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HomeMy WebLinkAboutShaw's 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health �eri�it to Operate a Food Service Establishment 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:. SHAW'S SUPERMARKET INC. Whose place of business is: SHAW'S SUPERMARKET #7431/165 390 WEST STREET License Number: FS -57 Permit Expires: December 31, 2016 BOARD OF HEALTH Food Fee: $137.50 Milk & Cream W MichaeCMcCCean, 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: SHAW'S SUPERMARKET #7431/165 390 WEST STREET License Number: FS -57 Permit Expires: December 31, 2016 BOARD OF HEALTH AichaeCNcCCean, 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: SHAW'S SUPERMARKET INC. having a place of business at. SHAW'S SUPERMARKET #74311165 390 WEST 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.: FS -57 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Date received: FOR BOARD OF HEALTH USE ONLY Date Inspected: Approved By: Permit # Issued FS -57 FOOD ESTABLISHMENT PERMIT APPLICATION F - pp ica ion rnu�b—esubrn�acreasl 3o-daysbe��Tie planned opeaing date) 1) Establishment Name SHAW'S SUPERMARKET #74311165 2) Establishment Address 390 WEST STREET 3) Establishment Mailing Address (if different) P.O. BOX 20 BOISE, ID 83726 3 4) Establishment Telephone No (508) 339-3987 i 5) Applicant Name & Title: SHAWS SUPERMARKETS, INC. `6) Applicant Address P.O BOX 20, BOISE, ID 83726 7) Applicant Telephone No.: (los) 395-6200 24 Hour Emergency No.: 508-880-5322 508.339-4986 800-379-2967 8) Owners Name & Title SHAW'S SUPERMARKET INC. 9) Owner Address (If different from applicant) 250 PARK CENTER BLVD. P.O. BOX 20 BOISE, ID 83726 Owner's telephone number (208) 395 6200 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 0 A Corporation Name Title Address ❑ An Individual { ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager etc.) Name & Title: M ;) p t / V STORE DIRECTOR Address: I390 WEST STREET, MANSFIELD, MA 02048 Telephone No: (508) 339-3987 24 Hour Emergency No: 508-880-5322 508-339-4986 800-379-2967 FAX: x(508) 964-1000 E-mail: ----- '- - , -j S07 _ 1' IR o r" 0/6 �° �' a7 _G�JS ° G cs_ �i'1L � jAlt E -Mail: 13) District Or Regional Supervisor (if applicable) - Name & Title: MELONIE BUCHANAN, DISTRICT MANAGER ff_ I Address: 1750 WEST CENTER STREET, WEST BRIDGEWATER, MA Telephone No: (508) 817-6220 FAX: 24 Hour Emergency No: (508) 821-9413 E-mail: MELONIE.BUCHANANPETTY@SHAWS.COM Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT 7 AM -10 PM SUN 7 AM -9 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 160 18) Name of Person In Charge Certified in Food Protection Management: r t I` w b a r cl 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: V Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: Retail ( 64,923 Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: ❑d Annual F ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 0 Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) i ❑ Caterer $12.50 j 0 Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $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 -PRFs 0 Sale of Commercially Pre -Packaged PRFs ❑ Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non -PH -Fs - Other Food Operations F./I PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held j -- - for More Than a Single Meal Service 0 Preparation of PHFs For Hot And —__ ___ _ -__ Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly — - -- — - - - Susceptible Population Facility Sale of Raw Animal Foods Intended -- _ _— --.- - to be Prepared by Consumer ❑ Vacuum Packaging/ Cook Chill ----- - --- ❑ Use of Process Requiring A Variance 0 Customer Self -Service 1 and/or HACCP Plan (including bare hand ---------- ❑ Ice Manufactured and Packaged for or I contact alternative, time as a public health Retail Sale - - -- I control) - r Juice Manufactuu red and Packaged for,i� [jManufactured Offers Raw Or Undercooked Food Of Retail Sale Animal Origin - — { -- ❑ Offers RTE PHF in Bulk Quantities 11 ❑Prepares Food/Single Meals for Catered Institutional ice E] eSalvage, Of -Date or Reconditioned Foo rT,becompleted by the Board of Health I, the undersigned, attest to the accuracy of the informatigA prop establishment operation will comply with 1 MR 590 >00 and board of health on how to obtain copies•6101'f5, � MRAO.00gaf 24) Signature of Applicant: _ / ;2� .4 vu Pursuant to MGL Ch.62C, sec 9(I certify under the penalties of perj and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-1123420 26) Signature of Individual or Corporate Name: _ f j Total Permit Fee: $137.50 / Payment is due with application ❑ waived affirm that the food ave been instructed by the to mylost knowledge and belief, have filed all state tax returns MMMM k"14 ( R 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: SHAW'S SUPERMARKET #74311165 ADDRESS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 339-3987 FAX NUMBER: (508) 964-1000 OWNER OF BUSINESS: SHAW'S SUPERMARKET INC. TELEPHONE OF OWNER: (208) 395 6200 FEDERAL ID/SS NUMBER: 04-1123420 FEE: $5.00 PERMIT NUMBER: FS -57 SIGNATURE: j j DATE:/ 3/_ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS -57 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: SHAW'S SUPERMARKET #7431/165 LOCATION OF SALE OF TOBACCO PRODUCTS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 339-3987 OWNER OF BUSINESS: SHAW'S SUPERMARKET, INC. ADDRESS OF OWNER: 250 PARK CENTER BOULEVARD, BOISE, ID 83726 TELEPHONE OF OWNER: (208) 395-6200 FAX NUMBER: (508) 964-1000 If a corporation or partnership, give name, title, and home address of officers or partner. 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 04-1123420 SIGNATURE: DATE: I% QEvanrMFhr Form CT -3T 04386 Massachusetts Departmen #Revenue 2014-2016 Q : Cigarette Excis Unit "sb c2" Retailer License for Sale of Cigarettes nd Cigars and Smoking Tobacco 00R This License must be posted and visible at all times. Sales to pers s under 18 years of age are prohibited by law. Application Number: � 53501 License Number: Date of Issue: Federal Identification or social security Number: 043-24-371 04386 09/26/2014 Mailing address for license: Retail sale location (if different than mailing address) STAR MARKETS COMPANY INC STAR MARKET #164-7430 PO BOX 20 65 MAIN ST BOISE, ID 83726 MEDWAY, MA 02053 0000 This certifies that the taxpayer named above hXs paid the required license fee and is licensed to sell at retail at the address shown above until September 30, 2016. This license is not trans rable, and is subject to suspension for failure to comply with the law. OtiVAR rMF�r Farm CT -3T 04555 a� Massachusetts Department of Revenue :Q2014-2016 Cigarette Excise Unit sb c2a Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco � a OOR This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law. Application Number: 61904 Licepse Number Date of Issue: Federal Identification or social Security Number: 041-12-3420 04555 09/26/2014 Mailing address for license: SNAWS SUPERMARKET INC P O BOX 20 ATT: TAX ACC BOISE, ID 83726 Retell sale location (if different than mailing address) SNAWS SUPERMARKET 7431 390 WEST ST MANSFIELD, MA 02048 t:ii; certifies that lh._� !�_�� e, _ �.ti paid the required license fee and is licensed to sell at retail at the address oho—,, Cu. ;"i1b�. ,C, 1tllti i i�lS Ilzen82 tS not Fran : :ct to 3uspen- v r-'oolpiy With the law. oEPARr"'Fti, Form'CT-3T 04555 Massachusetts Department of Revenue 2014-2016 Cigarette Excise Unit �6 Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco � a DOR This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law. Application Number: 61904 License Number: Date of Issue: Federal Identification or Social Security Number: 041-12-3420 04555 09/26/2014 Mailing address for license: Retail sale location (if different than mailing address) SHAWS SUPERMARKET INC SHAWS SUPERMARKET 7431 P O BOX 20 ATT: TAX ACC 390 WEST ST BOISE, ID 83726 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 until September 30, 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: Corp rateicer (MandatoOf applicable) CA — t k 6 -?-- (.) ** 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 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: <; w tS i L II1/Ut kr V t`-7 ` C_S � C Address: City/State/Zip: P #: C dG%_ 2�'2 Phone Are you an employer? Check the Rypropriate box: Business Type (required): ,- 1, l� t am a employer with ± I hU employees (full and/ 5, etail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, E] Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp, insurance required] $. 0 Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, [No workers'.comp. insurance req.] 12.