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HomeMy WebLinkAboutRite Aid 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:. MAXI DRUG, INC. Whose place of business is: RITE AID #10141 243 CHAUNCY STREET Permit Expires: December 31, 2016 License Number: RF -60 Food Fee: $67.50 Milk & Cream W BOARD OF HEALTH MichaeCvicCCean, Chairman Permit or 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: RITE AID #10141 243 CHAUNCY STREET License Number: RF -60 Permit Expires: December 31, 2016 BOARD OF HEALTH NichaeCNcCCean, 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 MAXI DRUG, INC. having a place of business at: RITE AID #10141 243 CHAUNCY 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 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: RF -60 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 05/02/201612:51ptfi Rite Aid Mansfield 5083376193 FOR 130ARD OF HEALTFM US i ONL Date received: Date Inspected: Approved FOOD ESTABLISHMENT PER P,AIT A must be'sotte'd a- 30 day§' .e re' th6- 1) Establishment Name RITE AID #10141 2) Fstablishrnent Address 243 CHAUNCY STREET . ... . ..... .3) Establishment Mailing Address (if different) P.0. BOX 3165 ATTENTI )N: LI HARRISBURG, PA 17106 4) Establishment Telephone No (608) 3378800 5) Applicant Name & Title: MAXI DRUG, INC. 6)" 'Applicant Address -'-"P^'.O, BOX 3165, HARRISBURG, PA, 17105 7) Applicant Telephone No,: (717) 761.2033 24 Hour Emergency No,: 8) Owners Name & Title MAXI DRUG, INC. 9405 Page 04/10 :7 --- Permit # Issued RF -60 LICATION ned opening da'07- 729,$649 9) Owner Address (If different from applicant} P.O.BOX 3166, HARRISB RG, R01105 Owner's telephone number (717) 761-2633 10) Establishment owned By; 11) if a corporation or partnership, give name, titl Ll An Association or partner. R A Corporation Name Title U An Individual 0 A Partnership home address of officers Address D Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in Chem, e, supe 1 lisor, manager etc,) Name & Title: (WILLIAM PEREIRA MANAGER i Address: 131 BOW STREET, PLAINVILLE, MA 02762 Telephone No: 1(508) 696-4013 24 Hour Emergency No: FAX;....---,-*, '(608) 3-374193 E-mail: BILL0906(D.COMCASTMET Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: VINNI P ZZI Address: 4 WASHINGTON STREET, CANTON, MA Telephone No, (781) 821-6038 24 Hour Emergency No: (401) 626 FAX: 1(781) 821-1448 E-mail; 725-3649 05/02/2016,12:51pm Rite Aid Mansfield 5083376193 ,,, 4405 Page 05/10 Food Establishment Info 71 4) WATER SOURCE; TOWN 15) SEWAI DEP Public Water Supply No; (If applicable) 16) No, of I 17) DAYS/HOURS; MON-FRI 8 AM -10 PM SAT 8 AM -9 PM SUN 8 AM -8 PM 18) Name of Person In Charge Certified in Food Protection Management, If more than 3 individuals are certified, complete list is on file, n I Required as of 101112001 in accordance with 905 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 goats or more) ❑ 20) Location: © Permanent Location ' 22) Establishment Type �❑ 1 ❑ Mobile Mobile Start Date: V9 Retail ( Sq, Ft) © M I Mobile End Data; ❑ Food Service up to 100 or ' ❑ M Moblie Common Is _ I up to 10' PHF display $62,50 i 21) Length of Permit; i E)Food Service up to 101.200 �$ n Annual or up to 25' PHF display $75.00 ❑ i seasonal ❑ Food Service up to 201 + I� or 25'+ PHF display $137,50 Seasonal Dates: - ❑ Temporary - ❑ Food Service - Institution Temporary Start Date: ( Meals/Clay) IJ Temporary End Date: i Temporary Time; Rain Date: od Operations Definitions: Phir - Potentially hazardous food (timmemperatum co trots mquir 23) Fo Non-PHFs • non -potentially hazardous lood(no t1me/1eip0M(oV o (Check all that apply): ( RTE - ready -to -eat foods (Ex. sandwiches, salads, mu ins whioh n I Sale of Commercially Pre -Packaged Non PHFs ❑ PHFCooked To order f (K) Sale of Commercially Pre�Packoged PHFs ❑Preparation of PHFs For Hof And i Cold Holding For Single Meal Sery ce C'::i P ❑ Delivery of Packaged PHFs—___.. ••--•---•-• - • ❑ galQ of Raw Animal Foods Intend d ❑ Reheating of Commercially to be Prepared by Consumer ❑ V Processed Foods for Service Within 4 Hours n Customer Self -Service of Non PHF and Non- ❑Customer Self -Service a Perishable Foods Only'••••.•'a' •. •• • , • • c, -_,_ • , , . ,• ❑Ice Manufactured nd Packaged for • i ❑ Preparation of Non-PHFs Retail Sale o' Other Food Operations I ❑ Juice Manufactured and PackagQ for iJ D Retail Sale A Offers RTE PHF in Bulk Quanlltlesr n Retail Sale of Salvage,�Out-Of-Date or Reconditioned Food I I ; To Tc i, the undersigned, attest to the accuracy of the information provided in this application and af#irm that establishment operation will comply with 105 CMR 5904( and all other applicable law. I he been i board of health on how to obtain copies o 105 CMR 070 and the federal Food Code. 15 2A) Q1 M.- f A re opplloant: , /Al- l"' V � r ' Pursuant to MGL Ch,62C, sec. 49A, I certify under the pe and paid state taxes required under law. 25) Social Security Number or Federal ID; 04-25 944 26) Signature of Individual or Corporate Name; 'T of perjury that I, to my beat tai_ `L . -l ' -C. SAL: TOWN a: 0 �rer $12,50 i Croam $5.00 lie Fcod & Consession $37,50 1 ufacture Frozen Desserts/ice Cream 50/freezer i (cart $12,50 # of Pushcarts ' i idential Kitchen $50,00 ill Food $50.00 01 Snack Food $12.50 icco Products $12.50 ols required) i no further processing) i 'HF Cooked and Cooled or Hot Held flora Than a Single Meal Service and RTE Foods Prepared For Highly ceptible Population Facility tum Packaging / Cook Chill of Process Requiring A Variance or HACCP Plan (including bare hand act altemative, time as a public health rol) r5 Raw Or Undercooked Food or iai Origin ores Food/Single Meals for red Events or Institutional Food Service completed by the Board of Health Permit Fee: $60.00 lent is due with application ❑ waived �ood cted by the belief, have filed all state tax returns 05/02/2016,12:52pm Rite Aid Mansfield 5083376193 Town of Mansfield - Board of Health Application, for Milk and I hereby Make application for a MILK AND CREAM PERMIT, which expires Ion Ju NAME OF BUSINESS: RITE AID #10141 ADDRESS: 243 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-8800 FAX NUMBER: (508) 337-6193 OWNER OF BUSINESS: MAXI DRUG, INC. TELEPHONE OF OWNER: (717) 761-2633 FEDERAL ID/55 NUMBER; 04-2960944 FEE: $5.00 PERMIT NUMBER. RF -60 SIGNATURE: DATE,, 4405 Page 06/10 Town of Mansfield 6 Park Row Mansfield, MA 02048 of each year, 05/02/2016" 12:52Pm Rite Aid Mansfield 5083376190 Town ofMansfield - .hoard of Health �0 d 4405 Page 07/10 Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -60 Application for the Sale of Tobacco Pi, t iducts I hereby make application for a permit to sell tobacco products in compliance with tt Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit a res on ]rune Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of thermit. NAME OF BUSINESS: RITE AID 010141 LOCATION OF SALE OF TOBACCO PRODUCTS: 213 GHAUNCY STREET TELEPHONE AT LOCATION: (608) 337.8800 OWNER OF BUSINESS: MAXI DRUG, INC. ADDRESS OF OWNER; P.K. BOX 3165, HARRISBURG, PA 17105 ATTN LI TELEPHONE OF OWNER: (401-)-45 ►� i ( 1 d� 6. FAX NUMBER; (508) 337-5968 If a corporation or partnership, give name, title, and home address of officers or pG * Provide a co of current Department of Revenue CT -3T Rote FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 04-2960944 SIGNATURE: 7-/L DATE: -� SING ?xcise Unit License. i' m 05/02/2016,12:52Pm Rite Aid Mansfield 5083376193 101 4405 Page 08/10 I certify under the penalties of perjury that 1, to my best kno, have filed all State tax returns and paid all State taxes requ Signature of IndividuA or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, If applicable) (D'A � o (,, o r-, (4cl Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the certification ci the opplicant. Ige and belief, under law, is signed by "Your Social Security number will be furnished to the Massae "Usetts Department of Revenue to determine whether you have met to filing ortax payment obligations. Licensees who fail to correct their non-fi� ng or delinquency will W subject to license suspension or revocation. This reque s t is made under the authority of Mass. General Laws, Chapter 620, Section 4E"?,, Corporate Officers and Directors of Maxi Drug, Inca Incorporated in the State of Delaware on 1112811990 Federal ID# 042960944 Kenneth Black, President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-214-2550 Home Address: 1710 Revere Drive; Mechanicsburg, PA 17050 Home Phone: 717-728-9626, SS# 334-58-4992 Michael Podgurski, Vice President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-975-5888 Home Address: 200 Turtle Creek Circle, Oldsmar, FL 34677 Home Phone: 727-784-1270, SS#: 233-76-2921 Susan Lowell, Vice President Office Address: Rite Aid Corporation, 200 Newberry Commons, Etters, PA 17319 Office Phone: 717-975-5744 Current Address: 114 Clover Lane, Elizabethtown, PA 17022 Home Phone: 717-367-6166, SS#: 151-58-1052 Ghislaine Lespinasse-Bond, Vice -President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-975-5768 Home Address: 17 Adams Drive, Burlington, NJ 08016 Home Phone: 609-239-2828, SS#: 119-46-1958 Daniel Miller, Vice President & Secretary Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-214-2541' Home Address: 1921 Monterey Drive, Mechanicsburg, PA 17050 Home Phone: 717-695-0298, SS#: 207-42-4454 Matthew Schroeder, Vice President & Treasurer Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-214-8867 Home Address: 8 Wheatland Drive, Mechanicsburg, PA 17050 Home Phone: 717-766-6106, SS#: 197-50-6528 1 he Contittomvealilt oj'Hassacliuselty Dep ir/tneW oj' ltnitt.vlrirtl ,• I cc,itleitl s Ofjice of firvestiptions 600 Washinglon Slreel ` 30.5101t, M/1 02111 svwlv,It? ass.(0vhlia Workers' COMPetlsation fnsurance tiff davit: General Businesses 1 pulieattt Information Please Print Legibly E3 L1i Hess/OrJanization Name: rzk City/.Mate/Lip: z1�_, _ � Phona il:_ ,k a you art employer? Check the appropriate box: 0u iness'ryps (required): 5. Retail 1. 1 am a employer with 1�5 i' omployeex (fiill andl qtr pnrt-time).° h. ❑ Restaurant/Bar/Fating Establishment Z. ❑ 1am s sola proprietor or partnership and have no 7. ❑ OfTice and/or Sales (incl, real estate, auto, etc,) _nployees'working for me in any capacity. 3. Non-profit (No workers' comp. insurance required) I. ❑ Wa me :t corporation and its ot71cer9 have exercised 9. ❑ Entertainment their right of exemptions per c. 152, j I(-;). and we have 10.0 Manufacturing no employees. (No workers' comp. insurance requiredl• 11.0 Health Caro '1. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.j 12.0 Other ,Any applicant Thai checks t>ox .41 must slip rill out the -wolon below ,howina theta worke"' cumPaualton policy iMbcmation. '"If the w"rata onl7cers hxve exempned themselves, but the corporsllon ha other employees, a workers' competnulo" policy is requimol and such an organirallon should check box 41. J «m an etrvployer that 1t prey( g workers' compallon irauruncelfar my employer' Bslow it the pulley infvrnrallor% insurance Company tVvne: c v dt° ✓ ice` 4 5 (® 4 �t tr cil A insurer's Address: ity/5tatdzip: 'olicy 3 or Self --ins. Lic. 1i- JL Ct— i Expiration Data: - Q attach it copy of th* workers' crimpensatiort policy declaration pate (ihosving the policy slumber ,nd espirattorr tante). tihire !o secure cuvt'rn a .0 r,:1luitcd tnnderScelion 25A of MCL c. 112 can lead to the imposition ref criminal penalties or'l tic tip !o S I,SQ0.00 ind/or orie•year imprisonment, js well .is civil penaltie.' in the form of.i STOP `NOR'C ORDER and i fins t type to S250.00a play against tha violator. He .advised that i copy of this statement may het for�vnriled to that Office of rvesti)t.tlinns of tha OfA t*f)r insurance coverige verification. '/a hereby cerdj.r' unde the lonc 4 - it penulNu ojperjurythat the injvrmutlon provided above it trot and currrcC Dace: � - S'► C' 0%ricial art ottly. 0a not wrNs in 009 arva, to be complet(d by cityor towtr ol/lc1 jai I city,)r f>tvrs: f crnsittfAceit.se `i f.9rliwA \uthority (circle ane): 1. Ifo Ird of ife:llth !. (lnddio" Deli trttnent 1. f ty, (',rtvu ( ler'< 1. f iceniinl Ito Ird i. IMice i. t )ther Cotit.tct I'crttln: _ _ _ _. _ _, Nhona 1►: � DATE (MMIDD)YYYY) ACRD CERTIFICATE OF LIABILITY INSURANCE 0110612016 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. TYPE OF INSURANCE',,- 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 lieu of such endorsement(s). LIMITS PRODUCER CONTACT NAME MARSH USA, INC. PHONE FAX 501 MERRITT 7 (AIC No ExJ;__ —__- -___ __--_ _LaC _ NORWALK, CT 06856 E-MAIL ADDRESS: Attn: Norwalk.cerlrequest@marsh com I Fax: 212-948-0929 _ 1X -�-i INSURERLS) AFFORDING COVERAGE i NAIC # 416752-DRUG-GAWU-16-17 E01 GUX INSURER A : ACE American Insurance Company 22667 - INSURED INSURER BTravelers Property Casualty Company of America 25674 — -- RITE AID AND AFFILIATES - ---_ _ --- -__- ACE Property and Casualty Insurance Company 20699 PO BOX 3165 INSURER c : — HARRISBURG, PA 17105 INSURER D I MED EYP (Any one person) - - p INSURER E: ..._.-- --------- ___�-__- - - I I INSURER F: n cn-rrcrvrwrc wu tnaoco. NvC_nna91d9n5-nA RF\/IRIn KI NIIMRFR-11 v 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. - - INSR LTR TYPE OF INSURANCE',,- ADD) "--T SUBRi ----- ---T ! POLICY NUMBER -- POLICY EFF POLICY EXP T IM,MMIDD/YYYY LIMITS Nancy Kalbfell ��x•a...c-\,, ����e L COMMERCIAL GENERAL LIABILITY XSL 627403603 01/0112016 '01/0112017 1 EACH OCCURRENCE 5 4,000,000 - 1X -�-i r � ; CLAIMS -MADE f OCCUR I DAMAGE Tb RENTED -- _ I PREMISES (Ea occurrence1 $ _ -. 2LUDED I -00 DRUGGIST LIABILITY INCLUDED SIR - $3,000A00 i I MED EYP (Any one person) - - p y EXCLUDED - - -- 1 X ' X ] J $ 4 000,000 --- - LIQUOR LIABILITY INCLUDED - -- PERSONAL & ADV INJURY -- GEN 'L AGGREGATE LIMIT APPLIES PER ! 1 GENERAL AGGREGATE - __- $ 15,000,000 -_----_ ---_ PRO- POLICY I J JECT LOC - -� J % I PRODUCTS - COMPIOP AGG _- .__ -._. _ S 15,000,000 _— -.' I OTHER: COMBINED SINGLE LIMIT S AUTOMOBILE LIABILITY A _. (Ea accident! - I ANY AUTO c --_.' SCHEDULED '..BODILY ! BODILY INJURY (Per person) QODILY^UURV $ , L OWNED ! AUTOS/ AUTOSnIr: (Per accidenn�£ PROPERTY DAMAGE accident)-_ .(Per accident)------$ -i NON -OWNED HIRED AUtOS ' AUTOS ( --------_--__-- $ -- C X UMBRELLA LIAB X OCCUR XOO G27939375 001 10110112016 10110112017 EACH OCCURRENCE $ 5 000 000 MADE EXCESS LIAB 1 L _ I AGGREGATE $ 5,0 00,000 - $ OED 1 X RETENTION s 25 000 II' 101,01120:17 B -WORKERS COMPENSATION ! TC2JUB-7<142L10A-16 AOS ( )� 0110112010 PER I X STAT OTH -- --L-- UTE B AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNIERIE (EcuTivE YLIN ;NIA 1 TRKUB-7442L I 11-16 AZ, MA ( ) 0110112016 01,01(2017 I , E L. EACH ACCIDENT 5 2,000,000 OFFICER/MEMBER EXCLUDED? ❑I (Mandatory In NH) E L DISEASE -_EA EMPLOfEO 5 2,000, 000 r If yes describe under DESCRIPTION OF OPERATIONS below E L. DISEASE POLICY LIMIT 1 S 2,000,000 i I I ' DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) EVIDENCE OF COVERAGE r -A nrr-ct r Aruiwr RITE AID AND AFFILIATES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 3165 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HARRISBURG. PA 17105 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Nancy Kalbfell ��x•a...c-\,, ����e L lJ IZ100-LU V# HV%Jrly I rryr too raacrvo.,. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD