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HomeMy WebLinkAboutCumberland Farms - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued 1 .. FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) r',\ Establishment Name Cumberland Farms #0187 y. Establishment Address 30 Chancy St. Mansfield Ma. 02048 Establishment Mailing Address (if different) 165 FLANDERS RD. WESTBOROUGH MA. 01581 ATTN: LEGAL DEPT. Establishment Telephone No 508-261-7857 Applicant Name & Title: Cumberland Farms, Inc. attn: Legal Dept. Applicant Address 165 Flanders Rd. Westborough Ma. 01581 Applicant Telephone No.: 508-270-1504 24 Hour Emergency No.: 508-270-1400 Applicant Email LSalvucci@cumberlandfarms.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 An Association partner. A Corporation Name Title Address O An Individual See attached List ® A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Cindy Medeiros Store Mgr. Address: Mansfield, Ma. Telephone No: 508-261-7857 FAX: N/A E-mail: N/A Alt E-Mail: LSalvucci@cumberlandfarms.com 24 Hour Emergency No: 508-270-1400 District Or Regional Supervisor (if applicable) Name & Title: JULIE IADAROLA DISTRICT MGR. Address: 2643 Hartford Ave. Johnston RI 02919 Telephone No: 508-380-2059 24 Hour Emergency No: FAX: 401-934-2670 same E-mail: jiadarola@cumberlandfarms.com Food Establishment Information WATER SOURCE: PUBLIC SEWAGE DISPOSAL. PUBLIC DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS:24 hours 7 days Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests terminix 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. H Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: "J Annual EJ Retail Food $125.00 Q Mobile Food Confession Ery Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream €<3 Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Rd Food Service up to 201 + $300.00 M Pushcart $50.00 # of Pushcarts: Temporary Time: i Supermarkets $400 €d Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 t+J Caterer $35.00 Food Operations: Definitions:PHF-Potenfiallyhazardous food(time/lemperature conhols required) $185.00 TOTAL (Check all that apply): Non-PHFs- non -potentially hazardous lood(notime/temperature controlsrequired) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) W Sale of Commercially Pre -Packaged Non-PHFs kd PHFCooked To Order E1 Hot PHF Cooked and Cooled or Hot Held IA Sale of Commercially Pre -Packaged PHFs to Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service Delivery of Packaged PHFs H8 PHF and RTE Foods Prepared For Highly V Reheating of Commercially Cd Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer tU Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand ' M Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only 0 Ice Manufactured and Packaged for control) DI Preparation of Non-PHFs Retail Sale rD Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale EJ Vacuum Packaging /Cook Chill ® Offers RTE PHF in Bulk Quantities 07 Prepares Food/Single Meals for Fl Retail Sale of Salvage, Out -Of -Dale 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 o r applicable law. I have been instructed by the board of health on how to obtain copi CMR 00 a federal Food Code. Signature ofAppli � SR.LICENSINGCOORDI Pursuant to K_CLCh.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: 04-2843586 Signature of Individual or Corporate Name: Cumberland Farms Inc. 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. L S 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. L_ S 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. L-S 1 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 Lazo-1, 12/4/2020 Applicant Name (please print clearly) Laura Salyuccl Sr. License Coordinator / \ ƒ \ 2 0 "h 0 \ � * \.\ D \ . § § f �© 4 \ \ � \ iW � � � P:� z � � � � � z � z C) I # Town of Mansfield Health Department Business/ Food Establishment Name: Cumberland Farms #0187 Address:30 Chancy St. Mansfield Ma. 02048 Mailing Address:165 Flanders Rd. Westborough Ma. 01581 Phone/Fax Number:508-261-7857 Email: thartley@cumberlandfarms.com Contact Person/Title for Grease Traps: Todd Hartley /FSS Maintence Supervisor Name of Company scheduled to pump internal grease trap(s) monthly: Patriots Service Inc. 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 $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 information submitted in these documents is true, accurate and complete. Signed Print Name Todd Hartley /FSS Maintence Supervisor Date 11/30/2020 1 Facility Onerational Informtton 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): 0 Seating Capacity (Actual Count): 0 Normal Hours of Food Preparation/Service: Monday 24 hours 7 days Tuesday Thursday Friday Sunday Wednesday Saturday 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 X 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink X Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods X Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): N/A Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? N/A 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on s Please list fixtures attached to each grease trap Grease Trap 1 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 gallons Where is the existing outdoor GRU located? 