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HomeMy WebLinkAboutMansfield Xtra Mart - 12/31/2020* S--)- - I5.3 FOR BOARD OF HEALTH USE ONLY Permit # Issued rnnn cC1-rAoi IcunACki-r nr7onniT AnnnA-rIr K[ F a (Application must be submitted at least 30 days before the planned opening date) Establishment Name Mansfield Xtra Mart Establishment Address 905 South Main Street, Mansfield MA Establishment Mailing Address (if different) 800 South Street, Suite 500, Waltham MA 02453 Establishment Telephone No 508-261-2812 Applicant Name & Title: Drake Petroleum Company Inc. Applicant Address 800 South Street, Suite 500, Waltham MA 02453 Applicant Telephone No.: 781-398-4342 24 Hour Emergency No.: 401-263-7169 Applicant Email permits@globalp.com 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 ;en An Association partner. O A Corporation Name Title Address 10 An Individual see attached IN A Partnership 12 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Jim Brodeur, Store Manager Address: 905 South Main Street, Mansfield MA Telephone No: 508-261-2812 24 Hour Emergency No: 401-263-7169 FAX: 781-398-7217 E-mail: permits@globalp.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Nathan Thomas, Territory Manager Address: 800 South Street, Suite 500, Waltham MA 02453 Telephone No: 401-263-7169 24 Hour Emergency No: 401-263-7169 FAX: 781-398-7217 E-mail: permits@globalp.com Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No. (if applicable) No, of Food Employees; DAYS/HOURS: 24 hours a day, 7 days a week Name of Person(s) In Charge Certified in Food Protection Management: ,im Brodeur Name of Person(') In Charge Certified in Allergen Awareness Training ji:'ni Srod�ur Name of pest control company routinely inspecting the premises for evidence of pests dA % VDl r9 If there is seating for 25 people or more, a person trained in manual choke saving procedures will be ons to at all tlmes food Is being prepared. 0 Yes Does this establishment require a FOG permit? e If yes, please attach the FOG permit application, Length of Permit: Establishment Type: Annual CX]'.j3atpll Food $126.00 _ ❑ e Food i] Temporary rood Service up to 100 INCLUDING NO PHF PREPARED AN.SITE $100.00 Temporary Start Dale: FOOD TRUCKS $175.00 " Q Manufacture Frozen Dessertslice cream 0 Food Service up to 101-200 $260,00 $26.0016eexor Temporary End Date: 0 Food Service up to 201 + .$300.00 i] Pushcart $50.00 If of Pushcarts: Temporary Tuna: Supermarkets $400 Q Su p 0 Residential Kitchen $100,00 Rain Date: ,® Milk &,Cream $10,00 112.Caterer $35.00 Food Operations: Dobnfponz PHF-Potenfiallyhazardousfood(IrmehoMperature contmismitoed) (Check all that apply): NomPNFs-non-POWPaly haaardausfood(no dmeRempenrumonhols requlrscq RTE • roady-to-eatroods (Ex. sandwkhes, salads, mumns mim Head no futther processing) 91 Sale of Commercially Pre -Packaged Non•PHF$ [:] PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held EI Sale of Commercially Pre-Packaged-PHFs i] Preparation of PHFS For Hot And for More Than a Single Meal Service 0 Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods. Prepared For Highly (] Reheating of Commercially El Sols of Raw Animal Foods Intended Susceptible Population Facility Processed Foods for Service WithinHours to be Prepared by Consumer Q Use of Process Requiring A Variance .4 customer Self-service 0 Customer 5elfSeNica of Non PHF and Nan• andtor HACCP Plan (Including bare hand contact allemative,:Ume $6 a public health Perishable Foods Only O Ice Manufactured and Packaged for control) El Preparation of Non-PHFs Retail Safe Q Onion Raw Or Undercooked Food Of 71 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale [] Vacuum Packaging/Cook 0htll 0 Offers. RTE PHF In Bulk Quantities Q Prepares. Food/Single. Meals for 0 Retail Sate 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 estabil3hment operationewill comply with 105 CMR 590,000 and all other applloable law, I have been instructed.. by the t board of health on how Wjbtaln c2les .S -CM 690.000 and tbelederal Food Code. a epavo COMpanylrw. J C Signature of APPiical-. —� By: Pna:xw SrMa. EVP Pursuant to MGL Ch.620 sec; d9pr, {cerci under the peva wof perjury that 1, to my rest knowledge and belief, have flied all stale tax returns and paid state taxes required under law, Social Security Number or Federal to: 04-2236089 Signature of Individual or Corporate Name; Drake Petroleum Company Inc. oFy4,C N�.. Town of Mansfield Health Department a E , APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT �q''epsA•s11 RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: MMnsfi eld'X 1m mar-- Address: q05 Sou+h MW S-l,T6+, Mtansfield HA Mailing Address: b��OtCSOU2+hp2110CL S(akP�.900,./1WC al`f'h(am MA M5 Phone/Fax Number:. Email, QrlYlt� S �° AiOI�CIf� um Contact Person/Title for Grease Traps:_lgn,(ai�(iIhPC CPi7lOr-�(1,(IlI1IPpS Name of Company scheduled to pump internal grease trap(s) monthly: -N/A Name of Company scheduled to pump external. grease trap quarterly: A Ilnd N\ter Gvw{rbt Mtn Please attach the following docdments to this application;. • Most recent waste hauler receipt or waste hauler manifest Cotcma) • 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 $50 ($200maX) I THE UNDERSIGNED HAVE OBTAINED AND .REVIEWED THE MANSFIELD BOARD OF HEALTH FATS OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER A, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents Is true, accurate and complete, Signed,-- Date 11 I a0h9 Print Name A iirP_W S II N',O , F V P DraicC Petroleum company Inc. 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. gg� Seating Capacity (per Fire Department Regulation): _t Seating Capacity (Actual Count): -1 Normal Hours of Food Preparation/Service: Monday 5A- IIIE Thursday 5A - 61 P Sunday 5A - H Tuesday 5A " `ti F Friday 5A- 1i F Wednesday 6A ` l l P Saturday 5A -11P 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 PiS 3 compartment sink 1 no Handwashing sink 0 I Commercial Dishwasher n/ a Bar sink �® Mop Sink Garbage Disposal (not o F1Se) Ice Making Machines n a Fryolators V n /ia Grills or Ovens /Q Exhaust Hoods rid Floor drains n/(x Other: How are hoodventscleaned? (i.e., in three (3) bay sink, off site by private company): N/A Is dinnerware pre -rinsed before being washed? Yes id No If yes, at what station/sink? M 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes >� No Size N f R gallons Where is the existing outdoor GRU located? N /A If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: rtrt{ Property Owner's Name: N /A Property Owner's Address: Property Owner's Telephone Number: NI . t Yellow Grease Waste N/ADo you store yellow grease waste from fryolators? C � r A Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 �� A N/A Please list fixtures attached to each grease trap Grease Trap 1 COCYi CAr YYieYli �{r)K Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes >� No Size N f R gallons Where is the existing outdoor GRU located? N /A If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: rtrt{ Property Owner's Name: N /A Property Owner's Address: Property Owner's Telephone Number: NI . t Yellow Grease Waste N/ADo you store yellow grease waste from fryolators? C � r A Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 �� A N/A The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations ' Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 wwrainass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeililr Business/Organization Name: Drake Petroleum Company, Inc. Address- 800 South Street, Suite 500 City/State/Zip: Waltham, MA 02453 Phone M (781) 894-8800 Are you an employer? Check the appropriate box: Business Type (required): 5. Retail 1.9 I am a employer with employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I ata 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. ❑ 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]** I L❑ HealthCare 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.N Other GwInA e- IRI &V 5}q'E'(0A *Any applicant that checks box N I trust also fill out are section below showing their workers' compensation policy information. **If the corporate officers have exempted Themselves, bat the corporation has other employees, a workers' compensation policy is required and such an organization should check box 0I. ,rain air employer that is providing rvarliers' compensation insurance for my eagdoyees. Below is the policy inforrnnation. Insurance Company Name: Liberty Mutual Insurance Corp Insurer's Address: 173 Berkeley Street City/State/Zip: Boston, MA 02116 Policy # or Self -ins. Lic. # "!I - (jAN - il & CO(dl) - o (,Q Expiration Date: 10/1/20 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 c frtify, ander tine pains and penalties ofperjary that the infornnation provided above is nwe and correct. Phone#: 'lz-m -401i Official use only. Do not nvrite in this area, to be completed by city or to un official. City or Town Permit/License # Issuing Authority (check one): L❑Boord of Health 2.❑ Building Department 50 Selectmen's Office 6. ❑Other 30City/Town Clerk 4. El Licensing Board Contact Person: Phone #: www.nrass,gov/dia ACRO® CERTIFICATE OF LIABILITY INSURANCE t`/ 10/112020 DATE(MM/DD YV) 1 10/1/2019 THIS CERTIFICATE 15 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 PRDDUCER, 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 endorsement(s). PRODUCER Locktml Insurance Brokers, LLC 777 S. Figueroa Street, 52nd Fl. CA License NOF] 5767 Los Angeles CA 900I7 (213) 689-0065 CAO.Nl T PHONE FAC No E.Mnu ADDRESS: INSURERIS) AFFORDING COVERAGE NAIL0 INBURERA:Liberty Mutual Fire Insurance Conutany_ 23035 _ INSURED Drake Petroleum Company, Ina 1370629 Global Partners, LP INSUREae:Libex Insurance CjI 'ation 42404 INSURERC: INSURER D: 800 South Street INSURER E: Wallham MA 02454 INSURER F: $ XXXXXXX _ COVERAGES GLOPA01 CERTIFICATE NUMBER: 15693144 REVISION NUMBER: XXXXXXX 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 T I TYPE OF INSURANCE man Seen r) Wer) POLICY NUMBER MIDDYEFF MWDDIYYYYY LIMITS COMMERCIAL GENERAL LIABILITY ElOCCUR NOT APPLICABLE FACHOCCURRENCE $ XXXXXXX DAMACLAIMS-MADE PREMISES Ea occur E TO encs 5 XXXXXXX MED EXP An one arson $XXXXXXX PERSONAL&ADV INJURY $ XXXXXXX _ GEN -1, AGGREGATE LIMIT APPLIES PER; POLICY ❑ PRO - ECT El LOC OTHER:$ GENERALAGGREGATE $ XXXXXXX__ PRODUCTS - COMPIOPAGG $XXXXXXX.__ A AUTOMOBILE LIABILITY X. ANYAUTO OWNED SCHEDULED _AUTOS ONLY ALTOS HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY N N AS2-691-460066-039 10/1/2019 10/1/2020 cEa rmckhDswGLE LIMIT a eBINEl $ 1 00) D 0000 BODILY 114JURY(Pe1 person) $ XXXXXXX BODILY INJURY(Peraccidanl) $ XXXXXXX ------ PROPERTY DAMAGE e e J9� _ - - $ X'X'XXXXX of Ded. 5 1,000 UMBRELLA LIAR EXCESS LIAO OCCUR CLAIMS -MADE NOTAPPLICABLE EACH OCCURRENCE $ XXXXXXX _ AGGREGATE - s XXXXXXX _ OED RETENTION $ XXXXXXX B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETORJPARTNEWEXECLUIVE YIN OFFICEWMEMBER EXCLUDED? ❑N (Mandatory In NH) Ifyes,d.mcIbountler DESCRIPTION OF OPERATIONS below NIA N WA7-69D-460066-019 10/1/2019 10/t/2020 PER OTH- X s TUE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE-EAEMPLOYEE $ ] 000000 _ E.L. DISEASE-PgUCY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Boarders, may be attached If more space Is required) 15683144 Commonwealth of Massachusetts Department