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HomeMy WebLinkAboutMansfield Xtra Mart 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:. DRAKE PETROLEUM COMPANY, INC. Whose place of business is: MANSFIELD -MA XTRA MART 905 SOUTH MAIN STREET Permit Expires: December 31, 2016 License Number: RF -77 BOARD OF HEALTH Food Fee: $50.00 Milk & Cream 0 NichaeCvicCCean, 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: MANSFIELD -MA XTRA MART 905 SOUTH MAIN STREET License Number: RF -77 Permit Expires: December 31, 2016 BOARD OF HEALTH MichaeCvicCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: DRAKE PETROLEUM COMPANY, INC. having a place of business at: MANSFIELD -MA XTRA MART 905 SOUTH MAIN 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 -77 Scott leite, 9-teaah ,agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 License to Manufacture Frozen Desserts and/or Ice Cream Mix The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made hereunder, hereby issues MANSFIELD -MA XTRA MART 905 SOUTH MAIN STREET a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31 st of each year. License Number: RF -77 Freezers: 1 TOTAL: $12.50 MANSFIELD BOARD OF HEALTH Scott Leite, Heaah .Agent FOR BOARD OF HEALTH USE ONLY I Date received: Date Inspected: Approved By: Permit # Issued RF -77 FOOD ESTABLISHMENT PERMIT APPLICATION --,----,-(Application --hiu-s-tbe submittedatTe—ast-30 days before theb planned opening dame) 1) Establishment Name MANSFIELD -MA XTRA MART 2201'E, 2) Establishment A-ddress__ 905 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 800 SOUTH STREET, P.O. BOX 9161 ATTN: LEGAL WALTHAM, MA 02454 Establishment Telephone No (508) 261-2812 5) Applicant Name & Title: DRAKE PETROLEUM COMPANY, INC. 6) Applicant Address 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 7) Applicant Telephone No.: (1609) -844 -8800(7M) -e44-4800 24 Hour Emergency No.: ---(860"36-&W0jM1j-844--M0 Lf Ll s,; 8) Owners Name & TitleAN DRAKE PETROLEUM COMPANY, INC. 9) Owner Address (if different from applicant) 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 Owner's telephone number (781) 844-8800 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. W A Corporation Name Title Address El An Individual 0 A Partnership El Other legal Entity 12) Person Directly Responsible F - or Daily Operations- (-owner, person in charge, supervisor, manager e_t_0._)__ Name & Title: (JIM BRODEUR, MANAGER Address: 1905 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: i(608) 261-281224 Hour Emergency No: (860) 935-5200 (781) 844-8800 I FAX: I(7-8 -67-4-77-99 1_-S z l E-mail: I"-HELA-N(0),GLOBALP=.M Alt E -Mail: 'I LENNY-Afi�XTRAmART_com 13) District Or Regional Supervisor (if applicable) Name & Title: ANDREA PALMIER( Address: 1800 SOUTH STREET, WALTHAM, MA 02454 Telephone No: 1(781) 844-8800 _ 24 Hour Emergency No: (860) 935-5200 Z� Q - FAX: tM)_6747-79S 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 - 117) DAYS/HOURS: 7 DAYS PER WEEK 24 HRS. 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 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 ii 22) Establishment Type E] Caterer $12.50 ❑ Moblie Mobile Start Date: n-/ Retail Sq. Ft) R*/ Milk & Cream $5.00 Moblie End Date: El Food Service up to 100 or E] Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 Manufacture Frozen Desserts/ice Cream 21) Lengthof-Permit: El Food Service up to 101 -200 $12.50/freezer Annual or up to 25' PHF display $75.00 El Pushcart $12.50 # of Pushcarts: F-1 seasonal E] Food Service up to 201 + E] Residential Kitchen $50.00 I Seasonal Dates: or 25'+ PHF display $137.50 Retail Food $50.00 Temporary Food Service - institution �El Retail Snack Food $12.50 Temporary Start Date: Meals/Day) 0 Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food (timellemperature controls required) Non-PHFs - non -potentially hazardous thod(no time,4emperature controls required) I(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non -PRFs I ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFS Prep-ar4ion of For - Hot And for More Than a Single Meal Service ❑D elivery of Packaged PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly E] Reheating of Commercially E] Sale of Raw Animal Foods Intended Susceptible Population Facility Processed Foods for Service Within 4 Hours to be Prepared by Consumer El Vacuum Packaging / Cook Chill iE] F1 Customer Self -Service of Non PHF and Non- Customer Self --Service Use of Process Requiring A Variance Perishable Foods Only and/or HACCIP Plan (including bare hand 'E] Preparation of Non -PHFs E] Ice Manufactured and Packaged for 1 contact alternative, time as a public health I Retail Sale control) Other Food Operations EJ Juice Manufactured and Packaged for E] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E] Offers RTE PHF in Bulk Quantities 1 E] Prepares Food/Single Meals for I i ❑ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service i__ - --- or Reconditioned Food — To be completed by the Board of Health Total Permit Fee: Payment is due with application ❑ waived 1, 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 of 105 CMR 590.000 and the federal Food Code, 24) Signature of Applicant- VAY) 6 r'LL Vi Pursuant to MGL Ch,62C, sec. 49A, I certify under the penalties of perjury that 1, 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: 04-2236089 26) Signature of Individual or Corporate Name: V'a V t t 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: MANSFIELD -MA XTRA MART ADDRESS: 905 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-2812 FAX NUMBER: (781) 674-7799 OWNER OF BUSINESS: DRAKE PETROLEUM COMPANY, INC. TELEPHONE OF OWNER: (781) 844-8800 FEDERAL IDISS NUMBER: 04-2236089 FEE: $5.00 PERMIT NUMBER: RF -77 SIGNATURE: DATE: —S 04P 42e -j Town of Mansfield Town of Mansfeld - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -77 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: MANSFIELD -MA XTRA MART LOCATION OF SALE OF TOBACCO PRODUCTS: 905 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-2812 OWNER OF BUSINESS: DRAKE PETROLEUM COMPANY, INC. ADDRESS OF OWNER: DRAKE PETROLEUM COMPANY, INC. TELEPHONE OF OWNER: (-78l)-844-8800 3" S FAX NUMBER: (-784)-674.7-799 S If a corporation or partnership, give name, title, and home address of officers or partner. PLEASE SEE ATTACHED Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: - FEDERAL ID/SS NUMBER: 04-2236089 SIGNATURE: DATE: ��PART,y�H� Form CT -3T 04589 y o� Massachusetts Department of Revenue 2014-2016 TT� m Cigarette Excise Unit uU'J6 3cr'' Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco k QOR This License must be posted and visible at all times, sales to persons under 18 years of age are prohibited by law. Application Number: • 63288 License Number: Date of Issue: Federal Identification or Social security Number: 042-23-6089 04589 09/26/2014 Mailing address for license: Retail sale location (if different than mailing address) DRAKE PETROLEUM CO INC MANSFIELD MA XTRA MRT 221 QUINEBAUG RD 905 SO MAIN ST NORTH GROSVENORDALE, CT 06255 MANSFIELD, MA 02048 - : A + 11 + mfll ni rhP address shown above until This certifies that the taxpayer named above has para me reyunru WuC„�v — a ,W ��••��- •- -_•• __ _ September 30, 2016. This license is not transferable, and is subject to suspension for failure to comply with the law. Town of Mansfield Town of'Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board ol'Heahh at the Toren gl`Hansfielek In accordance with the provisions ol'section 651-1 ofChapter• 94 c?f the General Lmvs, as most recently umended, and the regulations made thereunder, the undersigned hereby applies for cr license for a 11710LE.SALEIREIAIL mant#iichrre of frozen desserts crud ice cream mix and submits the fallouving injorntativrn: 1. Full name of applicant: MANSFIELD -MA XTRA MART 2. Business address 800 SOUTH STREET, P.O, BOX 9161 ATTN: LEGAL WALTHAM, MA 02454 3. 