HomeMy WebLinkAboutShaw's #431 - 12/31/2020oe
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FOR BOARD OF HEALTH USE ONLY Permit # Issued,'
01
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name S) ?n vi �S ( �
Establishment Address JJCi U VJ e S k` S-� C (G�✓ }� j e (( {
Establishment Mailing Address (if different) SHAW'S SUPERMARKETS, INC.
P.O. Box 29096 MS#6531
Phoenix, AF 65038-9096
Establishment Telephone No 50 9- 33 - _�Scj'R %
Applicant Name &Title: CRv (SA e
Applicant Address j5L4 ark�2✓r;t l�6j0 «�, E g30(�
Applicant Telephone No.: Ccg Z3-9(c`Y - L(IGL(0 24 Hour Emergency No.: ftC-.S-+9- a�tta
Applicant Email Na$C.tax@$afeway.COrn
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
R An Association
partner.
,g A Corporation
Name Title Address
i
"t
R An Individual
_._ _ Se F_ CXt+a. C
IJ A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: l�Uy1��
Address:,39OWe'S-k-�St•
Telephone No: 51� 9— i - 3�A d 24 Hour Emergency No: 8 CC�! - 3 i - 91 Lo 4
FAX: Ccv3-8(o&I-I+-fS_
E-mail: Na5G.tex@SdfeWSy.com
AltE-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: H i( _e (I b"lOL( t
Address: l:L iR Lev, -k -E.(` E J&k-2r P'1 A
Telephone No: 24 Hour Emergency No: S C
FAX: CP -';� -- 8 I - t `f t 5"
E-mail: NaSc.tax@safeway.cOm
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL: TA i D
DEP Public Water Supply No: (If applicable)
No. of Food Employees: l
DAYS/HOURS: t3 ✓1 _ -7 m _ i oILA ✓ 7 A � _ � rrl
--
--
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training K /Ff
Name of pest control company routinely inspecting the premises for evidence of pests CLQ Wo /-�_QV f -s U Q
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. 14 Yes n /GL � ';"s
r
_ Fa�lf�yes,
Does this establishment require FOG he FOG
a permit? please attach permit application.
Length of Permit:
Establishment Type:
�/
y=y Annual
/
d;
'Retail Food $125.00 iA Mobile Food Consession
fU Temporary
0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 O Manufacture Frozen Dessertsllce Cream
❑Gd Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
0 Food Service up to 201 + $300.00 0 Pushcart $50.00 # of Pushcarts:
TemporaryTime:
Supermarkets $400 0 Residential Kitchen $100.00
Rain Date:
Milk $ Cream $10.00 !J Caterer $35.00
Food Operations: Derriffons: PHF-Potentially hazardous food(amMemperature controls required)
(Check all that apply): Nan-PHF's-non-potentially hazardous(ood(no time/temperefure controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs XPHFCooked To Order ,Hol PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
19 Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly
Q Delivery of Packaged PHFs
Susceptible Population Facility
Reheating of Commercially Sale of Raw Animal Foods Intended
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 of Non PHF and Non- Customer Self -Service contact alternative, time as a public health
,
Perishable Foods Only 0 Ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale
p Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
tA Offers RTE PHF in Bulk Quantities 0 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 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 copies of 1.05 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 fled all state tax returns
and paid slate taxes required under law.
Social Security Number or Federal ID: q {
Signature of Individual or Corporate Name: ASF' AyL �s \�,l i7 f:itl`i CA t'f..Q� �, y`tC •
ar inert{
IN
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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.
r. Tiffany Corcoran
��q Supervisor Tax
Signature of Ind,} 'dual 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:\Usen\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Ulf
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Shaw's Supermarkets, Inc. D/B/A Shaw's #431
390 West Street
City/State/Zip: Mansfield, MA 02048
Phone #: 508-339-3987
Are you an employer? Check the appropriate box:
Business Type (required):
1. RV
I am a employer with ��� employees (full and/
S. Z Retail
orpart-time).*
6. ❑Restaurant/Bar/EatingEstablishment
2. ❑
I am a sole proprietor or partnership and have no
7• E] Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
g• ❑ Non-profit
3.❑
[No workers' comp, insurance required]
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
4. r-1
no employees. [No workers' comp. insurance required]*
Weare a non-profit organization, staffed by volunteers,
11,❑Health Care
12.❑ Other
with no employees. [No workers' comp, insurance req.]
*Any applicant that checks box #1 roust 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 #l.
I am an employer that is providing workers' compensation insurance for nny employees. Below is the policy information.
Insurance company Name: ACE American Insurance Company
Insurer's Address: 5600 West 83rd St, 8200 Tower, Ste 1100
City/state/zip: Minneapolis, MN 55437
Policy # or Self -ins. Lic. # WLRC6604287A
Expiration Date: 8/11/2020
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 coverage verification.
I do hereby certify„ under the pains and penalties ofperjury that the information provided above is true and correct.
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 Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to cavy workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permiblicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.rnass.gov/dia
Form Revised 5-26-05
ACORO®DATE(MMIOOTYYY)
�- CERTIFICATE OF LIABILITY INSURANCE
D7nenola
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 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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
Ann Risk Services central, Inc.
Minneapolis MN Office
5600 West 83rd street
8200 Tower, Suite 1100
CONTACT
!LIME.
—
(111. No, 11): C866) 283 7122 FAX
Ne : (800) 363-0105
E4UUL
ADDRESS:
INSURER(S)AFFOROING COVERAGE NAICa
Minneapolis MN 55437 USA
INSURED
INSURERA ACE American Insurance company 22667
Albertsons companies. Inc.
including Safeway Inc., Albertson's LLC
& subsidiaries
INSURER B: ACE Property & Casualty Insurance CO. 20699
any 26387 INSURER c: Steadfast Insurance Cam
p
250 East Parkcenter Blvd
Boise ID 83706 USA
INSURER O:
IN8URER E:
IN8URER F:
is &condi
COVERAGES CERTIFICATE NUMBER: 570077666367
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. Limits shown are as requested
LTR
TYPE OF INSURANCE
INSD
WvD
POUCYNUMBER
IMMIpp
Nip
LIMITS
X COMNERCWLGENERALUMILITY
XSLG
EACH OCCURRENCE $3,000,000
CUAIM541ADE FX OCCUR
SIR applies per policy ter
is &condi
ions
G o $3,000,000
PREMISES IE. ommence
MED EXP (My one person) Excluded
X DmaOut Uabindudsd
PERSONAL a ADV INJURY $3,000,000
GEMLAGGREGATE LIMIT APPLIESPER:
GENERALAGGREGATE $18,000,000
X POLICY [:]JRCI F] LOC
PRODUCTS-COMPIOPAGG 5610001000
OTHER:
LlquorUablldy Um included
A
AUTOMOBILE LNBILTY
ISA H25301274
08/01/201908/01/2020
COMBINED SINGLE LIMOflon.colApDU$5,000,000
BODILY INJURY ( Per person)
X ANYADTO
BODILY INJURY (Per acddan0
OWNED SCHEDULED
AUTOS ONLYAUTOS
HIREDAUr06 NON-0WNED
ONLY AUTOS ONLY
PROPERTY DAMAGE
Peraccidenl
B
X
UMBRELLALLIB
EXCESS UM
X
OCCUR
CWMSMADE
xooG2794761AO04
SIR applies per policy ter
08/01/2019
is & condi
08/01/2020
ions
EACH OCCURRENCE $10,000,000
AGGREGATE $10,000,000
DED I % RETENTION
A
n
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY YIN
ANYPROPMETORIPANERIEXECUTIVE
W
OFFICEPIMEMBEREXCLUDEDi
(Mandatory In NO
NIA
WLRC6604287A
ADS
EWT008362504
TX
08/01/2019
08/01/2019
08/01/2020
08/01/2020
X PER STATUTE OTH-
ER
E.L. EACH ACCIDENT $2,000,000
E.L.DISEASE-EAEMPLOYEE $2,000,000
D SCRIPTION under
DESCRIPTION.m OPERATIONS below
E.L. DISEASE -POLICY LIMIT $2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES(ACORD 101, Addmonal Remeriu Schedule, may be aHaohad IT apace Is inquired)
Blanket Additional Insured for General Liability and Waiver of subrogation for General Liability status extend to those parties
to whom the insured has contractually agreed to provide this status. Safeway Inc. is a qualified self -insurer for Workers'
Compensation in the following states: AZ, CA, CO, HI, MT, OR, WA. Albertsons LLC is a qualified self -insurer for Workers'
Compensation in the following states: AZ, CA, HI, MT, OR.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE
POLICYPROVISIONS.
Albertsons Companies, Inc. AUTHORREDREPRESENTATIVE
Including Safeway Inc.
Albertson's LLC & subsidiaries
250 East Parkcenter al vd.
Boise ID 83706 USA e.xCasa .✓laYc c./sbsuasr4 ec(i Asa
@1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
r
AGENCY CUSTOMER ID: 570000070861
A �® LOC M
ADDITIONAL REMARKS SCHEDULE
Page _ of _
AGENCY
Aon Risk services central, Inc.
NAMED INSURED
Albertsons companies, Inc.
POLICYNUMBER
See Certificate Number: 570077666367
CARRIER
See certificate Number: 570077666367
NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
FORM NUMBER: ACORD 25 FORM TITLE: Certificate
Insurance
If INSURER(S) AFFORDING COVERAGE I NAIC #
(I "DMONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD
certificate form for policy limits.
Wall
LTR
TYPROFURlm CE
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IN®
Soon.M
wVD
POLICYNUER
POLICY
EP DAd% E
DATE
(Ma(/DD/YYM
POLICY
EXPIDATE=
(MM/OD/YYYY)
LUVDTS
WORKERS COMPENSATION
C
N/A
EWr320330000
WY
08/01/2019
08/01/2020
® 2008 ACORD CORPORATION. All Nahfe reserved.
The ACORD name and logo are registered marks otACORD
Officer Listing
Shaw's Supermarkets, Inc.
FEIN: 04-1123420
Star Markets Company, Inc.
FEIN: 04-3243710
Name
Title
Address
Ownership
Michelle Larson
President
750 W. Center St., West Bridgewater, MA 02379
k
Laura A. Donald
Group Vice President, Corporate Law & Assistant Secretary
1015 EI Curtola Blvd., Walnut Creek. CA 94595
0%
Robert A. Gordon
Executive Vice President, General Counsel & Secretary
24 Robert Rd., Orinda, CA 94563
0%
Gary Morton
Vice President, Treasurer & Assistant Secretary
2000 Canal St., Boise, ID 83705
0%
CERTIFICATE OF AUTHORITY AND
LIMITED POWER OF ATTORNEY
I, Robert.A. Gordon, Executive Vice President, General Counsel &
Secretary of Shaw's Supermarkets, Inc., a Massachusetts corporation
("Company"), by authority granted to me under a standing resolution duly
adopted by the Board of Directors on April 19, 2017, hereby delegate authority
and grant a limited power of attorney to the persons listed in Exhibit A {as
such Exhibit A may be updated from time to time) for and on behalf of
Shaw's Supermarkets, Inc. to execute the following:
• Licenses, permits, WIC contracts, lottery contracts, tax and fee
returns, sales/use returns, fuel returns, property renditions,
applications for fictitious business names.
Notwithstanding this Certificate of Authority and Limited Power of
Attorney, the persons listed in Exhibit A (as such Exhibit A may be
updated from -time to time) remain subject to, and must comply with, any
applicable approval and procedural requirements set. forth in the Company's
policies on legal review, approval and signing of agreements; as such policy may
be amended from time to time.
This Certificate of Authority and Limited Power of Attorney shall
continue in effect for the individuals named in Exhibit A (as such Exhibit. A
may be updated from time to time) for so long as such individuals remain in
their present positions (or any more senior positions of authority) and maintain
responsibility for the tasks or functions described herein, unless earlier
modified or rescinded in writing.
Dated: 3-13 -1 a "Q",
Robert A. Gordon
Executive Vice President, General Counsel &
Secretary
I, Laura A. Donald, hereby certify that I am the Group Vice President,
Corporate Law & Assistant Secretary of the Company; that the approval
adopted by the. Board of Directors of the Company on April 19, 2017 is still,
on this day, in full force and effect; that Robert A. Gordon is Executive Vice
President, General Counsel & Secretary of the Company; and that Robert A.
Gordon has full right and authority to execute the.above Certificate of '
Authority and Limited Power of Attorney.
Dated:
" a ra A. Donald
Group Vice President, Corporate Law
& Assistant Secretary
Updated July 12, 2019, supersedes March 13, 2018 version.
Exhibit A
Certificate of Authority and Limited Power of Attorney
(Shaw's Supermarkets, Inc. — NASC Documents.)
Name
Title
Steve Barna
Manager Tax
Jana, Bohlman
Director Tax
William Carter
Manager Tax
Tiffany Corcoran
Super visor Tax
Joe Vaiente
Sr. Director Financial Reporting
Devin Whyte
Manager Tax
eff Wilson
Supervisor Tax
Christopher George
From: Laura Dudley <Laura.Dudley@albertsons.com>
Sent: Wednesday, December 11, 2019 12:57 PM
To: Christopher George
Cc: Amy Donovan -Palmer, Sheree Van Hise
Subject: Shaw's #431 - External Grease Trap Manifest & Pumping Company Information
Attachments: 99628.pdf, 255372.pdf
Hi Chris,
Please see the attached invoice and service log for the exterior trap at 390 West Street. Below is information regarding
the exterior grease trap and servicing:
Exterior Grease Interceptor size: 7000 gallons
Serviced: 4 times per year
Name of Hauler: Wind River Environmental
Our maintenance director has ensured quarterly service will be completed by Wind River Environmental on the exterior
grease interceptor, while Elge will continue to maintain/pump the interior grease traps.
I truly apologize for the delay on this, and I thank you and Amy for your patience as we've resolved this issue. Please let
me know if there are any other issues remaining which will hinder the renewal of our health permit.
Thanks again,
Laura Dudhey
Accounting Associate
Shaw's / Star Markets
Albertson's Companies
PO Box 29096, MS 6531
Phoenix, AZ 85038-9096
P: 623-869-4326 / Fax: 623-869-1445
La ura.Dudlev(cDalbertsons.com
UAII
Companies,
Warning: All e-mail sent to this address will be received by the corporate e-mail system, and is subject to
archival and review by someone other than the recipient. This e-mail may contain proprietary information and is
intended only for the use of the intended recipient(s). If the reader of this message is not the intended
recipient(s), you are notified that you have received this message in error and that any review, dissemination,
distribution or copying of this message is strictly prohibited. If you have received this message in error, please
notify the sender immediately.
ELLE PLUMBING & HEATING CO., INC.
P. 0. Box 1070
Burlington, MA 01803
s��reaaarn. (617) 782-4300
BILL SHAWS SUPERMARKETS INC
TO: Po Box 600
Attn: P. Blanchard
E Bridgewater MA 02333
WORK SHAWS 0431
DONE 390 WEST ST.
AT: MANSFIELD, MA 02048-0219
I N V O I C E
INVOICE# 99628
CUST# 83610
WO# 00255372
JOB NO. TERMS INVOICE NUMBER DATE
255372-000 NET 30 99628 12/05/19
DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT
PUMP TRUCK ARRIVED. PUMP GREASE AND JET TO LOOSEN
GREASE. NEEDED ( A SECOND PUMP TRUCK )A VAC TRUCK
DUE TO THE FACT THAT THE GREASE TRAPS HAS NOT BEEN
CLEANED OUT FOR A LONG PERIOD OF TIME. PUMPED OUT
ROUGHLY 6K — 7K GALLONS OF WASTE. JETT TRAP AND
PUMPED. TRANSFER WASTE FROM ONE TRUCK TO ANOTHER
SEVERAL TIMES. RECOMMEND TO HAVE THE GREASE TRAP
CLEANED ON A REGULAR BASIS.
11/06/19 LABOR 9.00 85.00 RT
11/06/19 LABOR 1.00 127.50 OT
VACTOR PUMP TRUCK
765.00
127.50
3,100.00
INVOICE TOTAL 3,992.50
,soarer Pumping, Inc.
195 Thrasher Street
Taunton, MA 02780
W
Elge Plumbing
12 Wilmington Road
Burlington, MA 01803
Invoice/
Date
Invoice #
11/6/2019
8250/
P.O. No.
Terms
Project
Quantity
Description
Vactor Service, Pumped Tank
Location: Shaw's Sumpermarket 390 West St. Mansfield
Please remit to above address.
Phone #
Fax #
E-mail
508-824-0487
508-824-9429
sales@soarespumpinl.com
;a9iexcrpvF ,.
Town of Mansfield Health Department
R APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
a!+
ASARESTAURANT& FOOD PREPARATION ESTABLISHMENTS
reu�1 i
Business/ Food Establishment Name: Shaw's Supermarkets, Inc. dba Shaw's H431
390 West Street, Mansfield, MA 02048
Mailing Address: NASC, MS 6531, PO Box 29096, Phoenix AZ 85038-9096
Phone/Pax Number:
Email: 043160@shaws,com
Contact Person/Title for Grease Traps: Nancy Kiley, Store Director
Name of Company scheduled to pump internal grease trap(s) monthly: Elge Plumbing & Heating
Name of Company scheduled to pump external grease trap quarterly: Wind River Environmental
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 flown of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
$50
container
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the informati(/on� submitted in these documents is true, accurate and complete.
Signed 'nl 'l.V ems/ t / Date December 12, 2019 Updated
Print Na a lane M. Anderson, P.G., Sr, Environmental Manager
jane.anderson@albertsons.com
Permit Preparer Sheree Van Hise, Environmental Affairs Dept. Specialist
sheree,vanhise@albertsons,com
II -
Please answer all questions in this section, if an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday 7am-10 pm
Thursday lam -10 pm
Sunday 7 am - 9 pm
Tuesday —7.am -10 pm
Friday 7 am • to pm
Wednesday 7 am -10 pm
Saturday 7 am -10 pm
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
G
Yes
3 compartment sink
6
No
Handwashingslnk
0
N/A
Commercial Dishwasher
0
N/A
Barsink
2
No
Mop Sink
0
N/A
Garbage Disposal
1
No
Ice Making Machines
2
No
Fryolators
1
No
Grills or Ovens
1
No
Exhaust Hoods
29
Yes
Floor drains
I
Other: Floral Sink
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Kitchen Kleen provides overnight service once a month No sinks are utilized
bake
Is di*#'orware pre -rinsed before being washed? / Yes No
If yes, at what station/sink? Each department; 3 -compartment sink
Internal Grease Traps
How many indoor Grease Removal Units (GRUJtrap) are on site? Six; 40 gallons each
120278 advised Cans George, Mansfield Public Health Dept., that we are unable to Identify the fixture($) attached to each grease trap.
Grease Trap 6 Seafood
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
V Yes No Size 7,000 gallons
Where is the existing outdoor GRU located? Grass area along side the produce area's exterior wall _
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone 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:
Fryolators utilize the RTI system
Rotisserie greaseloil is placed in a bucket which Is picked up weekly by DarPro
Please list fixtures attached to each grease trap
Grease Trap 1
Bakery
Grease Trap 2
Deli
Grease Trap 3
Meat
Grease Trap 4
Produce
Grease Trap S
Produce
Grease Trap 6 Seafood
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
V Yes No Size 7,000 gallons
Where is the existing outdoor GRU located? Grass area along side the produce area's exterior wall _
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone 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:
Fryolators utilize the RTI system
Rotisserie greaseloil is placed in a bucket which Is picked up weekly by DarPro
ELGE PLUMBING & HEATING CO., INC.
P. 0. Box 1070
Burlington, MA 01803
(617) 782-4300
BILL SHAWS SUPERMARKETS INC
TO: Po Box 600
Attn: P. Blanchard
E Bridgewater MA 02333
WORK SHAWS 0431
DONE 390 WEST ST.
AT: MANSFIELD, MA 02048-0219
I N V O I C E
INVOICE# 99628
CUST# RlAiA
WO# 00255372
JOB NO. TERMS INVOICE NUMBER DATE
255372-000 NET 30 99628 12/05/19
DATE DESCRIPTION
QUANTITY UNIT PRICE AMOUNT
PUMP TRUCK ARRIVED, PUMP GREASE AND SET TO LOOSEN
GREASE. NEEDED ( A SECOND PUMP TRUCK )A VAC TRUCK
DUE TO THE FACT THAT THE GREASE TRAPS HAS NOT BEEN
CLEANED OUT FOR A LONG PERIOD OF TIME. PUMPED OUT
ROUGHLY 6K — 7K GALLONS OF WASTE. TETT TRAP AND
PUMPED, TRANSFER WASTE FROM ONE TRUCK TO ANOTHER
SEVERAL TIMES. RECOMMEND TO HAVE THE GREASE TRAP
CLEANED ON A REGULAR BASIS.
11/06/19 LABOR
11/06/19 LABOR
VACTOR PUMP TRUCK
9.00 85.00 RT 765.00
1.00 127.50 OT 127.50
3,100.00
INVOICE TOTAL 3,992.50
Shaw, 431 390We3CMaosOeld MA 02048
6-Tnp,
Bakery
MA
Dell
Meat
2 Produce
Seafood
11/12/2019
6
30% SOLIDS 7D%WATER
10/8/2019
6
30% SOLIDS 70%WATER
9/9/2019
6
30% 500DS 70% WATER
9/21/2D39
6
90% SOLIDS Tay WATER
2/29/2019
6
30% SOLIDS 70% WATER
6/24/2019
6
30% SOLIDS 70% WATER
5/21/2039
6
30% SOLIDS 70% WATER
4/24/2019
6
30%SOLIM70%WATER
3/29/2D29
6
3MS00057MWATER
2/21/2019
6
30% SOLIDS 70% WATER
1/15/2019
6
30% SOLIDS M WATER