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HomeMy WebLinkAboutStop & Shop #7 - Gas 12/31/2019�0% FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application most be submitted at least 30 days before the planned opening date) Establishment Name: 5}0Pt Sb1Op -#� 7.. CARS Establishment Address: 37g GhOl)kl" free+ Establishment Mailing Address(if different):("T 2� 1385 NAtnCCGk sf AEIn: i.iuwsivtq , qutnctc MA ozlto9 TO Establishment Telephone No.: (pi's 17/70 MR EKY: Applicant Name & Title: ,SV7 11AV_ 1ie5ltr r OAS✓ 4V-7 I �ICit 1>It�C, Applicant Address: 13$5' dQViC( K %, Qu vie/ MA azjtoq Applicant Telephone No,:(p17 '7'70 g7o$� 24 Hour Emergency No.: e17 gQ3 53� Applicant E-mail: 5V7_ mom. keste- e a4ail �JU5IIILS55( ✓dIC¢5. CDYVI Owner Name & Title (If different from applicant):'-(rQ SVGgt SupevrvtaVVP_- CO. t_l cs Owner Address: 138j aavteoc� Si, QuiVIN MA O21t004 Owner Telephone No.: (p 11 9170 9g03 Owner E-mail: S u2 Ct✓1n2. 1CPsyEt/� r2i Qi l Just rt�SS SLtViC2s .Lot 1L 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 El An Individual St?e ��}QcYvt(1 LIST 0 A Partnership — Other legal Entity 0-11- Person .LPerson Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: 377 Ohav✓ieq St, danAu8 MA 0a0N9 Telephone No: Mpg - X37- q`(`� 24 Hour Emergency No: 07 993 539_ FAX: 1`0 E-mail: S°3. sAovp GC(' . �kDr�VVlQV1QC��(�(�(L01[�. CO3'VI, Alt E -Mail: SlZun11g. COMA. District Or Regional Supervisor (if applicable) ' ty` r.{pwlj 7a Name & Title: L�IY-Q(;nciC-- Address: c9)5 E 00in 5 M; 4dleW Cf Telephone No: ��� ��(�_a � 24 Hour Emergency No: �77 M3 5361s FAX: n0/A E-mail: t- k 3� 0z)�f1 Food Establishment Information WATER SOURCE:j Wn 7 SEWAGE DISPOSAL: '7—owy) DEP Public Water Supply No: (If applicable) NO. Of Food Employees' DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. QIA Person Trained in Anti -Choking Procedures (If 25 Seats or more): � t.-)�/� F -,,l Caterer $35.00 Location: ". Permanent Location Establishment Type Moblie Moblie Start Date: [4� Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: Food Service up to 100 INCLUDING Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length Of Permit. ij Manufacture Frozen Desserts/Ice Cream 0 Food Service up to 101 -200 $250.00 $25.001freezer [Jf Annual ------ -- ----- Q Food Service up to 201 + $300.00 E] Pushcart $50.00 # of Pushcarts: [711 Seasonal E] Residential Kitchen $100.00 Seasonal Dates: Supermarkets $400 Q Retail Food $125.00 ❑ Temporary [,�1��',,-1tail Snack Food $50.00 Temporary Start Date: ��e tobacco Products $150.00 Temporary End Dale: Temporary Time: Rain Date: _ Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) I(Chec all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ,, Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And E] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service 71 Delivery of Packaged PHFs l71 Sale of Raw Animal Foods Intended to be Prepared by Consumer F7 Reheating of Commercially 0 Vacuum Packaging f Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- L] Customer Self -Service Perishable Foods OnlyIce contact alternative, time as a public health control) Manufactured and Packaged for Retail Sale F1 Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for Q Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service 0 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 Q 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 ob copies of 1 5 ,and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I Urtily and 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. f' c' I�Q/� Signature of Individual or Corporate Name: —Q 4OP4- Shoo IVIY)CA&I 1 'D Social Security Number or Federal ID: Qt/_30u, qy `� Town of Town of Mansfield - Board o f Health 6 Park RoMvansfield Mansfield, MA 02048 PERMIT NUMBER: s'/5 - 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: LOCATION OF SALE OF TOBACCO PRODUCTS: 57-1 Ghaurcq TELEPHONE AT LOCATION: 5o8_ 33 1- 9q50 OWNER OF BUSINESS: S4tei- Shop 3VOeAWL,4-af CO ADDRESS OF OWNER: /386 k %ar7eQC,t< Si" Qijilic, M/4 20114 TELEPHONE OF OWNER: (.07 790 970k FAX NUMBER: ,717 94?o I R,3 If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 CT -3T NUMBER: c 9 63100g9C/' FEDERAL ID/SS NUMBER: Q N-3O1o1 L1 ,7 SIGNATURE: DATE: Commonwealth of r6ssachusetis Letter ID: L1637646976 <`ishm Department of Revenue Notice Date: September 18, 2018 S Christopher C. Harding, Commissioner Account ID: CGL -10044051.295 r dr mass.gov.'dor RETAILER LICENSE FOR SALE OF CIGARETTES plh��ll�'lld�llll�'{Lutlt�r�I11�JirIILIL�rI'I'i111PJ1 ATTN LICENSING DEPT STOP & SHOP SUPERMARKET CO LLC STOP & SHOP #001 1385 HANCOCK ST QUINCY MA 02169-5103 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 tog 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 c s SFS MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T a6 Retailer License for Sale of Cigarettes 7La /:5' N �Mt.,vroSr�° This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. STOP & SHOP SUPERMARKET CO LLC Account ID: CGL -10044051-295 SUPER STOP & SHOP FUEL #007 Location ID: 10044051-0228 377 CHAUNCY ST License Number: 2037204992 MANSFIELD MA 02048-1169 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 -ZL (? o-�r, #0656 7660 Universal Blvd., Suite 550, Orlando, FL 32819 (800) 446-0257 F (407) 352-3603 w .NRFSPeom ,lational Registry of Food Safety Professionals® Notification of Test Result ID#: xxx-xx- Scaled Test Score: 88 Candidate Status: Pass Test Date: August 24, 2016 ! f - NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® WA MIN -M HAS SUCCESSFULLY SATISFIED THE RECf9fCk MENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENGk; FOR FOOD PROTECTION STANDARDS 6-� Aw PRESIDENT; - v LAWRENCE J. LYNCH, CAE Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. Preventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product Time and Temperature (Competent) Conducting Cleaning and Sanitizing (Competent) Physical Facility Design & Maintenance: Preventing & Controlling Pests (Mastered) ISSUE DATE: AUGUST 24, 2016 EXPIRATION DATE: AUGUST 24, 2021 CERTIFICATE NO: 21 262740 TEST FORM: EZS34 This ser6finte 6 not valid for more than five years From dare or inset, hJ E *y FkQ j. National Registry of Food Safety ProfessionalsG CERTIFIED FOOD SAFETY MANAGER ra PA�'1tR,CTC,�H�GKE�X`; WN %Ceftiticateb 2ib2740' issue Dale: AigusE v�; 1016 Eapirztion Date: August 24, 2021 PATRICK J HICKEY 43 HARRIETT AVE BURLINGTON, MA 01803 National Registryof Food Safety Professionals@ 1 7680 Universal Blvd Ste 550 1 Orlando, FL 32819 I Phone: 407.352.3830 I Fax: 407.352.3603 The Stop & Shop Supermarket Company LLC Officers and Managers Title Name President Mark J. McGowan Treasurer Derk-Jan Terhorst Secretary Mark Messier Assistant Secretary Maria Silvestri Managers: Mark J. McGowan Steven Kienzle Derk-Jan Terhorst Stacy Wiggins Robert Yager All Officers & Managers of The Stop & Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 Page 1 of 2 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOIVYYV) 09/26/,0Ola 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 PRODUCER Willie of North Carolina, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA INSURED The.: Stop & Shop supermarket Company LLC 1149 Harrisburg Pik. Carlisle, PA 17013 USA 1-877-945-7378 com ACE American Insurance Company Indemnity Insurance Company of North ACE Fire Underwriters Insurance Comp rn\/FR Ar:FC r`FRTIFIr.ATF MI IK4RFR, 34812/1358 REVISION NUMBER: 1-888-461-2378 22667 43575 20702 THIS IS DO 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 A00L SU POLICY ) YYY LTR TYPEOPINSURANCE OI POLICY NUMBER MMIDWYYYY LIMITS Town of Mansfield Mansfield Board of Health X COMMERCIAL GENERAL LIABILITY Mansfield, MA 02048 T`L✓^"'GJ�,� EACHOCCURRENCE $ 2,000,000 DAM_ uen� Oncx1 21.000,000 CLAIMS MADE `X] OCCUR PREMISED (Ca A MCO EXP (Any en Oeson) S RDO 671210650 10/01/2018 10/01/2019 PERSONAL &AOV INJURY $ 2,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE - S 2,000,000 GENL x.1 _- POLICYry L._) JroT ) Luc POLICY PnGDucrs � cGMP,oP AGC 2,600, $ 000_ 6 OTHER: AUTOMOBILE LIABILITY COMBINEDSINGLEHMIT ILaaLdde,n)_ S ANY AUTO BODILY INJURY pco porton) $ -- OWNED CCHIEDULED.._ AUTOS ONLY AUTOS BCIDILY INJURY INe, eccldon0 -- $ AIRED NON OWNED PROPERTY DAMAGE _ `5 AUTOS ONLY _, AUTOS ONLY (PMI acudaal)... Y UMBRELLA LIAR OCCUR EACH OCCURRENCE S _ EXCESS LIAR CLAIMS -MADE ACCRCGATE $ _ DID 17 RETENTIONS 1 S WORKERS COMPENSATION XSTATIJiL [FII AND EMPLOYERS' LIABILITY VIN ' - — 1,0001000 B ANYIHOIHILIOHIPAHINEI4:CXECUTIVL 11 rACIIACCIOENT 6 OFFICkFIM MBLElt UUEUP NIA WLR 065937740 ltl/01/2018 10/01/2010 - 1,000,000 (Manda101y In NH) E DISEASE � EA EMPLOYEE $ _. I v deeube unde, ID RIPTIONOFOPERATIONSoelavi ( El DISEASE POLICYLIMIT S 1,000,00D C Workers Companeation-WI 9CF C6543782A 10/01/2018 10/01/2019 E.L. Each Accident $1,000,000 Per Statute E,L. Disease -Ea €Irpl $1,000,000 E.L. Disease-Po1 Lim $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) SEE ATTACHED ncoT2tn ATc UMl MICRO i-AAIP911 ATInh] © 1988.2016 ACORD CORPORATION. All lights reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD an m: 16771903 eA'XH4 862153 2of2 860 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield Mansfield Board of Health AUTHORIZED REPRESENTATIVE 6 Park Aow Mansfield, MA 02048 T`L✓^"'GJ�,� © 1988.2016 ACORD CORPORATION. All lights reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD an m: 16771903 eA'XH4 862153 2of2 860 WILLIS TOWERS WATSON 26 CENTURY BLVD. 6TH FL NASHVILLE, TN 37214 860 1 MB 0.421 Illl�lgl��lglpl�nlln�^dllpldild'u�q��hlginlll��l�l TOWN OF MANSFIELD MANSFIELD BOARD OF HEALTH 6 PARK ROW 860 MANSFIELD, MA 02048-2433 8e*Neok 1'ioG"" In order to expedite distribution of certificates to Certificate Holders, we would like to begin using electronic distribution for future issuances. Also, we would like to remove any certificates that are no longer needed. If you would like to receive electronic copies in the future or no longer require a certificate for this Insured, please note as such below. Please complete this form and submit with a copy of your current certificate to the contact information below: Do you wish to receive renewal certificates: Yes [ ] No [ ] Require a hard copy be mailed: Yes [ ] No [ ] Email Address or Fax Number: SR ID: 16771903 If you require additional information or have further questions, please feel free to contact: Willis Towers Watson Global Certificate Center Email: Certificates @wiIIistowerswatson.corn Fax: 888-467-2378 Phone: 877-945-7378 Please note that it is your responsibility to provide up-to-date contact information to assure correct distribution of any future renewal certificates. 1 o(2 860 Page 1 of 2 ACC)I? CERTIFICATE OF LIABILITY INSURANCE BATE(MMOMYYYY) L 12/12/2018 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($), 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. It 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 Willis of North Carolina, Inc. c/o 26 Century Blvd P.O, Box 305191 Nashville, IN 372305191 USA INSURED The Stop s Shop Supermarket Company LLC Attn: Rick Shaughneaay 1385 Hancock Street Quincy, MA 02169 OSA Willis Towers Watson Certificate Center 1-877-945-7378 ,FA/G Na. 1-888-467-2378 certificates@willis.com ACE American Insurance Company 22667 Allianz Global Risks US Insurance Company 35300 COVERAGES CERTIFICATE NUMBER' W9271776 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. _—__.__ _. _ LTR TYPE OF INSURANCE j POLICY NUMBER MM D�YEF 61M�UIYYYP LIMITS AUTHORIZED REPRESENTATIVE COMMERCIALGENERAL LIABILITY X I'. _ EACH OCCURRENCE '$ 2,000,000 Mansfield, MA 02096 �-CLAIMS-MADE , OCCUR PREM SES Ea aa_ur_renpa)-__' 21000,000 A Ii MED EXP (Any one person) 15 HDO 671210650 :10 O1/2016� / .30/01/2019 -' _.I , 000 PERSONAL&ADV INJURY :$ P,000. GEi LAGGREG_ATE LIMIT APPLIES GENERAL AGGREGATE j$ 2,000,000 X PRO LOC POLICY r IJECT PflODUCTS- COMP/OP AGO I $ 2,000,000 _ - OTHER: ! $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 000,000 a ! $ S0, X'I ANYAUTO BODILY INJURY (Per person) $ A ;OWNED I I SCHEDULED ISA 825268349 ) ! 10/01/2018 10/01/2019 BODILY INJURY i $ AUTOS ONLY AUTOS X15 HIRED H NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY -, (Per gscident) IS B X UMBRELLALIABX OCCUR ,EACH OCCURRENCE $ 5,000,000 EXCESS LIAR _IGLAIM6_MADE USLOO169518 112/O1/2o19� AGGREGATE ,12/01/2018 __ I$ 5,000,000 DEO I RETENTION $ I is WORKERS COMPENSATION X I STATUTE I OR AND EMPLOYERS' UAB1UTY Y N _ f $ 11000,000 A ! ANYPROPRIETOWPAI TNER/EXECUTIVE E L EACH ACCIDENT OFFICERRAEMBERE%CLUDED7 ((Mandatory N/A WLR C65437740 10/01/20113.10/01/2019 '- __I �ELDISEASE 1,000 000 In NH) EAEMPLOY_EE_IS _ If yes, describe under'' DESCRIPTION OF OPERATIONS bels. E.L. DISEASE -POLICY LIMIT $ 1,000,000 �� rrpensation-WI A �,Workers Co ', � SCSC6543782A ,10/01/2018 10/01/2019 1E. L. Each Accident li $1,000,000 ;Per Statute " '[E. L. Disease -Ea Empl 1$1, 000, 000 IS. L. Disease -Poi LLn,$1, 000, 000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be sheched it mare space is required) RE: Store #007. Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED CFRTIFICATF HAL DFR CANCFI I ATION ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SR Io: 17195383 &NTcH: 986711 2.f2 178E SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield Health Dept. AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02096 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SR Io: 17195383 &NTcH: 986711 2.f2 178E