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HomeMy WebLinkAboutShaw's Supermarket 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 Establishmen 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:. SHAW'S SUPERMARKET INC. Whose place of business is: SHAW'S SUPERMARKET #7431/165 390 WEST STREET License Number: FS-80 Permit Expires: December 31, 2018 BOARD OF HEALTH Food Fee: $275.00 Milk & Cream Ill MichaeCMcCCean, 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: SHAW'S SUPERMARKET #7431/165 390 WEST STREET License Number: FS-80 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: SHAW'S SUPERMARKET INC. having a place of business at: SHAW'S SUPERMARKET #7431/165 390 WEST STREET 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-80 Board of Health Michae(McCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH i ONLY Permit # Issued FSFS80 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opei 1) Establishment Name 2) Establishment Address SHAW'S SUPERMARKET #7431/165 390 WEST STREET 3) Establishment Mailing Address (if different) P.O. BOX 20 BOISE, ID 83726 4) Establishment Telephone No (508) 339-3987 5) Applicant Name & Title: SHAWS SUPERMARKETS, INC. 6) Applicant Address 8, 7) Applicant Telephone No.: (208) 395-6200 24 Hour Emergency No.: V 2 7 2017 F. NEW MAILING ADDRESS NASC Tax Department PO Box 29096 MS#6531 Phoenix, AZ 85038-9096 508-880-5322 508-339-4986 800-379-2967 8) Owners Name & Title SHAW S SUPERMARKET INC. 9) Owner Address (If different from applicant) 250 PARK CENTER BLVD. P.O. BOX 20 BOISE, ID 83726 - --- ------ - Owner's telephone number p (208) 395 6200 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers L' An Association or partner. A Corporation NameQ_ Title Address An Individual o Q j Ll A Partnership L Other legal Entity__ -G- _ -- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: iLISA COASH, STORE DIRECTOR Address: I390 WEST STREET, MANSFIELD, MA 02048 Telephone No (508) 339-3987 24 Hour Emergency No: 50E 880-5322 508-339-4986 800-379-2967 FAX: y508)964 1000 E-mail: MGRO165(n)SHAWS.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: MELONIE BUCHANAN, DISTRICT MANAGER -- _ _ _ _ -- -- ------------...--- Address: 1750 WEST CENTER STREET, WEST BRIDGEWATER, MA Telephone No ''(508) 817-6220 24 Hour Emergency No: (508) 621-9413 FAX: E-mail: MELONIE.BUCHANANPETTY@SHAWS.COM Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 160 17) DAYS/HOURS: MON-SAT 7 AM-10 PM SUN 7 AM-9 PM 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 certificate L, 9, Person Trained in Anti -Choking Procedures (If 25 Seats or more) 20) Location: [] Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: Ii Annual Seasonal Seasonal Dates: ❑_ Temporary-- -- -- - Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): 22) Establishment Type [VI Retail ( 64,923 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $125.00 ❑i Food Service up to 101 -200 or up to 25' PHF display $150.00 ['i Food Service up to 201 + or 25'+ PHF display $275.00 ❑, Food Service - Institution Meals/Day) LISA J. COASH ❑ Caterer $25.00 ❑J Milk & Cream $10,00 1 J Mobile Food & Consession $75.00 r-� Manufacture Frozen Desserts/Ice Cream L $25.00/1'reezer Pushcart $25,00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 ❑ Retail Snack Food $25.00 [ Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timeBemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [, Sale of Commercially Pre -Packaged Non-PHFs [! Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑JI Reheating of Commercially Processed Foods for Service Within 4 Hours [J] Customer Self -Service of Non PHF and Non - Perishable Foods Only [] Preparation of Non-PHFs Other Food Operations Idi 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 Ice Manufactured and Packaged for Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health j Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ' Offers RTE PHF in Bulk Quantities i. I Prepares Food/Single Meals for _ Catered Events or Institutional Food Service, _..i ] Retail Sale of Salvage Out -Of -Date -------- - ------ ---- or Reconditioned Food �To be completed by the Board of Health Total Permit Fee: $275.00 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 establishment operation will comply with 105 CC I,R 190.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 5 C 590.000 anal VOe ederal Food Code. 24) Signature of Applicant: V V Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties f perjury that I, 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: 04-1123420 D V -0LA S 26) Signature of Individual or Corporate Name: 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: SHAW'S SUPERMARKET#7431/165 ADDRESS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 339-3987 FAX NUMBER OWNER OF BUSINESS: (508) 964-1000 SHAW'S SUPERMARKET INC. TELEPHONE OF OWNER: (208) 395 6200 FEDERAL ID/SS NUMBER: 04-1123420 FEE: $10.00 PERMIT NUMBER: FS-80 SIGNATURE: DATE: Town of Mansfield Toren of'Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS-80 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: SHAW'S SUPERMARKET #7431/165 LOCATION OF SALE OF TOBACCO PRODUCTS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 339-3987 OWNER OF BUSINESS: SHAW'S SUPERMARKET, INC. ADDRESS OF OWNER: 250 PARK CENTER BOULEVARD, BOISE, ID 83726 TELEPHONE OF OWNER: (208) 395-6200 FAX NUMBER: (508) 964-1000 If a corporation or partnership, give name, title, and home address of officers or partner. SFE. All ACHED * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 818204672 FEDERAL ID/SS NUMBER: 04-1123420 611clor-A01:14 DATE: RETAILER LICENSE FOR SALE OF CIGARETTES JI��I"1�11�11�1�'1"I^��1119"II1�1�'I��'111111Lanl���h �� SHAWS SUPERMARKET INC SHAWS SUPERMARKETS INC STORE N PO BOX 20 BOISE ID 83726-0020 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------ ----- SP MASSACHUSETTS DEPARTMENT OF REVENGE Form CT-3T Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under IS years of age is prohibited. SLAWS SUPERMARKET INC Account ID: COL-11546651-107 SLAWS SUPERMARKET 7431 Location ID: 11546651-0121 390 WEST ST STE 1 License Number: 818204672 MANSFIELD MA 02048-1170 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. U ,' ^.tiKs Date: October,19, 2016, Expfirationa 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 Name By: Corporate Officer (Mandatory, if Applicable) 11 Z7-4 1�-0 "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:\Hn1thVane's Doe mmtsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doo The Commonwealth ofMassachusetts s PnntForr Department oflndustrialAccidents _ a Offzce of Investigations I Congress Street, Suite 100 { Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ��a�Aj S Qn. t�anyti���f A 743/ Address: City/State/ZipV/bdV>s,� �[ l OA 14 OZOd � Phone #: e, cad V7 _r Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with t 106 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. [No workers' comp. insurance required] 8. ❑ Non-profit 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 #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 insurmirf for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. # 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 fire 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 au "alties of perjury that the information provided above is true and correct. —/4 -/ 1,00.— (.etz5— Of 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 #: ww w.ru:us.guw r:a l ® A` o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) DsrDzm7 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(s). PRODUCER AD" Rlsk services Central, Inc. Minneapolis MN Office CONTACT NAME: PHONE (g66) 283-7122 FAX (800) 363-0105 (AIL. No. Ed): 5600 west 83rd street 8200 Tower, Suite 1100 EMAIL ADDRESS: INSURER(S)APFORDING COVERAGE NAIL Minneapolis MN 55437 USA INSURED INSURERA ACE American Insurance Company 22667 New Alber'tson's Inc. Including All Affiliated Subsidiaries & Associated Companies INSURER Be ACE Property & Casualty Insurance Co. 20699 — INSURERC- 250 E. Parkcenter Blvd. Boise ID 93706 USA INSURER D: INSURER E: INSURER R COVERAGES CERTIFICATE NUMBER: 570066570338 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 INISR TYPE OF ADD INSD SUBR wVD POLICY NUMBER POLIO MMUD PDU XP MKIDD LIMITS A X COMMERCIALGENERALLIABILRY XSLG 1 1 EACH OCCURRENCE 52,000,000 CLAIMS -MADE X❑OCCUR SIR applies per policy ter s & COndl LOOS DAMAGE TO HEWED PREMISES Eao..,,ce $50D, 000 X MED EXP(Any ane person) Excluded Druggist Liability induded PERSONAL &ADV INJURY S2,000,000 GEMLAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S4,000,000 X POLICY 0JECOT ❑Lac PRODUCTS - COMPIOPAGG i S4,000,000 Liquor Liability 52, Coo, 000 OTHER A AUTOMOBILE LIABILITY ISA H09042970 06/01/201608/01/2017 COMBINED SINGLE LIMIT Ea aaaldeni S2,000.000 BODILY INJURY (Per paoon) X ANYAUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON-0WNED ONLY AUTOS ONLY PROPERTY DAMAGE Peramitlent B X UMBRELLAUAB X OCCUR XOOG2794761AO02 06/01/2017 08/01/2018 EACH OCCURRENCE $$, 0001 000 EXCESS DAB CLAIMS -MADE AGGREGATE S5,000,0DO DED I X RETENTION S25,000 A WORKERS COMPENSATION AND EMPLOYERS'LUUMITTY YIN ANYPROPRIETOR/PARTNER/ EXECUTIVE OFFICEWMEMBEREXCLUDEDT (Mandatary in NH) NIA WLRC64413247 06/01/201706/01/-2018:;::X I PER STATUTE OTH- ER E.L EACH ACCIDENT $2,000,000 E.L DISEASE -EA EMPLOYEE $2,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Mart nal Remarks Schedule, may be attached if more space is requi,ed) Blanket Additional Insured for General Liability and Waiver of subrogation for General Liability status extend to those parties to whom the Insured has contractually agreed to provide this status. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICYPROVISIONS. New Albertson's, Inc. AUTHORIZED REPRESENTATIVE And All Affiliated, Subsidiary & Associated Companies East Parkcenter Blvd. Boise 7�/J `7Lta�C �%J CJo�sIAa� 2 Boise ID 83706 USA a �/Xo>a c/it-r.r.G �j>arx ©1988-2015 ACORD CORPORATION_ All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD c = N J L d N V L M N E 0 L V Q CD r- M Z �(nw L tL 0 N -h 3 0 N W U cn Ln W .�4 ��.. •A: �(%R.: �t .: Afa : is A• : •�`: Soy ' 'F•... yy 1 Of J"" a Q.148 Q 42 � n v � �•-S M o PP