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HomeMy WebLinkAboutStop & Shop 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:. THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 Whose place of business is: STOP & SHOP SUPERMARKET, COMPANY #007 377 CHAUNCY STREET License Number: FS-83 Permit Expires: December 31, 2018 Food Fee: $275.00 Milk & Cream I! BOARD OF HEALTH .MichaeC.7vlcCCean, 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: STOP & SHOP SUPERMARKET, COMPANY #007 377 CHAUNCY STREET License Number: FS-83 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: Town of Mansfield 6 Park Row Mansfield, MA 02048 THE STOP & SHOP SUPERMARKET COMPANY, LLC #007 having a place of business at: STOP & SHOP SUPERMARKET, COMPANY #007 377 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-83 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS83 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planneof op6 1) Establishment Name STOP & SHOP SUPERMARKET, COMPANY #007 2) Establishment Address 377 CHAUNCY STREET "date)—, 3) Establishment Mailing Address (if different) 1385 HANCOCK STREET, ATTN: LICENSING QUINCY, MA 02169 4) Establishment Telephone No (508) 337-9450 5) Applicant Name & Title: ASHLYE BRENNAN, LICENSING MANAGER 6) Applicant Address 1385 HANCOCK STREET, QUINCY, MA 02169 7) Applicant Telephone No.: (617( 770-8708 (877) 893-5393 24 Hour Emergency No. (877)893-5393 8) Owners Name & Title THE STOP & SHOP SUPERMARKET COMPANY, LLC #IHIT 9) Owner Address (If different from applicant) 1385 HANCOCK STREET, QUINCY, MA 02169 Owner's telephone number (617) 770-8708 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 Name Title Address An Individual S.E� A Partnership ' Other legal Entity- -_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) -- -- - - Name & Title: IDARREN-BEANGELIS; STORE MANAGER Address: 377 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: ',(508) 337-9450r j 24 Hour Emergency No: (877) 893-5393 FAX: fF - AE E-Mail: ASS H YE.BRENNAN(a)AHOLD.COM RaI !+O,I D COM ` r,f Gt ( `tc v'�te ri 13) District Or Regional Supervisor (if applicable) Name & Title )or>a kW=rM,,ie DISTRICT MANAGER Address: 4 i d? tc rrpr<�e5<-� Ci Telephone No. (860) { rj 24 Hour Emergency No: (877) 893.5393 ra FAX: U� E-mail: -7`" I � r✓ -T , e, �0 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees,? 17) DAYS/HOURS: SUN 7 AM-9 PM MON-SAT 6 AM - MIDNIGHT 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 C9) Person Trained in Anti -Choking Procedures (If 25 Seats or more) _ _ 4, 20) Location: 1JI Permanent Location - 22) Establishment Type i-] Moblie Moblie Start Date: Retail ( `fi j. t,t_�'Sq. Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: Jai Annual (..I Seasonal -__---- Seasonal Dates: _.. Temporary Temporary Start Date: Temporary End Date: Temporary Time: I- y L 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 Lj Food Service up to 201 + or 25'+ PHF display $275.00 [_ Food Service - Institution ( Meals/Day) DARREN"Nf. 015 AWG ELI'S'SR-- 1.. j 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 [_] Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 1--. _. ----- - — ----_ ..------ 23) Food Operations Definitions PHF- Potentially hazardous food(time/temperature contents required) Non-PHFs non -potentially hazardous tood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) W Sale of Commercially Pre -Packaged Non-PHFs [f Sale of Commercially Pre -Packaged PHFs Pj Delivery of Packaged PHFs F] Reheating of Commercially Processed Foods for Service Within 4 Hours [_ Customer Self -Service of Non PHF and Non - Perishable Foods Only [l Preparation of Non-PHFs Other Food Operations r] 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 V 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 Chili LJ Customer Self -Service - Use of Process Requiring A Vanance and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale __ control) _._1 Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin in Bulk Quantities_ ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service I i Retail Sale of Salvage, Out Of -Date ......__---------' or Reconditioned Food To be completed by the Board of Health IL_.._ _____ .--- Total Permit Fee: $275 00 Payment is due with application waived J I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code, 24) Signature of Applicant: !, XA UA Pursuant to MGL Ch.62C, sec. 49A, I certify ur and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 26) Signature of Individual or Corporate Name: penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 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: STOP & SHOP SUPERMARKET, COMPANY #007 ADDRESS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-9450 FAX NUMBER: (508) 337-ly (may OWNER OF BUSINESS: THE STOP & SHOP SUPERMARKET COMPANY, LLC #= TELEPHONE OF OWNER: (617) 770-8708 FEDERAL ID/SS NUMBER: 04-3061447 FEE: $10.00 PERMIT NUMBER: FS-83 i SIGNATURE: Lk.