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HomeMy WebLinkAboutAdvance Stores 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 FOOD LICENSE 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:. GEORGE E. SHERMAN, PRESIDENT Whose place of business is: ADVANCE STORES COMPANY, INC. #4452 292 CHAUNCY STREET PERSON(S) IN CHARGE: MICHAEL CONNOLLY Permit Expires: December 31, 201; Food Fee: $25.00 License Number: S-1 BOARD OF HEALTH MichaeCMcCCean, Chairman . S 4 FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be—submitted at leastdays- before the planned opening date) 1) Establishment Name Advance Stores Company, Inc DBA: Advance Auto Parts #4452 2) Establishment Address 292 Chauncy St., #296 -Mansfield, MA 02048 3) Establishment Mailing Address (if different) 5008 Airport Rd., NW -Roanoke, VA 24012-1601 4) Establishment Telephone No 508-851-9061 5) Applicant Name & Title: Anntoinette M Truxel, Associate Accountant 6) Applicant Address 5008 Airport Rd., NW- Roanoke, VA 24012-1601 7) Applicant Telephone No.: 540-561-6892 24 Hour Emergency No.: 8) Owners Name & Title George E Sherman, President 9) Owner Address (If different from applicant) 2635 E Millbrook- Raleigh NC 27602 Owner's telephone number 10) Establishment Owned By: D An Association M A Corporation D An Individual D A Partnership D Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Michael A Norona, EVP,CFO--2635 Millbrook Raleigh NC 27602 Jill A Livesay, SVP, Controller --5008 Airport Rd., NW Roanoke VA 24012-1601 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Michael Connolly Address: Telephone No: 508-339-4516 24 Hour Emergency No: FAX: E-mail: Michael.Connolly@advance-auto.com Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Bruce White Address: Telephone No: 508-254-3101 24 Hour Emergency No: FAX: E-mail: bwhite@advance-auto.com Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: M -S: 8am-8pm & SN: 9am-6pm 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 1011/2001 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): 11 1 20) Location: [& Permanent Location 22) Establishment Type Q Caterer $25.00 Mobile Mobile Start Dale: iJ Retail ( 7,242 Sq. Ft) IJ Milk & Cream $10.00 Mobile End Date: E] Food Service up to 100 or 0 Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 Food Service up to 101 -200 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21) Length of Permit: E] Annual or up to 25' PHF display $150.00 Food Service up to 201 + Pushcart $25 # of Pushcarts: Residential Kitchen $100.00 El Seasonal or 25'+ PHF display $275.00 E]Retail Food $100.00 Seasonal Dates: 0 Food Service - Institution Retail Snack Food $25.00 n Temporary Temporary Start Date: ( Meals/Day) Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food (Bmeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) E] Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Q 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 Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Q Delivery of Packaged PHFs Q Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours -- ----- Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- fN Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only 0 Ice Manufactured and Packaged for contact alternative, time as a public health F] Preparation of Non-PHFs Retail Sale control) Other Food Operations I Juice Manufactured and Packaged for EJ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin Offers RTE PHF in Bulk Quantities it Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 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 popigis of 1U CMR 590401 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49k, 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: �JQR 26) Signature of Individual or Corporate Name: 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 I'ndividuW or Corporate Name (Mandatory) By: Corpo ate Officer (Ma atory, if applicable) 54-0118110 ** 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 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Advance Stores Company Inc Address: 5008 Airport Rd., NW City/State/Zip: Roanoke, VA 24012 Are you an employer? Check the appropriate box: 1.0 I am a employer with 10 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 #: 540-561-6892 Business Type (required): 5. © Retail 6. ❑ Restaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (incl. real estate, auto, ete.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box #I 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 requhed and such an organization should check box fl, I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ACE American Insurance Company insurer's Address: Marsh USA Three James Center - 1051 East Cary St., Ste 900 City/State/Zip: Richmond, VA 23218 Policy # or Self -ins. Lic, # WLRC4860545A Expiration Date: 06/01/2017 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, Ido hereby certify, unifer th#ains andp&ides ofperjury that the information provided above istrueand correct 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.guviula Phone ACORD® CC> CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/07/2016 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(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 Marsh USA Inc. Three James Center 1051 East Cary Street, Suite 900 Richmond, VA 23219 Attn: AdvanceStores.CertRequest@marsh.com J32008--GAWC-16-17 API CONTACT NAME: PHONEFAX C No E AIC No): E'MAI ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company 22667 INSURED Advance Stores Company, Incorporated INSURER B : See Additional Page PREIM SESAGEOEa occuRENTEr ence $ 1,500,000 5008 Airport Road INSURER C: INSURER D : Roanoke, VA 24012 INSURER E: PRODUCTS - COMP/OP AGG $ 3,500,000 INSURER F: A rnVFRAr,FS CERTIFICATE NUMBER: CLE -004523868-16 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. /NSR LTR TYpE OF INSURANCE ADD N D I SUBR VJVD POLICY NUMBER POLICY EFF MMIDO/YYYY) I POLICY EXP (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR X Self -Insured Retention 500,000 XSLG27854400 06101/2016 0610l/2017 EACH OCCURRENCE $ 1,500,000 PREIM SESAGEOEa occuRENTEr ence $ 1,500,000 MED EXP (Any one person) $ PERSONAL &ADV INJURY $ 1,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- X POLICY JECT LOC OTHER: GENERAL AGGREGATE $ 10,000,000 PRODUCTS - COMP/OP AGG $ 3,500,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTS AUTOS HIRED AUTOS X NON -OWNED AUTOS Ix ISAH09042490 0610112016 06101/2017 COMBINED SINGLE LIMIT I $ 5,000,000 Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PeOaccident) YDAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE Is AGGREGATE $ DED I I RETENTION 5 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICER/MEMSER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A SEE ADDITIONAL PAGE 06101/2016 06/0112017 XSTER ATUTE �RH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER L.ANl_t:LLAI IUN Advance Stores Company, Incorporated 5008 Airport Road NW Roanoke, VA 24012 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 REPRESENTATIVE of Marsh USA Inc. Diana Holsinger U 1988-ZU14 AGUKD GUKVUKA I IUN. AU rlgnts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: J32008 LOC #: Richmond Aco " ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA Inc. NAMEDINSURED Advance Stores Company, Incorporated 5008 Airport Road Roanoke, VA 24012 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL KtMAKKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers' Compensation policies: Policy Number: WLRC48605448 (AOS) Carrier: Indemnity Insurance Company of North America Effective Date: 06/01/2016 Expiration Date: 0610112017 Policy Number: SCFC48605461 ('NI) Carrier: ACE Fire Underwriters Ins. Co. Effective Date: 06/01/2016 Expiration Date: 06/0112017 Policy Number: WLRC48605473 (TN) Carrier: Agri General Insurance Company Effective Date: G6/0112016 Expiration Date: 06101/2017 Policy Number: WLRC4860545A (CA, MA) Carrier: ACE American Insurance Company Effective Date: 06!0112016 Expiration Date: 06101/2017 Policy Number: WCUC48605436 (01-1) Carrier: ACE American Insurance Company Effective Date: 0610112016 Expiration Date: 0610112017 SIR: 5500,000 ACORD 101 (2008101) kSJ LUUt5 Ak VKU %.UMr VRAI IVIY. /All [[UllLb ICdC1VCU The ACORD name and logo are registered marks of ACORD �f2� �dm�2o��cc�ecc�t� >2���ccy�ccc�clr�e�.� ( c ! L v Mansfield LIU,, Application for Standard Permit FP -006 •/ Return completed application to, Anntoinette M Truxel p (Rev. 1.1.2015) Permit Number: DIG SAFE NUMBER City or Town: Mansfield Start Date: Date: July 13, 2016 In accordance with the provisions of M.G.L. Chapter 148, as provided in Section 527CMR:1400 application is hereby made by Advance Auto Parts #4452 (540)561-6892 (Full Name of Person, Firm or Corporation) (Phone Number) of 292 Chauncy St #296 Mansfield, MA 02048 (Address: Street or P.O. Box, City or Town, Zip Code) for permission to (state clearly purpose for which permit is requested) store flammable and/or Combustible fluids, - -- solids, -or gases -on premises. - - -- - -- - - -- - - Name of Competent Operator (if applicable) Date Issued -rejected Date of expiration Fee Cert. No. of Applicant) Amount Paid $ ----------------------------------------------------------------- MV ; 1 FP -006 (Rev. 1.1.2015) City or Town: Date: Permit Number (if applicable): X e0/wUrno/Woecc/t� �'1i�/�ccuaz a� PERMIT DIG SAFE NUMBER Start Date: In accordance with the provisions of M.G.L. Chapter 148, as provided in to (Full Name of Person, Firm or Corporation) for Restrictions: at Fee Paid $ Signature of Official Granting Permit: (Street and # or Describe Location for Adequate Identification) This permit will expire on Title this permit is granted -_ This permit must be conspicuously posted upon the premises 40_-_-, Bank # Pkt# TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: Date: IJUNE 17, 2016 Schedule: From Whom Account Number Amount ADVANCE AUTO PARTS 01512-445006 $ 12.50 Cash $ 12.50 Checks $ Total $ 12.50 Online or Wire Receipt $ TOTAL: $ 12.50 Mansfield, MA JUNE 17, 2016 To The Officer Making the Payments: The above is a detailed list of moneys collected by me, amounting in the ag re ate to: $ 12.50 Ifor the period ending JUNE 17 016 which I have paid to the Town Treasurer whose receipt I hold therefor. Employee or De t Head TOWN OF MANSFIELD PAID JUN 1 72C1� CHECK# Checl Date: June/08/2016 Check No. 0000305417 Invoice Number Invoice Date Voucher M Gross Amount Discount Available Paid Amount 71 LHQ-104452-060216 06/02/2016 X01310471 25.00 0.00 25.00 Standard Permit LHQ-104452-060216A 06/02/2016 01812310 12.50 0.00 12.50 Food Permit Aj&j/� 6 /i7��6 Vendor Number Name Total Discounts 0009102791 Town of Mansfield $0.00 Check Number Date AP Business Unit Total Amount Discounts Taken Total Paid Amount 0000305417 06/08/2016 30EAP $37.50 $0.00 $37.50 0000030S40,10 I:0 5 3 l0 L 56 Ll: 20 799006 294 260