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HomeMy WebLinkAboutDollar General Store #20417 - 12/31/2021G 7-1 �" d-'� A D 95, FOR BOARD OF HEALTH USE ONL(6 Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name Dollar General St( Establishment Address 650 Copeland Dr Mansfield, MA 02048 Establishment Mailing Address (if different) Attn:Tax Dept100 Mission Ridge Goodlettsville, TN. 37072 Establishment Telephone No 615-855-4000 Applicant Name & Title:'Zr RAr ;� C /VSh5 Applicant Address same as mailing f �5 W6 ®4{ 5' 'r �.xt q�s'4 Applicant Telephone No.: GiS--h666i 24 Hour Emergency No,: 615-517-8717 / )/ Applicant Email r -- a a - - M t rA! 4A0 G{vl l a Owner Name & Title (If different from applicant) Owner Address same as applicant Owner telephone number Owner email: Establishment Owned By: 0 An Association L1 A Corporation An Individual P51 A Partnership I� Other legal Entity LLC If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address see attached Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: Stephen Burgess, Store Mgr Address: Telephone No: 508-964-2370 24 Hour Emergency No: 615-517-8717 FAX: 877-364-4130 E-mail: tax-beerandwinelicense@dollargeneral.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name&Title: HUMBERTO RODRIGUEZ, Dist Mgr. Address: Telephone No: 615-517-8717 24 Hour Emergency No: 615-517-8717 FAX: 877-364-4130 E-mail: tax-beerandwinelicense@dollargeneral.com c� Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: n/a DAYS/HOURS: 8:00am-9:00pm daily Name of Person(s) In Charge Certified in Food Protection Management: n/a Name of Person(s) In Charge Certified in Allergen Awareness Training n / a Name of pest control company routinely inspecting the premises for evidence of Pests Ecolab 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. = I Yes n/a Does this establishment require a FOG permit? n/a If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual [ Retail Food $125.00 ❑ Mobile Food Consession i Temporary I ) Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Dale: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream I-1 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 Residential Kitchen $100.00 Rain Date: (_)[ Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(lime/lemperalum controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no lime/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [ Sale of Commercially Pre -Packaged Non-PHFs [] PHFCooked To Order I'l Hot PHF Cooked and Cooled or Hot Held Sale of Commercial) Pre -Packaged PHFs for More Than a Single Meal Service I� y g � Preparation of PHFs For Hot And U Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly �- iI Sale of Raw Animal Foods Intended Susceptible Population Facility -t Reheating of Foods for envy to be Prepared by Consumer I-1 Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand [] Customer Self -Service contact alternative, time as a public I _I Customer Self -Service of Non PHF and Non- p tic health Perishable Foods Only Ice Manufactured and Packaged for control) ❑ Preparation of Non-PHFs Retail Sale P E] Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale I Vacuum Packaging / Cook Chill -_� Offers RTE PHF in Bulk Quantities I� 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 105 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 filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 3 6— 4 5 7 7 2 4 2 Signature of Individual or Corporate Name: DG RETAIL LLC to L IIG ....LIL VJ [I1VJJLLt-If 4fJGLfJ Department ofIndustrial Accidents Office of Investigations 600 Washington Street y` Boston, MA 02111 wtvrumass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DG Retail, LLC/Dollar General Store# 20417 Address: Attn: Tax Dept 100 Mission Ridge City/State/Zip: Goodlettsvilte, TN. 37072 Phone M 615-855-4000 Are you an employer? Check the appropriate box: Business Type (required): L ® lain a employer with 6-10 employees Hall 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 (met. 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]* 1 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 organization should check box #1. I aar an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: Ace American Insurance Co. Insurer's Address: 3400 Overton Park Dr SE STE 300 City/State/Zip: Atlanta, GA 30339 Policy # or Self -ins. Lie. # WLRC66927908 Expiration Date: 2/10/2021 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 fire pains and penalties ofpeijury that the information provided above is tare and correct. 5-855-4000 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 1 ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 01/23/2020 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 MCGRIFF, SEIBELS & WILLIAMS, INC. 3400 Overton Park Drive BE CONTACT Keri Devine NAME: C No: lac No Eat) 404 497-7500 _ A/C E-MAIL kdevine@mcgriff.com ADDRESS: Suite 300 Atlanta, GA 30339 _ _ INSURERS) AFFORDING COVERAGE NAIC N INSURER A:ACE American Insurain Com an 22667 INSURED Dollar General Corporation & Its Subsidiaries and Affiliates 100 Mission Ridge Drive INSURER B:ACE Fire Underwriters Insurance Company 20702 INSURER C:Berkshire Hathaway Specialty Insurance Company _ _ - 22276 Goodlettsville, TN 37072 INSURER D INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER:BJ32GV9D 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. ITR TYPE OF INSURANCE INso WVDSLIBR POLICY NUMBER POLICY MMIDDNYVY LIMITS A X COMMERCIAL GENERAL LIABILITY XSL G71568210 02/10/2020 02/10/2021 EACH OCCURRENCE $ 500,000 CLAIMS -MADE OCCUR DAMA O REN PREMISES Ea occurrence) $ 500,000 X MED EXP(Any one named) S 0 SIR$750,000 PERSONAL B ADV INJURY $ 500,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 PRO- POLICY JECT LOC X PRODUCTS � COMP/OP AGG $ 2,000,000 _ OTHER: $ A AUTOMOBILE LIABILITY ISA H25294774 02/10/2020 02/10/2021 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED i SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) PROPERTYDAMAGE Per accitlenl $ $ _. C X UMBRELLA LIAe X OCCUR 7-UMO-303309-04 02/10/2020 02/10/2021 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 5,000,000 DIED I RETENTION$ $ A B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED4 N (Mandatory in NH) NIA WLR C66927908 fAOS) SCF C66927945 ( ) 02/10/2020 02/10/2021 X I PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE S 1,000,000 E.L. DISEASE- POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A EXCESS WORKERS COMPENSATION WCU C66927982 02/10/2020 02/10/2021 EL - Each Accident $ 1,000,000 AND EMPLOYERS' LIABILITY EL Disease - Each Empl $ 1,000,000 (Per Statute) EL Disease - Policy Limit $ 1,000,000 $ $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DOLGEN CORP of TX, Inc. is a non -subscriber to the Workers' Compensation System in the State of Texas and as such is not afforded benefits by the Workers' Compensation policies referenced herein in Texas only. Covers all cities/counties within the following states: AL, AR DE, FL, GA, IA, IL, IN, KS, KY, LA, MD, MI, MO, MS, NE, INC, NM, NJ, NY, OH, OK, PA, SC, TN, VA, WV CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DG Retail LLC AUTHORIZED REPRESENTATIVE 100 Mission Ridge Goodlettsville, TN 37072 Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rights reserved. DG RETAIL, LLC— a Tennessee limited liability company Officer Listing Jason Reiser Chief Merchandising Officer and Secretary Larry Gatta Senior Vice President, General Merchandise Manager 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. Signature of Individual or Corporate N m By: Corporate Officer (Mandatory, if Applicable) 36-4577242 `*Social Security No. (Voluntary) or Federal Identification Nannber *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. Ct\Users\.sleite\Desktop\Scott's Documents\Food Esmblishments-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. a- I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to e sure 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. 4^_.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. 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 4. �leaiZUCL uhA�i� Date: 13 Nov 2020 Applicant Name (please print clearly) A. Joshua Murphy