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HomeMy WebLinkAboutSunoco 06/01/2012Commonwealth 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:. SUNOCO, INC (R&M) Whose place of business is: SUNOCO #6035 70 COPELAND DRIVE Permit Expires: June 01, 2012 License Number: RF -54 Food Fee: $50.00 Milk & Cream W BOARD OF HEALTH eJVGic�aef 7,�"ea.%�/, �r+airma� -- Permit or the Sale o 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: SUNOCO #6035 License Number: Permit Expires. BOARD OF HEALTH 70 COPELAND DRIVE RF -54 June 01, 2012 e/VGicfi�aet ileafe�/. Vhainnan Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: SUNOCO, INC (R&M) having a place of business at: SUNOCO #6035 70 COPELAND DRIVE Town of Mansfield 6 Park Row Mansfield, MA 02048 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 June 01, 2012, unless previous to that time is suspended or revoked. Expires: June 01, 2012 License No.: RF -54 -Jcott lez'te, VealtFi o�ent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 04/06/11 10:25AN Coop 6035 508-339-8766 p.02 _ - '-= - FOR BOARD OF HEALTH USE ONLY _ Date received: Date Inspected: Approved By: Permit # Issued RF -54____ FOOD ESTABLISHMENT PERMIT APPLICATION A - Ircafion musfbe sir�mrfted of Ieasf30 days beTore ffie planned opening dafeJ 1) Establishment Name SUNOCO #6035 ........ _... 2) Establishment Address 70 COPELAND DRIVE------- 90 3) Establishment Mailing Address (if different) 999 BERKSHIRE BOULEVARD, SUITE -200 k ` WYOMISSING, PA 19610-12 58 - ........ _.__ 4) Establishment Telephone No (508) 339-2301 - _.. _ i -:_ 5) Applicant Name & Title: TINA-WOU, COMPLIANCE COORDINATOR � ,. 6) Applicant Address 999 BERKSHIRE BOULEVARD, SUITE 200, WYOMISSING, PA 19610-1258 7) Applicant Telephone No.: t510 1 988-2620 24 Hour Emergency No,; 1 > 769-5644 SUNOCO SECURITY c 8) Owners Name & Title SUNOCO, INC (R&M) --- ......_..._ ._...�,. 999 BERKSHIRE BOULEVARD, SUITE -200, WYOMISSING, I. 9) Owner Address (If different from applicant) -----..__.......- _ _.. _ - - - --_-----.__._..._•_._._,.._._._._._-.__ _ 1 OR -2620 Owner's telephone number (610) 988 26 9 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers r..! An Association or partner. Ill A Corporation Nme Title Address ` FJ An Individual' F_I A Partnership (_i Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge supervisor, manager e c - .._ _. Name & Title: Address: Telephone No: ---- -- - 24 Hour Emergency No FAX: E-mail Alt E -Mail: ..- _ .. .. _ _ _ . -------- - - - -----. 13) District Or Regional Supervisor (if applicable) 13) Name & Title: Address: Telephone No 24 Hour Emergency No.°r FAX: E-mail: .. --- .... __._...... ........... 04/06/11 10:25AII Coop 6035 508-339-8766 p.03 Food Establishment Information 1 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN ------- ---- DEP Public Water Supply No: (if applicable) 16) Na. of Food Employees: 0 17) DAYS/HOURS: 247 ... ............ 18) Name of Person In Charge Certified in Food Protection Management: JOSEPH T. BURROUGHS 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 certificate ----- ------ 19) Person Trained in Anti-Choking Procedures (if 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type 1 Caterer $26 1Moblie Mobile Start Date: Retail ( 480 Sq. Ft) Milk & Cream $2 Mobile End Date: 1! Food Service up to 100 or Mobile Food Consession $50 & 1 up to 10' PHF display $75 Comments: Manufacture Frozen Desserts/ice Cream i Moblie $5/freezer - - ­­­ ------- 21) Length of Permit: Food Service up to 101 -200 y $0 or up to 25' PHF displa10 1 Pushcart $25 # of Pushcarts: F Annual Residential Kitchen $25 _-----._........------•-----.-. 0 F Fo d Service up to 201 + Seasonal or 25'+ PHF display $125 Retail Food $50 Seasonal Dates: Food Service - Institution Retail Snack Food $10 Temporary Meals/Day) Tobacco Products No Fee Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations 00 1 nitions: PHF - Potentially hazardous food (00101lemperature controls required) Non-PHFs - non-potentially hazardous food(no timelYempersture controls required) '(Check all that apply): i RTE - ready-to-eat foods (Ex, sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre-Packaged Non-PHFs I _ PHFCooked To Order f Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service i�k --------- --- Sale of Commercially Pre-Packaged Fs E, Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer J Vacuum Packaging I Cook Chill Processed Foods for Service Within 4 Hours .............. Use of Process Requiring A Variance Customer Self-Service of Non PHF and Non- Customer Self-service . - - - . I - . - and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only[ Ice M anuf ac tu re da and Pa c k aged for ce control) Preparation of Non PHFs Retail Sale ❑ juice Manufactured and Packaged for! Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal origin ---- - -- ------ J Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out-Of-Date ---------- To be completed by the Board of Health or Reconditioned Food Total Permit Fee: $50,00 Payment is due with application waived 1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food will comply with 105 CMR 590,000 and all other applicable law. I have been instructed by the establishment operation board of health on how to obtai9,,coPieS of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: / CLL"r-4— .- Pursuant to MGL Ch,62C, sec. 49A, I cern under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 23-1743283 26) Signature of individual or Corporate Name: 04/06/11 10:25AM Coop 6035 508-339-8766 p.04 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row ansfeld MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1 st of each year. NAME OF BUSINESS: SUNOCO #6035 ADDRESS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 FAX NUMBER: (508) 339-8766 OWNER OF BUSINESS: SUNOCO, INC (R&M) TELEPHONE OF OWNER: (610) 988-2619 OR -2620 FEDERAL ID/SS NUMBER: 23-1743283 FEE: $2.00 PERMIT NUMBER: RF -54 yam, SIGNATURE: DATE: 04/06/11 10:25AM Coop 6035 508-339-8766 p.05 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 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: SUNOCO #6035 LOCATION OF SALE OF TOBACCO PRODUCTS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 OWNER OF BUSINESS: SUNOCO, INC. (R&M) FEDERAL ID/SS NUMBER: 23-1743283 PERMIT NUMBER: SIGNATURE: DATE:' .__.. 04/06/11 10:25AM Coop 6035 508-339-8766 p.06 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. ire * Signature of Individual or Corporate Name (Mandatory) By: o ate 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. 04/06/11 10:25AM Coop 6035 508-339-8766 p.08 '4♦ The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02.111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Please Print Lebl Applicant Information ' Business/Organization N Address: --I,'Z _2 `- City/State/Zip:_ Are you an employer? Check the appropriate box: 1. f 1 am a employer with _ employees (full and/ or part-time),* 2. ❑ 1 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]' 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #:_�° Business Type (required): S. jfffRetail 6. F] Restaurant/Bar/Eating Establishment 7, n Office and/or Sales (incl. real estate, auto, etc.) 8, n Non-profit 9, ❑ Entertainment 10,[] Manufacturing I L ❑ Health Care 12,❑ Other *Any applicant that checks box q 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 organisation should cheek box 01. I ant an employer that is providing workers' compensation insurance for my employees, Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: 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 certify, under the pains and penalties of perjury that the information provided above is true and correct 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: www.mass,gov/dia Phone #: ACORo� CERTIFICATE ®F LIABILITY INSURANCE 0524/2010 n' PRODUCER MARSH USA INC. TWO LOGAN SQUARE PHILADELPHIA, PA 19103-2797 THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EMEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Attn: Philadelphia.certs@marsh.com CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSMADD1 LTR J23351-ALL-GAWPR-10-11 INC. GAW INSURERS AFFORDING COVERAGE NAIC # I _ _ INSURED INSURER A: Zurich American Insurance CO 16535 j SUNOCO, INC. (R&M) 1735 MARKET STREET INSURER B: American Zurich Insurance Company 140142 1 PHILADELPHIA, PA 19103 INSURER C: 05/31/2011 EACH OCCURRENCE 1.000.000 INSURER D: MED FRCP (Any one person) $ N/A INSURER E: CLAIMS MADE O OCCUR rnv 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSMADD1 LTR INSR TYPEOF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MMIDD/YYYYI POLICYEXPWATION DATE(MWDDIYYYI LIMITS A GENERAL LIABILITYGLO X COMMERCIAL GENERAL LIABILITY 9308269-07 05/31/2010 05/31/2011 EACH OCCURRENCE 1.000.000 DA T( RENTED $ N/A PREMISES(Ea occurrence MED FRCP (Any one person) $ N/A CLAIMS MADE O OCCUR PERSONAL&ADV INJURY $ INCLUDED' GENERAL AGGREGATE $ 2,000,000 GENERAL AGGREGATE LIMIT APPLIES PER X POLICY JECT LOC PRODUCTS • COMPIOP AG INCLUDED' A AUTOMOBILE X LIABILITY ANY AUTO BAP 9308-119-07 05/31/2010 05/31/2011 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIREDAUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTOONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-1 CLAIMS MADE _ AGGREGATE $ $ DEDUCTIBLE $ RETENTION S B WORKERS COMPENSATION AND WC 9308270-09 05!31/2010 05131 2011 X WC STATU- 0TH• EMPLOYERS' LIAWLITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N (SELF INSURED IN PA,OK,OH,MI) .L EACH ACCIDENT $ 1,001),000 .L.DISEASE- EAEMPLOYE $ 1,000,000 OFFICER/MEMBEREXCLUDED7 (Mandatory in NH tf yes, describe under SPECIAL PROVISIONS below .L. DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS EVIDENCE OF INSURANCE CERTIFICATE HOLDER CI F-009584126-01 CANCELLATION ACORD 25 (2009/01) ©1998-2009 ACORD CORPORATION, All Rights Reserved The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE SUNOCO, INC. (R&M) 1735 MARKET STREET EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, PHILADELPHIA, PA 19103 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND THE INSURER, ITS AGENTS OR REPRESENTATIVES. JUUPOgNEp gE Ao1 MBrNSD U3APInOSENTATNE� Mary Radaszewski ACORD 25 (2009/01) ©1998-2009 ACORD CORPORATION, All Rights Reserved The ACORD name and logo are registered marks of ACORD 04/28/11 06:02AN Coop 6035 508-339-8766 M Ln It co vel n L_J r' CD Gh p.02 TMJ r- 0 1\ N 0 09/28/11 06:02AN Coop 6035 508-339-8766 p.01 v hal a Cd a a a