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HomeMy WebLinkAboutStop & Shop 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit 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:. THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 Whose place of business is: STOP & SHOP SUPERMARKET, COMPANY #007 377 CHAUNCY STREET License Number: FS -60 Permit Expires: December 31, 2016 Food Fee: $137.50 Milk & Cream W BOARD OF HEALTH MichaeCMcCCean, 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: STOP & SHOP SUPERMARKET, COMPANY #007 377 CHAUNCY STREET License Number: FS -60 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: Town of Mansfield 6 Park Row Mansfield, MA 02048 THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 having a place of business at: STOP & SHOP SUPERMARKET, COMPANY #007 377 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 g fess previous veming the l of time slk d Cream and shall remain in force until 12/31/2016 suspended or revoked. Expires 1213112016 License No.: FS -60 Scott Leite, HeaCth Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Date received: FOR BOARD OF HEALTH USE ONLYy Date Inspected: Approved By: Permit # Issued FS -60 I � FOOL? ESTABLISHMENT PERMIT APPLICATION -� _.._.—._.._.--_ appI�Ron mushy m aF-easT3U-crays- be ore'ffe –p 7an- no`aopeningaaco) 1) Establishment Name STOP & SHOP SUPERMARKET, COMPANY #007 2) Establishment Address 377 CHAUNCY STREET 3) Establishment Mailing Address (if different) 1385 HANCOCK STREET, ATTN: LICENSING DEPT, ; 4) Establishment Telephone No QUINCY, MA 02169 337-9450 5) Applicant Name & Title: y�f ye 1z,nf e1fn__, LICENSING MANAGER 6) Applicant Address 1385 HANCOCK STREET, QUINCY, MA 02169 71 Applicant Telephone No.: (617) 770-8708 (877) 893.6393 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No. (877) 893-5393 THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 1385 HANCOCK STREET, QUINCY, MA 02169 (617) 770-8708 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers O An Association or partner. O A Corporation Name Title Address t ❑ An Individual ..._ -�. �.��� ,�'� ��_s_...._—.....------•,�--------•_......_—.__.._—__...,.._ ❑ A Partnership ® Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Iaq.€-,, _ ,: STORE MANAGER i Address: 377 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (508) 337-9450 — — --_ 24 Hour Emergency No; PM 8934393 FAX:..–_._ E-mail: SSNESTORE.0007.STOREMANAGERVAHOLD.COM Alt E• -Mail: �5 3 '._ I� ._ :�Lj��1HOLD_COM__..:.._...---�-•---..._.........----..._......._....... .,.._........—_._....._......,....__........_.._,_...._ 13) District Or Regional Supervisor (if applicable) Name &Title: _ A ,.-----..---•-----..,_...—_..---•-._.,._.__.-•_••--•---...._..------•----._.....---._..._..__...---...__..._....,....—_..._ iL BENDER, DISTRICT MANAGER Address: 377 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (508) 337-8468 24 Hour Emergency No: (877) 893-5393 E-mail: PAUL, BENDERCAHOLD.COM FAX: ,/f//4--.--------•- Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL_ TOWN ee—� DEP Public Water Supply No: (If applicable) _— - _ --L 16) No. of Food Employees: Em p toy—_.._-...�s: 200 PLUS---•— �--1 r17) DAYS/HOURS: SUN 7 AM -9 PM MON-SAT 6 AM - MIDNIGHT 18) Name of Person In Charge Certified in Food Protection Management; f r"r evi e,4r� ap I jIf 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 -- - —^— - -y-- certifrcate 19) Person Trained in Anti -Choking Procedures ❑ (If 25 Seats or more): - Procedures— ------- — $12 50 20location: - M./Permanent Location - --- ) I❑ Moblie Moblie Start Date: Mobile End Date; Moblie Comments: - 21) Length of Permit: Annual - - - ❑ Seasonal Seasonal Dates: 'temporary Temporary Start Date: Temporary End Date: TempOrary Time: Rain Date: 22) Establishment Type ❑ a e e v Retail Ft (° i Sq. ) © Milk & Cream $5.00 i ❑ Food Service up to 100 or i❑Mobile Food & Consession $37.50 i up to 10' PHF display $62.50 ❑ Manufacture Frozen Desserts/Ice Cream 512,50/freezer I ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 [] Pushcart $12.50 # Of Pushcarts; d Food Service up to 201 + ❑ Residential Kitchen $50,00 I or 25'* PHF display $137,50 ❑ Retail Food $50.00 ❑ Food Service - Institution ❑ Retail Snack Food $12.50 ( Meals/Day) Q Tobacco Products $12.50 I -- I Uellnitiona; PHF - Pofentialty hdzafdous food (ilmelremperatule conlrols required) - 23) Food Operations Non-PHF's norrpotentlafly hazardous r00d(no timeAemperalure controls roquifed) F h®ck all that apply): RTE- ready -to -eat foods(Ex.sandwfches, salads, muftlns which need no lurcherprocessing)�- - �FS PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held ® Sale of Commercially Pre -Packaged Non -PH _- ❑ ______ __- ---- for More Than a Single Meal Service ❑ Preparation of or Si For Hot And RTE Foods -- © Sale of Commercially Pre-Packag®d pHFs _ Cold Holding For Single Meal Service ❑ gugcaeptible population Facility Prepared Highly Delivery of Pac PHFs ___ (� Sgle of Raw Animal Foods Intended - --...._ = ---� to be Prepared by Consumer ❑Vacuum Packaging / Cook C ill © Reheating of Commercially c I Processed Foods for Service Within 4 Hours - _ .,_.. �__ Q Use of Process Requiting A Variance .--.._._ ...__ - CusComer Self -Service and/or HACCP Plan (including bare an ❑ Customer Self -Service of Non PHF and Non- © - - _ — ___•__— ...._...__-- contact alternative, time as a public health Perishable Foods Only (] Ice Manufactured and Packaged for control) _ _ -_., ._.,_.•..•••-••----• • •-= ® Preparation of Non -PRFs Retail Sale ---,� ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food O Other Food Operations Retail Sale Animal Origin - __._..•,,.._.___._. _.. .• i Prepares Foodt5ingle Meals for [] Offers RTS PHF in Bulk Quantities Cafered Events or Institutional Food Service [] Retail Sale of Salvage, Out -Of -Date To be compte the Board of Health - or Reconditioned Food L, Total Permit Fee: $137.50 Payment is due with application ❑ waived providedest to the accuracy of the information this the food I, the undeBrat on will comply with 105 CMR 590.000 and all otherapplicab a law. 1 have beentinstructed by the establishmento p board of health on how to obtain copies of 106 CMR 590.000 and the federal Food Code. " " " , — -- 24) Signature of Applicant: - d belief, have filed all elate Pursuant to MGL Ch.62C, sec, 49A, I certify under the penalties of perjury that I, to my best knowledge anax returns ;� and paid state taxes required under law. 25) Social Security Number or Federal ID; 04-3061447 - to Name: 26) Signature of Individual or Corpora - 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: STOP & SHOP SUPERMARKET, COMPANY #007 ADDRESS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-9450 FAX NUMBER: (508) 337-9460 OWNER OF BUSINESS: THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 TELEPHONE OF OWNER: (617) 770-8708 FEDERAL ID/88 NUMBER: 04-3061447 FEE: $5.00 PERMIT NUMBER: FS -60 x.. SIGNATURE:` DATE: Town of Mansfield Town of Mansfield - Board ofHealth 6 Park tow Mansfield, MA 02048 PERMIT NUMBER: FS -60 _• Application for the Sale of Tobacco Products T 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: STOP & SHOP SUPERMARKET, CO. 4007 LOCATION OF SALE OF TOBACCO PRODUCTS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 3379450 OWNER OF BUSINESS: STOP & SHOP SUPERMARKET, CO, LLC ADDRESS OF OWNER; 1385 HANCOCK STREET, QUINCY, MA 02169 TELEPHONE OF OWNER; (617) 770-8708 FAX NUMBER: (617) 689-4061 If a corporation or partnership, give name, title, and home address of officers or partner. SEE ATTACHED LIST -- --- -- *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_3061447 SIGNATURE:, DATE: to Ir- o C) O C14 O r o - N o . \ _ 0 e & j aq /� \ C C \ 4 k § % { f E o z 2 mLo m2 co \\ Z \ / / k k k k w \ \ 0 ) � % § \\ \ 7 k c f � _ /k \\ mI *� $2 \/�« \\ � ¥ 2 $4 p / 0 6 2i �§ %o /U) _E S\ 2±±L \) \ƒ// -D»# t# ƒ e n 3 \ # \\ � �( \2 2\ . ) �\ / � O % z \\ ƒ / \w 2 ® /m LLJ �\ L § / / / ) 6 \ / ° a. ,n � \ §e 2 Gg �©ƒ/ m \± I m 2 , $ iE 2 . �) �o I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law, " Signature ofIndividu I r 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 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 s Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwmmass..gov/dia Workers' Compensation Insurance Affidavit: General $usinesses Please App licant Information Business/Organization Name. The Stop & Shop Supermarket Company LLC Address: 1385 Hancock Street City/State/Zip: Quincy, MA 02169 Phone #: 800-288-8415 Are you an employer? Check the appropriate bog: 1. Q I am a employer with employees (full and/ or part-time).