of Industrial Accidents Office of h vOstigatlons 600 Washington Street Boston MA 2111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BFFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED riahts reserved, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Notification of Test Results ID#: xxx-xx- Scaled Test Score: 75 Candidate Status: Pass Test Date: April 26, 2018 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES JAMES BRODEUR HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FCBD SAF'ET'V MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE 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 (Competent) Ensuring Personal Hygiene and Employee Health (Competenq Actively Managing Controls in a Food Establishment (Needs review) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Needs review) Conducting Cleaning and Sanitizing (Needs review) PnyScal Padlity Design a Maintenance: Preventing a Controlling Pests (Competent) ISSUE DATE: APRIL 26, 2018 EXPIRATION DATE: APRIL 26, 2023 CERTIFICATE NO: 21459837 TEST FORM: EXE70 This <mifaae m mnolid for more Jen fire Seas from dale oNo" oF5U00€y , National Registry of Food Safety Professionals i CERTIFIED FOOD SAFFTY MANAGER JANIES BRODEUR JAMES BRODEUR 392 COGGES HALL ST FALL RIVER, MA 02721 Ceniecata Na: 21459837 (sate Data: April 26, 2018 ' Expiration Date: April 26, 2023 National Registry of Food Safety Professionals'&+ 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 I Phone: 407.352.3830 I Fax:407.352.3603 V z *-.q z 1. N L O N Qi 0 N d• O N O L d i y r L � .fl O z r L d Li � Z d �— C Q E C O Q O OV`^ E /1 O w O z +� A m 0 w v Christopher George From: Celine Ramsingh <celine.ramsingh@globalp.com> Sent: Wednesday, November 27, 2019 12:59 PM To: Christopher George; Merideth Petz; permits Cc: Health; Stacey Hickey Subject: RE: Outstanding Items for Board of Health Permits 2020 Attachments: Site #10027 - Wind River Grease Trap Invoice.pdf; 10027 Food Establishment Renewal Additional Information and Check - 11.27.19.pdf Hi Christopher, Thank you for working with us on this application. Please find the following outstanding pieces: Pest Control Company: Braman Chemical has a monthly service to this site. Grease Trap Maintanance: Wind River Environmental conducted a service to our grease trap on Monday, November 25`". (see attached invoice). Updated check is on its way to your office. (see attached fedex/check). Please let us know if anything else is required. Enjoy your Thanksgiving. Celine M. Ramsingh Paralegal Global Partners LP 800 South Street, Suite 500 Waltham, MA 02453 P: (781) 398-4342 F: (781) 398-7217 From: Christopher George <cgeorge@mansfieldma.com> Sent: Monday, November 25, 2019 11:00 AM To: Merideth Petz <MPetz@globalp.com>; permits <permits@globalp.com> Cc: Health <Health@mansfieldma.com>; Celine Ramsingh <celine.ramsingh@globalp.com>; Stacey Hickey <shickey@globa Ip.com> Subject: RE: Outstanding Items for Board of Health Permits 2020 This message originated from outside of Global Partners - Please use caution before opening attachments or clicking on links. Hi Merideth, Thank you for working with me on the phone earlier in regards to your permit application. Attached to this email you'll find the notification letters sent to the email address we have on file. Please let me know if you have any questions. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 From: Merideth Petz fmailto:MPetz(&alobalp.com] Sent: Monday, November 25, 2019 9:50 AM To: Christopher George; permits Cc: Health; Celine Ramsingh; Stacey Hickey Subject: RE: Outstanding Items for Board of Health Permits 2020 Good morning, Apologies, I will have a check recut in the amount of $210, we added in the $50 fee for grease traps. We did not receive notice of the re -inspection fees, are notices sent to the store or the corporate office? I will revise the application to include the missing information. Thank you, Merideth Petz Paralegal Global Partners LP 800 South Street, Suite 500 Waltham, MA 02453 P:(781)398-4419 F: (781) 398-7261 From: Christopher George <cgeorae@mansfieldma.com> Sent: Monday, November 25, 2019 9:30 AM To: permits <permits@Rlobalp.com> Cc: Health <Health@mansfieldma.com> Subject: Outstanding Items for Board of Health Permits 2020 This message originated from outside oj'Global Partners - Please use caution before opening attachments or clicking on links. To Whom It May Concern, I recently left a voicemail with the Applicant number provided. We've recently received your application for a Board of Health Food Establishment Permit. We are unable to process your application until the following items are remitted and/or addressed: • Critical Violation Re -Inspection Fee: $100.00 issued on 10/15/2019 • Critical Violation Re -Inspection Fee: $100.00 issued on 11/20/2019 • Name of Pest Control Company • Number of Food Employees • Check supplied is for $260.00; but total permit cost is $210.00 • FOG Permit requires name of company scheduled to pump internal grease trap monthly • Random Black pages were submitted with the title of "Complete Solutions & Sourcing" Wind River Environmental LLC. Invoice IMRI-VER ND 46 Lizotte Or Suite 1000 ENVIRONMENTAL Marlborough MA 01752 Acquisition: Vvind River Environmental Billing Questions: 978-841-5080 BILL TO Customer Number: 17867 FSN Accounts Payable PO Box 1319 Hartford, CT 06143 JOB SITE OG Mobil #10027 905 South Main Street Mansfield, MA 02048 FM ouv-y iDoz Service Date: 25 -Nov -2019 Invoice Number: 4443730 Order Number: 0210173115 P.O.Number: 1-4378525682 Invoice Date: 26 -Nov -2019 Order Date: 25 -Nov -2019 Quantity Service Type Amount Tax 1,000.00 Commercial Pump Grease $190.00 $0.00 1.00 Trip Charge Per Truck $25.00 $0.00 Subtotal Non Taxed: $215.00 Subtotal Taxed: $0.00 Tax: $0.00 Subtotal: $215.00 Less: Credits: $0.00 Payments: $0.00 Balance: $215.00 Payment Terms: Net 30 — — — — — — — — — — — — — — — — — — — — — — — — — — — From: Customer Number: 17867 FSN PO Box 1319 Hartford, CT 06143 Remit To: Wind River Environmental LLC. P.O. Box 22074 New York, NY 10087-2074 Please detach here and return the bottom portion with your payment. Order Number Invoice Number Invoice Date Amount Due 0210173115 4443730 26 -Nov -2019 $215.00 Ifyour payment is retumed NSF it will be re -presented electronically, and you will be assessed a processing fee, the maximum allowed by law. To pay your invoice, please call 978.841.5080. We accept the following credit cards within 30 days of the invoice date. When paying your invoice with a credit card, Wind River Environmental will appear on your credit card statement for this transaction. For questions please visit www.wmnvim=ental.com/peiicies or call 800.499.1682 ``'' -VISA els ER Customer Service Report Schedule Now for Service Nov 2020 Call (800) 499-1682 Workorder # 0210173115 Customer Since: 1996 Technician :James Hatcher Arrived at: 07:09 PM Left at: 07:41 PM Tech Notes : High water level. tin bottom sludge, tin 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(s) secured. Serviced 1000ga1 (grease) water level high tee's ok removed moderate top solids and moderate sludge on bottom covers secured service as scheduled backwash to remove all solids. Tech Recommendation: High Velocity Jetting - Jet lines to prevent any future backups Customer Signature it • L PdVE \ ENVIRONMENTAL System Owner System Location Xtra Mast/Mobil/Sunoco Alliance/Global c/o Vixxo OG Mobil #10027 PO Box 1319 905 South Main Street Hartford, CT 06143 Mansfield, MA 02048 (860) 935-5200 x2325 FM Service Date: MON 