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HomeMy WebLinkAboutStaples 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Peri!! to Operate a Food Service EstabhshmenJ Type: RETAIL FOOD 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:. STAPLES THE OFFICE SUPERSTORE EAST, INC Whose place of business is: STAPLES THE OFFICE SUPERSTORE EAST, INC. #1551 390 WEST STREET PERSON(S) IN CHARGE: WILLIAM MCCOMMIS, MANAGER Permit Expires: December 31, 2016 License Number: RF -61 Food Fee: $50.00 BOARD OF HEALTH NichaeCNcClean, Chairman May, 4, 2016 ' MOW Date received: 1) Establishment Name 2) Establishment Address FOR BOARD OF HEALTH USE ONLY . Date Inspected: Approved By: Ku.',17-) P. ' Permit # Issued 5-98 FOOD ESTABLISHMENT PERMIT APPLICATION )[75ation must be sum ed at' e�asf30'dbjyi beioreTfio—p'?enried'openrn—g-d'i STAPLES THE ONCE SUPERSTORE EAST, INC, 1#1551 380 WEST STREET 3) Establishment Mailing Address (if different) 600 STAPLES DRIVE FRAMINGHAM, MA 01702 4) Establishment Telephone No ) 261.2888 5) Applicant Name & Title: JESSICA AUCOIN, TAX ACCOUNTANT 6) Applicant Address 500 STAPLES DRIVIE, FRAMINOHAM, MA 01702 7) Applicant Telephone No.: 1506} 289.0 96 24 Hour Emergency No.: (400)4014660 — _..._ ..._._. $) Owners Name & Title 9)Owner Address of different from applicant) _ Owner's telephone number5082535000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, comanager etc.) Name & Title:I~ STAPLES THE OFFICE SUPERSTORE EAST, INC 600 STAPLES DRIVE, FRAMINGHAM, MA 01702 Address: 1390 WEST STREET, -MANSFIELD, MA 02048 I Telephone No: 24 Hour Emergency No: UI -7,119,30--l-4 FAX: —Email: ; I Ii� p i`s iCL& P -- .—_.......---I Alt E -Mail 13) District Or Regional Supervisor (if applicable) Name & Title: Telephone No, FAX: 24 Hour Emergency No: E -main PAGE 141 RCVD AT 6141201612:04:15 PM gastem Day4N Time] I MMUSSPNAS06 I DNIS: 15083 821786 1 CSS: i DURATION (mm s):0142 iti+la'y+. 4, 210 1 4 ' 2 : i1lIFM Food Establishment Information 14) WAI tK SUUKUL' TOWN 1b) SPWAUP DISPOSAL: DPP Public Water Supply No: (If applicable) 1 G) No, of Food Employees: 17) DAYSIHOI.) RS: MON•FRI 7 AM -9 PM SAT 9 AM -9 PM SUN 10 AM -6 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete dist is on Me. Required as of 1011/2009 in accordance with 105 CMR 500.003(A) Ploose atleoh copy of certificate 19) Person Trained in Antl-Choking Procedures (if 25 Seats or more): 20) Location: 1 Moblie Moblie Saar# Date: Mobilo ind Date: Mobile Comments: 21) Length of urrnit: Annual Seasonal Sewonal Crates: _.._.Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): nnnent Location 22} tablisl»»enl Type Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $62.50 Food Service up to 101 -200 or up to 25' PHF display $75.00 Food Service up to 201 or 25'+ PHF display $137.50 Food Service - Institution ! MealufDay) N U 17 3 P. 2 TOWN .._.._._......... --- Caterer $12.50 Milk & Cream $5.00 Mobile Food & Consession Sa7.50 Manufacture Frozen Dessertsflce Cream $12,50/0eezer Pushcart $12.60 # of Pushcarts: 2esidential Kitchen $50.00 stall Food $50,00 Retail Snack Food $12.50 Tnhnrrn PrnrrllrFQ $12 Fin De initrons: PHF - Potentialty nazardous rood (tlme/tempetature controls required) Non-PHF's - non-polontlaltyiaxardous tood(no dme4emperature controls required) RTE - ready -to -eat toads (Ex, sandwiches, satads, mutPos vrtrfch creed no rather processing) ale of Commercially Pre -Packaged Nott-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs _ Reheating of Commercially_...__.,. Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Food$ Only Preparation of Non-PHFs Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sala of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ,juice Manufactured and Packaged for Retail Sale Offers RTE PHF In I3uik Quantlties Retail Salo of Salvage, out -Of -Date or Reconditioned Food Hot PHF Cooked and Cooled or Hot Hold for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging 1 Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin Prepares FoodlSingle Meals for Catered Events or Instihitional Food Service I To be completed by the &a ea I Total Permit Few Payment is due with ap li�atlon w 1, the undersigned, attest to the accuracy of the information provided In this application and aftlrm that the focd establishment operation will comply with 105 GMR 690,000 and all other applicable law. I have boon instructed by the board of health on haw to obtain copies of 105 9MR 500,000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, Sec, 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have riled all state tax relurns and paid state taxes required udder law. 25) Social Security Number or Federal ID: 04-3176982 26) Signature of individual or Corporate Name: r< `t PAGE 2141 RCVD AT 5141201612;04,15 PIN [Eastern Daylight Time]' SVR,YWS8PNASV0216 t: DNIS,15083821786 * CSID, I DURATION (mm•ss),0142 Mayr. 4. 