* 2.0 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, workers' comp. insurance req.] Business Type (required): 5. Q 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 with no employees. [No �------- *Anfill out the section below showing their workers' compensation policy information. y applicant that checks box #1 must also **selves, but the corporation has other employees, a workers' compensation policy, is required and such an If the corporate officers have exempted them organization should check box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: MAC RISK MANAGEMENT, INC. (TPA) Insurer's Address: 1385 HANCOCK STREET City/State/Zip: QUINCY, MA 02169 Policy # or Self -ins. Lic. # 576 Expiration Date: August 1,2016 compdeclaration page (showing the policy number and expiration date). Attach a copy of the workers' Failure to secure coverage as required policy red under Section 25A of MGL c. 152 can lme the formd to e imposition of of a STOP WORK ORDER criminal tand a fine fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties of up to $250.00 a day against the violator. Be advised that 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 and penalties of per jury that the information provided above is true and correct TlatP' I � rtr Phone #: 617-770-8708 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): nt 3. City/Town Clerk 4. Licensing Board 5: Selectmen's Office 1. Board of health 2. Building Departme 6. Other Phone #: Contact Person: www.mass.gov/dia r1 V � C •e' U U Lf} O �t Z F -i ZZ U i --r z wui w z cc Z f O w o _ -tpy ~ _ ` O rt� xao atrtry F"a 'I:z cn N W LL O e" lyse rc�i O ' C c._ " �i O d ca O wC J ❑ ; r } Q% _ } 4-0 � H � v co00O' in V C N O '0 S NAT - '000Z) ONAL REGISTRY OF FOOD SAFETY PRoFEssloNAts® .. CERTIFIES=:: -- 4 , h DARREN M DEANG_EL,rS SIR a HAS SUCCESSFULLY SATISFIED THE REQUIRE[YIENTS FOR THE f GERTI'1DFOOD SAFETY MANAGER i:oonsi ? z �� 2 -- UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS ��r<:;> PRESIDENT: LAWRENCE .I. LYNCH, CAE ISSUE DATE: OCTOBER 2:0, 2015 EXPIRATION DATE: OCTOBER 2-0,2-02-0 #0656 CERTIFICATE NO: 21 159848 TEST FORM: EZS29 This cerlincate isnot valid ror more 7680 Universal Blvd, Suits 55o, Orlando, FL 32818 than five years from daft or issut. (800) 446-0257 F (407) 352-3603 www.NRFSP.com T� 'lational Registry of Food Safety Professionals® i o��ooDsa ` : National Registry of Food 5arety Professional; J frT, CERTIFIED FOOD SAFETY MANAGER Notification of Test Result _ N z D?iRttEN M DEAN tLIS SR ID#: xxx-xx- G�RTIFIE�D Scaled Test Score: 96 Candidate Status: Pass 7s6o u�ive�sal ewa Test Date: October 20, 2015 Orlando Fl- 324. yo 21159848 Phone_(467) 352=3B3Q! Issue Date: October 20, 2015 Fax j*467),352-P15N.. Expiration Date: October 20, 2020 SR Dt�RREN M DEANGELIS Congratulations! Attached is your certificate and wallet card. Please notify 77 COLDMROOK G the National Registry o£name or address changes at the address below. CRANNSTON, Rl 02920 Preventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Mastered) Actively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Mastered) Conducting Cleaning and Sanitizing (Mastered) Managing: Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered) i 7680 Universal Blvd Ste 550 1 Orlando, Fl. 32819 Phone: 407.352.3830 Fax: 407.352.3603 National Registry of Food Safety Professioaais;l� R9 r -4- N.. N. 'r �, Ol i SUMMMI-Mis cIDIOM w �n b bn b w � 0 0 cq w [mac o 4 • �� m � 0 N�+ 0 � Q Q N. 'r �, Ol i SUMMMI-Mis cIDIOM w �n b bn b w � N. 'r �, Ol i SUMMMI-Mis cIDIOM 0 b w [mac o 4 • �� m � N. 'r �, Ol i SUMMMI-Mis cIDIOM The Stop & Shop Supermarket Company LLC Officers and Managers EI Na Division President, Stop & Shop NewEngland Mark McGowan Division President, Stop & Shop NY Metro Donald Sussman Chief Real Estate Development Officer James J. Sylvia Senior Vice President, Real Estate Timothy Mahoney Assistant Secretary Steven F. Rowell Assistant Secretary Gail Goolkasian Assistant Secretary Caroline Woodward Managers: President &Chief Operating Officer James McCann Executive Vice President &Chief Daniel J. Sullivan Financial Officer General Counsel and Secretary Thomas A. Hippler All Officers & Managers of The Stop & Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. *INhere a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass,gov/dia Form Revised 5-26-05