� �},-, o JLJ DATE: Town of Mansfield Town o f 'Nlansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS-83 Application fir 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: STOP & SHOP SUPERMARKET, CO. #007 LOCATION OF SALE OF TOBACCO PRODUCTS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-9450 OWNER OF BUSINESS: STOP & SHOP SUPERMARKET, CO, LLC ADDRESS OF OWNER: 1385 HANCOCK STREET, QUINCY, MA 02169 TELEPHONE OF OWNER: (617) 770-8708 FAX NUMBER: (617) 689-4061 If a corporation or partnership, give name, title, and home address of officers or partner. SEE A 7 ACHED LIST * Provide a copy of current Department of Revenue CT-3T FEE: $25.00 CT-3T NUMBER: 2040770560 FEDERAL ID/SS NUMBER: 04-3061447 SIGNATURE. Excise Unit License. DATE: i ( > I ( ? ssrcnUrF MASSACHUSETTS DEPARTMENT. OF REVENUE Letter ID: L2025935872 �N PO BOX 7044 Notice Date: October 17, 2016 ! BOSTON, MA 02204-7044 Account ID: CGL-10044051-295 CONTACTCENTER tiro- (617) 887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES (11'11IId1111111111111[111111111111611I1Idllhh1 ATTN LICENSING DEPT STOP & SHOP SUPERMARKET CO LLC STOP & SHOP 4001 1385 HANCOCK ST QUINCY MA 02169-5103 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. 17� I/:5�77=iJ�R7 SCSs S rh MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T P ? Retailer License for Sale of Cigarettes or" This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. STOP & SHOP SUPERMARKET CO LLC Account ID: CGL-10044051-295 SUPER STOP & SHOP #007 Location ID: 10044051-0303 377 CHAUNCY ST License Number: 2040770560 MANSFIELD MA 02048-1169 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. Effective Date: October 17, 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 Name r I n rr "Social Security No. (Voluntary) or Federal Identification Number By: Corporate dfhcer (Mandatory, if Applica *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:\HmlthUane's Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEibly Business/Organization Name: The Stop & Shop Supermarket Company LLC Address: 1385 Hancock Street City/State/Zip: Quincy, MA 02169 Phone #: 800-288-8415 Are you an employer? Check the appropriate box: Business Type (required): 1.9 I am a employer with employees (full and/ 5. 0 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 a 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]** 1 LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 Other *Any applicant that checks box #I 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 insurance far my employees. Below is the policy information. Insurance Company Name: MAC RISK MANAGEMENT, INC. (TPA) Insurer's Address: 1385 HANCOCK STREET City/State/Zip: QUINCY, MA 02169 Policy # or Self -ins. Lie. # 576 Expiration Date: August 1,2018 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 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 certl , under the pans and penalties ofperjury that the information provided above is true and correct IN 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 Page 1 of 2 AFRO® CERTIFICATE OF LIABILITY INSURANCE ATE Dil /29/20JMMIDD)YYYY) 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 Willie of North Carolina, Inc. c/o 26 Century Blvd P.O. Sox 305191 CONTACT NAME: PHONE u) 1-877 _945-7378 FA Ne: 1-,888_967-2378_ EMAIL certificates@willis.com ADDRESS: _ INSURERS AFFORDING COVERAGE NAICN Nashville, TN 372305191 USA INSURER A: ACE American Insurance Company 22667 INSURED The Stop & Shop Supermarket Company LLC 1149 Harrisburg Pike INSURER B: American Guarantee and Liability Insurance 26247 INSURER C: Indemnity insurance Company of North Ameri 43575 INSURER D: Agri General Insurance Company 42757 Carlisle, PA 17013 INSURER E: ACE Eire Underwriters Insurance Company 20702 INSURER F: COVERAGES CERTIFICATE NUMBER: W4488707 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, INSR LTB TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDINNNY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR _ PR_ MA ISES E .NccunD�ence $ 2,000,000 MED EXP(Any one parson) $ A PERSONAL&ADV INJURY $ 2,000,000 HDOG2787101A 10/01/2017 10/01/2018 AGGREGATE LIMIT APPLIES PER: $ 2,000,000 GENT %< POLICY �JECTPHI uLOG _GENERALAGGREGATE PRODUCTS-COMPIOP AGG 2,000,000 _$ $ OTHER, AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Its Insward) $ 5,000,000 BODILY INJURY (Per person) $ X MY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS ISA H09063183 10/01/2017 10/01/2018 BODILY INJURY Per accident) $ HIRED NONOWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Peracedom $ B X UMBRELLA LIAS EXCESS LIAS X OCCUR CLAIMS -MADE AUC08249868-07 10/01/2017 10/01/2018 EACH OCCURRENCE $ 5,000,000 _ AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10, 000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBEREXCLUDED9 No (Mandatory in NH) NIA WLRC64417502 10/Ol/2017 10/01/2018 _._. X STATUTE ERTIT EL EACH ACCIDENT $ 1,000, 000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below A Workers Compensation-tm1 MRC64620241 10/01/2017 10/01/2018 E.L. Each Accident $1,000,000 Per Statute E.L. Dieeaae-Ea Er,l $1,000,000 E.L. Dieeaae-Pol Lim $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additlonal Remarks Schedule, may be attached It more space is required) RE: Store N007. Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Mansfield Health Dept. AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02098 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD an aD: 15361771 aaxcn: 526229 AGENCY CUSTOMER ID: _ LOC #: A�RLI® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willie of North Carolina, Inc. The Stop 6 Shop Supermarket Company LLC 1149 Harrisburg Pike Carlisle, PA 17013 POLICY NUMBER See Page 1 CARRIER NAIC CODE See Page 1 9ee Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORDING COVERAGE: Agri General Insurance Company NAIC#: 42757 POLICY NUMBER: WLR C64417538 EFF DATE: 10/01/2017 EXP DATE: 10/01/2018 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation -TN E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 INSURER AFFORDING COVERAGE: ACE Fire Underwriters Insurance Company NAIC#: 20702 POLICY NUMBER: SCF C64417514 EFF DATE: 10/01/2017 EXP DATE: 10/01/2018 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation -WI E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WCU C64417526 EFF DATE: 10/01/2017 EXP DATE: 10/01/2018 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Excess Workers Comp. E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 e[K•1:11C © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 15361771 exres: 5Z6229 cenr: W4488707 Zbe CCom monweato Of Aag5arbU$eti$ License No. 576 Serial No. 12052 DEPARTMENT OF INDUSTRIAL ACCIDENTS Tbk; i; tD eertffp that AHOLD AMERICA'S HOLDINGS, INC. AND ITS' SUBSIDIARIES Of. 1385 Hancock Street, Quincy, MA 02169 , having conformed with the provisions of sub paragraph ( 2 b ) of Section 25AofChapter 152 of the General Laws is hereby licensed tobea SELF -INSURER This license is effective for a period of one yearfrom the F I R S T day of A U G U S T 20 17 at 12:01 A.M., unless sooner revoked. EPA TMEWOFI STRIALA IDENTS� .c �1-7 D I R E C T O R THIS LICENSE MUST BE POSTEDATTHE LOCATION OF THE BUSINESS The Stop & Shop Supermarket Company LLC Officers and Managers Division President, Stop & Shop New England Mark McGowan Division President, Stop & Shop NY Metro Donald Sussman Chief Real Estate Development Officer James J. Sylvia Senior Vice President, Real Estate Timothy Mahoney Assistant Secretary Steven F. Rowell Assistant Secretary Gail Goolkasian Assistant Secretary Caroline Woodward General Counsel and Secretary Thomas A. Hippler Division President, Stop & Shop New England Mark McGowan Division President, Stop & Shop NY Metro Donald Sussman All Officers & Managers of The Stop & Shoo Supermarket COMDanv LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 NATIONAL FOOD SAFETY 1 PATRICK J STRY OF HAS SUCCESSFULLY SATISFIED THE REQUIREivIENTS FOR THE #0656 7680 Universal Blvd., Suite 550, Orlando, FL 32819 (800) 446-0257 F (407) 352-3603 w .NRFSP.com ,lational Registry of Food Safety Professionals@a Notification of Test Result ID#: xxx-xx- Scaled Test Score: 88 Candidate Status: Pass Test Date: August 24, 2016 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. Preventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product Time and Temperature (Competent) Conducting Cleaning and Sanitizing (Competent) Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered) FOOD SAFETY MANAGER UNDERTHE ISSUE DATE: AUGUST 24, 2016 EXPIRATION DATE: AUGUST 24, 2021 CERTIFICATE NO: 21 262740 TEST FORM: EZS34 This Certificate is not said for more than five years from date of issue. National Registry of Food Safety Professionalsm CERTIFIED FOOD SAFETY MANAGER �ATWCW HICKEY 0,1° �, " a `a �'LCerhficate LQa >I262740 -- IssueDate: Augusf?4 4b 16 Expiration Date: August 24, 2021 PATRICK J HICKEY 43 HARRIETT AVE BURLINGTON, MA 01803 National Registryof Food Safety Professionals© 1 7680 Universal Blvd Ste 550 1 Orlando, FL 32819 I Phone: 407.3523530 I Fax: 407.352.3603