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Home My WebLink AboutFour Corners Citgo 12/31/2016z Commonwealth 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:. ANJANA D. PATEL, PRESIDENT Whose place of business is: FOUR CORNERS CITGO 4 SOUTH MAIN STREET Permit Expires: December 31, 2016 License Number: RF -74 Food Fee: $80.00 Milk & Cream BOARD OF HEALTH AichaeCAcCCean, 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: FOUR CORNERS CITGO 4 SOUTH MAIN STREET License Number: RF -74 Permit Expires: December 31, 2016 BOARD OF HEALTH 3WichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that. ANJANA D. PATEL, PRESIDENT having a place of business at: FOUR CORNERS CITGO 4 SOUTH MAIN STREET 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 12/31/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: RF -74 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 Ili Date received: Date Inspected: Approved By: Permit # Issued RF -74 - FOOD ESTABLISHMENT PERMIT APPLICATION ----- � pp ►ca ion mus e-su�t7eas�ys e ore e planned a e 1) Establishment Name FOUR CORNERS CITGO 2) Establishment Address 4 SOUTH MAIN STREET 1 3) Establishment Mailing Address (if different) 4 SOUTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-6111 5) Applicant Name & Title: DINESH PATEL - 6) Applicant Address 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (sos> zsa-�ssz 24 Hour Emergency No.: (soa) 982-8177 j 8) Owners Name & Title ANJANA D. PATEL, PRESIDENT 9) Owner Address (If different from applicant) 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 Owner's telephone number - (508) 982-8177 -- - F 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address j ❑ An Individual --- ---- - - - - - ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (DINESH (JACK) PATEL Address: 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 Telephone No: I(508) 337-6111 24 Hour Emergency No: (508) 982-8177 7FAX: (508) 337-6112 E -mail: Alt E -Mail: ------ ----- 13) District Or Regional Supervisor (if applicable) Name & Title: Address: j Telephone No- ; 24 Hour Emergency No: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 3 17) DAYS/HOURS: 7 DAYS 5 AM -10 PM 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 10/1/2001 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:d❑ Permanent Location 22) Establishment Type �❑ Caterer $12.50 Moblie Moblie Start Date: � ❑ ❑Retail ( Sq. Ft) � � Milk &Cream $5.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments:' to 10' PHF display $62.50 f F 21) Length of Permit. V Annual [_]Seasonal Seasonal Dates: E] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): E] Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 E] Food Service - Institution ( Meals/Day) ❑ Manu acture rozen es— s ce ream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 [] Retail Food $50.00 ❑ Retail Snack Food $12.50 Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs E] Sale of Commercially Pre -Packaged PHFs E] Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours F1 Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations E]PHFCooked To Order F] Preparation of PHFs For Hot And Cold Holding For Single Meal Service F1 Sale of Raw Animal Foods Intended to be Prepared by Consumer LJ Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service E] PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill F] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) E] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale � Animal Origin Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: $50.00 Payment is due with application ❑ waived 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 copies oRO5 CMR 590.000 and the federal Food Code. 24) Signature of Applica 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. 25) Social Security Number or Federal ID: 20-4684806 - 26) Signature of Individual or Corporate Name: 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: FOUR CORNERS CITGO ADDRESS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 337-6111 FAX NUMBER: (508) 337-6112 OWNER OF BUSINESS: ANJANA D. PATEL, PRESIDENT TELEPHONE OF OWNER: (508) 982-8177 FEDERAL ID/SS NUMBER: 20-4684806 FEE: $5.00 PERMIT NUMBER: RF -74 SIGNATURE DATE: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -74 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 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: FOUR CORNERS CITGO LOCATION OF SALE OF TOBACCO PRODUCTS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 337-6111 OWNER OF BUSINESS: ANJANA PATEL, PRESIDENT ADDRESS OF OWNER: 