HomeMy WebLinkAboutStop & Shop #007 - 12/31/2020NOV 1— — -
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
Establishment Address 7,'l `7 t) o,�
Establishment Mailing Address (if different)
(0�i,nc� Y�IA da.)hi
aN�cocl<_Sk- VV`t1`lU' L�cenS,nc�
Establishment Telephone No (� I (_ -7 i C>
Applicant Name & Title:
Applicant Address 1ckr)c c�c k.�S T- i cy
Applicant Telephone No.: o i -7 --7'70 - L, c i C) 24 Hour Emergency No.: KS T'7 - tri �_3 cs
Applicant Email SF � z c , i jet, , o es.� Sec v`, c e S' C_
Owner Name & Title (If different from applicant) 1,jC �j c, d>G j� <> r r,c c i 4 _u e_ t
Owner Address 9 c:c_k. S4-• 7t.;:,e'rc+. ro rO
Owner telephone number L-,/ 7 - 7 7& t%f C)
Owner email: c�� o i�± :Sir)rSSSC,(-k vers. Gt n
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
O An Association partner.
O A Corporation Name C` q Title Address
13 An Individual_ ---
0 A Partnership
EO' ther legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: 37-7 C %NC_ _13 i d, r i A o c, r4 s
Telephone No:Cs`5- :3 ?>'7.. Ci+6_0 6_0 24 Hour Emergency No: ' 7 -7 Ci - 93
FAX: Vr//,�cYR M AxH �etm. f f'eam� Old �8
E-mail: SS 5 fcrP . tic C ?,
Alt E -Mail: Sar c x Rete
District Or Regional Supervisor (if applicable) `(M V" C, T n-f-� % n
Name & Title:`,
Address: c4 -t.3- c
Telephone No: S(,06LR c'3_�4' 24 Hour Emergency No: f_'77-_Srj3 _y-393
FAX: ,fes/
E-mail: 1V hil
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL: M v
No. of Food�Employees:�y ! rS_J
DEP Public Water Supply No: (If applicable)
DAYS/HOURS; j1 thy) C - f y 4
1 _4'�
c
Name of Person(s) In Charge Certified in Food Protection Management: ��C y C; n �JCk
Name of Person(s) In Charge Certified in Allergen Awareness Training \� �S(C G-
L
Name of pest control company routinely inspecting the premises for evidence of pests R FYI ; tiara -n ; �--
If there is seating for 25 people or more,ta person trained in manual choke saving procedures will be onsite at all times
food is being prepared. UI Yes
Does this establishment require a FOG permit?e If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
[Annual
❑1 Retail Food $125.00 U Mobile Food Consession
0 Temporary
U Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 F -I Manufacture Frozen Desserts/ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Service up to 201 + $300.00 E] Pushcart $50.00 # of Pushcarts:
Temporary Time:
sFood
T Supermarkets $400 U Residential Kitchen $100.00
Rain Date:
['Milk &Cream $10.00 U Caterer $35.00
Food Operations: Definitions. PHF Potentially hazardous food(time/temperature controls required)
(Check all that apply): Non-PHFs- non-potentfally hazardous fwdfno time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Hot PHF Cooked and Cooled or Hot Held
[� ale of Commercially Pre -Packaged Non-PHFs U PHFCooked To Order M/
WIf of Commercially Pre -Packaged PHFs U Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service U PHF and RTE Foods Prepared For Highly
�r Q Sale of Raw Animal Foods Intended Susceptible Population Facility
Reheating of Commercially
LLf to be Prepared by Consumer 0 Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer
[(] Self -Service contact alternative, time as a public health
0 Customer Self -Service of Non PHF and Non-
Perishable Foods Only U Ice Manufactured and Packaged for control)
[Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of
U Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities U Prepares Food/Single Meals for
U3 Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
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 obtain collies 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 state taxes required under law.
Social Security Number or Federal ID:� �� C3 rr'7✓
Signature of Individual or Corporate Name`-f1E' r3C ll "dC tUi(`i
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.
1{...
SignatureIndivdualor Corporate Name By: Corporate Officer (Mandatory, if Apylicable)
O 3C) //7v
"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\Osen\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORNI.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u,p 600 Washington Street
Boston, NIA 02111
www,.ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�laiicant Information Please Print Lc�ibiv
Business/Organization Name. The Sto�� & Shop Sup rmarket CJQmpany
Address: 1385 Hancock St
City/State/Zip:
Phone l/ 800-288-8415
Are you an employer? Check the appropriate box:
Business Type (required):
1.0
lama employer with -,__—_employees (full and/
5. ® Retail
or part-time).'
6. ® Restaurant/Bas/Eating Establishment
2. ❑
1 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.
8. [! Non-profit
[No workers' comp, insurance required]
3.0
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and Nye have
10.0 Manufacturing
4. El
no employees. [No workers' camp, insurance requ red]
We by
11.❑ Health Care
are a non-profit organization, staffed volunteers,
with no employees. [No workers' comp. insurance j
12.❑ Other---.^-._._.._ ,...._,...._.. _
"My applicant that checks box al must also rill am the section below showing thoir workers' compensation policy info mmion.
"atf the corporate onicam have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and sucb ars
organization should chock box Ni.
Pam an employer that is providing workers' compensation insurance for my employees Below is the policy information.
Insurance Company Name: Ahold Delhaize America Holding, Inc. and its subsidiaries
Insurer's Address: 1385 Hancock St
CitylState/Zip: Quincy MA 02169
Policy hlor Self -ins. Lic. 4 576 Expiration Date Zl 0 2 -
Attach
Attach it copy of the workers' compensation policy declaration page (showing the policy number an 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
P do hereby certo�,uyge., the pains,and penahles of perjury that the information provided above,is tine and correct
0
Officiat use only. Do not write in this area, to be completed by city or torten official
City or Town:
Permit/lAcease
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
�vvnv.mass,go� dna
The Stop & Shop Supermarket Company LLC
Officers and Managers
Title
Name
President
Gordon Reid
Secretary
Mark Messier
Assistant Secretary
Maria Silvestri
Managers:
Steven Kienzle
Manager
Gordon Reid
Manager
Stacy Wiggins
Manager -
Robert Yager
Manager
; o�FOODs
NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®,
CERTIFIES
o z JESSICAL PATTIE
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
CERTIFIED
rooDserszrarncrecea '® FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT: Iwo X"..
LAWRENCE J. LYNCH, CAE
ISSUE DATE: JANUARY 21, 2015
40656 EXPIRATION DATE: JANUARY 21, 2020
CERTIFICATE NO: 21058840
7680 Universal Blvd., Suite 550, Orlando, Fl- 32819 TEST FORM: EZS26
t800)446-0257 F(407)352-3603 www.NRFSP.com Tuis,maricnle is and valid Far more
, ational Registry of Food Safety Professionals® than rive year. from dam orint e.
yeFFo00f y National Registry of Food Safety Professionals
Notification of Test Result
CERTIFIED FOOD SAFETY MANAGER
a
ID#: XxX-%X- e -
Scaled Test Score: 97
Candidate Status: Pass
Test Date: January 21, 2015
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 (Mastered)
Actively Managing Controls in a Food Establishment (Mastered)
Monitoring the Flow of Foods (Mastered)
Ensuring Product Time and Temperature (Competent)
Conducting Cleaning and Sanitizing (Mastered)
Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered)
JESSICAL PATTIE
JESSICAL PATTIE
330 EAST AVE
HARRISVILLE, RI 02830
-. Certificate No: 21058840
Issue Date: January 21, 2015
Expiration Date: January 21, 2020
National Registry of Food Safety Professionals iO 1 7680 Universal Blvd Ste 550 j Orlando, FL 32819 1 Phone: 407.352.3830 1 Fax: 407.352.3603
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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.
-o
Signature of Inorvicluaf or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
� X P
C9Y- -3">(,,iL/�-,l%
*"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\Usem\sleite\Desktop\ScotCs Documents\Food Establishments-Temp\TAX CERTIFICATION FORNLdoc
t-�'p0OODs
NATIONAL REGISTRY OF
�14 FOOD SAFETY PROFESSIONALS®.
CERTIFIES
O z O
JESSICAL. PATTIE
z
HAS SUCCESSFULLY SATISFIED THE REQUIREMENT'S FOR THE
CERTIFIED
Foons4narrnrnxncerz ® FOOD SAFETY MANAGER
UNDERTHE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT:
a LAWRENCE J. LYNCH, CAE
f ®im
ISSUE DATE: JANUARY 21, 2015
40656 EXPIRATION DATE: JANUARY 21, 2020
CERTIFICATE NO: 21058840
7680 Universal Blvd., Suite 550, Orlando, FL 32819 TEST FORM: EZS26
'(800)446-0257 F(407)352-3603 www.NRFSP.com This certificate is nor valid for more
lational Registry of Food Safety Professionals® then rvr,,,r, from dmn mane.
u' oopf r National Reoistry of Food Safety Professionalse
CERTIFIED FOOD SAFETY MANAGER
Notification of Test Result g
ID#: xxx-xx- = i I JESSICALPATTIE
Scaled Test Score: 97 CexTrr,co
Candidate Status: Pass7680
Test Date: January 21, 2015 Suite 550 Universal Blvd.