11'applicum is an individual: Full name: DRAKE PETROLEUM COMPANY, INC. Residence: 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 .3a. 11'applicant is it partnership, All name and residence ol'all partners: 3b. If applicant is a corporation: State of incorporation:_ MASSACHUSETTS Date of incorporation:_ APRIL 16, _1-958 Full pante and address of : Principal office: 800 SOUTH STREET, P.O. BOX 9161 ATTN: LEGAL pt•esider71 PLEASE SEE ATTACHED Treasurer: C.'lerk: 4. Location ol'Plants: IN STORE SOFT SERVE MACHINE S. Names ol'brands and trade or corporation imine, VanY, under which the products are to he sold: UNBRANDED -_ 6. Number and capacity of freezers crud fees: 1 Fee: ($12.50 per freeze! j $ 12.5 - 7. Is the mix purchased? YES Ifso, front whom purchased? 8. is the rnix pasteurize(/ oj'rrot? YES 9. Number o1'gallons q1 fi-ozern desserts and/or ice cream mix to he sold in Massachusetts during the licensing period 600 /0. Number q/'galbrts offtozen desserts and/or ice cream nus sold in Alassaclntselrs during the previous licensing period 11. Is the plant constructed and equipped as provided in the regulations? Yes NSF/approved T 12. Ls t/nc water suppl}v pubhe or not? YES 13. Have t ou receired a copy ol'Ihe regndatians? NO I hereby certify that the frozen desserts and/or ice cream rnix t sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and w111 be manufactured under sanitary conditions I attest that the information stated in this application is true and accurate under the pains and penalties ofperjury. (Company owner/officer's sig ature) qg {"Te.(DATg) (Title) (City or Town) 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 Individua or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) U'", - :') ,(RcI ** 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 600 Washington Street Boston, MA 0211.1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General businesses Applicant Information Please Print Legibly Business/Organization Name: Address � c City/State/Zip: , ' a a i '' : �` ` Phone # `' # ` Are you an employer? Check the appropriate box: 1. [ 1 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. ] Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. [] Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other t% fly appueam mar cnecKs nox n r must also till 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: i t @ Y I �. Insurer's Address: City/State/Zip: 4 C Policy # or Self -ins. Li c. # _ __ $��- h C, t Expiration Date: 1 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 e. 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. Ido hereby certify,.under thgpains andpena/ties ofperjury that the information provided above is true and correct Date: 2-H Phone # -` _ �K 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.gowota Phone 1 ®75/25/2016 ACORO CERTIFICATE OF LIABILITY INSURANCE 10/1/2016 TE (MMIDDIYYYY) THI�RTIFICATE 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 pollcy(ies) 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 lieu of such endorsement(s). PRODUCER Lockton Insurance Brokers, LLC 725 S. Figueroa Street, 35th Fl. CA License #OF15767 Los Angeles CA 90017 (213) 689-0065 CONTACT NAME: PHONEFAX Ext): FAX AIC No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Liberty Insurance Corporation 42404 INSURED 1369067 Global Companies, LLC Global GP, LLC INSURER B : INSURER C: INSURER D: 800 South Sheet INSURER E : Suite 500 Waltham MA 02454 INSURER F O1 CERTIFICATE NUMBER: 14077217 KtViSiON IVUIVIeCK: 1iAellsAAA COVERAGES %ii - 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. NSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS NERAL LIABILITY OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX DAMAGE TORENTEDE PREMISES Ea occurrence $XXXXXXX MED EXP (Any one person) $ XXXXXXX rCOMMERCI,AL PERSONAL & ADV INJURY $ XXXXXXX GENL AGGREGTE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXXXX PRODUCTS - COMP/OP AGG $ XXXXXXX PRO- LOC POLICY F-1 OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT Ea accident $ XXXXXXX BODILY INJURY (Per person) $ XXXXXXX ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BODILY INJURY (Per accident) $ XXXXXXX (PROPERTY DAMAGE $ XXXXXXX Per