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Home My WebLink About4 Corners Citgo - 12/31/2021FOR BOARD OF HEALTH USE ONLY ( Permit # Issybd FOOD ESTABLISHMENT PERMIT APPLICATION�G (Application must be submitted at least 30 days before the planned opening date) Establishment Name i--k corn e-r5 U 50i9� LUgcm', C'urp Establishment Address LA �,Uok" ` y-\C r\ j}- r^r1S�-)rcV l MIN l iUL-lZ 1 Establishment Mailing Address (if different) Establishment Telephone No 0 % _ �`3? V� Applicant Name & Title: 01YN?O-VC A Applicant Address LA C)\ �j }g 6j\� �(� (v� fjy�S kr-, t(/✓l k C) 2�cl� Applicant Telephone No.: �j(J� S}g2 45t7 7 24 Hour Emergency No.: _7 7L-�-Z 6G _GLc3 ( Applicant Email �) d i 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. IL - AA corporation Name Title Address ❑ An Individual r� \ �\'\_��5� 3��` n`�r_ V� _ dLC �%nh�� u�S'h° 1/1 A Partnership El Other legal Entity 0 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: D,\\t\igv\ VC4' Address: \ C U "Arry\f'- &- f ✓V\UfSA"Z:`(L1 Telephone No: S C� 6 -'�r V? 24 Hour Emergency No: -2 7 L-k'-ZC C --N g 3 1 FAX: E-mail: V � v� -5 tv 6 � ��(J Govh Alt E-Mail: -2�2_�� , may' t District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: (� 0 �I — S—o _ Gr' HpLC)U PV✓] _ �i a r1 - (�!� 1 �k `, P✓% 1. Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training nn ,L Name of pest control company routinely inspecting the premises for evidence of pests l""tr w AM Pe S (P�11�rd 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 ql/ Does this establishment require a FOG permit? -__ If yes, please attach the FOG permit application. 7Len th of Permit: Est blishment Type: Annual 7RRetail Food $125.00 ❑ Mobile Food Consession ❑ Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: [ FOOD TRUCKS $175.00 �vtanufacture Frozen Desserts/Ice Cream _I Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ElResidential Kitchen $100.00 Rain Date: [Milk &Cream $70.00 El caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time/tempemtum controls required) Check all that I Non-PHFs- non -potentially hazardous food(no timeRempereture controls required) t PPY) RTE-ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) [r� S le of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Vle of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs ❑ Susceptible Population Facility Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- ElCustomer Self -Service contact alternative, time as a public health [] Perishable Foods Only Ice Manufactured and Packaged for control) ❑ Preparation of Non-PHFs Retail Sale I ` ' ❑ OfferS Raw Or Undercooked Food Of J Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging / Cook Chill ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for ❑ Retail Sale of Salvage, 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 \bta�q)cc ies-r_f)105 CIARR 590.000 and the federal Food Code. Signature of, �.�/ I` 0'-` 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:) core, Signature of Individual or Corporate Name: L,o Y lrV `7� e. SUBHLAI OP ' TL .A,C� CERTIFICATE OF LIABILITY INSURANCE DATE(M9120 101212020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS HQ 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 poiicy(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 endorsament a . PRODUCER 508-947-1818 J.K. Olivieri Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivieri co recT Kenneth W. Olivieri PHONE 508-947.1818 FAX No), Alc, No, Eat Eo l-ARe ^ --- INSURERISI AFFORDING COYERAGE NAIL# INSURER A: Union Mutual Fire Ins. Co. 25860 ru%' LD Inc. u dba Fouurr Corners Cltgo 4 South Main St Mansfield, MA 02048 INSURERS: Ma. Retail Merchants We Group 23612 INSURER C: INSURER D: _ — - INSURERE: -_ INSURER F: COVERAGES GtHTIr1L,AIC numnctc: ------- - ------- 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. INSft TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICYEFF 07/1412020 POLICY EXP 07/1412021 qL LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OX OCCUR Business Owners BOP0173545 EACH OCCURRENCE S 1'000,000 DAMAGE TO co 500,000 MEDEXP(AnYonecerson $ 10,000 X PERSONALBADV INJURY S 1'000,000 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PET LOC OTHER: AUTOMOBILE LUIBILITY AUTO ES ONLY SCHEDULED UT yy ONLY AUTOS ONLYnl)UMBRELLA PRODUCTS-COMPIOP AGG 2,000,000 $ SINGLE LIMIT nANY JURY Per arsonOWOS JURY Peraccide tt�q Y pAMAGEAUTOS B LIAB EXCESS LIAR OCCUR CLAIMS -MADE NIA 014005033710120 01/01/2020 01/0112021 CURRENCE ATE X SER E OTH- DED RETENTION$ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN QQppFICCER/MEMBEER EXCLUDED? (mantlatov In NH) If yes, desaiba antler DESCRIPTION OF OPERAT ONS below EL, EACH ACGIOENT _ 100,000 .._ E1,DISEASE-. EA EMPLOYE $ 100,000 EL, DISEASE- POLICYL IT 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD lot, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RUED REPRESENTATIVE fF / ACORD 25 (2016103) 1 ' """'„--""� The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I its ft Office of Investigations 600 Washington Street `?� Boston, MA 02111 s' wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information aa \\ Please Print L ccegibly Business/Organization Name: XJY�`^ L W)Y)" core Address: � SdtJly\ Yho� (\ S)�- City/State/Zip: CU?lJ Phone #: �C) '97 -33%��\ Are you an employer? Check the appropriate box: Bues Type (required): sh Ln I am a employer with employees (full and/ 5. Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2. ❑ I am 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. g. Non-profit 3.Q Wo workers' comp. insurance required] e 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]* 110 Bealth Care 4. We are a non-profit organization, staffed by volunteers, 12.Q Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organisation should check box Sl. Iran an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: l/ 1V ' a v ` von — t " ` Insurer's Address: G U e kv GCGti� S� */ " ` && '��uNt MCT� C' /St te0 r 0- sty a 1. Policy # or Self -ins. Lic. # ��U f 1 �1 �1 Expiration Date: U� UZ� 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�rtify, under thepains and penalties ofperjuty that the information provided above is trite and correct. J �� IR,t-1A i Date: L0-2 7--2-D -none rr: 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 Person: Phone #: 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. jS2,vYA P I i , Pat-O Signature of Individual 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\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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. D.P. 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. D.P. 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. D.P. 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 Signature TRA � Date: 10/28/2020 Applicant Name (please print clearly) Dhruv Patel