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HomeMy WebLinkAboutAdvance Stores Co. Inc. 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: RETAIL SNACK 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:. BWP DISTRIBUTOR INC. Whose place of business is: ADVANCE STORES COMPANY, INC. #4452 292 CHAUNCY STREET PERSON(S) IN CHARGE: MICHAEL CONNOLLY Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RF-17 BOARD OF HEALTH .T1ichaeC.McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must lie submitted at least 30-daysbeore -the pTanned opening date) 1) Establishment Name ADVANCE AUTO PARTS #4452 2) Establishment Address 292 CHAUNCY STREET #296 3) Establishment Mailing Address (if different) - PO BOX 2710 ROANOKE, VA 24001 NOV 2 1 201Z 4) Establishment Telephone No 508-851-9061 5) Applicant Name & Title: JOSH LOUIS - AGENT 16) Applicant Address 5008 AIRPORT RD ROANOKE, VA 24012 7) Applicant Telephone No.: 24 Hour Emergency No.: 513-394-6161 8) Owners Name &Title BWP DISTRIBUTOR INC 9) Owner Address (If different from applicant) 5008 AIRPORT RD ROANOKE, VA 24012 Owner's telephone number 540-362-4911 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers U An Association or partner. X A Corporation Name Title Address I-] An Individual SEE ATTACHED El A Partnership 0 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MICHAEL CONNOLLY Address: Telephone NO: 508-339-4516 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: E-mail. Telephone No: FAX: Food Establishment Information 14) WATER SOURCE: PUBLIC 15) SEWAGE DISPOSAL: PUBLIC 16) No. of Food Employees: DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/l2001 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 ❑ Caterer $25.00 Moblie Mobile Start Date: Q Retail ( 25 Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: ( _1 Food Service up to 100 or El Mobile Food & Concession $75.00 Mobile Comments: up to 10' PHF display $125.00 E] Food Service up to 101 -200 Manufacture Frozen Dessertslice Cream $25.00/freezer 21) Length of Permit: Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 Pushcart $25.00 it of Pushcarts: ❑ Residential Kitchen $100.00 � Retail Food $100.00 Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 --__-_-- Temporary --- "_--- Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF-Potentially hazardous food (timelemperature controls required) Non-PHFs - non -potentially hazardous food(no fime/temperatum, controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) * Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order El Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs El Preparation of PHFs For Hot And Cold Holding For Single Meal Service ------------ - E]Sale of Raw Animal Foods Intender to be Prepared by Consumer ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs ---- Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ... Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only ___. 0 Preparation of Non-PHFs ❑ Customer Self -Service -- - - ❑ Ice Manufactured and Packaged for Retail Sale Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities _ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: —"-- Payment is due with application E] waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply wit 5 CMR 590.09A,1 nd all other applicable law. I have been instructed by the board of health on how to obtain co s of 05 CMR 59Q Oqb and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I Certify under thiZpenalties of perjury that 1, to my best knowledge and belief, have filed all state lax returns and paid stale taxes required under law. ( �/ 25) Social Security Number or Federal ID: /3-3f Y D 26) Signature of Individual or Corporate Name: --21li� lu�n TAX CERTIFICATION FORM 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. 6 I/Iq Siggl0ture of legividual or Corporate Name 13-3143287 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. C:\Osers\sleRe\Desktop\Scotts Docoments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: ADVANCE AUTO PARTS City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. []Retail 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] 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.] 12.0 Other *Any applicant that checks box Nl 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 ilt. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: SEE ATTACHED Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration Attack 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 certfif tinder thpNins andpenalties ofperitoy that the information provided above is true and correct. 513-394-6161 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 ® AC Ro CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYW) 061gv2017 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(ies) 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). PRODUCER Marsh USA Inc. Three James Center 1051 East Cary Street, Suite 900 Richmond, VA 23219 Attn: AdvanceStores.CedRegues(@mamh.com J32008--GAWU5-17-18 CONTACT NAME_ FA HICNN E lP A/C No), qDD ILSS: -- INSURERS) AFFORDING COVERAGE-,., NAICk __ __ INSURER A : ACE American Insurance Company 22667 INSURED Advance Stores Company, Incorporated 5008 Airport Road INSURER B : ACE Property And Casualty Ins GO 20699 INSURER C :See Additional Page -- INSURER D: Roanoke,VA 24012 INSURER E: INSURER F : COVFRAGFS CERTIFICATE NUMBER: CLE-004988490-10 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, OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYW POLICY EXP MMIDDPYYYY LIMITS L GENERAL LIABILITY -MADE X I OCCUR etention 500,000 rGEN'LAGGREGATE XSLG27865835 06/0112017 06101/2018 EACH OCCURRENCE $ 1,500,000 PREMSES Ea oaMAGE TO TEre $ 1,500,000 MED EXP (An one arson) $ PERSONAL &ADV INJURY $ 1,500,000 TE LIMIT APPLIES PER: jECT LOG OTHER: GENERALAGGREGATE S 10,000,000 PRODUCTS - COMP/OP AGG S 3,500,000 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS NON OWNED X HIREDAUTOS X AUTOS ISAH09056373 06101/2017 0610112018 COMBINED SINGLE LIMIT Ea accident $ 5,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccitlenl $ S B X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE XOOG28122779002 06101/2017 06/01/2018 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICERIMEMBER EXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below N/A SEE ADDITIONAL PAGE 0610112017 O6/01I2018 ,- X PER OTH- STATUTE ER E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMB 1,000,000 $___ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attac hod It more space is required) CFRTIFICATF HOLDER CANCELLATION Advance Auto Pads, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 5008 Airport Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Roanoke, VA 24012 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Diana Holsinger @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACORH L� AGENCY CUSTOMER ID: J32008 LOC #: Richmond ADDITIONAL REMARKS SCHEDULE Page 2 of AGENCY Marsh USA Inc. NAMED INSURED Advance Stores Company, Incorporated 5008 Airport Road Roanoke, VA 24012 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers' Compensation policies: Policy Number. WLRC64409633 (ADS) Carver: Indemnity Insurance Company of North America Effective Date: 06/0112017 Expra0m Date: 0610112018 Policy Number: SCFM409657 (WI) Carder: ACE Fire Undemeters Ins. Co. Effective Date: 06/01/2017 Expiration Date: 06/0112018 Policy Number. WLRC64409669 (TN) Carder: Ago General Insurance Company Effective Date: 0610112017 Expiration Date: 06/0112018 Policy Number. WLRM409645 (CA, MA) Carder: ACE Amencaninsurance Company Effective Date: 0610112017 Expiration Date: 06101/2018 Policy Number: WCUC64409621 (011) Caller. ACE American Insurance Company. Effective Date: 06/01/2017 Expiration Date: 06/0112018 SIR: $500,000 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD Effective 3/2/15 B.W.P. Distributors, Inc. New York - 10/17/2001 Directors William H. Carter Tammy M. Finley Michael A. Norona Officers William H. Carter Chairman and Chief Executive Officer Neil Stockel President Michael A. Norona Executive Vice President and Chief Financial Officer Tammy M. Finley Executive Vice President, Human Resources, General Counsel and Corporate Secretary Rachel E. Geiersbach Assistant Secretary