accident $XXXXXXX UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below $ XXXXXXX X STATUTE EERPERI H A N / A N WA7-69D-460066-015 10/1/2015 10/1/2016 E.L. EACH ACCIDENT $ 1 000 000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: Site #10027 — For food & tobacco licenses Mansfield MA Xtra Mart 905 South Main Street Mansfield, MA 02048. lil)LUtK 14077217 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. AUTHORIZED ©1 81 8-201 QIi D CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ,a o►® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 5/25/2016 INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES 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 of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the the terms and conditions certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: No): (866) 597 9827 AIC Ext): ( ) FAX Commercial Lines - (617) 330-1005 PHONEo 617 330 1005 MAIL Wells Fargo Insurance Services USA, Inc. ADDRESS: 200 Berkeley St., 23rd Floor INSURER(S) AFFORDING COVERAGE NAIC # Boston, MA 02116 INSURER A : Liberty Mutual Fire Insurance Cc 23035 INSURER B: ACE Property and Casualty Ins, Co. 20699 INSURED Global Partners LP INSURER C; P.O. Box 9290 INSURER D: 800 South Street, INSURER E: Waltham MA 02454-9290 INSURERF: ___ encn�ocn Dr-ximInN rdl IMRFR- See below :OVERAGES ccrcnrwr+Ic l4ulvi— . •� -• --- E BEEN ISSUED TO THE INSURED NAMED ABOVE THE HAV ND CATED.PERIOD THIS IS TOCERTIFY NOTWITHSTANDINGTHAT THEOES ANYI REQUIREMENT, TERM OR CONDOF INSURANCE LISTED BELOTION OF ANY CONTRACT OR OTHER DOCUMENT WITH REO SPECT TOLICY 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. IR TYPE CE ADDL SUBR POLICY EFF POLICY EXP LIMITS OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A E62 691 461574 015 10/01/15 10/01/16 CLAIMS -MADE I ^I DAMAGE TO RENTED 250,000 �� OCCUR PREMISES Ea occurrence $ DED X RETENTION $ 25,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTI IVE — N / A nFFICI FR/MEMBER EXCLUDED? GEN'L AGGREGATE LIMIT APPLIES PER: MED EXP (Any one person) $ X JE � � LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 AUTLIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident ED SCHEDULED OLIABCLAIMS-MADE XOOG2783503A 10/01/15 AUTOS NON -OWNED EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 TOS AUTOS X A LIAB X OCCUR B LIAB CLAIMS -MADE DED X RETENTION $ 25,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTI IVE — N / A nFFICI FR/MEMBER EXCLUDED? E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) PC#10027 Mansfield Xtra Mart 905 South Main Street Mansfield, MA 02048. As required for Food, Frozen Dessert and Tobacco License Permit CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield MA 02048 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) (Thus cefcale replaces wroroetep 9585594 Issued on 91252915) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ XOOG2783503A 10/01/15 10/01/16 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) PC#10027 Mansfield Xtra Mart 905 South Main Street Mansfield, MA 02048. As required for Food, Frozen Dessert and Tobacco License Permit CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield MA 02048 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) (Thus cefcale replaces wroroetep 9585594 Issued on 91252915) Drake Petroleum Company, Inc. CORPORATE OFFICERS Name Address & Phone No. DOB Title Eric Slifka 4/27/65 Director, President and Chief 9 Clark Road Executive Officer Wellesley, MA 02481 781-263-0041 Andrew Slifka 11/25/68 Executive Vice President 14 Lehigh Road Wellesley, MA 02482 781-237-6507 Edward J. Faneuil 7/02/52 Secretary, Executive Vice 100 Belvidere Street, Unit 5H President and General Counsel Boston, MA 02199 857-277-0704 Charles A. Rudinsky 7/19/47 Chief Accounting Officer and 34 Drinkwater Road Executive Vice President Exeter, NH 03 83 3 603-778-7043 Daphne Foster 7/02/57 Chief Financial Officer 27 Fairgreen Place Brookline, MA 02467 617-505-5782 Mark Romaine 10/25/68 Chief Operating Officer 4 Pats Place Kingstown, MA 02364 781-582-2458