE LIABILITY x ANYAUTO OWNED SCHEDULED AUTOS ONLYAUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY COVERAGES CERTIFICATE NUMBER: 570072434505 REVISION NUMBER: 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD BUSH WVO POLICYNUMBERMMIDOIYYYY POLICY EFF POLIGYEXP MMIOD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [X]OCCUR X Druggist Liability Included XSLG SIR applies per policy terns & condi ions EACH OCCURRENCE $3,000,000 DAMAGE TO RENTED $3,000,000 PREMISES Ee occurrence MED EXP (Any one poison) Excluded PERSONAL &ADV INJURY $3,000,000 GENIAGGREGATE LIMITAPPLIESPER: X POLICY ❑JER0- LOC OTHER: GENERALAGGREGATE $18,000,000 PRODUCTS - COMPIOP AGG $6,000,000 Liquor Llabilay Included A AUTOMOBILE LIABILITY x ANYAUTO OWNED SCHEDULED AUTOS ONLYAUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY ISA H25268313 o8/O1/2o1808/01/2019 COMBINdED SINGLE UMIT $5,000,000 BODILY INJURY (Par person) BODILY INJURY(Peracciden0 PROPERTY DAMAGE PeracNdent) B IDED UMBRELLALIAB EXCESS LIAB X OCCUR CIAIM&MAGESIR xooG2794761A003 applies per policy ter 08/01/2018 s & condi 08/01/2019 ions EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 X IRETENTION A WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY ANY PROPRIETOR I PARTNER I EXECUTIVE 1] OFFICERIMEMBER EXCLUDED? Y (Mandatory in NH) If yes, descnbeuntlar DESCRIPTION OF OPERATIONS below NIA WLRC65434623 08/01/2018 08'01 2019X PER STATUTE GTH- ER E.L. EACH ACCIDENT $2,000.000 E.L. DISEASE -EA EMPLOYEE $2,000,000 E.L. DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Blanket Additional Insured for General Liability and Waiver of Subrogation for General Liability status extend to those parties to whom the Insured has contractually agreed to provide this status. CERTIFICATE HOLDER CANCELLATION ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. New Albertsons L.P. AUTHORIZED REPRESENTATIVE Including All Affiliated Subsidiaries & ASSOBois Gated Companies 250 E. Parkcenter Blvd A ��L � '� Boise ID 83706 USA t('Y.XXP//D2 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Name- of Recipient: NancyL. Kiley Dale of Completion: 10/,9/2018 Dats of Expiration: 30/29/20-3 TG=a!—, —,df--;, b.r:lp luut.itbir... rfJda,r J rar 1"g -a;, ,lg nreru,-P..... 8 p..re,a fy,c-nr„ r,,.e,r1 , "n,,,afr,bhcl alb ;,.,,; ni3 C,tv]i s�durv(c1P7(.,J. '/hi, a (� r !iP ht v✓f !/ 1i�o- (SJy.nr J. - J nl �";n6viwr. iw�aap Ilerk.Ltre �AHEC a 1'Inrvtidd M1lux.elwntn Officer Listing Shaw's Supermarkets, Inc. FEIN: 04-1123420 Star Markets Company, Inc. FEIN: 04-3243710 Name Title Address Ownership Michelle Larson President 750 W. Center St., West Bridgewater, MA 02379 0% Laura A. Donald Group Vice President, Corporate Law & Assistant Secretary 1015 EI Curtola Blvd., Walnut Creek. CA 94595 0% Robert A. Gordon Executive Vice President, General Counsel & Secretary 24 Robert Rd., Orinda, CA 94563 0% Gary Morton Vice President, Treasurer & Assistant Secretary 2000 Canal St., Boise, ID 83705 0% CERTIFICATE OF AUTHORITY AND LIMITED POWER OF ATTORNEY I, Robert A. Gordon, Executive Vice President, General Counsel & Secretary of Shaw's Supermarkets, Inc., a Massachusetts corporation ("Company"), by authority granted to me under a standing resolution duly adopted by the Board of Directors on April 19, 2017, hereby delegate authority and grant a limited power of attorney to the persons listed in Exhibit A (as such Exhibit A may be updated from time to time) for and on behalf of Shaw's Supermarkets, Inc. to execute the following: Licenses, permits, WIC contracts, lottery contracts, tax and fee returns, sales/use returns, fuel returns, property renditions, applications for fictitious business names. Notwithstanding this Certificate of Authority and Lirnited Power of Attorney, the persons listed in Exhibit A (as such Exhibit A may be updated from time to time) remain subject to, and must comply with, any applicable approval and procedural requirements set forth in the Company's policies on legal review, approval and signing of agreements, as such policy may be amended from time to time. This Certificate of Authority and Limited Power of Attorney shall continue in effect for the individuals named in Exhibit A (as such Exhibit A may be updated from time to time) for so long as such individuals remain in their present positions (or any more senior positions of authority) and maintain responsibility for the tasks or functions described herein, unless earlier modified or rescinded in writing. Dated: .3--13'1 � "Q . Robert A. Gordon Executive Vice President, General Counsel & Secretary I, Laura A. Donald, hereby certify that I am the Group Vice President, Corporate Law & Assistant Secretary of the Company; that the approval adopted by the Board of Directors of the Company on April 19, 2017 is still, on this day, in full force and effect; that Robert A. Gordon is Executive Vice President, General Counsel & Secretary of the Company; and that Robert A. Gordon has full right and authority to execute the above Certificate of Authority and Limited Power of Attorney. Group Vice President, Corporate Law & Assistant Secretary Exhibit A Certificate of Authority and Limited Power of Attorney (Shaw's Supermarkets, Inc — NASC Documents Name Title Steve Barna Mana er Tax Jana Bohlman Director Tax William Carter Manager Tax Tiffany Corcoran Supervisor Tax Don ohnson Sr. Director Financial Reporting Devin Whyte Mana er Tax Jeff Wilson Supervisor Tax New Fees for Food permits Food Establisluuents Fee Caterer $35 -0 - Milk& Cream $I ;Pushcart Pushcart $50 Manufacture Frozen Desserts/Ice Cream per freezer $25 Mobile Food $100 Residential Kitchen $100 Retail Snack Food, no PHF $50 Retail Food -°J - HACCP review and approval $100 Restaurants Seating up to 100 $175 Restaurants Seating 101-200 $250 Restaurants Seating 201+ $300 Supermarket $40 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 too $100 Plan review $100 Tobacco and Nicotine Delivery Products 50' Fr P ti 3 t MrGB_ v3/ 76 Lr31 t"' 383 Officer Listing Shaw's Supermarkets, Inc. FEIN: 04-1123420 Star Markets Company, Inc. FEIN: 04-3243710 Name Title Address Michelle Larson President Ownership Laura A. Donald Group Vice President, Corporate Law & Assistant Secretary 750 W. Center St., West Bridgewater, MA 02379 0% Robert A. Gordon Executive Vice President, General Counsel & Secretary 1015 EI Curtola Blvd., Walnut Creek. CA 94595 24 0/ Gary Morton Vice President, Treasurer &Assistant Secretor Robert Rd., Orinda, CA 94563 0% Y 2000 Canal St., Boise, ID 83705 0%