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HomeMy WebLinkAboutWalgreens - 12/31/2019n Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: RETAIL FOOD 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:. WALGREEN EASTERN CO., INC, Whose place of business is: WALGREENS #19441 243 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM PEREIRA Permit Expires: December31,2019 Food Fee: License Number: RF-3 BOARD OF HEALTH Michae(Aeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued RFRF=14 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Walgreens #19441 Establishment Address 243 CHAUNCY STREET Establishment Mailing Address (if different) P.O. BOX 901 DEERFIELD, IL 60015 Establishment Telephone No (508) 337-8800 Applicant Name & Title: KAY LYNN DE LOS SANTOS Applicant Address 300 WILMOT ROAD, MS 3215, DEERFIELD, IL 60015 Applicant Telephone No.: (847) 316.3376 24 Hour Emergency No.: (800) 695-9904 Applicant Email Owner Name & Title (If different from applicant) WALGREEN EASTERN CO., INC. Owner Address P.O. BOX 901, DEERFIELD, IL. 60015 MS #3216 Owner telephone number (847) 526-4669 Owner email: Establishment Owned By: An Association A Corporation An Individual A Partnership Other legal Entity It a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address See Attached See Attached Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: WILLIAM PEREIRA Address: 243 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (508) 337-8800 24 Hour Emergency No: (800) 695-9904 FAX: (508)337-6193 E-mail: TAXLICENSERENEWALS@WALGREENS.COM Alt E-Mail: kaylynn.delossantos@walgreens.com District Or Regional Supervisor (if applicable) Name & Title: VINNIE PIZZI (DM) Address: Telephone No: (401) 626-7099 24 Hour Emergency No: (800) 695-9904 FAX: E-mail: VINCENT.H.PIZZI@WALGREENS.COM Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (if applicable) No. of Food Employees: 16 DAYS/HOURS: Man -Sat ROO (AM) 09:09 (PM) Sun: 09:00 (AM) 06:00 (PM) Name of Person In Charge Certified In Food Protection Management If more than 3 individuals are certified, complete list is on file. N/A Prepackaged Food Only Person Trained in Anti -Choking Procedures (If 25 Seats or more) 0 Location: ® Permanent Location Establishment Type Caterer $36.00 I FTIMablle Mobile Start Date: X❑ Retail (12,928 Sq. Ft) Total Store i(] Milk &Cream $10.00 Mobile End Date: 71 Food Service u to 100 INCLUDING p Mobile Food Cansession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length Of Permit: ! Manufacture Frozen Dessertsllce Cream Length El Food Service up to 101 .200 $250.00 j $25.001rreezer ----- - - ---i [] Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: 5] Seasonal Supermarkets $400 I3 Residential Kitchen$100.00 Seasonal Dates: - Retail Food $125.00 Q Temporary Temporary Start Date: Retail Snack Food $60.00 Temporary End Date: Temporary Time: Rain Date: Food Operations Dehnillons:PHF -Potentially hazardous food nimMempere)um c huhr requhed) Non-PHFs -non-polene'ally hazardous food(no enR4en pwmium conlmis required) (Check all That apply): RTE-reedy-fo-eaf foods (Ex sandwiches, salads, mupfns which need no fudherprocebslna) ® Sale of Commercially Pre -Packaged Non-PHFs I W Sale of Commercially Pre -Packaged PHFs Q Deliveryof Packaged PHFs Q Reheating of Commercially Processed Foods for Service Within 4 Hours [I Customer Self -Service of Non PHF arvd Non - Perishable Foods Only IPreparation of Non-PHFs _ Other Food Operations I, the undersigned, attest to the accuracy of the establishment operation will comply Win 105 Ct board of health on how to obtain copies of 106 r PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held --- �Preparation of PHFs For Hot And III 7 for More Than a Single Meal Service II Cold Holding For Single Meal Service 1 PHF and RTE Foods Prepared For Highly --- 1 Sale of Raw Animal Foods Intended Susceptible Population Facility _ __- to be Pre p y Consumer b Prepared Q Vacuum Packaging I Cook Chill j --- - ----- 0 Customer Self Service ❑,a Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand 2 Ice Manufactured and Packaged for � contact alternative, lime as a public health j Retail Sale control) i.