Orlando, FL 32879
ToilOee(800)446-0257j - Certificate No: 21058840
Y Phone (407) 352-3830, Issue Dare: January21, 2015
Fax (407j SP.oca 03 Expiration Date: January 21, 2020
.www.NRFSP.com. P �'
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 (Mastered)
Actively Managing Controls in a Food Establishment (Mastered)
Monitoring the Flow of Foods (Mastered)
Ensuring Product Time and Temperature (Competent)
Conducting Cleaning and Sanitizing (Mastered)
Managing:Physicai Facility Design & Maintenance:Preventing & Controlling Pests (Mastered)
JESSICAL PATTIE
330 EAST AVE
HARRISVILLE, RI 02830
National Registry of Food Safety ProfessionalsO 1 7680 Universal Blvd Ste 550 1 Orlando, FL 32819 1 Phone: 407.352.3830 1 Fax: 407.352.3603
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The Stop & Shop Supermarket CompanV LLC
Officers and Managers
Title
Name
President
Gordon Reid
Secretary
Mark Messier
Assistant Secretary
Maria Silvestri
Managers:
Steven Kienzle
Manager
Gordon Reid
Manager
Stacy Wiggins
Manager
Robert Yager
Manager
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
u,p 600 Washington Street
Boston, MA 02111
www. ntass. gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: The Stogy & Shy}- Supermarket Company LLC__.
Address: 1385 Hancock St
City/State/Zip:_Quincy MA 02169 _ Phone i# 800-288-8415
Are you an employer? Check the appropriate box:
1. ® I am a employer with -__employees (full and/
or pari -time). a
2. ❑ I 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.1
Business Type (required):
5. ® Retail
6. [] Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
9. ❑ Non-profit
9. ❑ Entertainment
10 El Manufacturing
11.❑ Health Care
12.[] Other
*My appliceat a,at chocks box U1 must also fin out the aecsion below showing their workers' compensation policy infoemasion.
4' If the corpomo oflicon have examptad themselves, but the eorpuntion hen other employees, a workers' compesuation policy is required and such an
organisation should check box 41,
I am an eWtoyor that isproviding workers' compensation imarareee for my employees Below is the policy information.
Insurance Company Name: Ahold Delhaize America Holding, Inc. and its subsidiaries
Insurer's Address: 1385 Hancock St
City/StatdZip: Quincy MA 02169
Policy 9 or Self -ins. Lic. 0 576 Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number an 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 fire
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
0
ofperjury that the information
dffaciat use only. Do not write in this area, to be completed by city or town official
City or Town:
PermitfLicense
true and correct.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
,ww.mass.go, dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: ` - L) 4
Mailing Address: c C i%- _ c CA n -C _CC. k -L,
r
Phone�#axNumber:��>!'% - '9 7A -/ I>
`J n i
Contact Person�tle for Grease Traps: C' + ' s1 ' f� 0k
Name of Company scheduled to pump Internal grease trap(s) monthly: Win -d'
Name of Company scheduled to pump external grease trap quarterly: w1ha 41
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
container
$50
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledge that the information submitted in these documents is true, accurate and complete.
igned Rat
tom; tC> 2 t t
S 2 .r'it 4 e
Print Name `u S Cr yt
Please answer all questions in this section. if an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation): J f
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday
Thursday
Sunday
IN
Tuesday Wednesday
Friday Saturday
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
3 compartment sink
Handwashing sink
Commercial Dishwasher
Barsink
Mop Sink
Garbage Dis sai
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., In three (3) bay sink, off site by private company):
Is dinnerware pre rinsed before being washed?
If yes, at what station/sink?
Yes
No
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site? C 5/
'External Grease eT Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes No Size 'ROQD gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Tetephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied?_
Please list the vendor who removes the waste:_
Please list fixtures attached to each grease trap
Grease Trap I
Grease Trap 3
omqaL L
Grease Trap 4
y
Grease Trap 5 _
_m.�YY .....
'External Grease eT Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes No Size 'ROQD gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Tetephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied?_
Please list the vendor who removes the waste:_
WorkOrderft 0238387123
Cust#2201976
Job Commen
PO 010001707144 /Service (IG) 6 Trap - Every 1 month -
TECH MUST Check In/Out Using Corrigo Pro APP< - Take clear
before/after pictures - No Pricing On Site - If any
Problem with APP Email: (Checkin0wrenvironmental.com)
MUST HAVE PO TO SERVICE -'" -
System
C&W Services/Stop & Shop
275 Grove Street
Suite 3-200
Auburndale, MA 02466
(000) 000-0000
Service Date: MON 10/14/2019 11:3o PM Frequency
Service Type: Standard
Previous Service:
Approx. Gals: 0
CCLS:
Depth Below Grade:
Custom Clean:
Cost Home: No
Filter:
Township:
Inspection/T5:
County: Middlesex
Build Up:
Customer Since: 2 O 19
IG Stop & Shop 0007
377 Chauncy Street
Mansfield, MA 02040
Manager : (508) 337-9450
Monthly-Specif icDays (Call to Confirm:
Unit Price Ext Price
Location Details:
Tax: 6.2500 a
Tech Comments
System
We suggest these 3 keys steps to keep your system healthy:
• Regular servicing
• Use CCLS bacteria additive
• Use a filter
Disposal Site: Disposal Volume: Payment Detail:
Waste Code : 0.0000
Invoice
Sales Rep : No Rep CSR : Kelly Drohan Due on Receipt
Truck : Technician : Arnulfo Martinez On Site : o2: a AM P 0 Number : AUD001707144
Tech Notes :
(Bakery]:. Heavy rust need replaced $100. 7" H2O. 5" SOL. 4" GRS. Left 0 btl
solution. Replace gasket. BOH logs signed. Extra Services : . [Mop Sink]:.
Moderate rust 450. 8" H2O. 5" SOL. 1" GAS. Left 0 btl solution. Replace gasket
BOH logs signed. Extra Services : . [Meat]:. Moderate rust 4100. 12" H2O. 4"
SOL. 0" GRS. Left 0 btl solution. Replace gasket. BOH logs signed. Extra
Services [Produce]:. Heavy rust need replaced 450. 5" H2O. 5" SOL. 4" GRS.
Left 0 btl solution. Replace gasket. BOH logs signed. Extra Services : .
[Seafood]:. Heavy rust need replaced 4100. 11" H2O. 5" SOL. 0" GRS, Left 0 btl
solution. Replace gasket. BOH logs signed. Extra Services [Deli 1 ]:.
Moderate rust 4100. 0" H2O. 8" SOL. 8" GRS. Left 0 oft solution. Replace
gasket. BOH logs signed. Extra Services : . Pumping and Clean G traps. Did you
check in and out? : Unchecked. No signature/store stamp.
-
�_
X
Customer Signature
I
AUND
a
R -
ENVIRONMENTAL
Work Order# 0210170815 Cust#2201976 Customer Since: 2019 Tax:6.2500
Tech Notes :
Normal water level. 15in bottom sludge. Sin top solids. Both baffles are
intact. Main line Clear. No filter is present on the tank; current tank is not
designed to be used with a filter. Cover(a) secured. Popped all 4 covers heavy
solids and sludge in bottom covers secure.
Customer not on site
Signature
Job Comments
Tech Comments
October PO #AHD001707468 /Service (OG) 8000 Gals - Every 3
months - NOTE Amount Pumped - > TECH MOST Check In/Out using
Corrigo Pro APP, - No Pricing On Site -
If any Problem
with APP Email: (Checkin0:wrenvironmental.com)
- ••'MUST HAVE
PO TO SERVICE•^. - Take before and after
pictures
System Owner
System location
C&W Services/stop & Shop
OG Stop & Shop #007
275 Grove Street
377 Chauncy Street
Suite 3-200
Mansfield, MA 02048
Auburndale, MA 02466
Manager : (508) 337-9450
(000) 000-0000
Service Date: THU 10/10/2019 03too AM
Frequency: Monthly-Specificnays
Call to Confirm:
Service Type: Standard
Previous Service:
Approx. Gals: 0
CCLS:
Location Details:
Depth Below Grade:
Custom Clean:
Cost Home: No
Filter:
Township:
Inspection/T5:
County: Bristol
Build Up:
Description
Qty Unit
Price Ext Price
Commercial Pump Grease 8000.00
We suggest these 3 keys steps to
keep your system healthy:
• Regular servicing
• Use CCLS bacteria additive
• Use a filter
Disposal Site: Earthsource
Disposal Volume:
Payment Detail:
Waste Code: PumpOrease
8000.0000
Invoice
Sates Rep : No Rep
CSR : Matthew Donchin
Due on Receipt
P 0 Number : AHDO01707468
Truck: Technician: Francis Gibney On Site : o3 :is AN
Tech Notes :
Normal water level. 15in bottom sludge. Sin top solids. Both baffles are
intact. Main line Clear. No filter is present on the tank; current tank is not
designed to be used with a filter. Cover(a) secured. Popped all 4 covers heavy
solids and sludge in bottom covers secure.
Customer not on site
Signature