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Home My WebLink AboutStop & Shop Gas 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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 CO., LLC Whose place of business is: STOP & SHOP SUPERMARKET, CO., GAS STATION #007 BOARD OF HEALTH 377 CHAUNCY STREET License Number: S_97 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream ❑ MichaeCMcCCean, Chairman _Permit for the Sale of Tobacco Products -J Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: STOP & SHOP SUPERMARKET, CO., GAS STATION #007 BOARD OF HEALTH 377 CHAUNCY STREET License Number: S_97 Permit Expires: December 31, 2016 NichaeC-icCCean, Chairman �. . FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved ByPermit# Issued FOOD ESTABLISHMENT PERMIT APPC1_CAf_1ON 1>Establishment Name STOp& SHOP SUPERMARKET, CO., GAS STATION #007 / 2) Establishment Address 377 CHAUNCY STREET .3) Establishment Mailing Address (if different) 1386 HANCOCK STREET, ATTN: LICENSING DEPT. � Qw/m'~r,00An216w 4) Establishment Telephone No (508) 337-9450 5) Applicant Name & Title, 6) Applicant Address 7)Applicant Telephone No. /LICENSING MANAGER ----'-----------'-- �------'------�------�--r'--�---'—'-------'�---7| 1386#ANCC}CK STREET, 00|NCY,K8A 02169 -- - (617) 770-8708 (077) 893-5393 24 Hour Emergency No.: (077) 893-5393 --_---- ----- ------- __--___-----_-____._--_-'-- �8\Owners Name &Title STOP& SHOP SUPERMARKET CO.,LLC � 1385 HANCOCK STREET. QWINCY88A@2169 |[AOwner Address UfdUferentfnnnmppxcmr __,________�___._.__________ `---Owner's telephone number 6177708708 ----------'--------�'--�---� |10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officersEl An Association or partner.1-1 A Corporation Name Title AddressCJ An IndividualI R Other legal Entity12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)Name STORE MANAGER�REET, MANSFIELD, MA 02048Telephone 10.)1508) 337-9460 24 Hour Emergency No: 077) 693 -5393E -mail: SSNE.STORE0007.$TOREMANAGERO-)AHOLD.COM13) District Or Regional Supervisor (it applicable)Name & Title: ]1PAUL BENDER, DISTRICT MANAGERAddress: 377 CHAUNCY STREET, MANSFIELD, MA 02048'Telephone N 8)337-8468 24 Hour Emergency No: (877) 893-5393 \ Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6 . ......... 17) DAYS/HOURS: MON-SAT 6 AM -10 PM SUN 7 AM -9 PM 18) Name of Person In Charge Certified in Food Protection Management: tj If more than 3 individuals are certified, complete list is on file. Required as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of cort1ficate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): LJ 20) Location: Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date; Retail Sq. Ft) Moblie End Date: Food Service up to 100 or Mobile comments: up to 10' PHF display $62.50 21) Length of Permit: Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ f Seasonal Food service up to 201 + or 25'+ PHP display $137.50 Seasonal Dates: 3 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23)Food'Operations (Check all that apply): ❑ Food Service - Institution Meals/Day) 0 Caterer $12,50 C] Milk & Cream $5.00 C] Mobile Food & Consesslon $37-50 E] Manufacture Frozen Desserts/Ice Cream $12.50/freezer [] Pushcart $12.50 # of Pushcarts: E] Residential Kitchen $60.00 f_-1 Retail Food $60,00 66 Retail Snack Food $12,50 95 Tobacco Products $12.50 Definitlon,%' PHF - Potenflaffil hazardous road (time,%mperatvre conlrols required) Non-PHF's - non -potentially hazardous WOW tim&?emporature controls required) RTE - readyfo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) I -P ., ��sale of Commercially Pre -Packaged Nor PHrCooked To Order 7 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service FFTDC] Sale of Commercially Pre-Paokaged Preparation of PHFs For Hot And 0" Cold Holding For Single Meal Service_ F-1 PHF and RTE Foods Prepared For Highly =Ii� of Packaged PHFs `0 _0er1very Susceptible Population Facility (7�a _WR;WknimWI Foods Intended ....... 