___—__._____—_.._____. -- 0 Juice Manufactured and Packaged for'D Offers Raw Or Undercooked Food Of Retail Sale i Animal Origin _ Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date I -I ------ — orRecondilionadFootl ( To be completed by the Board of Heal#t ---- Total Permit Fee: Payment Is due win application Q waived I _ _ alion provided in this application and affirm that the food .000 and all other applicable law. I have been instructed by the )0.000 and the federal Food Code. Signature of Applicant: �/,• m Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my beat knowledge and belief, have filed all state tax returns and paid state taxes required under law. Signature of Individual or i)op)oralo Name: Walgreen Eastern Co.. Inc. Social Security Number or Federal I(} 36-1924026 Town of 6 Town ofMrnisfeld - Board of Health 6 Park Ro Mansfield Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each NAME OF BUSINESS: Walgreen Eastern Co., Inc. DBA Walgreen #19441 ADDRESS: 243 Chauncy Street TELEPHONE AT LOCATION: (508) 337-8800 FAX NUMBER: (508) 337-6193 OWNER OF BUSINESS: Walgreen Eastrn Co., Inc. TELEPHONE OF OWNER: (847) 526-4669 FEDERAL ID/SS NUMBER: 36-1924026 FEE' $10.00 PERMIT NUMBER: IF-32 SIGNATURE: O� R/"//ICJ-- 7-3-17 L/censirq Specfq/rsf 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 By: Corporate Officer (Mandatonj, if Applicable) 36.1924026 "Social Security No. (Vohrntanj) or Federnl 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 111serslslei1c10cskloplScml's Documents\Food Esleblishmenls- Tonp\TAX CERTIFICATION FORM.doc rilzx The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t ss www.ntassgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print legibly Business/Organization Name: Walgreens #19441 243 CHAUNCYST, City/State/Zip: MANSFIELD , MA 02048 Phone #: (508) 337-8800 Are you an employer? Check the appropriate box: 1.0 1 am a employer with I8 employees (full and/ or part -throe).* 2, ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.l •Any applicant that checks box #1 must also fill out Business Type (required): 5. ❑ Retail 6. ❑ Restaumnt/Bar/Ealing Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9, E] Entertainment 10,❑ Manufacturing 1 l.❑ Health Care 12.® Other _Retail Di n.; c, Sundries ^If the corporate ollicers have exempted themselves, but the corporation has other employees, a workers compensation policy is regmrea spa soon an organiaetion should check box #I. I am an employer that Is providing workers' compensation insurance for my employees. Below is the policy Inforisnation. Insurance Company Nan Insurer's Address:— City/State/Zip; ,_ Policy # or Self -ins. Lie. ., _ ru,,1 �,,;1 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. l do hereby certify, under dre pains and penalties of perjury that the Information provided above is true and correct. i1471 i I 511% Official rise 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. CityiTown Clerk 4. Licensing Board 5. Sefectmen's Office 6. Other Contact Phone MEMORANDUM OF LIABILITY INSURANCE current as of: June 21 2019 PRODUCER MARSH USA INC 540 W. MADISON CHICAGO, ILLINOIS 60661 UNITED STATES OF AMERICA THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM. THIS MEMORANDUM DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW. ANY USE, DUPLICATION OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS PROHIBITED. INSURED WALGREEN CO. AND SUBSIDIARIES 300 WILMOT RD„ MS #3228 DEERFIELD, ILLINOIS 60015-5223 UNITED STATES OF AMERICA COMPANIES AFFORDING COVERAGE NAIC it COMPANY A ZURICH AMERICAN INSURANCE COMPANY 16535 COMPANY B INDIAN HARBOR INSURANCE COMPANY 36940 COMPANY C AMERICAN ZURICH INSURANCE COMPANY 10142 COMPANY 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 RESPECT TO 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 LETTER TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION GATE LIMITS -NMTtS IN USD UNLESS :OTHERWISE INDICTED A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY C1.AIM5 MADE Q OCCUR Blanket Additional Insured Per Policy Blanket Contractual Liability Liquor Liability GLO 931009116 GLO 9310184 16 (Puerto RICO) 7/i/2019 7/1/2019 7/1/2020 7/1/2020 GENERAL AGGREGATE _ 51000,00 X X X X PERSONAL &ADV INJURY 4000000 EACH OCCURRENCE 4,000,00 FIRE DAMAGE (Any One Fire 500,00 MED EXP (Any One Person 0 A AUTOMOBILE X 1 LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BAP 9310096 16 BAP 9310183 16 (Puerto RICO) 7/1/2019 7/1/2019 7/1/2020 7/1/2020 COMBINED SINGLE LIMIT $ 5,000,000 BODILY INJURY (Per Person) $ BODILY INJURY (Per Accident) $ PROPERTY DAMAGE $ B EXCESS X LIABILITY UMBRE"FORM OTHER THAN UMBRELLA FORM U500079295LI18A 7/1/2018 8/1/2019 PER CLAIM 5000000 AGGREGATE 5000000 C A A A A WORKERS COMPENSATION/ EMPLOYERS LIABILITY PARTNERWEXECUTNE BINCL. OFFICERS ARE: EXCL. WC 931009216 (ADS) WC 9310094 16 (WI) EWS 9310448 16 (MA) 7/1/2019 7/1/2020 WORKERS COMPENSATION LIMITS STATUTORY EL EACH ACCIDENT 2000000 EL DISEASE • POLICY LIMIT I S 2 000 000 EL DISEASE Mo EMPLOYEE 2000000 D PRODUCT LIABILITY Self -Insured 7/1/2019 7/1/2020 EACH OCCUR ENCE 2000000 AGGREGATE 2000000 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 hereto are not authorized. Walgreen Co. Corporate Offices 300 Wilmot Rd. MS#3215 Deerfield, IL 60015 wwwmalgreens,com July 10, 2019 Town of Mansfield Health Department 6 Park Row Mansfield, MA 02048 RE: Trade Name Change (Milk and Cream Permit) Permit Number: RF-32 Location: Walgreens #19441 243 Chauncy Street Mansfield, MA 02648 To Whom It May Concern: Walgreen Eastern Co., Inc. has acquired a Rite Aid pharmacy in Mansfield, MA. As a result, the above location will undergo a name change in August. The store is already under Walgreen Eastern Co., Inc. ownership, so only the trade name will change. Walgreen Eastern Co., Inc. DBA Rite Aid #10141 will change to Walgreen Eastern Co., Inc. DBA Walgreens #19441. We ask that you please update your records to reflect the name change and issue a new milk/cream permit for this store location. Upon updating your records, please mail the new permit to the following address: Walgreen Co. PO Box 901 Deerfield, IL 60015 Attn: Lee Gualano MS #3215 You may also send it electronically to my email address below. Let me know if you have any questions or require additional information. Thank you for your assistance with this matter. Sincerely, Walgreen Co. Lee Gualano Licensing Specialist (847)315-5946 lee.gualano@walgreens.com \ \ ! ; all ) k ! ® } § \ 1p \ )� / \ \ \ ( ) (( ) ! ! 7 © e §2 no k ®/ ( !! ® ! ? ! \ \\ i e } - 50 *\\\\k 71 m\ ; = 7 ; !k | ) 2L f! a! e$! /! ;! ;! \| \( )E 2| ! , ! , « ; ■ , � Jane Doucette From: Amy Donovan -Palmer Sent: Thursday, July 18, 2019 9:51 AM To: Jane Doucette Subject: FW: Trade Name Change (Walgreens Food/Milk Permit) Attachments: MA 19441 FoodMilk.pdf Hi Jane, Could you process this and follow up with sending them the new permit? Thanks, Amy From: Gualano, Lee[mailto:lee.gualano(cbwalgreens.com] Sent: Thursday, July 18, 2019 9:45 AM To: Amy Donovan -Palmer Subject: RE: Trade Name Change (Walgreens Food/Milk Permit) Amy: Both of these things will remain the same as well. If no fee is required, I have attached the application packet. I have included both the food and milk applications along with an updated officer list. I am sure you have been in contact with a Kaylynn De Los Santos before. She will remain your contact for renewals. Let me know if you require any additional information. Once you have updated your records to reflect the name change, feel free to send the new food and milk permits electronically to this email address or mail them to the address within the attachment. Let me know if you have any questions or concerns. Thanks, Lee Gualano Licensing Specialist Walgreen Co. 1 300 Wilmot Road, MS #3215, Deerfield, IL 60015 (847) 315-5946 1 lee.gualano@walgreens.com From: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Sent: Thursday, July 18, 2019 8:35 AM To: Gualano, Lee <lee.gualano@walgreens.com> Subject: RE: Trade Name Change (Walgreens Food/Milk Permit) Will the tax Id number change or is the workers' compensation paperwork any different? If that stays the same, then the name change is just clerical. If the other paperwork changes, then we'll need to process it as an ownership change. Jane Doucette From: Amy Donovan -Palmer Sent: Wednesday, July 31, 2019 10:47 AM To: Jane Doucette Subject: FW: Trade Name Change (Walgreens Food/Milk Permit) Fli jane, I don't think I ever forwarded these along to you because I thought he was going to contact you directly. Did he? It looks like he may have submitted paperwork earlier in the month. Could you follow up with Lee with a new permit? Or if he needs any other paperwork to be submitted? Thanks, Amy From: Gualano, Lee [mailto•lee.gualano@walgreens.com] Sent: Wednesday, July 31, 2019 9:03 AM To: Amy Donovan -Palmer Subject: RE: Trade Name Change (Walgreens Food/Milk Permit) Good Morning Amy: I just wanted to follow-up on the below request for name changes to the food/milk permit for our store in Mansfield. Do you know if these changes have been processed yet? If so, can you please provide me with an updated copy of the permits? You can send them electronically to this email address. Let me know if you have any questions. Thanks, Lee Gualano Licensing Specialist Walgreen Co. 1 300 Wilmot Road, MS #3215, Deerfield, IL 60015 (847) 315-5946 1 lee.gualano@walgreens.com From: Gualano, Lee Sent: Thursday, July 18, 2019 8:45 AM To: 'Amy Donovan -Palmer' <adpalmer@mansfieldma.com> Subject: RE: Trade Name Change (Walgreens Food/Milk Permit) Amy Both of these things will remain the same as well. If no fee is required, I have attached the application packet. I have included both the food and milk applications along with an updated officer list. I am sure you have been in contact with a Kaylynn De Los Santos before. She will remain your contact for renewals. Let me know if you require any additional information. Once you have updated your records to reflect the name change, feel free to send the new food and milk permits electronically to this email address or mail them to the address within the attachment. Let me know if you have any questions or concerns. Thanks, Lee Gualano Licensing Specialist Walgreen Co. 1 300 Wilmot Road, MS #3215, Deerfield, IL 60015 (847) 315-5946 1 lee.gualano@walgreens.com From: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Sent: Thursday, July 18, 2019 8:35 AM To: Gualano, Lee <lee.aualano@walgreens.com> Subject: RE: Trade Name Change (Walgreens Food/Milk Permit) Will the tax Id number change or is the workers' compensation paperwork any different? If that stays the same, then the name change is just clerical. If the other paperwork changes, then we'll need to process it as an ownership change. Thanks for checking in. Amy From: Gualano, Lee [mailto:lee gualano(&walcireens.comj Sent: Thursday, July 18, 2019 9:29 AM To: Amy Donovan -Palmer Subject: Trade Name Change (Walgreens Food/Milk Permit) Good Morning Amy: We have a store in Mansfield that will be undergoing a trade name change. The store is currently operating as a Rite Aid and will change to "Walgreens #19441". 1 have filled out a new food and milk permit but was wondering if there is a fee if the store is just going to change names. It will remain under our ownership and no physical changes will be made aside from signage. Please let me know at your earliest convenience and I can get this application packet over to you to be processed. Let me know if you have any questions. Thanks, Lee Gualano Licensing Specialist Walgreen Co. 1 300 Wilmot Road, MS #3215, Deerfield, IL 60015 (847) 315-5946 1 Iee.gualano@walareens.com Disclaimer The Information contained in this communication from the Town of Mansfield Is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 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