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 982-8177 FAX NUMBER: (508) 337-6112 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: 20-4684806 SIGNATURE: CG -Ad DATE: 1 16 �EPAR ry�yr Form CT -3T 03081 a Massachusetts Department of Revenue 2014-2016 m Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco DOS This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law. Application Number: 64580 License Number: Dale of Issue: Federal Identification or Social Security Number: 204-68-4806 03081 09/18/2014 Mailing address for license: Retail sale location (if different than mailing address) SUBH LAXMI INC. SUBH LAXMI INC 4 SOUTH MAIN STREET 4 SOUTH MAIN ST MANSFIELD, MA 02048 MANSFIELD, MA 02048 This certifies that the taxpayer named above has paid the required license fee and is licensed to sell at retail at the address shown above unti'. `--419r30,2016. This license is not transferable, and is subject to suspension for failure to comply with the law. 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) �)a6 _'4( - ��-() ** 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 Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: L 4 x M I IN( - Address: N( - Address: G ,a�o" i tl MA -JN 97 City/State/Zip: M p k/S G-1 ju, M 6 JaLf,k Phone #: �o i� - 3 3 "7 - 6 It 1 Are you an employer? Check the appropriate box: 1.F -1I am a employer with 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.] Business Type (required): 5. V9 Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other real estate, auto, etc.) *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' Insurance Company Name:cVJ h r Insurer's Address: P n 60 X A " 1-1 insurance for my employees. Below is the policy information. � 4w� City/State/Zip: Cti tWry-C 14 Policy # or Self -ins. Lie. #, i' q o) 6 1-1 Expiration Date: % / I t-,' I 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: o'n'J'2-a I I o$- 33'1 GI.i 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: www,mass,gov/dia Phone Apr,26.2016 10:39AM A Olivieri Ins Agency No,0793 P. 2/5 SUBHLA1 01P ID: TL . A�COR�" CERTIFICATE OF LIABILITY INSURANCE °ATE 1 04126120Y6 04/2612016 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 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 Ileu of such endorsement(s). PRODUCER J.K. Oliviers Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. 011vlerl TACT NAME: Kenneth W. 011vierl PHONE P fi • 608.947-1818 K-MAIL 9: INSURER(S) AFFORDING COVERAGE NAIL $ ABP89026H INSURERA: NGM Insurance Co. 14788 INSURED SubhInc. dba FooururCorners Citgo dba Four Corners Citgo 4 South Main St INSURER a!Me. Retail Merchants We Group INSURER c: American Safety Indemnity Co. INSURERO; Mansfield, MA 02048 INSURERE: INSURER F : PERSONAL & ADV INJURY $ 1,000,00 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. ILSR TYPEOFINSURANC6 ADDL a POLICY NUMBER POLICY FP MMIDDIYYYY POLICYfiXP IOOrrYYY LIMITS ABP89026H COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR Business owners 0 07114/20115 0 0711412016 EACH OCCURRENCE $ -1,000,00 PREMISES E occurrence)i 600,00 MED EXP (My oneperson) $ 10,00 PERSONAL & ADV INJURY $ 1,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: X POLICY JEOT ❑ LOC GENERAL AGGREGATE $ 2,000,00 PRODUCTS-COMP/0P AGO $ 2,000,00 $ OTHER AUTOMOBILE LIABILITY CO Mt3TE 81NGLE L—W T $ ct BODILY INJURY (Per person) $ ANY AUTO AUTOWNED AUTOS NON -OWNED HIREDAUTOS AUTOS BOD14YINJURY (Per scoldenq $ PROPERTY DAMAGE (Ps r accident)1 41$ UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTIONt- B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIEB R/EARTNERE ECUTNYIN E IN OFFICERIMEM(Mandatory in NH) Nyyess, IPTIONescribe under DE6CRIPTION OF OPERATIONS be ow N!A 014006033710116 01101/2016 01101/2477 PER O X E IT _ ,E.LEACHACCIDENT $ 100,00 E.L. DISEASE - EA EMPLOYEE $ 100,00 E.L. DISEASE • POLICY LIMIT $ 600,00 C Pollution Ltab. 8 P105260 11/28/2014 11/28/2016 Aggregate 2,000,00 CLAIMS MADE RETRO DATE 11/29/2005 Ded/claim 6,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sohedulo, may be aKeahod It more apsaa Is required) Convenience Store w/Self Service Gas MANST02 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, REPRESENTATIVE W IUUU-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks. of ACORD Information and Instructions Massachusetts General Laws• chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantwho has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like. to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number; The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05