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HomeMy WebLinkAboutSunoco #40082H - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION JA (Application must be submitted at least 30 days before the planned opening date) <'G Establishment Name SU"Q Gd LNQ S 2 Establishment Address -IQ C Q P00i 0lV4 D r, 0 A'\ S pl eld y / r Vh 0 Lo `�s ` Establishment Mailing Address (if different Establishment Telephone No `2, Applicant Name & Title. `7- 5lsNe(n �( Applicant Address 3e&.0® QL��IO�V1 y Y tdd%cg �i i S b Applicant Telephone No.: �� ^� j — "�1 24 Hour Emergency No.: Applicant Email Q% (VvC'g ed, C 0 M a 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. El A Corporation 'Name 9 Title Addre s p,I An Individual �A CAI �1 �tY®� �' - -� r' Ll A Partnership ��� -.0 -- ❑ Other legal Entity Person Directly Responsible For D2l1•, Operations (owner, person in charge, supervisor, manager etc.) Name &Title: SOS I� 18lyt((,,pv' -b l��j�S tnj r Address:-'® (TAIO'V\A 3)--7 Agfb-S-f"Q,C , ffift— eCrtM Telephone No: sq--331-230I 24Hour Emergency No:— 339 LA FAX: I JtA`�— Ik-37 E-mail: 0 ANG � 4&gs�''4 `76i'41 o Q/0 fi Alt E-Mail: Ce mr �A3s �l." 'r'o 1 District Or Regional Supervisor (�if applic��ble) Name&Tlyt1 itle: �Q t\Akv(A If{n� �IAir, g Address: qfQ 0.Shf n%V�t(/ � U PG kaov) trf Telephone No: 24 Hour Emergency No: FAX: q-gZ %3 ZS" tASI E-mail: �jhC1CPQ/� �j�� rG�i 1 j�3 700, 3 Food Establishment Information WATER SOURCE: �w�l� SEWAGE DISPOSAL: IND. DEP Public Water Supply No: (If applicable) of Food Employees: DAYS/HOURS: / d*V,,s Name of Person(s) In Charg Certified in Food Protection Management: �'urrou�ks Name of Person(s) In Charge Certified in Allergen Awareness Training Qs-�h��y��h� Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a per��ned in manual choke saving procedures will be onsite at all times food is being prepared ❑ Yes 'hV/ Does this establishment require a FOG permit? Al \0 If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual etail Food $125.00 ❑ Mobile Food Consession EJ Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 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 Food Operations: Definitions:PHF- Potentially hazardous food(lime/lemperature controls required) (Check all that apply): Non-PHFs - non-potentally hazardous foodfno time/femperaluna controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no /urtherprocessing) (Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged Pr'�,s ❑ Preparation of PHFs For Hot And Delivery 9 of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly 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 ❑ Customer Self -Service ❑ Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Only &46e Manufactured and Packaged for control) Perishable Foods Retail Sale reparation of Non-PHFs Offers Raw Or Undercooked Food Of . Juice 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, Oul-Of-Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, alle to the accuracy of the establishment operalio wit comply with 105 �'1 board of health on how oZin copies of 10("i Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I cznfi,1 and paid stale taxes required under law. -- (, �,�J -Is' 1,3I provided in this applic2 and all other applicabl( 0 and the federal Food Social Security Number or Federal ID: Signature of Individual or Corporate Name: penalties of perjury that and affirm that the food I have been instructed by the my best knowledge and belief, have filed all state tax returns CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Joseph T Burroughs Date of Completion: November 16, 2016 Date of Expiration: November 16, 2021 "AHEC S Tim O � N O �n V / 00 4 g � _ m � Z� R� o x O s Z .- n 4 _'..; '" 0 n 3� �3 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 Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate r (Mandatory, if N licable) *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\Scott's DOCUnletitffood Establishments- Teinp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 0 ci,o tr.rn City/State/Zip: 01041 Phone #: Q - -� 3 1— Z- � a) ArgyoWau employer? Check the appropriate box: Business Type (required): I.ff I am a employer with t, employees (full and/ 5. etail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partner=! ip 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.❑ Manufacturing no employees. [No workers' comp, insurance required]** 114 ❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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 #I. - I am (tit empla>.ver that is providing vorkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: p r (� � Insurer's Address: '7���.t ! V r `'ti4 q s4<� 0 Av ` , City/State/Zip: V 0UVVU* `J::� r— Policy # or Self -ins. Lie. c, Expiration Date: ��_� ` o _ 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 herehv certify, under the painssand penalties ofperjury that the information provided above is true and correct. .. ( ` n rl A -A., n.,.,.. i s Official use only. Do not write in this area, to be completer) 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 wwcv.mass.gov/dia Phone TIIPICATE 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. Exp: 866 283-7122 FAX INc, No): (847) 953-5390 2711 North Haskell Ave, Suite 800 Dallas, TX 75204 E-MAIL ADDRESS (214) 989-0000 INSURERS AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURER B. ACE American Insurance Company 22667 7-Eleven, Inc. 3200 Hackberry Road INSURER c Indemnity Insurance Cc 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. ICTR TYPE OF INSURANCE ADOL INSR SUBS WVO POLICY NUMBER POLICY Err DATE(MM/DDNY) POLICY EXP DATE(MM/DDNY) LIMITS B GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE XO OCCUR. OWNERS' & CONTRACTOR'S PROT. LIQUOR LIABILITY $600.000 SELF INSURED RETENTION XSLG7145292A 10/1/2019 10/1/2020 EACH OCCURRENCE $ 1 50p000 DAMAGE TO RENTED PREMISES (Ea occurrence) $1,500,000 MED EXP (Any One Person) $ Excluded PERSONAL & ADV. INJURY $ 1,500,0m GENERAL AGGREGATE $ 1,500,Coo PRODUCTS-COMP/OP AGG $ InclutledLoc ` 37488 AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accitlenp $ BODILY INJURY (Per Person) $ BODILYINJUR (Per Accident) $ PROPERTY DAMAGE (Per Accident) $ EXCESS X LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE $ C B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY NY PROPRIETOR/ Yes PARTNERS/EXECUTIVE No OFFICER EXCLUDED LRC65893216 Z, CA, MA 10/1/2019 10/l/2020 X WC STATU-TORY LIMITS Other EL EACH ACCIDENT $1 1,000.000 EL DISEASE — POLICY LIMIT EL DISEASE — EA EMPLOYEE $ $ LOGR000 1,000,ow B OTHER Liquor Liao CVy HDOG71453005 1/1/2020 1l1/2021 Ea. Common Cause Aggregate $500.000 $500,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS LOD 37488 / 77 Cedar Street, Dedham, MA 02026. Ziad Greige, R&Z Greige, Inc. as add'[ insd I.HIV4GLLHI IVn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE t THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE AON RISK SERVICES SOUTHWEST, Inc. © 1988-2010 ACORD CORPORATION. All riohls reserved. ACORD 25 (2010105) The ACORD name and logo and registered marks of ACORD