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HomeMy WebLinkAboutCumberland Farms 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. CUMBERLAND FARMS, INC. Whose place of business is: CUMBERLAND FARMS #0187 30 CHAUNCY STREET Permit Expires: December 31, 2016 License Number: RF -42 BOARD OF HEALTH Food Fee: $50.00 Milk & Cream ❑� MichaeCvlcCCean, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: CUMBERLAND FARMS #0187 30 CHAUNCY STREET License Number: RF -42 Permit Expires: December 31, 2016 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. CUMBERLAND FARMS, INC. having a place of business at: CUMBERLAND FARMS #0187 30 CHAUNCY STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: RF -42 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF -42 FOOD ESTABLISHMENT PERMIT APPLICATION - -(App icaion m-us—fbe submifted of eas -30-days �bfo�i�e—p-lannedopening e 1) Establishment Name CUMBERLAND FARMS #0187 ---- 2) Establishment Address 30 CHAUNCY STREET � 3) Establishment Mailing Address (if different) 100 CROSSING BOULEVARD ATTENTION: TAX DEPART. FRAMINGHAM, MA 01702 4) Establishment Telephone No (508) 261-7857 5) Applicant Name & Title: CUMBERLAND FARMS, INC. 6) Applicant Address 100 CROSSING BOULEVARD, TAX DEPT., FRAMINGHAM, MA 01702 7) Applicant Telephone No.: (506) 2704400 24 Hour Emergency No.: (609) 369-1097 ` 8) Owners Name & Title CUMBERLAND FARMS, INC. 9) Owner Address (If different from applicant) 100 CROSSING BOULEVARD, FRAMINGHAM, MA 01702 mOwner's telephone number (508) 270-1400 10) Establishment Owned By: ❑ An Association OO A Corporation ❑ An Individual (] A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address --_ _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: RUTHANN MCCARTHY, AREA MANAGER Telephone No: (508) 380-3720 24 Hour Emergency No: (506) 369-1097 821-0653 — FAX: --(781) E-mail: AltE-Mail: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: LYNDA MARTONE, REGIONAL SUPERVISOR Address: Telephone No: (401) 529-9625 24 Hour Emergency No: (508) 369-1097 FAX: �E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: SUN -SAT 5AM -12PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/9/2009 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑- 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Mobile Mobile Start Date: © Retail ( 3,500 Sq. Ft) lV Milk & Cream $5.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Mobile Comments: up to 10' PHF display $62.50 E] Manufacture Frozen Desserts/Ice Cream F]Food Service up to 101 -200 $12.50/freezer 21) Length of Permit: © Annual or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Pushcart $12.60 # of Pushcarts: El Residential Kitchen $60.00 Retail Food $50.00 ❑ Retail Snack Food $12.50 I Tobacco Products $12.50 El Seasonal Seasonal Dates: v — ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: t Rain Date: -------------�----- 23) Food Operations (Check all that apply): Definitions: PHF- Potentially hazardous food (tlme/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) ` ❑ Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service n Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PRFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill — — E] Delivery of Packaged PHFs E] sale of Raw Animal Foods Intended to be Prepared by Consumer -- ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours — --- -- ❑ Use of Process Requiring A Variance i and/or HACCP Pian (including bare hand contact alternative, time as a public health control) _ ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service _ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned FoodTo --- _ be completed by the Board of Health Total Permit Fee: $60.00 Pa ment is due with a plicat on Payment Y p ❑ waived_ I, the undersigned, attest to the accuracy of the information provided in establishment operation will comply with 105 CMR 590.000 an all thr board of health on how to obtain copies of 105 CMR 590.00(an�i tf fi )(24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2843586 �26) Signature of Individual or Corporate Name: application nd affirm that the food )plic bie la I hav ern instructed by the ard Fournier that I to my best kn owle ge and belief, have filed all state tax returns 1 I..:. � I?it;haECs Fol.itt-11ei` Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year, NAME OF BUSINESS: CUMBERLAND FARMS #0187 ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 261-7857 FAX NUMBER: (781) 821-0653 OWNER OF BUSINESS: CUMBERLAND FARMS, INC, TELEPHONE OF OWNER: (508) 270-1400 FEDERAL ID/SS NUMBER: 04-2843586 FEE: $5.00 PERMIT NUMBER: RF -42 SIGNATURE: DATE: Fournier anagen Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -42 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CUMBERLAND FARMS, #0187 LOCATION OF SALE OF TOBACCO PRODUCTS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 261-7857 OWNER OF BUSINESS: CUMBERLAND FARMS, INC., TAX DEPARTMENT ADDRESS OF OWNER: 100 CROSSING BOULEVARD, FRAMINGHAM, MA 01702 TELEPHONE OF OWNER: (781) 828-4900 FAX NUMBER: (781) 459-2407 If a corporation or partnership, give name, title, and home address of officers or partner. *Provide a copy of current Department of Revenue CT -3T Retail Excise -Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 04-2843586 SIGNATURE: DATE: Ric x �A n C r i ( Form CT -3T 02725 Massachusetts Department of Revenue 2014-2016 Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco 1 TMs Lk snse must be posted and visible at all tones. Sala lo parsons under Is years of ape are protlblted by law. AppNcadat.Number. A8913 License Number: Date of Issue: Federal Iden f lostion or soder Sew* Number: 042-04=3686 02726 •09/17/2014 lI i Ma" address for licanse: Retail sale looatlen (b dtlfemM then mdkV s toss) 'CUMBERLAND FARMS INC CUMBERLAND FARMS 00187CUMBERLAND PO BOX 1019 30 CHAUNCEY ST FRAMINGHAM, MX 01702 MANSFIELD, MA 02048 This "dMas that the b ngeyer named above has paid the requW Ilceme fee and Is licensed to sell at retell at the address shown above until September 30.2018. This Ileense Is not transferable, and is subject to suspension for latlure to comply with the law. I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns, and paid all State taxes required under law. Signature of Individu Corporate Name (M By: Corporate Officer (Mandatory, if applicable) -tumberland Farms Inc. Tax Department 100 Cros'sing Boulevard Framingham, MA 01702 Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents > 1 Congress Street, Suite 100 _ o Boston, MA 02114-2017 'p www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Cumberland Farms, Inc. Address: 100 Crossing Boulevard City/State/Zip: Framingham, MA 01702 Are you an employer? Check the appropriate box: 1. Q I am a employer with 3,208 employees (full and/ or part-time).* 2. ® I 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.] Phone ff: 508 270 1400 Business Type (required): 5. M Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 L Health Care 12.❑ Other *Any applicant that checks box N1 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 ail an employer that is providing workers' compensation insurance for n(v employees. Below is the policy information. Insurance Company Name: ACE Property & Casualty insurance Company Insurer's Address: 33 Arch Street, Suite 2900 City/State/Zip: Boston, MA 02110 Policy # or Self -ins. Lic. # SCF48603257 Expiration Date: 4/1117 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 againsturance e violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA coverage verification. I do hereby certify, jtx(rer the Airins and penalties ofperjury that the information provided above is true and correct. 508 270 1480 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.gowdta Phone #: AC I `.� CERTIFICATE OF LIABILITY INSURANCE DAT DYYY) 03/30/2016 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(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 lieu of such endorsement(s). PRODUCER Aon Risk Services Northeast, Inc. Providence RI office CONTACT NAME: PHONE (g66) 283-7122 FAx 800-363-0105 (AIC. No. Ext): A/C. No.): E-MAIL ADDRESS: 100 Westminster street, 10th Floor Providence RI 02903-2393 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: ACE Property & Casualty Insurance Co. 20699 INSURER B: ACE American Insurance Company 22667 CUMBERLAND FARMS, INC. 100 Crossing Boulevard Framingham MA 01702 USA INSURER C: Indemnity Insurance Co of North America 43575 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570061581861 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. Limits shown are as requested INSIR LTR TYPE OF INSURANCE DDDNSD UBRI POLICY NUMBER POLICY ti -t- MMIDDIYYYY MO ICY EXP YYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X❑ occuR y�/- �,r� `,1 y/� tY�IL i���G cJst�LtrG*Cr0 c/ //Wi�+v4 V 9sct XSLG 7 SIR applies per policy terns & conditions EACH OCCURRENCE $1,000,000 G o $1,000,000 PREMISES Ea occurrence MED EXP (Any one person) Excluded PERSONAL &ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 PRODUCTS-COMP/OP AGG $4,000,000 X POLICY ❑ PRO ❑ LOC JECT OTHER: B AUTOMOBILE LIABILITY ISA-HO9041485 04/01/201604/01/2017 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLYAUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Peraccident A LIAB X OCCUR XOOG27835053 10/01/2015 04/01/2017 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 JU.M.BRELLA ESSLIABCLAIMS-MADE RETENTION C B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR / PARTNER /EXECUTIVE WLRC48603245 SCFC48603257 04/01/2016 04/01/2016 04/01/2017: 04/01/2017 X STATUTE ERH E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE -EA EMPLOYEE $2,000,000 OFFICER/MEMeER EXCLUDED? EN:NIA (Mandatory in NH) E.L. DISEASE -POLICY LIMIT $2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD `m w c tv d M O S ta� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield AUTHORIZED REPRESENTATIVE Six Park ROW Mansfield MA 02048 USA y�/- �,r� `,1 y/� tY�IL i���G cJst�LtrG*Cr0 c/ //Wi�+v4 V 9sct ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD `m w c tv d M O S ta