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Home My WebLink AboutSunoco #40082H - 12/31/2021FOR BOARD OF HEALTH USE ONL Permit # Issued zaFOOD ESTABLISHMENT PERMIT APPLI ATION (Application must be submitted at least 30 days before the planned opening date) n Name Establishment AddressCty Establishment Mailing Address (if different) `" t 2a Establishment Telephone No _17� _� CI — z-W j w Applicant Name & Title: t Applicant Address 5 QOb ,,( vA y 't Applicant Telephone No.: % 'i7`^ P 24 Hour Emergency No.: Applicant Email CyV,\-C 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 0 An Association partner. L�fiCorporation Name Title tAddress r _ 11 An Individual -_ P 0 gz'Cf) A Partnership�4 �"-{k"`Ei/ El Other legal Entity Person Directly Responsible For Daily Oper tions (owner, person in charge, supervisor, manager etc.) Name & Title: _ _a' h q �pkil Address: 1'0 Q_o j,� 1Ck1 s 'FJ a tol " A Telephone No: - 'u = -A 24 Hour Emergency No: �`} j FAX ��'�"1."b �C .w 1� �1 E-mail: r�. Alt E-Mail: District Or Regional Supervisor ((if applicable) Name & Title: ya':i` 4F \ Address: P IDS etf� "1 "' .t � .G�Yi� a _o'LL Telephone No: Cf -7' �h" 24 Hour Emergency No:� bJ Z FAX: LA lz__ (e,,, Z- -- iu-3 i } E-mail: (;< C �a�Z y r _d -- �' C.. (� -...-- Food Establishment Information WATER SOURCE: --(; SEWAGE DISPOSAL ) DEP Public Water Supply No: (If applicable) No. of Food Employees: '1 Ci DAYS/HOURS: Name of Person(s) In Charge ertified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training h-S Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a persoin trai ed in manual choke saving procedures will be onsite at all times food is being prepared. ❑ Yes Does this establishment require a FOG permit? f If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual etail 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: ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 El Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: c ilk & Cream $10.00 ❑ Caterer $35,00 Food Operations: Definitions: PHF- Potentially hazardous food (lime/lemperature controls required) Non-PHFs -non-potentially hazardous rood(no time/temperature controls required) a (Check all that apply): RTE- ready-lo-eat roods (Ex. sandwiches, salads, muffins which need no turtherprocessing) [ale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service - Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And 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 Q: 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 contact alternative, time as a public health Customer Self -Service of Non PHF and Non - Perishable Foods Only Ve6"KAanufactured and Packaged for control) reparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of P"0'ulce 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 obtain coples,,of 105 CMR 590.000 pnd thefederal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify der 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. g) yy Social Security Number or Federal to: ` n .r Signature of Individual or Corporate Name: 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 Name ly.,....�a.. "Social Security No. (Voluntary) or Federal Identification Number �fAj 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\Scolrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ®u DATE January 10, 2020 TO/ Wayne McGee LOCATION FROM/ Rankin Gasaway LOCATION 0182 SUBJECT Power of Attorney Dear Wayne In order to expedite the signing of certain licenses for 7-Eleven stores, I have appointed you attorney -in -fact of 7-Eleven, Inc. This appointment will remain in effect until such time as it is revoked, This appointment gives you certain authority to bind the Company. Please understand, however, that this appointment applies only to the execution of documents reating to certain licenses that the Company holds or is applying for. Notwithstanding the above -described limitations of your author ty, it is possib'e ll,at yo- might conceivably be able to bind the Company legally in connection with other matters. You shoud not do this, regardless of how important you think the situation might be. If you feel at some point that it Is desirable for you tc sig•i other Instruments on beha.f of the Company, you must receive specific authorization to do so, either from me or any Board appointed Vice President of the Company. If you have any questions about the extent of your authority, please give me a call. Otherwise, please sign this letter in the space set forth below in order to acknowledge that you understand compete y Nine limits of the authority that has been granted to you. Please return the signed letter to Casey Pennell at location 0182. Very truly yours, Rankin Gasaway Senior Vice President, General Counsel and Secretary I have read this letter and understand the limits of my authority to act as attorney in -act of 7-Eleven, Inc By, 1 IVf�jdyne McGee Date: /� 1l a (i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street IV Boston, MA 02111 wwmi nass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ( Please Print Legibly Business/Organization Name: _ > j fJi 40 Z Address: —{ 0 ` Phone #: — -5 A .— Z '2 Are you an employer? Check the appropriate box: 4111 am a employer with —ice— employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. MRetail 6. Restaurant/Bar/Eating Establishment 7. Q Office and/or Sales (met. real estate, auto, ctc.) 8. Non-profit 9. ❑ Entertainment 10.Q Manufacturing l I.Q Health Care 12.0 Other *Any applicant that checks box 01 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 #I. I am an employer that is providing rp�rkers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: wJ'' City/State/Zip: )' ` Policy # or Self -ins. Lie. # W ('" c- ll 1"• ` Expiration Date: 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 imprisomnent, 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 the pains and penalties of perjury that the information provided above is true and correct. �/�p.� r ig i it 'A� irk Ilatr• �"'...,,.•- t._. 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 Phone www.snass.gov/dia DATE (10/01/20) A� CERTIFICATE OF LIABILITY INSURANCE 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 CONSITUTE A CONTACT 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME (A/C. E,t): 866 283-7122 FAX (A/C, No): (847) 963-5390 AON Risk Services Southwest, Inc. 5006 LBJ Freeway, Suite 1400 Dallas, TX 75244 E-MAIL ADDRESS (214) 989-0000 INSURERS AFFORDING COVERAGE NAIC# INSURER A: I(onshore Specialty Insurance Company 25445 INSURED INSURER B: ACE American Insurance Company 22667 INSURER C: Lloyd's Syndicate No, 2003 AA1128003 7-Eleven, Inc. 3200 Hackberry Road Irving, TX 76063 INSURER D: Indemnity Insurance Co of North America 43575 INSURER E: ACE Fire Underwriters Insurance Co. 20702 30702 COVERAGES CERTIFICATE NUMBER KtVlblUN NUNIt3tK 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUB WVD POLICY NUMBER POLICY EFF DATE IMMIDD;Y1') POLICY EXP DATE(MMIDD/YY) LIMITS B GENERAL LIABILITY OMMERCIAL GENERAL LIABILITY CLAIMS MADEQX OCCUR. OWNERS' 8 CONTRACTOR'S PROT. LIQUOR LIABILITY $500,000 SELF INSURED RETENTION EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any One Person) $ PERSONAL & ADV. INJURY $ GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ 0 AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per Person) $ BODILY INJUR (Per Accident $ PROPERTY DAMAGE (Per Accident) $ A EXCESS X LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE $ C B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/ Yes PARTNERS/EXECUTIVE- I No OFFICER EXCLUDED WLRC67458771 SCFC67458813 WI VVLRC67468734 /CA/MA 10/1/2020 10/l/2021 X IWC STATU-TORY LIMITS I I Other EL EACH ACCIDENT $ 1,000,000 EL DISEASE -POLICY LIMIT EL DISEASE - EA EMPLOYEE $ $ 1,000,000 1,000,000 B OTHER Ea. Common Cause A re ate ADS DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES;SPECIAL ITEMS Evidence of Workers Compensation Coverage for all 7-Eleven Corporate Stores Whom It May Concern 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 REPRESENTATIVE reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Joseph T Burroughs Date of Completion: November 16, 2016 Date of Expiration: November 16, 2021 &='AIIEC 0 m n co C 3- ry m A � o m CQ 9 v 'o b v91 n mJ ■ 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 ba s to customers. 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. WP\ 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. A(Y� 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 Date:-' �� " Applicant Name (please print clearly)