7 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 $elfService of Non PHF and Non- ❑ Customer self-service and/or HACCP Plan (including bare hand alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for contact Retail Sale control) Preparation of Non-FHFs ❑ Juice Manufactured and Packaged TQ1 F-1 offers Raw Or Undercooked Food Of Other Food OperationG Retail Sale Animal Origin ❑ Offers RTE PHF —in -- Bulk -Quantities "-, M Prepares Food/Single Meals for Catered Events or institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -ro, —Board-_ or Reconditioned Food of Health t Total Permit Fee: $12,50 Payment is due with application El waived_ 1, 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 Ward of health on how to obtain copies of 106 CMR 690,000 and the federal Food Code. 24) Signature of Applicant, all state tax returns Pursuant to MGL Ch,62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed and paid state taxes required under law. 25) Social Security Number or Federal ID' 04-3061447 26) Signature of Individual of Corporate Name; Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S =97 _•__„—___-__ —.•___ _ 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: STOP & SHOP SUPERMARKET, CO., GAS STATION #007 LOCATION OF SALE OF TOBACCO PRODUCTS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-9450 OWNER OF BUSINESS: STOP & SHOP SUPERMARKET, CO. LLC ADDRESS OF OWNER: 1$85 HANCOCK STREET, QUINCY, MA 02169 TELEPHONE OF OWNER: (617) 770-8708 FAX NUMBER: (508) 337-6791 If a Corporation or partnership, give name, title, and home address of officers or partner. SEE ATTACHED LIST * Provide a 9m of current Department of Revenue `CT 3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: C-4 FEDERAL ID/SS NUMBER: 04-3061447 SIGNATURE:, : _............_. -- DATE: \ ca C � Q . � N CL 0 o r 2q /�Zo 00 2 a) o f {_± ®\ \ ca C = o \ - � CL 0 j { \ \ �kq /�Zo I,% 6 2 a) o f {_± ®\ e » o . \ O \Lu , LL k cn c \ Em / G\ � \ k t� k � \ � / ) \_ \ \ \ / n \ 3n« CL ± }\0 !®RE�« J ®. § < U- C 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. YV Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal'ldentification 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 z _ Office of'Investigations } d 1 Congress Street, Suite 100 Boston, MA 02114-2017 At SJ♦ ' - www•mass..gov/dia Workers' Compensation Insurance Affidavit: General -Businesses 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: Business Type (required): 5 Q Retail 1. A I am a employer with employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 9. ❑ Entertainment 3. ❑ 'We' are a corporation and its officers have eexeer`cis h their right of exemption per c. 152, § 1(4), vhave 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12 -El Other with no employees. [No workers' comp. insurance req.] *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 in(TPA)ce for my employees. Below is the policy information. Insurance Company Name: MAC RISK MANAGEMENT, Insurer's Address: 1385 HANCOCK STREET City/State/Zip: QUINCY, MA 02169 # 576 Expiration Date. August 1,2016 Policy # or Self -ins. Lic. 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 lmeat�de f theme orm f a STOP WORK ORDER imposition of criminal tand ies oa 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 ces tify, under the pains and penalties of perjury that the information provided above is true and correct. 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): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5: Selectmen's Office 6. Other Phone #: Contact Person: v/dia www.mass.go :J r. v CIO � \ U. LL C-.') `o O w t H m v' z w w4-4 z tj O anlf1 = O Q w � w ww t� W' U N N p U L e^i O o o CD � •1 r�1 u � vtktay � � a ol a C4 o w z= ' N V) i o LLr" �_ O C.} O Asa rc;�' O � �"' II. UT r-. +^ o o N vwi +- �1 z T� L c . 1 r� U �. {� N E -H c —v co ice.? O F �. F Y 6 -co The Stop &Shop Supermarket Company LLC Officers and Managers TITLE N Division President, Stop & Shop New England 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 Mana ers: President & Chief Operating Officer James McCann Executive Vice President & Chief Daniel J. Sullivan Financial Officer General Counsel and SecretaryThomas 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/]icense 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. Where 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 -MASSA -FE Fax # 617-727-7749 www.mass,gov/dia Form Revised 5-26-05