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HomeMy WebLinkAboutFour Corners Citgo - 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:. ANJANA D. PATEL, PRESIDENT Whose place of business is: FOUR CORNERS CITGO 4 SOUTH MAIN STREET Permit Expires December 31, 2019 License Number: RF-4 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH AichaeCHeaCey, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: FOUR CORNERS CITGO 4 SOUTH MAIN STREET License Number RF-4 Permit Expires December 31, 2019 BOARD OF HEALTH MichaeCHeaCey, Chairman 9 FOR BOARD OF HEALTH USE ONLY Permit # issued FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned o g&W 3 12018 Establishment Name: LA %rV-1"> Establishment Address: (,` SrJU}h r,-\cA'n 5 r^nS A etZj M IK, i Establishment Mailing Address(if different): Establishment Telephone No.: ko C) - �j3 - ra \\ Applicant Name & Title: 1� �" 25 vo �e" Applicant Address: U Cl 1 � S vo bl�-_ �� I ✓v ° s �, Applicant Telephone No.: \ G$ - q g L- $ 2 24 Hour Emergency No.: 5 tv8 '2t t Applicant E-mail: £SV-N (� K o Uj hcv ..Grsr Owner Name & Title (If different from applicant): (AY)^-e- p-3 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 El An Association partner. 1!kA Corporation ame Title Address An Individual 0' owne✓- t1uIz5VCnhle A Partnership v� El Other legal Entity__ �_ _ Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 1Y125� 1 �a� Mn ✓ SA/e ��� M I�r� vZ tS Address: LA & Q 5hrnb�C C'ri TelephoneNo:'jC,,K'_ 67_--`6A72 24Hour EmergencyNo:5 FAX: E-mail:�G�c�c5Nn (o6 i cJvl , AltE-Mail: PG\hNv2Z%jn � District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) '., No. of Food DAYS/HOURS: 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 Seals or more): 11 Location: ❑ Permanent Location ]Moblie Mobile Staff Date: Mobile End Date: Moblie Comments: Length of Permit: Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type Retail ( Sq. Ft) Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Q Food Service up to 101 -200 $250.00 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 Manufacture Frozen Dessertslloe Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 5Z Retail Food $125.00 Mi3etail Snack Food $50.00 Ll Tobacco Products $150.00 Food O rations Definitions: PHF- Potentially hazardous food pimeeemperaf ne controls required) Pe Nor-PHFs -non-pofenfially hazardous /ord(no timertemperafam controts required) '.(Check all that apply): R7E- ready-fo-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessmill Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pm -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 Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Ice Manufactured and Packaged to Retail Sale Juice Manufactured and Packaged Retail Sale ' Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date I or Reconditioned Food 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 I Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin Prepares FoodlSingle Meals for Catered Events or Institutional Food Service To be -- Total Permit Fee: - Payment is due with application 0 waived J 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 690.000 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 perjury that I, to my best knowledge and belief, have filed all state tax returns and paid slate taxes required under law. Signature of individual or Corporate Name: Social Security Number or Federal ID: Z!) (q 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. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. OF BUSINESS: LOCATION OF SALE OF TOBACCO PRODUCTS: L1 �JCJi�f� f`1��V\ s ✓fir^^S �I�� � � � C/`ZG�U� TELEPHONE AT LOCATION, NER OF BUST SS: \V\P�\/-\ a'NeA S OF OWNEW N\�TC'Z��� TELEPHONE OF OWNER: FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. RcP'\ , C"'u-Y�e/— , a-,,� S'SK b\ S 1-' /0 (� '\ VCA * Provide a of Revenue CT-3T FEE: $150.00 yy�/n CT-3T NUMBER: \\ O D-"l O't 6 oa FEDERAL ID/SS NUMBER: '-2-0 LA- Xo 6 - W�0 6 SIGNATURE: DATE: W/S / `K unit 2 6 GH4@ y�} Commonwealth of Massachusetts Department of Revenue Clmstopher C. Harding, commissioner E4•rdr0 mass.gov/dor o Letter ID: L0945599104 AN Notice Date: September 26, 2019 Account ID: CGL-11981294-006 RETAILER LICENSE FOR SALE OF CIGARETTES pt��Iptl�Idr[it 1111119't1'11111,pJlIII ll11111,1111, Milil SUBH LAM INC o CrWO 4 CORNER CONVENIENCE 4 S MAIN ST v ORE. MANSFIELD MA 02048-2516 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 --- ------ --- - ------------------------ ------------- -------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age Is prohibited. SUBH LAXMI INC CITGO 4 CORNER CONVENIENCE 4 S MAIN ST MANSFIELD MA 02048-2516 Account ID: CGL-11981294-006 License Number: 1102489600 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. �yU % LC4N, core- Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) -�_lJVI, — G,6^ "l O u "Social Security No. (Voluntary) or Federal Identification Nmnber *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\ScoICs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc AML The Commonwealth of Massachusetts Department of Industrial Accidents Off►ee,of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �U LTV ` S `^ C Address: LA �C�b` 4—)-\ ,� , /",AInr�s�'e.�L /\/\,P,- C_'-2_ City/State/Zip:�g r� \r\, ✓✓1 N4 G1C`t T' Phone #: go K — 33 7 Are yqu an employer? Check the appropriate box: Busi ss Type (required): MRetail 1. I am a employer with employees (full and/ 5. or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. g• ❑Nop-profit [No workers' comp. insurance required] 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.❑ Manufacturing no employees. (No workers' comp. insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.0 Other with no employees. [No workers' comp. insurance req.] *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 organimion should check box N. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:: ' I \-.0 � \ V t e_r t Insurer's Address: (7 [A rTASt 6,rUVC_ City/State/Zip: /V\ C•\CC, (U AA Expiration Date: U-7 / l LA / o l Wj Policy # or Self -ins. Lic. # � N P ' 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 penalties of perjury that the information provided above is true and correct Date: ' V / 31 / t 9 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 Person: Phone #: www.mass.gowma SUBHLAI q��2o CERTIFICATE OF LIABILITY INSURANCE OP [DR TL DATE( 6/O(Yyy 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(ies) 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 endorsements . PRODUCER 508-947-1818 J.K. OlivieriGroIns. Agency 84 East Grove St. Middleboro, MA 02346 Kenneth W. Olivieri 92W. CT Kenneth W. Olivieri PHONE 508-947-1818 FAX ac ryo, EXL : ac, No E-MAIL INSURERS AFFORDING COVERAGE NAICM INSURER A: NGM Insurance Co. 14788 INSURED Subh LaXml Inc. dba Four Corners Citgo 4 South Main St Mansfield, MA 02048 INSURER B : Crum & Forster Specialty IDS INsuRERc:Ma. Retail Merchants WC Group 28612 INSURER D : INSURER E : INSURER F: MBER• REVISION NUMBER: COVERAGES ERTIFICATE NU 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 TH A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY X CLAIMS-MADE❑OCCUR DDL UBR POLICY NUMBER BP09026H POLICY EFF 07/14/201807/14/201g POLICY EXP LIMBS EACH OCCURRENCE 1,000,000 DAMASETESOREoNcSTEo MEDEXP An one eman 500,000 $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GEML AGGREGATE LgIIMIT APPLIES PER: X POLICY jE�T LOC GENERAL AGGREGATE 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Per erson BODILY INJURY Per accident $ OWNED TUTU EDOS ONLV SCHEDULED H RED NON-0WryED TOS ALTOS ONLY AUTOS ONLY PeOraE«R'�de DAMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY Y/ry ANY PROPRIETOR/PARTNER/ ECUIVE OFFICERIMEMBER EXCLUDED? (Mantletmy. N)l 0 yas, describe under DESCRIPTION OF OPERATIONS be. Pollution liab. Claims Made C B N/A 074005033710117 STP115094 01/01/2018 11/28/2016 01/01/2019 11/28/2018 X PER OTH- E.L EACH ACCIDENT 100,000 $ E.L. DISEASE - EA EMPLOYE 100,000 $ E.L DISEASE -POLICY LIMIT aggregate ded/claim 500,000 2,000,000 5,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER `�^"�'-'-`•^ 1— MANST02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 ACORD 25 (2016l03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD