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HomeMy WebLinkAboutStop & Shop - 12/31/202110 66 q 5q - `6 44 6 q SS - FOR BOARD OF HEALTH USE ONLY Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) am Establishment Name Establishment Address Establishment Mailing Address (if different) Lic Establishment Telephone No 7- 170 c) ',C Applicant Name &Title: f Applicant Address 1 Q_ Applicant Telephone No i 7 770 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant)-( J,,4e Owner Address 1 ho�ACC3( :,,,-\c It, I I -D Owner telephone number L,r 7 —1 0 Owner email: Ck Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or D An Association partner. El A Corporation Name Title Address 41 C9 n An Individual 11 A Partnership WOther legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: _- 1� S f, oz� Address: Telephone No: IT 24 Hour Emergency No: 17� '7 - FAX: E-mail: Alt E-Mail: (7) District Or Regional Supervisor (if applicable) Name & Title: Address: � C;c'j Telephone No: 24 Hour Emergency No: � 7 7- FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: F J�l `'s`1 (jl_ No. of Food Employees: t C„ DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: €, < r.- t CZ ('60'. Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests 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 �°ji 11 dt Does this establishment require a FOG permit? -IL`?—ILL5 If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual 0 Retail Food $125.00 F� Mobile Food Consession 0 Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 0 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 0 Pushcart $50.00 # of Pushcarts: Temporary Time: [KSupermarkets $400 Residential Kitchen $100.00 Rain Date: " Milk &Cream $10.00 Caterer $35.00 Food Operations: Dentitions: PHF- Potentially hazardous food (time/temperature controls required) (Check all that apply): Non.PHFs- non -potentially hazardous food(no time/lemperature controls required) RTE - ready-lo-eat foods (Ex. sandwiches, salads, mums which need no further processing) Lw1 sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order VL' Hot PHF Cooked and Cooled or Hot Held [�/ for More Than a Single Meal Service sale of Commercially Pre -Packaged PHFs of iSinglerHot And Cold Holding ForPreparation Meal Service E] PHF and RTE Foods Prepared For Highly 0 Delivery of Packaged PHFs Dt Susceptible Population Facility Sale of Raw Animal Foods Intended &y -Reheating of Commercially be Prepared by Consumer E] Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours °to and/or HACCP Plan (including bare hand L+o Customer Self -Service Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) VI Preparation of Non-PHFs Retail Sale 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 E] 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 obtaid copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant -C 1 Ll - V i Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID. Signature of Individual or Corporate Name`' -I' "t —` te ijr /aa'4 o, e, - 'd pl�`<'�. ( � U- �t"`"``-' TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature oi Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Volitntary) 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\Usemisleite\Desktop\ScoR's Documents\Food Establishments- Temp\TAX CERTIFICATION FORbLdoc NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALSO CERTIFIES JESSICA PATTIE HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS 17, PRESIDENT: LAWRENCE J. LYNCH, CAE ANSI nncxeunm vn0cmm� ao�o..miaionasuousiaan:we,. aneinennm.,.o�e ioi rweem�.uoo 6751 Forum Drive, Suite 220, Orlando, FL 32821 P (800) 446-0257 F (407) 352-3603 wwwNRFSRcom National Registry of Food Safety Professionals' Notification of Test Results ID#: xxx-xx- Scaled Test Score: 97 Candidate Status: Pass Test Date: August 15, 2018 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 (Mastered) Ensuring Personal Hygiene and Employee Health (Mastered) Actively Managing Controls in a Food Establishment (Mastered) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Competent) Conducting Cleaning and Sanitizing (Mastered) Managing: Physical Facility Design & Maintenance: Preventing & Controlling Pests (Mastered) ISSUE DATE: AUGUST 15, 2018 EXPIRATION DATE: AUGUST 1 5, 2023 CERTIFICATE NO: 21 495582 TEST FORM: EZS41 nns eenna0me s net yard far none than five years front date of issue National Registry of Fmd Safely Prolcssiimal+ CERTIFIED FOOD SAFETY NIANAGI; It JESSICA PATTIE 6751 Feat nave S.111110 .do. FL 32021 To I Par 000) 4460257 Cenificule No: 21495592 Phone(40»552-38M Issue Date, August 15, 2918 Fix(407)352JW1 Expiration Date: August 15, 2023 —TeRFSP.eom JESSICA PATTIE 69 KEENE STREET PROVIDENCE, RI 02906 National Registry of Food Safety Professionals® 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3830 1 Fax: 407 352.3603 § «%»l ) � \ / % \ M / / � \ \ § } / 6 / / \f F I a .Not, � I k » The Stop & Shop Supermarket Companv LLC Officers: Title : Name President Gordon Reid Treasurer Mary Lynn Phillips Secretary Mark Messier Assistant Secretary Maria Silvestri 11' FTiFi•TT= Gordon Reid Mary Lynn Phillips Mark Messier Robert Yager Rudolph Thomas Di Pietro III IStacy Wiggins All Officers & Managers of The Stop & Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 }n+.•w. mass. gol/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Stop & Shop Supermarket Company LLC Address: 1385 Hancock St City/State/Zip: Quincy CIA 02169 Phone±: 800-288-8415 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with employees (full and/ 5. M Retail orpart-time).* I 6. ❑Resiau:a_^:tBar.ratingEstablishment 2. ❑ a sole proprietor or partnership and have no I ;, ❑Office and/or Sties (incl. real estate, auto, etc.) employees working for me in any capacity. (No workers' comp. insurance required) 8. ❑Noc-profs[ 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we base i N.❑ Manufacturing no employees. (No workers' comp. insurance required)* 4. ❑ We are a non-profit organization, staffed by vohmteers, 11.❑ H.- Health Ca with no employees. [No workers' comp. insurance req.J ( LID Other •,kv applicant that checks box #1 must also idl era the section beiew =Lowing atair ccrnpersaticn p�Gcy icfor_natior.. • 41he corperute officers have exempted themeives, but the crporat"On has :rye; cmpi.;veas. s wn:!c::rs'-.:ormpzrea.icn policy is required and each w.. organization should check boat -l. I am an employer that is providing workers' compensatim insurance for inv employees. Below is the policy infor"ratio. Insurance Company Name: Ahold Delhaize America Holdin„ Inc. and its subsidiaries Insurer's Address: 1385 Hancock St City/State/Zip: Quincy Iv'fA 02169 Policy # or Self -ins. Lic. 9 576 E..,cmmcon Dar: 8/1 /2021 Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25?, of MGL c 152 can lead to :he imposition of criminal penalties of a fine up to S1,500.00 and/or ore -year imprisonment, as •.vell as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement tray be forwarded to the Office of Investigations of the DIA for insurance coverage ve ir:ca I I do hereby certify, ykgder the pains and penalties of perjury that th e informatu;n provuied above is true and correct 617.689.4921 FOffwialonly. Do not write in this area, tv be completed oy city or W+n offr::LL n: Permitilicemehority (circle one): Health 2. Building Department 3. City Town C!erk 4. Licensin�, I34,ard 5. Selectmen's Office rson: Phone»: ACiI CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYO 1210812020 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(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 Marsh USA Inc. 1717Arch Street Philadelphia, PA 19103-2797 CONTACT NAME: _ HONE Ex[: FAX Nol: EtAAt, ADDRESS: INSURER(SI AFFORDING COVERAGE NAICIf INSURER A: ACE American Insurance Company 22667 CN101 295509 -GAWXW-20-21 INSURED The Slop &Shop Supermarket Company LLC INSURER B: ACE Fire Undemmers Ins. Co. 20702 INSURER C: Indemnity Ins Co Of North America 43575 Adn: Rick Shaughnessy 1385 Hancock Skeet Quincy, MA 02169 INSURER D : N/A — NIA -- INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER' CLE-00663542402 RFVISION NIIMRFR- 2 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. INES LTR rypE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF ! POILDYEXP MMIDDIYE Y M, LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR HOOG71574349 12101/2020 12101/2021 III I EACH OCCURRENCE f OAMAGE TO RENTED PREMISES(Ea occurrence) $ 2,000,000 $ 2,000,000 GE X IMED EXP (Any one person) S 5,000 PERSONAL BApV INJURY $ 2,000,000 N'L AGGREGATE LIMIT APPLIES PER: POLICY ECT LOC OTHER: GENERAL AGGREGATE § 2,000,000 PRODUCTS-COMP/OP AGG $ 2.000,000 $ A AUTOMOBILELIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ISAH25308840 'SELF INSURED FOR PHYSICAL' 'DAMAGE' 12/01/2020 12/0112021 !! ICI COMBINED SINGLE LIMIT -Es rr1dmuU_ § 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY Per accident ( ) S PROPERTYDAMAGE Per accident)$ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE i EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS $ C B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERIEXEcunvE Y/N OFFICER/MEMBEREXCLUDEO? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WLRC6781244A(AOS) SCFC67812529(Wit WLRC67EI12566(TN) 12M1J2u2U 1210112021 '12101/2020 12120/2021 12101/2020 72/0112021 PER orH- ISTATUTE ER E.L. EACH ACCIDENT s 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMiT $ 1,000,000 A EXCESS WORKERS COMPENSATION WCUC67812487 12/01/2020 '12/01/2021 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance The Stop and Shop Supermarket Company LLC Alto: Rick Shaughnessy 1385 Hancock Street Quincy, MA 02169 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. of Marsh USA Inc. Manashi Mukherjee _�t.0.'xitPdM,i sc ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS C r. Business/ Food Establishment Name: Mailing Address: f Phone/Fax Number: L (7- I 70G-.c� € r am Email 4"t x (6 J %-Ck,\ c r' e c Contact Person/Tifle for Grease Traps: �' <; r.� i Ef-t h f i�fA .t Name of Company scheduled to pump internal grease trap(s) monthly: t E 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 Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $SO container Each grease interceptor/trap over 3 $SO ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWEDTHE 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 acknowledgesthat the information submitted in these documents is true, accurate and complete. Signed i,' .''ytti, ,_^ Date . Print Name Facility Oaerational 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): f F Normal Hours of Food Preparation/Service: Monday 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 establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink \) Mop Sink Garbage Disposal Ice Making Machines 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? If yes, at what station/sink? Yes M 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 I r 01 », , . yv, �J- Grease Trap 2 �-s , , o Grease Trap 3 j (a Grease Trap 4 Grease Trap S ? (`.Fiio�pcU- Y,"•'t�'_k" a External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? ><- Yes No Size <> ��(;�.d; gallons Where is the existing outdoor GRU located? r r* r la C `, , r 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: TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. )fI have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature r C (`3 C- ' T Date: Applicant Name (please print clearly)