Loading...
HomeMy WebLinkAboutMansfield Xtra Mart - 12/31/20214 �(p,�{(306 FOR BOARD OF HEALTH USE ONLY, Permit # Issued FOOD ESTABLISHMENT PERMIT APPEICATION (Application must be submitted at least 30 days before the planned opening IVY Establishment Name: Mansfield Xtra Mart Establishment Address: 905 South Main Street, Mansfield, MA Establishment Mailing Address (if different): 800 South Street, Suite 500, Waltham, MA 02453 Establishment Telephone No: (508) 261-2812 Applicant Name & Title: Drake Petroleum Company, Inc. Applicant Address: 800 South Street, Suite 500, Waltham, MA 02453 Applicant Telephone No.: (781) 398-4419 24 Hour Emergency No.: (781) 999-2123 Applicant Email: permits@globalp.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. IN A Corporation Name Title Address 0 An Individual Please see attached EJ A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Jim Brodeu, Store Manager Address: 905 South Main Street, Mansfield, MA Telephone No: (508) 261-2812 24 Hour Emergency No: (781) 999-2123 FAX: (781) 398-7261 E-mail: permits@globalp.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Farron Lopes Address: 800 South Street, Suite 500, Waltham, MA 02453 Telephone No: (781) 999-2123 24 Hour Emergency No: (781) 999-2123 FAX: (781)398-7261 E-mail: permits@gloablp.com Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: 5:00 A.M. - 11:00 P.M.; 7 days per week Name of Person(s) In Charge Certified in Food Protection Management: Jim Brodeur Name of Person(s) In Charge Certified in Allergen Awareness Training Jim Brodeur Name of pest control company routinely inspecting the premises for evidence of pests Braman Chemical Enterprise Inc. 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 N/A Does this establishment require a FOG permit? yes If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [)Q Annual N Retail Food $126.00 Mobile Food Consession Temporary E Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/lee 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 Pushcart $50.00 # of Pushcarts: Temporary Time: EJ Supermarkets $400 Residential Kitchen $100.00 Rain Date: [X Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(time/lempemaire controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) X1 Sale of Commercially Pre -Packaged Non-PHFs ❑i PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service El PHF and RTE Foods Prepared For Highly 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 I] Customer Self -Service and/or HACCP Plan (including bare hand X] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) 0 Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging I 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 1, 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 690.000 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: _ i ` ' - Pursuant to MGL Ch.62C, srgc. 490 certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes requiredpnder aw. Social Security Number or Federal ID: 04-2236089 Signature of Individual or Corporate Name: Drake Petroleum Company, Inc. 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. Drake Petroleum Company, Inc. Signature of Individual or Corporate Name By: 04-2236089 "Social Security No. (Voluntary) or Federal Identification Number Officer (Mandatory, if Applicable) *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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc r ' . The Commonwealth of Massachusetts Department of IndustrialAccidents Of fice of Investigations Lafayette City Center M ,� 2Avenue de Lafayette, Boston, MA 02II1-U50 — s, wwtumass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibly Business/Organization Name: Global Montello Group Corp. 800 South Street, Suite 500 City/State/Zip: Waltham, MA 02453 Plione #: (781) 894-8800 Are you an employer? Check the appropriate box: Business Type (required): EA I am a employer with employees (full and/ 5. ® Retail or pall -tune).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for tne in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 1 ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 1 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care n 4. ❑ We are a on -profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant thnt checks box 91 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 N I. I ant of employer thin is proelding workers' contpenvation insurance for ray employees. Below is the pollee inforn:alion. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. 11� i 1 �t putExpiration Date: —1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 it fine orup 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 D1A for insurance coverage verification. hereby eL ify, under t(w pains and penalties of perjury that lire information provider) above A true and correct. Dfficial u.se only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (check one): 1013oard of Health 2.❑ Building Department 50Selectmen'sOffice 6.1­10ther Permit/License 3.00ty/Town Clerk 4.❑Licensing Board Contact Person: Phone #: wuwnuss.gov/dia `'� K" CERTIFICATE OF LIABILITY INSURANCE °10/6/'°°"YYY' ton/zozl 10/6/2020 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 pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION 1S 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 Locklon Insurance Brokers, LLC CA License#OF 15767 Three Embnrcadero Center, Suite 600 San Francisco CA 94111 -NAME _ ___ PHONE FAX —" ac. No: MAIL Aoo E INSURER(S)AFFORDINGCOVERAGE NAIOIf (415)568AOOO -----�___.. __-_ INSURED Global Montel In Group Corp. 1369067 404 Wyman St, Ste 425 Waltham MA 02451 INBURERA, Libeny lllsurftmC Corp01-atlon __.__ INSURERS: _ __42404 INSURERC: ---- INSURER D: INSURER E; _ INSURER F : I�GYIJIVIY IYYIYI6CR: j{JLxxJ(x]( 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 F SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ODL SUBR POLICYEFF POLICYEXP- POUCYNUMBER MMIODIY MMILIC YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS MADE ru NOT APPLICABLE EACH OCCURRENCE_ $ XXXXXXX P EAGEET(EaE114TM OCCUR nce $XXXXXXX MED EXP (An one Person) $ XXXXXXX --- - --- ---- PERSONAL &ADV INJURY $ XXXXXXX AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT ❑ GENERAL AGGREGATE _ §XXXXXXX_ GEN'L PRODUCTS - COMPIOPAGG $ XXXXXXX _ ECT LOC OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT Ea ecUdent $XXXXXXX ANY AUTO BODILY INJURY (Per porace) $XXXXXXX OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ XXXXXXX HIRED NUN0WNE11 AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE R-,thEdentl § XXXXXXX $XXXXXXX UMBRELLALIAS OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXxxiX AGGREGATE $ A•XXXXXX EXCESS LIAR - CLAIMS -MADE DEO RETENTIONS _ _ $XXXXXXX A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN N WA7-69D-460066-010 10/1/2020 l0/1/2021 X STATUTE ERH _ E.L. EACH ACCIDENT_ - _... $ L 000,000 OFFICANY ERIMEMBER EXCLUDED? n NIA (Mandatory sent NH) If yes, eacdhe under E.L,DISEASE -EA EMPLOYE 1,000,QQQ_ El DISEASE -POLICY LIMIT _$ $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional RerowlJ Schedule, maybe aeacl e l it more apace is required) 77045s22 Evidence of hlsurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR E ATIVE W 1908.2015 ACORD CORPORATIeW. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. `Thave 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. _=1 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 v olations 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. hreceived a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my re ponsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Drake Petroleum Company, Inc. ApplicantSignature'-_— Date:a- Applicant Name (please print clearly) By: p' Notification of Test Results ID#: xxx-xx- Scaled Test Score: 75 Candidate Status: Pass Test Date: April 26, 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 (Competent) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Needs review) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Needs rav(ea9 Conducting Cleaning and Sanitiztng (Needs feaw) Physical Facility Design & Maintenance: Preventing a Controlling Peam (Competent) ISSUE DATE: APRIL26, 2018 EXPIRATION DATE:. APRIL 26, 2023 CERTIFICATE N40: 21459837 TEST FORM: EXE70 Thisc ffw. 000t,�Ad(Or .. r fi.