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HomeMy WebLinkAboutCumberland Farms - 12/31/2020Lt6S �q Z FOR BOARD OF HEALTH USE ONLY Permit # Issued FOLD ESTABLISHMENT PERMIT APPLICATION z;...-, �( nation must be submitted at least 30 days before the planned opening date) U Establishment Name CliauAG)/ �JTi �RilS*rG�d /,/a• �'?�y� Establishment Address ,30 Establishmen�t �M�]ailIng Address(ififfer�en�t)j �lo✓�/'/csno/C✓� �. Establishment Telephone No ----- Applicant Name & Title: (;umbo and Fartm, Iric. Applicant Address Tax, C)e pavti ent Applicant Telephone No.: P 65 Flanders Road � S`I Hour Emergency No.: �rt�irata�(yyhMP,( a S Applicant Email LSWu mI(gcbmberlankirins.com 5r0!r-,9 A9 Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ❑ An Association partner. X -A Corporation Name Title Address ❑ An Individual__— ❑APartnership ❑ Other legal Entity Person Directly Responsible For Dail Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �,t✓�/ ��G� i� ��// Address: `%%Gyys Telephone No: '5-n% P61- 10-5* 24 Hour Emergency No: FAX: IP/,IvG, S�NI?O/ii%�Gr�6o/%ysscf�olYns. Coii-i E-mail: Alt E -Mail: WeNuxl@cumberlendfarrns.com District Or Regional Supervisor (if applicable) M --T—etcicirola-o"S7-r, Name & Title: o%- Address: ozy3 /'/iU'i�;'rc/ At. Jo�,�STN "-r may/9 Telephone No: 5� 090-,4.OS'jP 24 Hour Emergency No: SgrraL- FAX: yoi- 93y � aG 7A E-mail: S,�RdARo �s�6ya�r�-��/�IryS.co�►+ Food Establishment Information WATER SOURCE:/ SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) I No. of Food DAYS/HOURS: oO(— Name of Person(s) In Charge Certified in Food Protection Management: STa o� �j d rpu/ Name of Person(s) In Charge Certified in Allergen Awareness Trainingn R e b -eGGa. 19' G2 5� Gt K f a r'l Name of pest control company routinely inspecting the premises for evidence of pests / GI m L � If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. ❑ Yes — Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ R let Food $125.00 ❑ Mobile Food Consession Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 ❑ Temporary FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: [] Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 ❑ Caterer $35.00 1Q �� Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) T Non-PHFs - non -potentially hazardous food(no lime/temperature controls required) (Check all that apply): RTE -ready-fo-eat foods (Exsandwiches, salads, muffins which need no further processing) Vsale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order [.� Sale of Commercially Pre -Packaged PHFs ❑Preparation of iFs Cold Holding For SinglerMeal Hot And ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended (Reheating of CommerciallyIo be Prepared by Consumer Processed Foods for Service Within 4 Hours iV Customer Self -Service axcC Customer Self -Service of Non PHF and Non- ❑Ice Manufactured and Packaged for Perishable Foods Only Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ 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 ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Retail Sale ❑ Vacuum Packaging / Cook Chill ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this establishment operation will comply with 105 CMR 590.000 and all other ar board of health on how to obtain copies of 105 CMR 590.0" the fede ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service n that lbe food been i trucked by the i, ✓Cr ,- tI,s[ Signature of Applicant Pursuant to MGL Ch.62C, sec. 49A, I certify under the enalties of perjury lh 11, t my best know edge4,and belief, have fled all state tax returns and paid state taxes required under law. f ilmborliTnd a✓clrms Inc Social Security Number or Federal 0:if ®�-p�GW"r'v�V Tax i u"1r�tiAn9i'nt Signature of Individual or Corporate Name: 16 J Flanders Road VVostborough, MA 0-1581 � + g ' � \ I {; b U }| ƒ \�\}\ \ t / \ \ \ @ � � 0 m ± \ y/\ \ >®\) \ 4 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. ASSISTANT TREASURER �.. el/� d d/his (�W ��✓t- � Y Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **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\Desklop\ScotVs Docutnents\Food Establishments- TempVFAX CERTIFICATION FORM.doc -\ Tile Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 nvw%nurss.gov/dia Workers' Compensation insurance Affldavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. A } licant Information Please Print Leeibly Business/Organization Name: Cumberland Farms Inc. 165 Flanders Road City/State/Zip: Westborough, MA 01581 Phone #; 508.270.1400 Are you an employer? Check the appropriate box: 1.0 1 am a employer with 3571 employees (full ands or part-time).* 2.0 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 requiredp 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req -1 Business Type (required): 5. 1711 Retail 6. Restaurant/BarEating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I].[] Health Care 12.❑ Other-- *Nt}• npplicanuhal checks bnx ql musl also rill oul the section belay sho\s ing their v, orkers' eompemanon 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 RI. I am an ennployer ltat is providing workers' contpensatloa inrsarance for any employees. Below is the policy inforanation. Insurance Company Name: ACE American Insurance Company insurer's Address:33 Arch Street, Suite 2900 City'State:Zip: Boston, MA 02110 Policy # or Self -ins. Lic.:rSCFC65896382 Expiration Date: 04101/2020 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 �}yenag¢.`eriftcation. I do hereby cerlify, ander phone #;,508-270.1443 that Official use only. Do not write in this area, to be completed by city or towa ofcial. City or Town: Permit/License is (rue and correct 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\V\V.mass Phone s r=�RO® CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDD YYV) Dal2slzo19 THISCERTIFICATEIS 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: [he certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If 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 endorsement(s). PRODUCER Aon Risk Services Northeast, Inc. Providence RI Office 100 Westminster Street, 10th Floor Providence RI 02903-2393 USA CONTACT NAME: PHONE (866) 283-7122 FAX 800-363-0105 (PJC. No. Ext):INC. No.: EMAIL ADDRESS: DA TO $1,000,000 PREMISES Ea occurrence MED EXP one person) Excluded COVERAGE NAIC qINSURED CUMBERLAND FARMS, INC. 165 Flanders Road Westborough MIA 01581 USA INSURER Insurance Company 22667 INSURER surance CO of North America 43575 MINSURER(S)FORDING INSURER & Casualty Insurance Co. 20699 AAUTOMOBILE INSURER INSURER INSURER 04/01/201904/01/2020 -,.....,.-- DCa/Ielnm MI IMRFR• GVVtKHV CJ a.�n n v..,�....,.,.FISTE....LO THIS IS TO CERTIFY THAT THE POLICIES UI INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED U ME T WITH 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. Limits shown are as requested _r;!T7M1Tr_ LTR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR AUDI INSD gm WVO POLICY NUMBER XSLG 3037 SIR applies per policy ter MMIDDIYYYY s & condi MMIDDIYYYY 01 ions LIMITS EACH OCCURRENCE $1,000,000 DA TO $1,000,000 PREMISES Ea occurrence MED EXP one person) Excluded PERSONAL INJURY $1,000,000 GENERAL AGGREGATE $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑�Ea 1:1 LOC OTHER: PRODUCTS-COMPIOPAGG $4,000,000 AAUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED OWNED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY ISAH25277211 04/01/201904/01/2020 COMBINED SINGLE LIMIT $1,000,000 BODILY INJURY (P., person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Peraccidenl C X UMBRELLALIAS EXCESS LIAB X OCCUR CLAIMS-MAOE 3OOG46621220003 04/01/2019 04/01/2020 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED X RETENTION $25,000 B A WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR f PARTNER I EXECUTIVE OFFICERIMEMSER EXCLUDED?N (Mandataryin NH) Ifyead",mm under DESCRIPTION OF OPERATIONS below NIA WLRC6S89634$ SCFC65896382 04/01/2019 04/01/2019 04 01/2020 04/01/2020 X STATUTE OH E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE -EA EMPLOYEE $2,000,000 EL DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be atlached if more space Is required) The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. neo CANCELLATION ` ` 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 AUTHORIZED REPRESENTATIVE Six Park ROW Mansfield MA 02048 USA J� ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD L ea Cumberland F A R M S Date of Incorporation: September 14, 1984 State of Incorporation: Delaware Principal Address: 165 Flanders Road, Westborough, MA 01581 Office Telephone: 508-270-1400 Federal ID No: 04-2843586 PRINCIPAL OFFICERS: Mohsin Issa President 165 Flanders Road Westborough, Ma. 01581 Howard S. Rosenstein Treasurer 165 Flanders Road Westborough, MA 01581 Brian E. Glennon, II Secretary 165 Flanders Road Westborough, MA 01581 John T. Daly Assistant Treasurer 165 Flanders Road Westborough, MA 01581 Lyn M. Lustig Assistant Secretary 165 Flanders Road Westborough, Ma. 01581 Laura Sherman Assistant Secretary 165 Flanders Road Westborough, Ma. 01581 Cumberland Farms, Inc. 165 Flanders Road, Westborough, MA 01581 508-270-1400 www.cumberlandfarms.com 0 Business/ Food Establishment Mailing Phone/Fax Number: - /�� Email:�=�/�12�-'.�Cu/H G�T�i•�s • CO w! p _..-� ....�'Ci l._. _ kl.�>Ir�inhut ✓,,r rvI SG`/ Contact Person/Title for Grease Traps:_ "`ToDa rld fz" Via_ Name of Company scheduled to pump internal grease traps) monthly: Name of Company scheduled to pump external grease trap quarterly: 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 e 3 grease Interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3200 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 acknowledges that t) a information submitted in these documents is true, accurate and complete. Date /0//�Z/5 Print Name IDDM " f-'- O'I Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? ---i Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 Please list fixtures attached to each grease trap External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes O No Size gallons Where is the existing outdoor GRU located? if the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: Property Owners Address: Property Owners 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 waster 3 Facility Operational Information 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): Seating Capacity (Actual Count):' — --T Normal Hours of Food Preparation/Service: Monday % 7 Tuesday Wednesday Thursday Friday Saturday Sunday 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 Attached to establishment GRU 3 compartment sink Handwashins sink Commercial Barsink i I ty 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? M Yes --No� It yes, at what station/sink? 0 � � � 0 z OM* z � � W4 z P4 1\ \ �!7 / # � � 3® \ 0 u to / ti % ƒ Cq V At n _ � \//\ } k B { � \ ' / ƒ q / \ % \ \ d Q �!7 / to / ti % ( \ At \//\ } � / W a W-4 Y w 0 z H �z{� Cia zw W 04 W .o w 'd N 42 C a'a b a� N N 5 nU a H N 4J T� H 4 � o ° w o al M z A .o 42 C a'a b 5 nU a .Vp 4 4