❑ Other *Any applicant that checks box R I must also fill out the section below showing their workers' compensation policy information. OU 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 ant an employer that is providing workers I compensation Ins urancefor my employees. Below is the policy information, Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date Attach a copy of theworkers' 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 andpena{ties of perjury that the information provided above is true and correct: is p �Ik �p Official use only. Do not write In this area, to be completed by city or town official City or Town; Permit/license # <,---- t U - 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.gowaia Phone #: ACOA"" `._- CERTIFICATE OF LIABILITY INSURANCE DAT 06 2/201!1'YYY) 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Insurance services West, Inc. San Francisco CA office CONTACT NAME' (AIC. No Ext): (866) 283-7122 FAX No.: (800) 363-0105 425 Market Street suite 2800 E-MAIL ADDRESS: San Francisco CA 94105 USA XSLG INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: ACE American insurance Company 22667 New Albertson's Inc. including All Affiliated subsidiaries & Associated Companies INSURER B: ACE Property & Casualty Insurance Co. 20699 INSURER C: 250 E. Parkcenter Blvd. Boise ID 83706 USA INSURER D: INSURER E: INSURER F: MED EXP (Any one person) Excluded COVERAGES CERTIFICATE NUMBER: 570062347170 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. Limits shown are as requested INR LTR TYPE OF INSURANCE ADDLLICY INSD BR POLICY NUMBER EFF MMID� EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Associated companies 250 East Parkcenter Blvd. XSLG Boise ID 83706 USA EACH OCCURRENCE $2,000,000 �tG CLAIMS -MADE X❑ OCCUR SIR applies per policy terns & conditions G O $500,000 PREMISES Ea occurrence MED EXP (Any one person) Excluded X Druggist Liability Includedd PERSONAL &ADV INJURY $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY ❑ PRO- ❑ LOC JECT PRODUCTS - COMP/OP AGG $4,000,000 OTHER: Liquor Liability $2,000,000 A AUTOMOBILE LIABILITY ISA H09042970 06/01/2016 06/01/2017 COMBINED SINGLE LIMIT $2,000,000 a accident) BODILY INJURY (Per person) X ANYAUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY(Per PROPERTYDAMAGE accident e X I UMBRELLALfAsX OCCUR XOOG2794761AO01 06/01/2016 06/01/2017 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $5,000,000 DED X RETENTION $25,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR / PARTNER / EXECUTIVE WLRc48608450 06/01/201606/'0172017 -. X I PER STATUTE I OTH- ER E.L. EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? Y (Mandatory In NH) NIA E.L. DISEASE -EA EMPLOYEE $2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Blanket Additional Insured for General Liability and Waiver of Subrogation for General Liability status extend to those parties to whom the Insured has contractually agreed to provide this status. CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 0 Z d A V t: N U SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. New Albertson's, Inc. AUTHORIZED REPRESENTATIVE And All Affiliated, subsidiary & Associated companies 250 East Parkcenter Blvd. r„ (�1�p/ jj(f�/cJ Boise ID 83706 USA f(f� c(f-f/ n 1ullili �tG ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 0 Z d A V t: N U Certificate Request I Berkshire AHEC Certificate Request Page 1 of 2 Be rks h i re AH EC ai ng, x Sgr viCeb ie al )) C.)i cels t C :1Pndai Donate 1 certify that I have watched the Food Allergen Training video in full. I understand that a false statement in this regard wil certification and that I will be liable to all applicable penalties under Massachusetts General Laws." Only one request/submission per person. Each training participant needs to request individually. You will re ve�rodr ceftificate- via mail within 10 business days after submitting the form below. First Name: Last Name: martin tibert E-mail address: subject: Request for Certificate Submit The following documents have been provided by the Massachusetts Department of Health. Please feet free to click below and save for your use. Welcoming Guests With Food Allergies Food Allergies: What You Need to Know (Poster) Alergias Alimentarias: Lo Que Listed Necesita Saber (PBster) Professional Development Community Programs Continuing Educatkm National HPV Jmmunie.aIRt) Protect a MA Food Alleicjen'rraining R 7'ntxrcco-Frr�e Corrirnuntty poo bleYsliip ftedical interpreting 'vent Management Conference Man<zgen gent & Hosting Quick Links ® About Us Contact Vs Admin Login http://www.berkshireahec.org/certificate-request/ 6/6/2016 � v o � r O Z to(/) W L 6s V 0 cu ® U) SN z z W z W 3 z W W a a a Orb m O 00 O N N _ t4 'o ca � o U Q a 0 `moo 'o � y � � o m � a