>mn fi mdu� d :. JAMES BRODEUR" JAMES BRODEUR 392 COGGES HALL ST FALL RIVER, MA 02721 Pmfm4onals MANAGER femfioteNo:'2143A837 " ` Isivt now ApnT26, 2015.>:` FiP whoa Date: April 26.2023 National Regism, of Food Safety Pmfessionalsb 16751 Fong Drive Ste 220 I Orlando, FL 32821 I Phone: 40735-13830 1 Fax: 407352.3603 w O W U w 1H w U V z H z z F� a) ilt 0 d N N � d' � r d co > ..:. 0 L z w R o s C �' p Iytl �dps w "CS O CC y� Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 To the Board of Health at the Town of Mansfield: In accordance with the provisions ofsection 6511 ofChapler 94 ofthe General Laws, as most recentlyamended, and the regulations rnade thereunder, the undersigned hereby applies for a license fora WHOI FSALE/2ETAIL many{facture offr'ozen desserts and ice cream ndv and submits the following information: t. Full name of applicant: Mansfield Xtra Mart 2. Business address 905 South Main Street, Mansfield, MA 3. ljapp/icanl is an individual: Full name: Residence: 3a. If apphcant is it partnership, firll name and residence oliall partners: 3b. IJapplicarn is a corporation: State of incorporation: Massachusetts Date of incorporation: 04/17/1958 Full name and address of: Principal office: 800 South Street, Suite 500, Waltham, MA 02453 president Please see attached Treasurer: Clerk: d. Location ofplants: in store soft serve machine S. Names of brands and trade or corporation mule, I arty, under which the: products are to be sold: 6. Number and capacity of f -eezers and fees: 7, Is the nns purchased' Fee: ($25.00 per freezer) $ #Type! If'so. from whom purchased? Hood 8, Is the mix pasteurized? yes, ultra pasteurized 9. Number (if gallons of f-ozen desserts and/or ice it any to be sold in Massachusetts daring the licensing period 300 10. Amruber ofgallons offrou n desserts and or ice cream nex sold in 11a.ssat huseas during the In licensing period 300 11. is the plant constructed and equipped as provided in the regulations? yes 12. Is the water supply public or not yes 13. Have you received a copy of the regulations? yes I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conddions. I attest that the information stated in this application ig true and accurate under the pains and penalties of perjury. (Company owns officer's signature) (DATE) r Waltham, MA (Title) (City or Town) Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS All items in this section must be completed. Business Name: Mansfield Xtra Mart 905 South Main Street, Mansfield, MA Mailing Address: 800 South Street, Suite 500, Waltham, MA 02453 Phone/Fax Number: (781) 786-6353 / fax: (781) 398-7261 Email: permits@globalp.com Contact Person/Title: Diana Haines, Senior Facility Specialist Person to contact concerning information provided herein: Merideth Petz Title: Business Phone Number: (781) 398-4419 Does the business own or rent the facility? Lease If rented, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Richard Brothers, LLC Property Owner's Address: 905 South Main Street, Mansfield, MA Property Owner's Telephone Number: 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. I THE UNDERSIGNED CERTIFY UNDER THE PENALITIES OF PERJURY THATTHE APPLICANT HAS FILED ALL STATE AND LOCAL TAX RETURNS AND PAID ALL STATE AND LOCAL TAXES AS REQUIRED BY LAW (MGL CH. 62c Sec. 49A) Drake Petroleum Company, Inc. APPLICANT DATE 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): Seating Capacity (Actual Count): 4 Normal Hours of Food Preparation/Service: Monday 5:OOA.M.-11:OOP.M. Thursday 5:00 A.M. -11:00 P.M. Sunday 5:00A.M.-11:00P.M. Tuesday 5:00 A.M. - 11:00 P.M. Wednesday 5:00 A.M. - 11:00 P.M. Friday 5:00 A.M. - 11:00 P.M. Saturday 5:00 A.M. -11:00 P.M. 