HomeMy WebLinkAboutWalgreens #19441 - 12/31/2021FOR BOARD OF HEALTH USE ONLermit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening
0
Establishment Name Walgreens #19441
Establishment Address 243 Chauncy Street, Mansfield, MA 02048-1247
Establishment Mailing Address (if different) p0 BOx 901, Deerfield, IL 60015
Establishment Telephone No 508-337-8800
Applicant Name & Title: Walgreen Eastern Co., Inc. - Lisa Hora, License Team Lead
Applicant Address PO Box 901, Deerfield, IL 60015
Applicant Telephone No.: 847-527-4208 24 Hour Emergency No.: 800-695-9904
Applicant Email taxlicenserenewals@walgreens.com
Owner Name & Title (If different from applicant) Walgreen Eastern Co., Inc.
Owner Address PO Box 901, Deerfield, IL 60015
Owner telephone number 847-527-4208
Owner email: taxlicenserenewals@walgreens.com
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
1-1 An Association
partner.
IX A Corporation
Name Title Address
(1 An Individual
See Attached
O A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Michael Wilbur, Store Manager
Address: 243 Chauncy Street, Mansfield, MA 02048-1247
Telephone No: 508-337-8800 24 Hour Emergency No: 800-695-9904
FAX: 508-337-6193 �el 4y
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District Or Regional Supervisor (if applicable)
Name & Title: Christopher Gosnold, District Leader
Address: 62 Forest St., Ste. 120, Marlborough, MA 01752
Telephone No: 774-843-7520 24 Hour Emergency No: 800-695-9904
FAX: I
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E-mail:
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Food Establishment Information
WATER SOURCE: Public
SEWAGE DISPOSAL: Public
DEP Public Water Supply No: (If applicable)
No. of Food Employees: 16
DAYS/HOURS: Mon - Sat 8AM - 913M, Sun 9AM - 6PM
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 h Q �I
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. 13 Yes
Does this establishment require a FOG permit❑ No If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
A Annual
❑X 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 O 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. U Pushcart $50.00 # of Pushcarts:
Temporary Time:
❑I Supermarkets $400 [I Residential Kitchen $100.00
Rain Date:
0 Milk &Cream $10.00 Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(Unnellemperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous/ood(no fime4emperature controls required)
RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
[X] Sale of Commercially Pre -Packaged Non-PHFs FI PHFCooked To Order 0 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 n PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Reheating of Commercially Sale of Raw Animal Foods Intended
n 9 Y to be Prepared by Consumer 0 Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
l Customer Self -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)
Retail Sale
Preparation of Non-PHFs Otters Raw Or Undercooked Food Of
F] Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging I Cook Chill
L Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
I Retail Sale of Salvage, Out -Of -Dale 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 h�'ain copies of 105 CMR 590.000 and the federal Food Code.
Signature of
License Team Lead
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: 36-1924026
Signature of Individual or corporate Name: Walgreen Eastern Co., 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.
Walgreen Eastern Co., Inc.
Signature of Individual or Corporate Name
36-1924026
"*Social Security No. (Voluntary) or Federal
Identification Number
Susan Halliday
Assistant Treasurer
4 � z� G
By: Corporate Of�tory, 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\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Walgreens #19441
Address: 243 Chauncy Street
City/State/Zip: Mansfield, MA 02048-1247 Phone #: 508-337-8800
Are you an employer? Check the appropriate box:
Business Type (required):
LZ
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.
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
4. ❑
no employees. [No workers' comp. insurance required]*
We by
11.❑ Health Care
are a non-profit organization, staffed volunteers,
with no employees. rNo 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: See Attached
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
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 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, tinder the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 11 /23/2020
847-527-4208
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/dia
MEMORANDUM OF LIABILITY INSURANCE
current 0
s zo July z0
PRODUCER
Willis Towers Watson Midwest, Inc. like Willis Of Illinois, Inc.
c/o 26 Century Blvd
Nashville, TN 37230-5191
United States of America
THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO
RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM. THIS MEMORANDUM DOES NOT
AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW. ANY USE, DUPLICATION
OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS
PROHIBITED.
INSURED
Walgreen Co. and Subsidiaries
300 Wilmot Rd., MS #3228
Deerfield, IL 60015-5223
United States of America
=COMPANIES
AFFORDING: COVERAGE
INAIC #
COMPANY
A
ZURICH AMERICAN INSURANCE COMPANY
16535
COMPANY
B
INDIAN HARBOR INSURANCE COMPANY
36940
COMPANY
C
AMERICAN ZURICH INSURANCE COMPANY
40142
COMPANY
D
SELF INSURANCE
COVERAGES
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 MEMORANDUM 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.
C OMPANY
OMPAN
LETTERDATE
TYPE OF INSURANCE
POLICYNUMBER
-POLICY
EFFECTIVE
POLICY
EXPIRATION'S
DATE
LIMITS
LIMITSIN USD UNLESS
OTHERWISE INDICATED
A
GENERAL
XI
LIABILITY
COMMERCIAL GENERAL UABUJTY
CIAIMS MADE FX OCCUR
Blanket Additional Insured
Per Policy
Blanket Contractual Liability
Liquor Liability
GLO 9310091-17
GLO 9310184-17(Puerto Rico)
7/1/2020
7/1/2020
7/1/2021
7/1/2021
GENERAL AGGREGATE
S 5000000
X
X
X
X
PERSONAL & ADV
INJURY
4,000,00
EACH OCCURRENCE
4000000
FIRE DAMAGE (Any One Fire
500,00
MED EXP (Any One Person
0
A
AUTOMOBILE
X
1
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
BAP 9310096-17
BAP 9310183-17 (Puerto Rico)
7/1/2020
7/1/2020
7/1/2021
7/1/2021
COMBINED SINGLE LIMIT
$ 5,000,000
BODILY INJURY (Per Person)
$
BODILY INJURY (Per Accident)
$
PROPERTY DAMAGE
$
B
EXCESS
X
LIABILITY
UMBRELLA FORM
OTHER THAN UMBREUA FORM
US00079295LI20A
7/12020
7/1/2021
PER CLAIM
5,000.00
AGGREGATE
5000000
C
A
A
A
A
WORKERS COMPENSATION/
EMPLOYERS LIABILITY
PARTNERS/EXECUTWE BX INCL.
OFFICERS ARE: EXCL.
WC 9310092-17 (ADS)
WC 9310094-17 (WI)
ENS 9310448-17 (MA)
7/1/2020
7/1/2021
WORKERS COMPENSATION
LIMITS
STATUTORY
EL EACH ACCIDENT
2000000
EL DISEASE - POLICY LIMIT
2 000 000
EL DISEASE - EACH EMPLOYEE
2,000,000
D
PRODUCT LIABILITY
Self -Insured
7/1/2020
7/1/2021
EACH OCCURRENCE
2,000.00
AGGREGATE
2,000,000
ADDITIONAL
INFORMATION
OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS, LENDERS, MORTGAGEES, GROUND LESSORS,
VENDORS, CUSTOMERS, CLIENTS, AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED
AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE, CONTRACT OR OTHER WRITTEN AGREEMENT.
THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE, CONTRACT OR OTHER WRITTEN AGREEMENT.
The Memorandum of Insurance Serves solely to list Insurance policies, limits and dates of Coverage. Any modifications hereto are not authorized.'
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.
n\Y
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.
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.
PLI 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 Cc��- �Ll J Date: l\`a3
Applicant Name (please print clearly) \--\<_�O- \kc V-C- LiCeY s,� TiZe_xr l Qa t}�
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