2i�14 +2; j PM L,,. i 173 P. I certify under the penalties of perjury that I, to my best knowledge and belief, hove filed all Mate tax returns, and paid all Mate taxes required under law, ` Signa re of Individual or Corporate Name (Mandatory) By. Corporate Officer (Mandatory, if applicable) ** 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 payrrment 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 49(x. PAGE 3141 RCVDAT 6141201612,04,15 PM [Eastern Daylight Time] I SVRMUSSPNASUM2161DNIS,16083821786 S CSID. I DURATION (mm.ss);0142 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents i - Office of Investigations I Congress Street, Suite 100 Boston MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Staples the Office Superstore East, Inc. Address:500 Staples Drive City/State/Zip:Framingham, MA 01702 Phone #:508-253-5000 Are you an employer? Check the appropriate box: 1.21 I 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 *Any applicant that checks box #1 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 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:ACE American Insurance Company Insurer's Address:436 Walnut Street City/State/Zip: Philadelphia, PA 19106 Policy # or Self -ins. Lic. #WLRC48598171 Expiration Date:2/1/17 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. I do hereby cert, under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: S'. 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: Phone #: www.mass.gov/dia ACCW" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1/28l2016 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 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). Beecher Carlson Insurance Services 6 Concourse Parkway, Suite 2300 Atlanta, GA 30328 CONTPRODUCER NAME: ATL Judith Boich PHONE FAX A/c o Ext): 678.539.4800 A/c No); 770-870-3031 E-MAIL ADDRESS: jboich@beechercarlson.com INSURER(S) AFFORDING COVERAGE NAIC # 2/1/2016 INSURER A: ACE American Insurance Company 22667 www.beechercarlson.com INSURED Sta les, Inc. and attached Named Insureds INSURER B: Indemnity Insurance Company of North America 43575 INSURER C: Agri General Insurance Company 42757 INSURERD: ACE Fire Underwriters Insurance Company 20702 500 Staples Drive Framingham MA 01702 INSURER E: ACE Property & Casualty Insurance Co 20699 INSURER F: A COVFRAGFS CERTIFICATE NUMBER: 9Ra9a9an 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. INSR LTR TYPE OF INSURANCE ADDL SD SUBR D POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A V COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [z OCCUR ✓ Contractual Liability XSLG27404091 2/1/2016 2/1/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES(E. oocur ence)$ 975,000 MED EXP (Any one person) $ 0 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ✓ POLICY ❑ PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 F $ A AUTOMOBILE LIABILITY ✓ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS ✓ HIREDAUTOS �/ AUTOSWNED ✓ Ded $250,000 ISAH08867252 2/1/2016 2/1/2017 C MBINEDtSINGLELIMIT $ 3,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PerOa c,dePERTnDAMAGE $ $ E r/ UMBRELLA LIAB EXCESS LIAB ,/ OCCUR CLAIMS -MADE XOO 627947542 001 2/1/2016 2/1/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I I RETENTION $ $ B A D C WORKERS COMPENSATION TY AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? � (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WLRC48598134 (AOS) WLRC48598171 (AZ,CA,MA) WCUC48598298 (OH) SCFC48598250 (WI) WLRC48598213 TN 2/1/2016 2!1/2016 2/1/2016 2/1/2016 2/1/2016 2/1/2017 2/1!2017 2/1/2017 2/1/2017 2/1/2017 SPER TATUTE EORH ,/ E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEd $ 1,000,000 E.L. DISEASE - POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION "Evidence of Insurance" 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 Sharon D. Brainard ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 8326240 1 39 1 16.17 GL AL WC XS $514 1 (ATL) Judith Boich 1 1/28/2016 11:32:21 AM (EST) I Paae 1 of 2 C" AGENCY Beecher Carlson Insurance Services POLICY NUMBER XSLG27404091 CARRIER AGENCY CUSTOMER ID: 39 LOC #: ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED Staples, Inc. and the attached Named Insureds 500 Staples Drive Framingham MA 01702 ( ACE American Insurance Company 22667 EFFECTIVE DATE: 2/1/2016 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (01/14) HOLDER: 'Evidence of Insurance`* ADDRESS: INSURED: Staples, Inc. POLICY PERIOD: 2/1/16 - 2/1/17 NAMED INSUREDS: Staples the Office Superstore East, Inc. Staples the Office Superstore LP Page of Staples Contract & Commercial, Inc., including: - Staples National Advantage - Business Interiors by Staples (fka Corporate Express Business Interiors) - Coastwide Laboratories, Inc. - Staples Promotional Products (fka Corporate Express Promotional Marketing, Inc.) - Kross Outfitters - Corporate Express Imaging & Computer Graphic Supplies - Any other entity formerly known as Corporate Express - Staples Technology Solutions.com - Staples Enterprise Advantage - Staples Business Advantage - Staples Advantage - Staples Industrial - Staples Print Solution Quill Corporation - MAP (Medical Arts Press, Inc.) Schoolkids.com, Inc. Smilemakers, Inc. Thrive Networks, Inc. Corporate Express Document & Print Management, Inc. Lonesource PNI Digital Media, ULC Sun Office Solution ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATTACHMENT 8326240 1 39 1 16.17 GL AL WC XS S51-7 1 (ATL) Judith Boich 1 1/28/2016 11:32:21 AM fE Tt I Pane 2 �f 2