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 1 yes 3 compartment sink 1 no Handwashing sink 0 N/A Commercial Dishwasher 0 N/A Domestic Dishwasher 0 N/A Bar sink 1 no Mop Sink 0 N/A Garbage Disposal 1 not in use no Ice Making Machines N/A N/A Fryolators N/A N/A Grills or Ovens N/A N/A Exhaust Hoods with Automatic Cleaning System N/A N/A Exhaust Hoods without Automatic Cleaning System N/A N/A Floor drains N/A N/A Other: If exhaust hoods are without an automatic cleaning system, how are hoods cleaned? (i.e., in three (3) bay sink, off site): N/A Fa Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? Any additional water using devices? If yes, how many: If yes, what type: Sanitary Fixtures (Total): Number of Lavatory Sinks 2 Number of Toilets 2 Number of Urinals _ Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? X Yes No Size 1,000 gallons Yes X No Where is the existing outdoor GRU located? front of store, in parking lot Does this establishment have any indoor Grease Removal Units (GRU/trap)? X Yes No If yes, where are the existing indoor GRUB located? G Location Size (gallons) Automatic/ Passive under 3-bay sink 100 gallons N/A If a grease removal unit is utilized, how often is the grease removal unit cleaned? Outdoor: i-2— q peryear Name of Hauler Wind River Environmental Indoor: 12 per year Name of Hauler Wind River Environmental Do you have external storage of grease waste? Where is the grease storage unit located? Is the grease storage unit locked? How is the grease storage unit cleaned? How is the area around the unit cleaned? Yes x No N/A N/A N/A N/A t Are there any storm drains near the unit? N/A How often is this grease storage unit emptied? N/A Please list the vendor who removes the waste: N/A Describe the location(s) in your facility where samples may be obtained after any grease removal processes but prior to any mixing with domestic sewerage: Outside Manhole In parking spaces in front of store Outlet Tee Inside Floor Drains Under sink Grease Traps under 3-bay sink Other Describe liquid wastes, other than what is removed from any GRUB that are hauled away for disposal (such as recyclable oil, etc.): Type of Waste Waste Hauler Disposal Site N/A N/A N/A Please attach the following documents to this application: • Menu of the foods prepared and served at the facility • 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) Any establishment that generates FOG and does not have FOG $50 containment 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. Drake Petroleum Company, Inc. Date 1 /a ri Print Name`RY: Wind River Environmental LLC 46 Lizotte Dr Suite 1000 Marlborough MA 01752 Acquisition: wind River Environmental BILL TO Customer Number: 17867 FSN Accounts Payable PO Box 1319 Hartford, CT 06143 Invoice WINDRIWR ENVIRONMENTAL Billing Questions: 978-841-5080 JOB SITE OG Mobil #10027 905 South Main Street Mansfield, MA 02048 FM ovvwvv- 1 ooc Service Date: 13-Oct-2020 Invoice Number: 4763096 Order Number: 0210182491 P.O.Number: 1-4683795454 Invoice Date: 13-Oct-2020 Order Date: 15-Jul-2020 Quantity Service Type Amount Tax 1,000.00 Commercial Pump Grease $220.00 $0.00 1.00 Trip Charge Per Truck $25.00 $0.00 Subtotal Non Taxed: $245.00 Subtotal Taxed: $0.00 Tax: $0.00 Subtotal: $245.00 Balance: $246.00 Payment Terms: Due on Receipt From: Customer Number: 17867 FSN PO Box 1319 Hartford, CT 06143 Remit To: Wind River Environmental LLC. P.O. Box 22074 New York, NY 10087-2074 Less: Credits: $0.00 Payments: $0.00 Please detach here and return the bottom portion with your payment. Order Number Invoice Number Invoice Date Amount Due 0210182491 4763096 13-Oct-2020 $245.00 If your payment is returned NSF it will be re -presented electronically, and you will be assessed a processing fee, the maximum allowed by law. To pay your invoice, please call 978.841.5080. We accept the following credit cards within 30 days of the invoice date. When paying your invoice with a credit card, Wind River Environmental will appear on your credit card statement for this transaction. For questions please visit www.wrenviromnentaLcom/policies or call 800.499.1682 ,j.VISADISG;.VEa Customer Service Report Schedule Now for Service Jan 2021 Call (800) 499-1682 Workorder # 0210182491 Customer Since: 1996 System Owner System Location xtra Mart/Mobil/Sunoco Alliance/Global c/o Vixxo OG Mobil #10027 PO Sox 1319 905 South Main Street Hartford, CT 06143 Mansfield, MA 02048 (860) 935-5200 x2325 FM Service Date: Tub 10/13/2020 12:00 PM Frequency: Household Occupancy 1 2 3 4 5 6 7 8 Service Type: Trap Previous Service: 07/15/2020 Approx. Gals: l000 CCLS: 1000 22 20 18 16 14 12 12 12 Depth Below: Custom Clean: ;;; 1250 22 20 18 18 16 14 12 12 Cust Home: No Filter: c 1500 24 22 20 20 18 16 14 14 Township: Inspection/T5: R ~ 2000 26 24 22 22 20 18 16 16 County: Bristol Build Up: Description Qty `: Unit Price Ext Pricey Score From Table Commercial Pump Grease 1000.00 Garbage Disposal? -6 Trip Charge Per Truck 1.00 System Age > 10 Years? -5 Seasonal Occupancy? +8 Bacteria Additive Used? +5 Total Adjustments '. Net Score Score Service Every: < 5 6 Months 6— 15 12 Months 16 — 23 18 Months 24 + 24 Months ❑ System Normal Keep your system healthy by following these 3 steps: Schedule Now for Service • Regular Service Jan 2021 • Use CCLS Bacteria Additive • Use a Fitter Call (800) 499-1682 ❑ Excessive Solids Use CCLS Bacteria Additive Payment Detail: Invoice Due on Receipt Customer not on site ❑ Heavy Sludge Use CCLS Bacteria Additive ❑ Tee Missing/Broken Re air/Re lace Tee ❑ High Liquid Level Possible system failure. Call for evaluation or custom cleaning. ❑ Distribution Box Issue See notes below for details. © Missing Filter Use a filter ❑ Other See notes below for details. To schedule repairs, custom cleaning, or system evaluation, call (800) 499-1682 . X Technician :Michael welby Arrived at: 09: 12 AM Left at: o9:31 AM Tech Notes: Normal water level. tin bottom sludge. Oin top solids. Both baffles are intact. Main line Clear. No filter is present on the tank; current tank can be outfitted with a filter. Cover(s) secured. Serviced 1000 gallons of Co. Secured covers. Tech Recommendation: No Recommendation - None Customer Signature X., ,. ,�., Wind River Environmental LLC. 46 Lizotte Dr Suite 1000 Marlborough MA 01752 Acquisition: Wind River Environmental BILL TO Customer Number: 17867 FSN Accounts Payable PO Box 1319 Hartford, CT 06143 Invoice WINDRIVER ENVIRONMENTAL Billing Questions: 978-841-5080 JOB SITE IG - Mobil #10027 905 South Main Street Mansfield, MA 02048 ovu-4aa-IUoz Service Date: 15-Oct-2020 Invoice Number: 4766519 Order Number: 0238421659 P.O.Number: 1-4683846328 Invoice Date: 15-Oct-2020 Order Date: 10-Jul-2020 Quantity Service Type Amount Tax 1.00 Inside Grease Trap Pumping $87.50 $0.00 1.00 Trip Charge Per Truck $25.00 $0.00 Subtotal Non Taxed: $112.50 Subtotal Taxed: $0.00 Tax: $0.00 Subtotal: $112.50 Balance: $112.60 Payment Terms: Due on Receipt From: Customer Number: 17867 FSN PO Box 1319 Hartford, CT 06143 Remit To: Wind River Environmental LLC. P.O. Box 22074 New York, NY 10087-2074 Less: Credits: $0.00 Payments: $0.00 Please detach here and return the bottom portion with your payment. Order Number Invoice Number Invoice Date Amount Due 0238421659 4766519 15-Oct-2020 $112.50 If your payment is resumed NSF it will be re -presented electronically, and you will be assessed a processing fee, the maximum allowed by law. To pay your invoice, please call 978.841.5080. We accept the following credit cards within 30 days of the invoice date. When paying your invoice with a credit card, Wind River Environmental will appear on your credit card statement for this transaction. For questions please visit www.wrenvimnmentaLeom/polieies or call 800.499,1682 :,VISAD6G"3VER' Customer Service Report Schedule Now for Service Nov 2020 Call (800) 499-1682 Workorder# 0238421659 Customer Since: 1996 System Owner System Location Xtra Mart/Mobil/Sunoco Alliance/Global c/o Vixxo IG - Mobil #10027 PO Box 1319 905 South Main Street Hartford, CT 06143 Mansfield, MA 02048 (860) 935-5200 x2325 Manager : (508) 261-2812 Service Date: THU 10/15/2020 08:30 AM Frequency: Household Occupancy Service Type: Standard Previous Service: 09/11/2020 1 2 3 4 5 6 7 8 Approx. Gals: too CCLS: 1000 22 20 18 16 14 12 12 12 Depth Below: Custom Clean: v 9250 22 20 18 18 16 14 12 12 Cust Home: NO Filter. c 7500 24 22 20 20 18 16 14 14 Township: Inspection/T5: m ~ 2000 26 24 22 22 20 18 16 16 County: Bristol Build Up: Description Qty Unit Price Ext Price:: Score From Table Inside Grease Trap Pumping 1.00 Garbage Disposal? -6 Trip Charge Per Truck 1.00 System Age > 10 Years? -5 - - - Seasonal Occupancy? +8 Bacteria Additive Used? +5 Total Adjustments Net Score