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HomeMy WebLinkAboutTedeschi Food Shops #37484H - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued Ij FOOD E3)TARLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date}" , Establishment Names Establishment Address l-V- 4 owvv ;-Y _S-, ► Ao n 54 �id f0A O'L4 H , Establishment Mailing Address (if different) p o poi- Establishment Telephone No jd 3:3 S 2 l Applicant Name & Title: qc�`1,�G ISO b `S Applicant Address 3 �L'O O # }�b P,vy-,q r V! Y,8 1 >~CiC Applicant Telephone No.: ��2 b' �4 (I 24 Hour Emergency No.: b® JA m'o S Applicant Email (D & c_ G U-6"t I, C.(uyy' 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 El An Association partner. IV-9 Corporation Name Title wry .Address U An Individual O A Partnership trc} �`{{{!555>thnCtzvrr_ ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & TitIle1 bofb �Ames, jhj� Address: � dL76 v�T()4)f�t nr Telephone No: 24 Hour Emergency No: SOS _ 3_�V FAX: T L-"- io 3-7 E-mail:dVYV,�jQgVeZ((},—j 7��1/ Alt E-Mail: S)-)(-O, 1gUY / Y �s /'4Ie LAM District Or Regional Supervisor (if applicable) IJp //yy)� &Title: J/��%Q�l �---�ja, /rpjr'�ry(� Name (1�j�� r �Z®tK1 Address: q�o Vv �sllly��gf+ovi S� 1 DQ ���Vn•i Itkl p Telephone No: -6 (2- ®1 a d2 — 24 Hour Emergency No: FAX: E-mail: o v" 7S'013 Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: -_ --- ----- ion Name of Person(s) In Charge Certified in Food Protec Management: n�1 -� n k4o l a� Name of Person(s) In Charge Certi ied in Allergen Awareness Training 010nVA 0S Name of pest control company routinely inspecting the premises for evidence of pests f" a it aV► If there is seating for 25 people or more, a person try nad'An manual choke saving procedures will be onsite at all times food is being prepared. L Yes Does this establishment require a FOG permit? _moo If yes, please attach the FOG permit application. Lengt of Permit: Type: Annual �E,sttaablishment Food $125.00 ❑ Mobile Food Consession ❑ Temporary brood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Wood FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Temporary Start Dale: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up l0 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Dale: ilk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food (timedemperature controls required) (Check all that apply): Non-PHFs- non-potentally hazardous rood(no time/temperature controls required) RTE- mar;. -.:u-eat foods (Ex. sandwiches, salads, muffins which need no rudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held 13�4ale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand EJ Customer Self -Service contact alternative, time as a public health Customer Self -Service of PHF and Non- ❑ 1-,.i . Perishable Foods Only Irk Ice Manufactured and Packaged for control) reparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of -^ uice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for 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 operatic, II comply, 105 MR 9 �0 and all other applicable law.ve been instructed by the board of health on ho lot I copies of 10 , �1MR .000 and the feder Food Code. ` i Signature of Applicant: - Pursuant to MGL Ch.62C, sec. 49A, I certify unde a penalties of perjury that I, my best knowledge and belief, have filed all state tax returns and paid slate taxes required under law. 11 Social Security Number or Federal ID: 08�113I Signature of Individual or Corporate Name,,,,;6v?/�t �r� f TAX CERTIFICATION FORM I certify under the p�_-nalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required trader law. Signature of Individual or Corporate Name By: Corporate 'tYs r (Mandatory, if 4;rylicable) I'S._ to _S 1 _S I "Social Security No. (Voluntary) atFederal 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\sleile\Desktop\Scott's DUQmrentsWood Es(ablishrients-Temp\TAX CERTIFICATION FORM.doc 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 of Birtg has successfully/ completed Food Safety First Principles., For Food Handlers HRTS'� / Business Name Authorized/Manager Signature Aug 2.7; 2017 Aug 27, 2022 I1039 Date of Completion Expiration Date AsrJA W4 C.Ukimlistier National Registry of Food Safety Professionals • Orlando, Fl. • www,NRFSP.com • 80OA46.0257 xoxu,ws,twu 0 National Registry of Food Safety Professionals 11039 cvrtvl &"N. FOOD SAFETY FIRST PRINCIPLES Food Handler Training Program Donald Ames 3/6/1965 Employee Name Date of girth has successfully completed Form safety First Principles:. For food Handlers HRTS* Business Name Authorized/Manager Signature AuLZL 7017 _ Aug 27, 2022 Date of Completion Expiration Date MNttt llttOt I.1 w+wNtnlo+n Muiaul Registry of Food Safety Professi0fills t Otfando, Ft t ~.NRFSRcom - e00 446.0257 • Employer/Manager- Keep this stub as proof of completion in employee's file. t Detach the cenificate and wallet card and give to the employee. Npl luM4UAllf Nalronol ArOnVY a/ rood 5N/sty PwletlbnaL Ippp iNnY11I15T MIN(I/I!f ~ face NanaRr Gtun1 hyem Donald Ames 3/6/1965 EmWget Nlmt ont of 101h aNnorrhe/Nmtgrr ipntrurt Aug 27, 2017 AuR 27. 2,(122 Dal, of cwplrlwn LpnIN,n DtR ha )wjx I.dlWyxt,WNlt N NRFSP,tom NnNDAWAUNI/ AN, 44&n, t• a a (D 0 M 13 n. Um z r- (A a N N C) tom z I tz t7l z U) n 0 OTI 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,imited 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 1�_, 2016. 7-ELEVEN, INC. Attest; ( / 'I BY: Arth , Rubinett Rankin L. Oas ay Assistant Secretary senior Vice President 177658v13 Stale of Texas County of Dallas On this �_ day of 2016, before me, the undersigned notary public, personally appeared Rankin L. G saway and Arthur E. Rubinett a Senior Vice Presldent and an Assistant Secretary, respectively, of 7-E1-EVEN, 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 signsture Su'u'1111f N ate —UMW (typed or printed name) (S `"Q +raalllttSUZANEHARMSON01 of 7Nalary PNYCEl No 1PS7.,' 17765903 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street o Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 01-5 Phone #: SRO ' 9 1 " _ TJ L I Are you an employer? Check the appropriate box: Business Type (required): Lam a employer with mployees (full and/ 5. etail 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 requited] 8• ❑ 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.❑ 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.] 120 Other *Any applicant that checks box #] 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 #I. I um an employer that is providingxworkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: 'U7 City/State/Zip: M Policy # or Self -ins. Lie. \NL ,k7-S g 1 N Expiration Date: �,_� L Attach a copy of the workers' compcc.sation 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. Ida hereby certi r, under thepains and penakies ofperjury that the information provided aboveiss true and correct. Si¢nature: �r\�rA.., U fL�'1�Q� Date: I--9- eiL 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 lDepgrtment 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone #: /OERVOICATE OF LIABILITY INSURANCE DATE (10/01/19) 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(ies) 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 endorsements . _ PRODUCER CONTACT NAME: AON Risk Services Southwest, Inc. Dallas Location PHONE INC, No. Ext): 866 283-7122 FAX (AIC, NO). (847) 963-5390 2711 North Haskell Ave, Suite 800 Dallas, TX 75204 E-MAIL ADDRESS INSURERS AFFORDING COVERAGE NAICN (214) 989-0000 INSURER A - INSURED INSURER 8: ACE American Insurance Company 22667 7-Eleven, Inc. 3200 Hackberry Road INSURER C. Indemnity Insurance Co of North America 43575 INSURER D: Dallas, TX 75201 INSURER E: COVERAGES CERTIFICATE NUMBER 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 ADDL7WVDDATE(MMK)DrYY) INSR POLICY EFF POLICY EXP DATE(MMIDONY) LIMITS B GENERAL X LIABILITY OMMERCIAL GENERAL LIABILITY CLAIMS MADE XO OCCUR. OWNERS' & CONTRACTOR'S PROT. LIQUOR LIABILITY $500,000 SELF INSURED RETENTION 1I2019 10/1/2020 EACH OCCURRENCE $ i500,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $1,500,000 MED EXP (Any One Person) $ Excluded PERSONAL& ADV. INJURY $ 1500.000 GENERAL AGGREGATE $ 1,500,000 PROOUCTS-COMP/OP AGO $ IncludedLac 37488 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per Person) $ BODILY INJUR (Per Accident) $ PROPERTY DAMAGE (Per Accident) $ EXCESS X LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE It AGGREGATE $ C B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/ Yes PARTNERS/EXECUTIVEX No OFFICER EXCLUDED LRC65893216 AZ, CA, MA 10/1/2019 10/1/2020 X I WC STATU-TORY LIMITS Other EL EACH ACCIDENT $1 1,000,000 EL DISEASE - POLICY LIMIT EL DISEASE - EA EMPLOYEE $ $ 1000,000 1000,000 B OTHER Liquor Liab Cvg IDOG71453005 1/l/2020 IIJJ2021 Ea. Common Cause Aggregate $500,000 $500.000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Loc 37488 / 77 Cedar Street, Dedham, MA 02026. Ziad Greige, R&Z Greige, Inc. as add'i insd 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 © 1988-2010 ACORD ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD