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HomeMy WebLinkAboutShaw's #431 - 12/31/20215IY�do15541— ✓� D a�'0���y2~ �pa, �, 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) Establishment Name Shaw's # 431 Establishment Address 390 West St Mansfield, MA 02048 Establishment Mailing Address (if different) PO Box 29096, MS-6531 Phoenix, AZ 85038-9096 Establishment Telephone No 508-339-3987 Applicant Name & Title: Shaw's Supermarkets, inc. Applicant Address PO Box 29096, MS-6531 Phoenix, AZ 85038-9096 Applicant Telephone No.: 623-869-4326 24 Hour Emergency No.: 800-379-2967 Applicant Email NASC.Tax@safeway.com Owner Name & Title (If different from applicant) Shaw's Supermarkets, inc. Owner Address 250 Parkcenter Blvd. Boise, ID 83706 Owner telephone number 623-869-4326 Owner email: NASC.Tax@safeway.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. * A Corporation Name Title Address ® An Individual SEE ATTACHED IN A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Nancy Kiley, Store Director Address: 390 Main St Mansfield, MA 02048 Telephone No: 508-339-3987 24 Hour Emergency No: 800-379-2967 FAX: E-mail: s043lc9O@shaws.com Alt E-Mail: NASC.Tax@safeway.com District Or Regional Supervisor (if applicable) Name & Title: Mike Goulart, District Manager Address: 17 School St. Fairhaven, MA. 02719 Telephone No: 508-789-7045 24 Hour Emergency No: 800-379-2967 FAX: E-mail: Michael.Goulart@shaws.com Food Establishment Information WATER SOURCE: PUBLIC SEWAGE DISPOSAL: PUBLIC DEP Public Water Supply No: (If applicable) No. of Food Employees: 141 DAYS/HOURS: SUN: 6 a.m. - 9 p.m. / MON-SAT: 6 a.m. - 10 p.m. Name of Person(s) In Charge Certified in Food Protection Management: Nancy Kiley Luke Dimeo Name of Person(s) In Charge Certified in Allergen Awareness Training Nancy Kiley Luke Dimeo Name of pest control company routinely inspecting the premises for evidence of pests Rentokil/Ehrlich 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. O Yes N/A Does this establishment require a FOG permit? Yes If yes, please attach the FOG permit application. Length of Permit: Establishment Type: ® Annual ❑® Retail Food $125.00 ® Mobile Food Consession ® Temporary ® Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ® Manufacture Frozen Desserts/Ice Cream Temporary Start Date: IN Food Service up l0 101 -200 $250.00 $25.00)freezer Temporary End Date: ® Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: ,1[, u Supermarkets $400 ®Residential Kitchen $100.00 Rain Date: ,1L, u Milk $Cream $10.00 ®Caterer $35.00 Food Operations: Definitions:PHF-Potentially hazardous food ltime4emperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no time/(emperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no furtherprocessing) 1] Sale of Commercially Pre -Packaged Non-PHFs a PHFCooked To Order [10 Hot PHF Cooked and Cooled or Hot Held 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 � PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended [] Reheating of Commercially to be Prepared by Consumer ❑M Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand ©Customer Salf-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) ] Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of ® Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 0 Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities 0 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 05 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cop[wX",,frCMR580"g000Kd the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I rtify 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 I w. Social Security Number or Federal to: 04-1123420 Signature of Individual or Corporate Name: Shaw S Supermarkets, Inc. E LL ..... . .. . P H, IMM 1" x LL & \ m ) arƒ ƒ a \a+@ \ )\k\ \\\§ : m i. k mom Q J V W � U Z W Z t v m� E° a :�u_ a 5�^syy1 w w FOG431 $200 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Shaw's Supermarkets, Inc. D/B/A Shaw's #431 390 West St Mansfield, MA 02048 Address: NASC MS-6531 PO BOX 29096 Phoenix, AZ 85038-9096 Mailing Address: 508-339-3987 Phone/Fax Number: Email: NASC.Tax@safeway.com.. s0431c9o@shaws.com Contact Person/Title for Grease Traps: Nancy Kiley Store Director Name of Company scheduled to pump internal grease trap(s) monthly: Elge Plumbing & Heating Name of Company scheduled to pump external grease trap quarterly: n/a Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest Emailed • 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. Date ®T aceve odmd Print Name nn y�T 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): Normal Hours of Food Preparation/Service: Monday 6 AM - 10 PM Thursday 6 AM - 10 PM N/A Tuesday 6 AM - 10 PM Wednesday 6 AM - 10 PM Friday 6 AM - 10 PM Saturday 6 AM - 10 PM 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 6 Yes 3 compartment sink 6 No Handwashing sink 0 N/A Commercial Dishwasher p N/A Bar sink 2 No Mop Sink 0 N/A Garbage Disposal 1 No Ice Making Machines 2 No Fryolators 1 No Grills or Ovens 1 No Exhaust Hoods 29 Yes Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Kitchen Kleen provides overnight service once a month. No sinks are utilized. bake Is dinnerware pre -rinsed before being washed? X Yes No If yes, at what station/sink? Each department: 3-compartment sink Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Six; 40 gallons each Please list fixtures attached to each grease trap Grease Trap 1 Bakery Grease Trap 2 Deli Grease Trap 3 Meat Grease Trap 4 Produre Grease Trap S Prndiirp External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes X No Size N/A gallons Where is the existing outdoor GRU located? N/A 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 Owners Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Fryolators utilize the RTI system Where is the grease storage unit located? N/A How often is this grease storage unit emptied? N/A Please list the vendor who removes the waste: Rotisserie grease/oil is placed in a bucket which is picked up weekly by DarPro 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 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. A I have received a copy of the Polystyrene Container Reduction bylaw. I understand my Aspon bility 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. P I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my esponsibility 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 Date: Steve Barna Applicant Name (please print clearly) ManayerTax 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 dive ual or Corporate ame 04-1123420 "Social Security No. (Voluntary) or Federal Identification Number Manager Tax By: Corporate 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 The Commonwealth of Massachusetts Department oflndustrialAccidents x Office of Investigations a a 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Shaw's #431 Address: 390 West St City/State/Zip: Mansfield, MA 02048 Phone #: 508-339-3987 Are you an employer? Check the appropriate box: Business Type (required): 1. © I am a employer with 141 employees (full and/ 5. X❑ 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. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § I (4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers , with no employees. [No workers' comp. insurance req.] 12.❑ Other *Anv anoticam that checks box #1 must also fill out the section below showing tha it 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. Ian an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ace American Insurance Company c/o AON Risk Services Central, Inc. Insurer's Address: 5600 West 83rd Street, 8200 Tower, Suite 1100 City/State/Zip: Minneapolis, MN 55437 Policy # or Self -ins. Lic. # WLRC67463511 Expiration Date: 8/1/2021 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, user the pains and penalties ofperjury that the information provided above is true and correct. 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 #: www.mass.gov/am t� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYY) 07/29/2020 I 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 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 lleu of such endorsement(s). PRODUCER Aon Risk services Central, Inc. Minneapolis MN Office 5600 West 83rd street 8200 Tower, suite 1100 CONTACT NPHNEAME: (NC. N. EXO; (866) 253-7122 aC NP : (800) 363-0105 E-MNL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICR Minneapolis MN 55437 USA INSURED INSURER A: ACE American Insurance Company 22667 New Albertsons L.P. including All Affiliated subsidiaries & Associated companies 250 E. Parkcenter Blvd. Boise ID 83706 USA INSURER B: ACE Property & Casualty Insurance Co. 20699 INSURER C: INSURER O: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570083350112 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested LTR TYPE OF INSURANCE Iwo VIVO POLICY NUMBER MMdH MMA1 LIMBS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Om001a1 Uabiiiw Included XSLG SIR applies per policy turns & condi ions EACH OCCURRENCE $3.000,000 GET R T PREMISES Ea ocwponoe $3,000,000 X MEO EXP(My... person) Excluded PERSONAL& ADV INJURY $3.000,000 GENT AGGREGATE LIMITAPPLIES PER: X POLICY ❑JET LOC OTHER: GENERALAGGREGATE $18,000,000 PRODUCTS -COMPIOP AGG $6,000,000 Liquor Llabllity xncluded A AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOSONLY AUTOS HIREDAUroS NON OWNED ONLY AUTOS ONLY H ISA H25308384 08/01/202008/01/2021 COMBINED SINGLE LIMB 1 $5,000,000 _ BODILY INJURY (Per person) BODILY INJURY (Per aalden0 PROPERTYOAMADE Per acddent B X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS MAOE XEUG2794761AOOS SIR applies per policy terns 08 01/2020 & condi 08/ 1/2021 ions EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED I X RETENTION A WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/ PARTNER/EXECUDVE ❑ OFFlCEPoMEMBER EXCLUDED? Y (Mendelory le NH) Ii yes, descnbe under DESCRIPTION OF OPERATIONS below N/A WLRC67463511 08 Ol 2020OS 01 2 221 X PERSTATUTE OTH. ER E.L. EACH ACCIDENT $2,000,000 E.L.DISEASE-EAEMPLOYEE $2,000,000 E.L. DISEASE -POLICY LIMB $2, 000,005 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, AbIdiftruil Remark. Schedule, may be attached It more space la required) Blanket Additional Insured for General Liability policy and Waiver of Subrogation for General Liability policy status extend to those parties to whom the Insured has contractually agreed to provide this status. co Un n N CERTIFICATE HOLDER CANCELLATION 51M SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. New Albertsons L.P. AUTHORIZED REPRESENTATIVE Including All Affiliated Subsidiaries & Associated companies Blvd. ! — q //7nJ 1/ BoiseE. D 83706 US aoi se ID 83706 USA ✓Uj i 41 eLVAerO na 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 9