11/25/2019 06:00 PM Frequency: Household Occupancy 1 2 3 4 5 6 7 8 Service Type: Trap Previous Service: 06/20/2016 Approx. Gals: l000 CCLS: w 1000 22 20 18 16 14 12 12 12 Depth Below: Custom Clean: 1250 22 20 18 18 16 14 12 12 Cust Home: No Filter: c 1500 24 22 20 20 18 16 14 14 Township: Inspection/T5: 122 2000 26 24 22 22 20 18 16 16 County: Bristol Build Up: Description . Qty Unit Unit Price Ext Price Score From Table Commercial Pump Grease 1000.00 Garbage Disposal? -6 Trip Charge Per Truck 1.00 System Age > 10 Years? -5 Seasonal Occupancy? +8 Bacteria Additive Used? +5 Total Adjustments Net Scare _ Score Service Every: ' '1< 5 6 Months ' 6— 15 12 Months 16 —23 18 Months 24+ ...24 Months ❑ System Normal Keep your system healthy by following these 3 steps: Schedule Now for Service • Regular Service NOV 2020 • Use CCLS Bacteria Additive • Use a Filter Call (800) 499.1682 ❑ Excessive Solids Use CCLS Bacteria Additive Payment Detail: Invoice Net 30 Customer not on Site ❑ Heavy Sludge Use CCLS Bacteria Additive ❑ Tee Missing/Broken Repair/Replace Tee © High Liquid Level Possible system failure. Call for evaluation or custom cleaning. ❑ Distribution Box Issue See notes below for details. ❑ Missing Filter Use a filter ❑ Other See notes below for details. To schedule repairs, custom cleaning, or system evaluation, call (800) 499-1682. X Technician :James Hatcher Arrived at: 07:09 PM Left at: 07:41 PM Tech Notes : High water level. tin bottom sludge, tin 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(s) secured. Serviced 1000ga1 (grease) water level high tee's ok removed moderate top solids and moderate sludge on bottom covers secured service as scheduled backwash to remove all solids. Tech Recommendation: High Velocity Jetting - Jet lines to prevent any future backups Customer Signature it • L PdVE \ ENVIRONMENTAL Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Mranufacture Frozen Desserts and/or Ice Cream Mix In Conjunction with Food Establiahment Permit To the Board of Health at the Tou,n ofNlansfield: In accordance u4th the provisions ofsection 65HofChapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license for a WHOLESALE/RETAIL manufacture offrozen desserts and ice cream inie and submits the following information: 1. Food Establishment Name Mansfield Xtra Mart 2. Establishment Address: 005 South Main Street, Mansfield MA 3. Location of Plants/ dessert machines: In store son Serve Machine 4. Names of brands and trade or corporation name, if any, under which the products are to b unbranded 5. Number and capacity of freezers and f Fee: ($25.00perfi•eezei) $ #Type! g Is the mix purchase e S If so, from whom purchase J • ?01C P... y Is the mix pasteurized? -�Ls..r�11 asp eUv-�z d g Number of gallons of frozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period}__ 9. Is the plant/ dessert mcachine constructed and equipped as provided in the regulations 10. Certified laboratory used for monthly testing MorrC(t ASSOCIa+C5 OF W S1 hCd MA 11. Regulations can be found at https://www.mass.gov/regulations/105-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulations emailed to you I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions. I attest that the information stated in this application is true and accurate under the pains and penalties of perjury. Drake Pe-traderre,Lam any Inc (Company-ovJhier/officer's sig re) (DATE) Andrew Slifka, EVP Waltham, MA (Title) (City or Town) 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. Drake Petroleum Company Inc. Signature of Individual or Corporate Name By' -Corporate Officer (Mandatory, if Andrew Slifka, EVP 04-2236089 "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. CAUsers\sleite\Desklop\Scolrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe