HomeMy WebLinkAboutTedeschi Food Shops 37484H - 12/31/2019503q
FOR BOARD OFMALTH USE ONLY Permit
FOOD ESTABLISHMENT PERMIT APPLICA
(Application must be submitted at least 30 days before the planned
so
Establishment Name:�BY:---
Establishment Address: l
Establishment Mailing Address(if different):
P 10 RoX
Establishment Telephone No.: 54'9-- 33
Applicant Name & Title: 1 w e -- Zvvner
Applicant Address: ;-Lo 0 yu)
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Applicant Telephone No.: Z®, ` 24 Hour Emergency No.:� pry�c,Q ^PY�
Applicant E-mail: O C�g(2���1, C'QW1
Owner Name & Title (If different from applicant):
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
0 An Association
Qa';�'_Corporation
An Individual—
partner.
ame i Title Address
O A Partnership
_
0 Other legal Entity5�1
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 1),;s y\ GIV A-Ayyq,�,, mJ r
Address: 1-70 4N hlewd 's+3 �, fT*t4Qr1
Telephone No: _ q_3"3 4- St(�' 24HourEmergencyNo:2
'
FAX: 928-•.10-sI l 'fP`rrCdVNCe' GraW�7�r
E-mail: l%im��2@ �7-��►G�%h(��L�9
[n� 7 /�
Alt E-Mail: S- tfQ
District Or Regional Supervisor (if applicable)�Qt J CQgsl�r
'(�mr C.-
Name & Title: V' 0.nc-c t-fAViP
Address: 0 VrAvQ-> (�'COr_�l�-+oVk
Telephone No: 2 % - -
(�y� 24 Hour Emergency No:
7�
FAX: q'�Z'�2'S�yto�-3-1
f�
E-mail: ft%VriC (iV/L-�i 1=�1. V in
Food Establishment Information
F
ATER SOURCE: �5� � SEWAGE DISPOSAL:P Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS:
Name of Person In Charge Certified in Food Protectiotl Management �
If more than 3 individuals are certified, complete list is on file. fnQ s
Person Trained in Anti -Choking Procedures (If 25 Seats or more): El
Location: M
0 Moblie Mobile Start Date:
Mobile End Date:
Mobile Comments:
Length of Permit:
nnuaI
Ej Seasonal
Seasonal Dates:
Temporary
Temporary Start Dale:
Temporary End Date:
Temporary Time:
Rain Date:
Location Establishment Type
M"Retall (3 L0(J Sq. Ft)
(/,°Food Service up to 100 INCLUDING
FOOD TRUCKS $175.00
E] Food Service up to 101 -200 $2%00
RI Food Service up to 201 + $300.00
Supermarkets $400
Caterer$35,00
ilk & Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
0 Manufacture Frozen Dessertslice Cream
$25.00/freezer
Ej Pushcart $50.00 # of Pushcarts:
Residential Kitchen $100.00
71 Retail Food $125.00
0 Retail Snack Food $50.00
fit]-I'omacco Products $150.00
Food O Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required)
P Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
I Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
Cus Omer Self -Service
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
ce Manufactured and Packaged for
Retail Sale
Offers Raw Or Undercooked Food Of
Animal Origin
Juice Manufactured and Packaged for
Retail Sale
E Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
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 F] waived
I, the undersigned, attest to the accuracy of the information provided in lhis•appllcation and affirm that the food
establishment operation wi mply with 105 C 0 and all other applicable aw. I have been instructed by the
board of health on how to t opies of 105 M 90. 0 and the fed I Food de.
Signature of Applicant:
Pursuant to MGL Ch 62C sec. 49A I certify unde Onalties of perjury the 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:
National Registry of Food Safety Professionals
FOOD SAFETY FIRST PRINCIPLES
Food Handler Training Program
CERTIFICATE OF COMPLETION
Donald Ames 3/6/1965
Employee Name Date o Birt
has successfully completed Food Safety First Principles: For Food Handlers
HRTS'
Business Name
Authorized/Manager Signature
Aug 27, 2017 Aug 27, 2022
Y1039 Date of Completion haNN.>m r�w�.I,�l,n Expiration Date
ASTM E26S9
cartkate Issuate National Registry of Food Safety Professionals • Orlando, FL • www.NRFSP.com • 800-446-0257
NONiAU6EEAAaIE
C) National Registry of Food Safety Professionals
A'1039 _
ASTM f1ti59 /'—FOOD SAFETY FIRST PRINCIPLES
C ASTIA to hsuer
14
Food Handler Training Program
Donald Ames 3/6/1965
Employee Name Date of Birth
has successfully completed Food safety First Principles: For Food Handlers
HRTS"
Business Name Authorized/Manager Signature
Au¢272017 Aug 27, 2022
Date of Completion Expiration Date
rtw.r sNuao rtr aaNyaeALnlll
Nation) Registry of Food Safety Professionals a Orlando, Fl. a www.NRFSP.com t 800-446.02 S7
• Employer/Manager • Keep this stub as proof of completion in employee's file.
• Detach the certificate and wallet card and give to the employee.
NON IJU NS(IA a
National Registry of food Safety Profesnonals
(DOO SA((iY flAti IAINCIIItS
fooAHandle. Lmmnp l,�am `�\
�T
Donald Ames 3/6/1965
Employee Name One of Balh
AutNOneea/Manager Signature
Aug 27, 2017 Aug 27.2022
(1011 Date of Compltpon trwel ou Dne
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
y Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leizibly
Business/Organization Name:
Address:
..47�-4Y-;
,QA d y • , C)E09 Phone #:
Are you n employer? Check the appropriate box: Business Type (required):
1. I am a employer with — lT—employees (full and/ 5. [Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10. El 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.] 12.0 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 the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing2vorkers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: r 0 )A
Insurer's Address: 2� b� Aft '4u kcA 71 V-a,2 b
City/State/Zip: VIV"% L:. C—
Policy # or Self -ins. Lic. # %0L_&R r_` c v s q %S J TL Expiration Date:
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 certify, under the pains and�pena(lfties ofperjury that the information provided above is 1truye/ 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 Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
v
Phone
www.mass.gov/dia
ACC>R" CERTIFICATE OF LIABILITY INSURANCE
DATE (IO/Ol/18)
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 CONSITUTE A CONTACT 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 be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the 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
CONTACT
NAME:
(AICNNo. Exl):
(866 283.7122
(A/C, No):
(847) 953-5390
AGIN Risk Services Southwest, Inc.
Dallas Location
2711 North Haskell Ave, Suite 800
E-MAIL
ADDRESS
INSURERS AFFORDING COVERAGE NAICN
Dallas, TX 75204
(214) 989-0000
INSURER A:�i Mitsui Sumitomo Insurance Co of America 20362
INSURED
INSURER B: ACE American Insurance Company'.. 22667
INSURER C: Indemnity Insurance Co of North America 43575
7-Eleven, Inc.
One Arts Plaza
1722 Routh Street, Suite 1000
INSURER D:
INSURER E:
Dallas, TX 75201
COVERAGES CERTIF!C-ATF NIIIMRFR 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
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUER
WVD
POLICY NUMBER
POLICY EFF
DATE(MMIDDNY)
POLICV EXP
DATE(MMIDD/YY)
LIMITS
8
GENERAL
LIABILITY
OMMERC GENERAL LIABILITY
CLAIMSMADEQX OCCUR.
OWNERS' & CONTRACTOR'S PROT.
EACH OCCURRENCE
$DAMAGE
TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any One Person)
$
PERSONAL & ADV. INJURY
$
GENERAL AGGREGATE
$
LIQUOR LIABILITY
$500,000 SELF INSURED RETENTION
PRODUCTS-COMP/OP AGO
$
B
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
ALL OWNED AUTOS
(Ea amiden0
BODILY INJURY
_
$
SCHEDULED AUTOS
HIRED AUTOS
(Per Person)
BODILY INJUR
$
NON -OWNED AUTOS
(Per Accident)
PROPERTY DAMAGE
$
(Per Accident)
A
EXCESS
X
LIABILITY
UMBRELLA FORM
EACH OCCURRENCE
$
AGGREGATE
$
OTHER THAN UMBRELLA FORM
C
B
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
NY PROPRIETOR/ Yes
PARTNERS/EXECUTIVEX NO
PRICER EXCLUDED
LR C66435706
OS
SCF C65435780
LR C65435743
Z/CA/MA
10/1/2018
10/1/2019 '-
X
I WC STATU-TORY LIMITS
Other
EL
EACH ACCIDENT
$
1,ow,000
EL DISEASE— POLICY LIMIT
EL DISEASE —EA EMPLOYEE
$
$
1,000,000
1,000,Wo
e
OTHER
Ea. Common Cause
A re ale
ADS
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESISPECIAL ITEMS
Evidence of Workers Compensation Coverage for all 7-Eleven Corporate Stores
Whom It May Concern
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
AON RISK
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Inc.
rights
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 &rporate Name By: Corporate cer (Mandatory, if plicable)
*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.
C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
POWER OF ATTORNEY
Know all persons by these presents that 7-Eleven, Inc. (7-Eleven" or the "Company'), has
made, constituted, and appointed, and by these presents does hereby make, constitute, and
appoint Cheryl Swinford;
Its true and lawful attorney -In -fact, for it, and in its name, place, and stead, to take all actions
necessary and appropriate to renew, apply for and obtain any licenses, permits or similar
services incidental to the business of the Company including, but not limited to, the following
categories:
• alcoholic beverages;
• lottery;
• tobacco;
• food processing;
• food service;
• food products/retailing;
• volatile chemical; and
• utilities.
Also included are any and all other documents relating to or necessary for the issuance or
transfer of such licenses, including but not limited to guarantees to the licensing agency, and to
assign and reassign any and all necessary papers in connection therewith, giving and granting
unto its said attorney -in -fact full power and authority to do and perform all and every act, as to
all intents and purposes as it might or could do, with full power of revocation, hereby ratifying
and confirming all that its said attorney -in -fact shall lawfully do or cause to be done by virtue
hereof.
The individual appointed as an attorney -in -fact herein shall remain an attorney -in -fact with the
authority granted herein for until such appointment is otherwise revoked by 7-Eleven.
In witness whereof, said 7-Eleven has caused these presents to be signed by its proper
corporate officer as of May K 2016.
7-ELEVEN, INC.
Attest:
ey
Rubinett Rankin L, Gas ay
Secretary Senior Vice President
177658v13
State of Texas
County of Dallas
On this 1� day of 00,aj , 2016, before me, the undersigned notary
public, personally appeared Rankin L. G saway and Arthur E. Rubinett a Senior Vice President
and an Assistant Secretary, respectively, of 7-ELEVEN, INC., a Texas corporation, known to me
to be the persons whose names are subscribed to the foregoing instrument, and acknowledged
to me that the same was the act of the said corporation and that they each executed the same
as the act of such corporation for the purposes therein expressed and in the capacities therein
stated.
In witness whereof, I hereunto set my hand and official seal.
(Notary ublic signature)
JrL)T.& Y� i� t (A_ VYt S IM%
(typed or printed name
(S _ _ �
1'•ryY A(j�., SUZANNE HARRISON
,* Notary PubllgState ofTo"&
�� �AfMyComm.ErPlreeOY•23301T
' Notary 10262632.3
17765803