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HomeMy WebLinkAboutCumberland Farms 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 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:. CUMBERLAND FARMS, INC. Whose place of business is: CUMBERLAND FARMS #0187 30 CHAUNCY STREET License Number: FS-56 Permit Expires: December 31, 2018 Food Fee: $125.00 Milk & Cream ill BOARD OF HEALTH 9blichaeC.McCCean, Chairman Permit for 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: CUMBERLAND FARMS #0187 30 CHAUNCY STREET License Number: FS-56 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: CUMBERLAND FARMS, INC. having a place of business at: CUMBERLAND FARMS #0187 30 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 governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-56 Board of Health NichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred (Application must be submitted at least 30 days before the 1) Establishment Name 2) Establishment Address CUMBERLAND FARMS #0187 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) 165 FLANDERS ROAD ATTENTION: TAX DEPART. WESTBOROUGH, MA 01581 4) Establishment Telephone No (508) 261-7857 5) Applicant Name & Title: CUMBERLAND FARMS, IIVC. 6) Applicant Address 165 FLANDERS ROAD TAX DEPT., WESTBORO GH, MA 01581 7) Applicant Telephone No.: (508) 270-1400 24 Hour Emergency f ,. (508) 359-1097 8) Owners Name & Title CUMBERLAND FARMS, IF 9) Owner Address (If different from applicant) 165 FLANDERS ROAD, Wf TBOROUGH, MA 01581 Owner's telephone number (508) 270-1400 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 i An Individual APartnership 7 OtherlegalEntity_—__ ---- _ -- —__ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title !JULIE IADAROLA, AREA MANAGER Address: Telephone No: !(508) 380-2059 24 Hour Emergency No: FAX 1(781) 821-0653 E-mail: Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title LYNDA MARTONE, REGIONAL SUPERVISOR Address: Telephone No. I(401) 529-9625 24 Hour Emergency No (508) 369-1097 FAX: E-mail: (508) 369.1097 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: DEP Public Water Supply No. (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: s�sArnr a�PtGl f Citf 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 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of �r certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) F 1 -- 20) Location: C Permanent Location 22) Establishment Type j._] Mobile Mobile Start Date: 1y] Retail ( 3 500 Sq. Ft) Mobile End Date: Mobile Comments 21) Length of Permit: y1 Annual [_I Seasonal Seasonal Dates: L,Temporary Temporary Start Date: Temporary End Date: -, Temporary Time: Rain Date: TOWN STACY L. WIDROW JASON C. OLIVEIRA [Food Service up to 100 or -7 FF — up to 10' PHF display $125.00 �7llJ" Food Service up to 101 -200 ❑ Caterer $25.00 LVI Milk & Cream $10.00 [] Mobile Food & Consession $75.00 E] Manufacture Frozen Desserts/Ice Cream $25.00/freezer or up to 25' PHF display $150.00 f I Pushcart $25.00 # of Pushcarts: 0 [ 1 Food Service up to 201 + ❑ Residential Kitchen $100.00 or 25'+ PHF display $275.00 i[� Re ai .,_ Food Service- Institution"I! Retail Snack Food $25.00 ( Meals/Day) Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timeRemperature controls required) ' 23) Food Operations Non-PHFs - non -potentially hazardous /ood(no timeltemperalure controls required) ,(Check all that apply): I RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I--[--i 1y1 Sale of Commercially Pre -Packaged Non-PHFs [J1 Sale of Commercially Pre -Packaged PHFs -1 Delivery of Packaged PHFs y Reheating of Commercially Processed Foods for Service Within 4 Hours _ Customer Self -Service of Non PHF and Non - Perishable Foods Only ' Preparation of Non-PHFs Other Food Operations El PHFCooked To Order [.) Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I__I PHF and RTE Foods Prepared For Highly Susceptible Population Facility I Vacuum Packaging / Cook Chill 1 ..1 Use of Process Requiring A Variance I s� customer Self -Service 5,, r yer_ and/or HACCP Plan (including bare hand -- - -__-- --- contact alternative, time as a public health Ice Manufactured and Packaged for Retail Sale control) [] Juice Manufactured and Packaged for [_] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin - I -] Prepares Food/Single Meals for ' Offers RTE PHF in Bulk Quantities - Catered Events or Institutional Food Service Retail Sale of Salvage Out -Of -Date --- ----- - - _ - — r - -- --- or Reconditioned Food To be completed by the Board of Health , I. - - -- ---- Total Permit Fee: ° PO Payment is due with application ] waived lb(1r I, the undersigneshment d, attest to the an will ccuracy of the information provided in this aappr ation and affirm tha t the food board estahof health on how to obtain copieth 105 CMR 590.000 and s of 105 CMR 590 007 a dltp other feda a IMF od Coc le w b ve been Instructed by tHIC he i Hrrt Fournier 24) Signature of Applicant: cx: S f, MinaCer Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties off erjudy th I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 6�um a land Farms, Inc. 25) Social Security Number or Federal ID: 04-2843586 Tax )e rtment 26) Signature of Individual or Corporate Name: AS CL....J..�.. a.,,.,u Westborough, MA 01581 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 December 31st of each year. NAME OF BUSINESS: CUMBERLAND FARMS #0187 ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 261-7857 FAX NUMBER: OWNER OF BUSINESS: (781)821-0653 CUMBERLAND FARMS, INC. TELEPHONE OF OWNER: (508) 270-1400 FEDERAL ID/SS NUMBER: 04-2843586 FEE: $10.00 PERMIT NUMBER: RF-3 SIGNATURE: DATE: F,',)LIfI lint.. oanaCg` er Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF-3 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 December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CUMBERLAND FARMS, #0187 LOCATION OF SALE OF TOBACCO PRODUCTS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 261-7857 OWNER OF BUSINESS: CUMBERLAND FARMS, INC., TAX DEPARTMENT ADDRESS OF OWNER: 165 FLANDERS ROAD, WESTBOROUGH, MA 01581 TELEPHONE OF OWNER: (508)270-1400 FAX NUMBER: (781) 459-2407 If a corporation or partnership, give name, title, and home address of officers or partner.. * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 1801605120 1371770880 FEDERAL ID/SS NUMBER: 04-2843586 SIGNATURE: DATE: anager _yam, MASSAMSEM DEeAalMOrr OF UVENVE Udall) L0515183616 �I PO BOX 7044 Notice Date Oetoba 11, 2016 BDT1W,M 0ZiD4.7044 Account 117 CG410031037486 OONTACrCRTM d (617) /87-6367 RETAILER LICENSE FOR SALE OF CIGARETTES rvblRnlplq"p�PIIlh�typpuglhlllrnPlluhhl�p� CUMMMLAM FARMS INC CUAMERLAND FARMS 00176 CUNWEtL loo CROSMa BLVD pRAM[KGHAMMA 01702-5401 Attached below Is your Retailer License for Sale of Cigarettes (Fowl CT-37) Cut along the dotted line and display at your business location At any time, you can log into your MassTaxColmax account at mass gov/massmlcconnect to view and re -print a copy of this licalse if you have any questions about your hennas, call us at (617) 897-6367 or toll -five in Massachusetts at (800) 392-6089, Monday through Friday, 830 am. to 4 30 p m. DETACH WERE 0 �,y+ ,� MASSACHUSE7TS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes '�i� i This license must be posted and visible at aU times. The sale of tobacco products to anyone under 18 years of age Is prohibited CUMBERLAND FARMS INC AcoountID CGL-10031037-486 CUMBERLAND FARMS #0187 Location ID 10031037-0481 30 CHAUNCY ST License Number 1371770880 MANSFIELD MA 02048.1958 This certifies that the taxpayer named above is hoensed under Chapter 64C of the MessacbueGts General Laws to sell at retail at the address shown above This hoenae is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations Effective Data October 11, 2016 Expiradon Date September 30, 2018 1 AB CHLVW 8 DFPARTbWM OF REVV= LOW ID L107213024 PO BOX 7044 Nonce Diso October 7, 2D16 WMN MA 022W7044 Account ID' CRL 10031037.499 CONTACrCEMER. 04 (617) 887.067 RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO C(1MBRIt1ADID FARMS INC CUMBBIU AND FARMS 41D176 CUMBM too CROSSWO BLVD FRAUNGHAMMA 01702-5401 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T) Cut along the dotted line and display at your business location. At any time, you can log into your MwTaxConnect account at mass gov/masstexconneet to view and ro-print a copy of this license if you have any questions about your license, call us at (617) 987-6367 or toll -flee in Massachusetts at (800) 392-6089, Monday through Friday, 8 30 a.m. to 4 30 p in DETACH HERE "uCy� MASSACHUSETI'S DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smelting Tobacco of This license must be posted and visible at all tunes The sate of tobacco products to anyone under 18 years of age is prohibited. CUMBERLAND FARMS INC Account ID CRL-10031037.489 CUMBERLAND FARMS N0187 Location m 10031037-0679 30 CHAUNCY ST License Number. 1801605120 MANSFIELD MA 02048-1959 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations Et[eewe Date' October 7, 2016 Expiration Date September 30, 2018 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. Signature of Individual or Corporate I� amk By: Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntary) or Federal Identification Number *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. R:\Itm1thVane's DocumentAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print UAW Business/Organization 165 Flanders Road Cumberland Farms, Inc. City/State/Zip: Westborough, MA 01581 Phone #: 508-270-1400 Are you an employer? Check the appropriate box: Business Type (required): 1. ©. I am a employer with 3433 employees (full and/ 5. ❑� Retail orpart-time).* 6.❑RestaurantBar/EatingEstablishment 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]* I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. Wo workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box Nl must also fill out the section below showing their workers' compensation policy infomation, **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organination should check box In. I am an employer that is providing workers' compensation Insarancefor my employees. Below is the policy information. Insurance Company Name: ACE American Insurance Company Insurer's Address: 33 Arch Street, Suite 2900 City/State/Zip: Boston, MA 02110 Policy # or Self -ins. Lie. # SCFC64409244 Expiration Date: 04/01/2018 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 o year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day agains a violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.('o i urance coverage verification. I do ofperjury that the Offkiul use only. Do not write In this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Permit/License is true 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: Phone CERTIFICATE OF LIABILITY INSURANCE DATE(MM 0MMID17120VY) 17 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER Aon Risk Services Northeast, Inc. Providence RI Office CONTACT NAME: jNC. No. Expo (866) 283-7122 FAX No.); 800-363-0105 EMAIL ADDRESS: 100 Westminster Street, 10th Floor Providence RI 02903-2393 USA INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA ACE American Insurance Company 22667 CUMBERLAND FARMS. INC. Flanders Road WestboroughMA 01581 USA INSURER B: Indemnity Insurance Co of North America 43575 INSURER C: opy asy ace6ACE Property & casualty xnsurnCo.c 20699 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570065925580 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. Limits shown are as requested LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMJDDIYYYY MMIDDr YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CIAIMS-MADE Fx] OCCUR XSLG SIR applies per policy terns & condi ions EACH OCCURRENCE EL, OOO, OOO o PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) Excluded PERSONAL &ADV INJURY f1, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO ❑ LOC ECT OTHER: GENERALAGGREGATE $10,000,000 PRODUCTS. COMPIOP AGG $4,000,000 A AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY ISA-HO9056178 04/01/201704/01/2018 COMBINED SINGLE LIMIT Ea accident y1,000, 000 BODILY INJURY( Per person) BODILY INJURY (Par accident) PROPERTY DAMAGE Peracddent C X UMBRELIJILIAB EXCESS LIAR X OCCUR CLAIMS -MADE G46621220001 04/01/2017 04/01/2018 EACH OCCURRENCE $5,000,000 AGGREGATE i5,000,000 DED I X RETENTION $25, 000 B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/ PARTNER I EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N (Mandate, in NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below NIA WLRC64409232 SCFC64409244 04/01/2017 04/01/2017 04 01'2018 04/01/2018 X SPER OTH- TATUTEEN E.L. EACH ACCIDENT s2,000,000 E.L. DISEASE -EA EMPLOYEE $2,000,000 E.L. DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached if more space Is required) The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. CERTIFICATE HOLDER CANCELLATION Ilai SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield AUTHORIZED REPRESENTATIVE Six Park ROW Mansfield MA 02048 USA % �� �' Q Wa�M ✓L eyltitfAked c/,{l ✓L ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD kdand- .. Date of Incorporation: September 14, 1984 State of Incorporation: Delaware Principal Address: 165 Flanders Road, Westborough, MA 01581 Office Telephone: 508-270-1400 Federal ID No: 04-2843586 PRINCIPAL OFFICERS. Ari N. Haseotes President and CEO Howard S. Rosenstein Treasurer Brian E. Glennon, II Acting General Counsel & Assistant Secretary John T. Daly Assistant Treasurer a ANS/ 141drifivirel 1 JASON OLIVEIRA for successfully completing the standards set forth for the SewSofeo Food ProWion M000w Ceri Rcation Exasnindion, which is accredited by the American National Standards Institute (AN5Q-,Canters" for Food Protection (CFP). MEER 7/17/210 DATE OF E DATE OF EXPIRA Lord laws apply. Ch v "? 6ney Far n cealftculion regeiremenb. C wi., quwin,a 175wb ", Sa 15W, G' , L. 60501 a SuvSoLAra,uvii.ap. EXAM FORM NO. 4938 CERTIFICATE NO. 11109774 � LE1 1. STACY L WID for successfully completing the standards which Is accredited by the American Nat DATE DATE OF EX Ma nager Certification Exemina9en, ce for Food Protectlon(CFP). ServSafe Student Name STACYL WIDHOW Cbss Number, 1421120 Exam Data 05272014 6phafon Date )W 2019 Iremclar Name ADRIAN KONN SpDnaM Name Heap Nht,ftcmlers Esnm L-recn MA Wun Form Name 4938 Da.mil Pont Scom 60 Oyeroll%Svote 75 P... 1,% Score 75 End.. PASSED Peeled Your Peter poim Sayre Sayra 60 6D Domain Nemea Implement From Salory SOPS 16 ID Employee HYDlene and Health 6 la"opL St..". lmnsport 13 11 Food Reg Display and Sm— 32 20 Compfuneo wilh R"bory II D "I". unam a.s..�no��a.v mhxni vnna am oa u«rannw. mymna.mmeu 1w11.—r--r1-1.1-1 .-,r. a.e..... .1 ServSafe ew^'^^"a'a" 4,,0 ServSafe CERTIFICATION ro STACV L W�DflOW n OSTRDIB / % i 7 � 4 & r w / LO LO ( { d � � 7 / t \ % \ 4 \ Q \ ;r} \ / {) } % B}4» « % \){) % r ¥ Cum "erland, bl Foods"ervice Offer AIM Dispensed Beverages Cumber;[and — We offer the following dispensed beverages: • 16 Head Soda Fountain • 2-4 Head Frozen Carbonated Beverage Machines • 8 Brew And Serve Coffee Stations • Iced Coffee made and dispensed on premises • Iced Tea made and dispensed on premises • Frozen Made To Order F'real Shakes