Score Service Every: < 5 6 Months 6 — 15 12 Months 16 — 23 18 Months 24 + 24 Months ❑ System Normal Keep your system healthy by following these 3 steps: Schedule Now for Service • Regular Service Nov 2020 • Use CCLS Bacteria Additive • Use a Filter Call (800) 499-1682 ❑ Excessive Solids Use CCLS Bacteria Additive Payment Detail: Invoice Due on Receipt 7 ❑ Heavy Sludge Use CCLS Bacteria Additive ❑ Tee Missing/Broken Repair/Replace Tee ❑ High Liquid Level Possible system failure. Call for evaluation or custom cleaning. ❑ Distribution Box Issue See notes below for details. ❑ Missing Filter Use a filter ❑ Other See notes below for details. To schedule repairs, custom cleaning, or system evaluation, call (800) 499-1682 Technician :Giovany Santiago Arrived at: 11:10 AM Left at:11:25 AM Tech Notes : [3 Bay Sink]:. Moderate rust. 11" H2O. 1" SOL. 0" ORE. Gasket OK. BOB logs signed. Extra Services : . Moderate rust. Did you check in and out? Checked. Got signature/store stamp. Tech Recommendation: No Recommendation - None Customer Signature Merideth Petz From: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Sent: Tuesday, July 21, 2020 3:02 PM To: Merideth Petz Cc: Christopher George Subject: RE: Xtra Mart - 905 S. Main Street - FOG Permitting This message originated fteml oulsede of Cilobal Partners - Please use excretion before opening attachments or clicking oil links. Perfect. I'll keep this email as a record to remind me at the time of permitting. Amy From: Merideth Petz [mailto:MPetz@globalp.com] Sent: Tuesday, July 21, 2020 2:59 PM To: Amy Donovan -Palmer Cc: Christopher George Subject: RE: Xtra Mart - 905 S. Main Street - FOG Permitting Hi Amy, We have a contract covering multiple locations with Wind River Environmental that will guarantee monthly pumping. Thanks, Merideth Petz Paralegal Global Partners LP 800 South Street, Suite 500 Waltham, MA 02453 P: (781) 398-4419 C: (860) 420-9119 F: (781) 398-7261 From: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Sent: Tuesday, July 21, 2020 2:12 PM To: Merideth Petz <MPetz@globalp.com> Cc: Christopher George <cgeorge@mansfieldma.com> Subject: RE: Xtra Mart - 905 S. Main Street - FOG Permitting This mnessage originatedfrom outside of Global Partners - Please ease caution before opening atiachments or clicking on links. Hi Meredith, I will note in your record that you just started pumping in July. Do you have a contract with a company that will guarantee monthly pumping? Or do you have to call them every time you need it to be pumped? Thanks, Amy From: Merideth Petz [mailto:_MPetz d lip ccim] Sent: Monday, July 20, 2020 2:30 PM To: Amy Donovan -Palmer Subject: Xtra Mart - 905 S. Main Street - FOG Permitting Hi Amy, Sorry I missed your call. It wasn't until recently that our maintenance department confirmed that we had an internal grease trap at the Xtra Mart location. In November, maintenance confirmed that there was an outdoor trap and began the quarterly pumping. My former coworker listed we had an internal grease trap on the 2020 renewal but it had not been confirmed at that time. We did not begin monthly pumping until this month so we will not have the full 12 months of pumping reported needed for our food permit renewal. How will this affect our Food Permit? The store currently only offers Thanks, Merideth Petz Paralegal Global Partners LP 800 South Street, Suite 500 Waltham, MA 02453 P: (781) 398-4419 C: (860) 420-9119 F: (781) 398-7261 ►3�iF'ti"L�� The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here, The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. Global Montello Group Corp. CORPORATE OFFICERS Name & Address Title Eric Slifka Director, President and Chief Executive 800 South Street Officer Waltham, MA 02453 Andrew Slifka Executive Vice President 800 South Street Waltham, MA 02453 Edward J. Faneuil Secretary, Executive Vice President and 800 South Street General Counsel Waltham, MA 02453 Matthew Spencer Chief Accounting Officer 800 South Street Waltham, MA 02453 Daphne Foster Chief Financial Officer 800 South Street Waltham, MA 02453 Mark Romaine Chief Operating Officer 800 South Street Waltham, MA 02453