HomeMy WebLinkAboutStaples 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 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:.
OFFICE SUPERSTORE EAST LLC
Whose place of business is:
STAPLES THE OFFICE SUPERSTORE #1551
390 WEST STREET
PERSON(S) IN CHARGE:
TIFFANY MCNULTY, MANAGER
Permit Expires: December 31, 2018
Food Fee: $100.00
License Number: RF-16
BOARD OF HEALTH
.Michaet'McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued RF 16
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name STAPLES THE OFFICE SUPERSTORE
2) Establishment Address 390 WEST STREET
3) Establishment Mailing Address (if different) 500 STAPLES DRIVE
FRAMINGHAM, MA 01702
4) Establishment Telephone No (508) 261-2889
5) Applicant Name & Title: �'01 I"Pc
6) Applicant Address 500 STAPLES DRIVE, FRAMINGHAM, MA 01702
#1551
7) Applicant Telephone No.: (508) 253- . 24 Hour Emergency No.: (617) 719-3074
8) Owners Name & Title jr. OFFICE SUPERSTORE EAST) LC.
9) Owner Address (If different from applicant) 500 STAPLES DRIVE, FRAMINGHAM, MA 01702
Owner's telephone number 5082535000
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
L I An Association or partner.
A Corporation Name Title Address
C_1 An Individual SeC
A Partnership
_rXOther legal Entity--
12) Person Dire i charge, supervisor, manager etc.)
Name & Title: TIFFANY NCNULTY, STORE MANAGER
I
Address: 390 WEST STREET, MANSFIELD, MA 02048
Telephone No. (617) 719-3074 24 Hour Emergency No: (617) 719.3074
FAX:
E-mail: DAVIMLAVALLEE@STAPLES.COM
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
j Address:
Telephone No: 24 Hour Emergency A
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 0
17) DAYS/HOURS: MON-FRI 7 AM-9 PM SAT 9 AM-9 PM SUN 10 AM-6 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 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
C9) Person Trained in Anti -Choking Procedures (If 25 Seats or more)
20) Location: II Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
l�� 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
[/ Retail ( Sq. Ft)
j Food Service up to 100 or
up to 10' PHF display $125.00
❑ Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
I.] Food Service - Institution
Meals/Day)
❑ Caterer $25.00
❑ Milk & Cream $10.00
❑ Mobile Food & Consession $75.00
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
❑ Pushcart $25.00 # of Pushcarts: 0
1 Residential Kitchen $100.00
❑� Retail Food $100.00
❑ Retail Snack Food $25.00
Tobacco Products $25.00
Definitions PHF- Potentially hazardous food (tlme/temperature controls required)
Non-PHFs - non -potentially hazardous food(no limeRemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
U Sale of Commercially Pre -Packaged Non-PHFs I _ PHFCooked To Order
❑ Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
[ _ 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
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
I_I Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
I,] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
I -_I Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Other Food Operations I I Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
t Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage Out -Of -Date
or Reconditioned Food To be completed by the Board o! Health
L _-- — — — - - al Permit Fee: $100.00
Payment is due with application ❑ waived
I, the undersigned, attest to the cc r cy of the information provided in this application and affirm that the food
establishment operation will co ply with 105 CMR 590.000 and all other pplicable law. I have been instructed by the
board of health on how to obtain opies _ f 105 CMR 59 .00 an the f ral Food Code.
24) Signature of Applicant: \..
Pursuant to MGL Ch.62C, sec. , I certify under the penalties of 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: 04-3176952
26) Signature of Individual or Corporate Name: `�CL < uk_4AP,
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.
L sl)t�fj 7a, e-4sy,
Signature of Indi idual or Corporate Name 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.
RAHRhVane's Doc=entsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
s I Congress Sh'ee4 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 LeObly
Business/Organization
Address:
6ZPhone M 56�-2.tS�;' 5OW
Arey' an employer?Cbeckffieappropriate box:
1. I am a employer with employees (full and/
or part-time).*
2.0 I 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. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req j
Busft es,a,Type (required):
S. 2letail
6. Restaurant/Baz/Badng Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. ❑ Entertainment
10, ❑ Manufacturing
11.❑ Health Care
12,❑ Other
*Any applicant that checks box #I most 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 M.
f am an employer that is providing ivorkrrrs' compensation insurance for my employees. Below is the policy informadoh.
Insurance Company
Insurer's Address: i�0 61.II/t,�,&k S
City/State/Zip: (D
Policy # or Self -ins. Lic. #- Expiration Date: 02` (IT
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.
[do
Phone #:
the pains end periafties of
derjury that the information provided above is true and correct
5% d53
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Fermit/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#:
w .mass.guwma
NOTICE
TO
EMPLOYEES
*= -_NOTICE TO
EMPLOYEES
�ryy
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 00, this will give you notice
that I (we) have provided for payment to our injured employees under the above -mentioned chapter by
insuring with:
ACE AMERICAN INSURANCE COMPANY
NAME OF INSURANCE COMPANY
436 Walnut Street PO Box 1000 Philadelphia, PA 19106.3703
ADDRESS OF INSURANCE COMPANY
POLICY NUMBER EFFECTIVE DATES
NAME OF INSURANCE AGENT WILLIS OF MASSACHUSETTS 617-437-6900
ADDRESS THREE COPLEY PLACE PHONE #
BOSTON MA 02116-6105
EMPLOYER USR PARENT INC.
ADDRESS 500 STAPLES DRIVE --
FRAMINGHAM MA 01702
EMPLOYER'S WORKER'S COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to
furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's
Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select
his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the
insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital
attention, employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
WC 99 97 20C (04111) Ptd. in U.S.A.
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