HomeMy WebLinkAboutHome Depot 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: RETAIL SNACK
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:.
HOME DEPOT USA, INC
Whose place of business is:
THE HOME DEPOT #2609
390 WEST STREET
PERSON(S) IN CHARGE:
MATTHEW D. LUCAS, OPERATIONS MANAGER
Permit Expires: December 31, 2016
License Number: S-26
Food Fee: $12.50
BOARD OF HEALTH
AichaeCAcClean, Chairman
FOR L30ARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit 0 Issued II
S -2F
FOOD F—STABLISHMENT PERMIT APPLICATION
(Applicafion must be siibrrilfaif"af east 30 clays bi3fo�� 7- �e pl'aiijied 'gp�ing da'fe)--- - : ' --""-""
1) Establishment Name THE HOME DEPOT 42609
2) Establishment Address 390 WEST STREET
3) Establishment Mailing Address (if different) 2455 PACES FERRY ROAR 1312
j u � �
ATLANTA, GEORGIA 30339
4) Establishment Telephone No
p (508) 337-2050
6) Applicant Name & Title: HOME DEPOT USA, INC.
•
,6) Applicant Address 2455 PACES FERRY ROAD NW, ATLANTA,.OA 30330_
:7) Applicant Telephone No.: (770) 433.8211 24 Hour Emerpnoy. No,: G;774) 3123494
8) Owners Name & Title HOME DEPOT USA, INC'. '
9) Owner Address (If different from applicant) 2455 PACES FERRY ROAD, ATLANTA, GA 30339
Owner's telephone number 7704338211
10) Establishment Owned By: 11) If a corporation or partnership, gtvq i ame, title, and home address of officers
j n An Association or partner.
0 A Corporation Name Title Address
O An Individual _
O A Partnorshl"p _ �,�.� tit' -he
f I Other legal Entity
12} Person Directly Responsible For Daily Operations (owner, person in chargiE, supervisor, manager etc.)
Name & TiOe: MATTHEW D, LUCAS, OPERATIONS MANAGED
i
Address: 390 WEST STREET, MANSFIELD, MA 02048 '
Telephone No: (508) 337-2050 24 Hour Emerggool ywo: C (YT#*317-3'194
_...... ..........
............ -_............_.._._.._........._.__.....
FAX: (508) 851-6013
F -mail: MA'I'L•Ht:W,D LUCAS(MHOMEDEPOT.COM _
Alt E -Mail: �L� �s _ yLG.►�-ts �G,:�tz c� }'% �c�tv�;
13) District Or Regional Supervisor (if applicable)
Namo & Title: PAUL_ DEVENO, DISTRICT MANAGER
Address: 390 WEST STREET, MANSFIELD, LIMA 02046
Telephone No: (508) 337-2060 24 Hour Emergency No,-
FAX;
Q,FAX: . (508) 851-6013 E-mail:
Food Establishment Inforni4ifloi n
- ----
.......... ..
'14) WATER SOURCE: TOWN ---------
16) SEWAGE DISPOSAL.* TOWN
DEP Publio Water Supply No: (it applicable) 16) No. of Food Employee$:
17) DAYS/1-10URS: MON-SAT 6 AM -1a PM SUN 7 AM -8 PIA
..............
... .... .......... ....
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 101112001 in accordance with 105 CA,1R 590.003(A) Please attach copy ol'
coffifiouto
19) Person Trained in AnikChokino Procedures If 26 Seats Of more):
20) Location: Permanent Location 22) Establishment Type ❑ Caterer 512.60
n Moblie Mobile Stott Date.
Sq. Fl) E] Milk &'Crea'm $5.00
Mobile End Dale! Food Service up to 100 or Ej Mobilo Food & Corigagston 937,60
Mobile Comments: up to 10' PHF display $62-60i
Ej Manufacture Frozen DessertstIce Cream Len th of Permit; —
0 Food Service up to 101 -200
Annual or up to 26' PHF display $76,00 i ❑Puehl�'arl $12,50 6 of PuohGarls:'
...........
Ci
Seasonal Food servio up to 201ld�
Rea� nlial Kitchen $50.00
or 26'+ PHr display 5137-50
Seasonal DatoR: ❑ Reloit Food $60.00
r7j- Temporary Food Service - Institution Raipil
I Snafk Food $12.60
Temporary Stan Date; Meals/Day) E] TQ4aco'o Products $12.50
Temporary End Dole:
Temporary Time;
Rain Date: F
23) Food Operations Darfflilio= PHF - POWU&hy hazardous food (t1tj?o4&(np9rEdvra'
qonirols taquifed).
Non -PI -W3 - non -potentially hazardous rood(rio f1majivinporatura conr(ol� raquifad)
(Check all that apply): RTJ� - toady-fo-eat ods (Ex. 5amhviGhes, salads, vhq�fflfls WhIC11 nesvno (ualfor" procassing)
®Sale of Sale of Commercially Pro-Puckaged Non-PHFs Ej pHFCookad To Order tof0 Hot PCduned
for More Than a Single Meal Service.PHFs r sForHotAndreparation of P4-4
Cold Holdingl For Single Meal 8(tuvie'e ti"13HF 40 RTC Foods Prepared For 1-11ohly
Delivery of Pockaflod PHI's Suz)ceptIbI6 Population Facility
... ... E] Sale of Raw Animal Foods Intqrided.
R he ng of Coni CWfj to be Prepared by Consumer; Packaging / Cook Chill
Processed Foods for Service Within 4 Hours I I
.. ..........
0 Process Requiring A Variance.
and/Or j1ACCP Plan (Including bare hand
Perishable Foods Only
E -j lce*' main'-6-fact—we—d a-n—and-a`ck*aqe
Preparation contact alternative, time as a public health
❑ '-e—Pa-R,3, No- A-pw� Retail Sale control
other rood Operations Ej Juice Manufactured and Packagaq foe L) Offers Raw Or Undercooked Food Ol'-
Retail Sale
Anim4l.Or1q)n
F] Offers Pre'iQr0.e FoodlSingl& Meals for
PHF In Bulk Ouentities P
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -O -Dqttji
or Reconditioned Food
To be 0qMP16fo(;
Total Permit $112,501
Fee:/
1 ""i'l
POYM01 Is (iu. /,114�hhhp!p1loaft 111 Is
wyivq
1, the undersigned, attest to the accura f the information provided In this application and affinn that the f000,
"Jill �Ompjjjy -1 14�
.V establishment operation 10 MR 690.000 and all other applicable law. I have been iuisjri;qlgd by the
CM
board of health on how to obtain ies 0 R 000 and the federal Food Code,
24) Signature of Applicant:
Pursuant to MOIL Ch.62C, sea, 49100 4d)r the 'penal Iles of penury that [, to my'be oil. 0 wlodgo ani bqlief, have filed all state tax returns
and paid slate taxes required and %A
215) Social Security Number or Federal 10; 58.18533t9
26) Signature of Individual of Corporate Name;
90/60 39VJ
69 -6T
I certify under the penalties of perjury that I, to my best knowledge.and belief,
have filed all State tax returns and paid all State takes required, under law.
' Signature of Indivi uai or
Corporate Name (Mandatory)
By; Corporate Officer
(Mandatory, if applicable)
b33 l
* Social Security Number (Voluntary) or
Federal identification Number
This license will not be issued unless fhe certification clause is signed by
tine applicant.
Your Social Securlty number will be furnished to tf a Massachusetts
Department of Revenue to determine whether you have met tp'g filirj$ or tax
payment obligations. Licensees who fail to correct heir non -filing a`r delinquency
will be subject to license suspension or revocation, This request is made under
tho authority of Mass. General Laws, Chapter 62C, Seotion 49A<
5000 39va i L�i`� l 380i
THE HOME DEPOT, USA INC.
Officer Listing
PERSONAL ARD CONFIDENTIAL
Craig A. Menear, Ci)ief Executive Officer 770-433-8211 - 2455 PACES FERRY RD NW ATLANTA GA 30339
and -President
Carol Tome', EVP, Corporate Services and 770-433-8211 2455 PACES FERRY RD NW ATLANTA GA 30339
Chief Financial Officer
Karen Dewalt, VP Tax and Finance 770-433-8211 2455 PACES FERRY RD NW ATLANTA GA 30339
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