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. LS 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. LS 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. LS I 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 Signatu Applicant 11 /30/2020 e (please print clearly) Laura Salvucci Retail License Coordinator Page 1 of 1 �►� aD CERTIFICATE OF LIABILITY INSURANCE GATE(MMIDONYYY). 11/01/2019 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: It the certlficale holder Is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL, INSURED provisions or he endorsed. It 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 confor rights to the certificate holder In lieu of such endorsements .' PRODUCER N111ia of Greater X"948, Ina. o10 26 Cantvzy alud P.O. Do. 305191 Naehvilla, TN 372305191 USh CONTACT A E' PHONE 1-877-945-73is FAX 1-888-467-2319 dC, Nol: EMAIL Aonprift certificates9N1111s.eom INSUR59( AFFORDINGCOVERAGE NAICs INSURERA: Safety National Casualty Corporation 15105 INSURED D,dted Site services Northeast, Inc. 118 Flanders Road, suite 1000 Nest2wtaush, M 01301 USA INSURERBI X1. Specialty Inevrance Company 37885 INSURER C: INSURER O: INSURER E: INSURER F i C..m !C!C ATE an IMoc" W13729Dae REVWlune Ivulu..M; COVERAGES u1 n r„�1. uu". 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 W4TH 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 T0. TYPE OFINSUPA CE AOOL SUBR POLICY NUMBER POUCY EFF M810 11/03/2019 POLICY EXP MM 0 UMRS' A X COMMERCIALGENERALLIAeILITY CLAIMS-MA➢E OCCUR M4057787 11/03/2020 EACH OCCURRENCE s 1, 000,000 PRETAWMISES Ea amvlren s 1,000, 000 MED EXP one ar s. 30, 000 PERSONALAADV INJURY - $ 1,000,000 GENLAGGREGATE UMITAPPLIES PER: PRo_ X POLICY ❑ JECT Loc GENERALAGGREGATE s 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 f O HER AUTOMHEIR IABIIJTY COMBINEOSINGLEUMIT a and s 3,000,000 BOOILYINJURY(Purksmon) s A X ANYAUTO OVdJED SCHEDULED AUTOSONLY AUTOS HIRED NON-0WNED AUMS ONLY AUTOS ONLY Oar4047379 11/03/2019 11/03/2020 BODILY INJURY tPrramident) s PROPER DAMAGE ere $ $ . a X UM8REIA UAB EXCESS LMB X OUR CLAIMS-MAGE U900076933LI19A 11/03/2019 11/03/2020 EACHOCCURRENCE $ 1, 000, 000 AGGREGATE S _ 1,000,O00 X 5 ATUTE ER s - OED J0 RETENnONS 10,000 WORKERSCOMPENSATION EL EACH ACCIDENT s 1,000,000 A ANDEMPLOYERS'UASIUTY YIN ANYPROPRIETOR/RARTNEFUEXECDDVE Nc `MCCE EMNEREXCLUDE07 iq Mya dexplbe Nader DESCRIPTION OF OPERATION5 belos N/A ws4047370 11/03/2019 11/03/2D20 EL DISEASE -FA EMPLOYE S 1,000,000 ELDISEASE-POUCYUMIT s 1,000,000 DESCRIPnONOFOP -DONSILOCATIONS/VEMICLES(ACORD 101, Additional Remarks Schedule, may ha attached it mare space is required) United Site Services Northeast, Inc. 11B riandera Road, Suite 100 W..tl,ornunh. MA 01581 SHOULD ANY OF THE ABOVE DESCRIBED, POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE.WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHOR= REPRESENTATIVE ' no 1988-2016 ACORD CORPORATION. All r ghts reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD OR ma 19752115 baste: 1438819 w 0 w u w W Q. z I� z C!) w z W z W (4� 14 W 3 N N N a N N 4 H 1.4 goo GJ jya iC � yw0 O A 0 c o E I 0 ca,V b w , a rK Z O N y � a hN W ti ti w U 4b l � � V ,N_ Aft. t �:�. �� 1'i �.... � a � 4• M �>k gn gfw.F '. T Business/ Food Establishment Name: Cumberland Farms #0187 Address:30 Chancy St. Mansfield Ma. 02048 Mailing Address:165 Flanders Rd. Westborough Ma. 01581 Phone/Fax Number: 508-261-7857 Email: thartley@cumberlandfarms.com Contact Person/Title for Grease Traps: Todd Hartley /FSS Maintence Supervisor Name of Company scheduled to pump internal grease trap(s) monthly: Patriots Service Inc. 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 $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 information submitted in these documents is true, accurate and complete. Print Name Todd Hartley /FSS Maintence Supervisor Date 11/30/2020 1 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. Seating Capacity (per Fire Department Regulation): 0 Seating Capacity (Actual Count): 0 Normal Hours of Food Preparation/Service: Monday 24 hours 7 days 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 I Attached to establishment GRU i 1 ! X 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink 1 X Mop Sink Garbage Disposal Ice Making Machines i Fryolators Grills or Ovens Exhaust Hoods X Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): N/A Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? N/A 7 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 Floor drain, mop sink, 3 bay sink 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 x No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: Property Owners Address: Property Owners 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: 3