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Home My WebLink AboutStop & Shop 12/31/2018 (2)Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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 CO., LLC Whose place of business is: STOP & SHOP SUPERMARKET, CO., LLC GAS STATION #007 BOARD OF HEALTH 377 CHAUNCY STREET License Number: S-15 Permit Expires: December 31, 2018 Food Fee: $25.00 Milk & Cream L ' 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: STOP & SHOP SUPERMARKET, CO., LLC GAS STATION #007 377 CHAUNCY STREET License Number: S-15 Permit Expires: December 31, 2018 BOARD OF HEALTH Mich aeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued S=15 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name STOP & SHOP SUPERMARKET, CO., LLC GAS STATION #007 2) Establishment Address 377 CHAUNCY STREET 3) Establishment Mailing Address (if different) 1386 HANCOCK STREET, ATTN: LICENSING DEPT. 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 CO., LLC 9) Owner Address (If different from applicant) 1385 HANCOCK STREET, QUINCY, MA 02169 Owner's telephone number 6177708708 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1, 1 An Association or partner. a A Corporation Name Title Address C ] An Individual —__-_ A Partnership L (--� - - - _ 11WI Other legal Entity , 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title OARREWBEANGELIS, STORE MANAGER Address: 377 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No. (508) 33�7-9450 24 Hour Emergency No: (877) 893.5393 �1 FAX: E-mail: SS-�STORE.0007.STOREMANAGER@AHOLD COM o\af'e r r 7-r;tc ar�ctn Alt E-Mail: ASH LYE.BRENNAN((@AHOLD.COM 13) District Or Regional Supervisor (if applicable) Name & Title y �C� y�F'lEViSfRICT MANAGER Address: __ ---- — - .------------------ (y® L; t'Y7'i{CScy- r % j Telephone No: :(860) W jj _ ,� 24 Hour Emergency No: (877) 893-5393 FAX: L'� E-mail: r�� ; f �-7�_ Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: DEP Public Water Supply No (If applicable) _ i - 16) No. of Food Employees: 17) DAYS/HOURS: MON-SAT 6 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.J Required as of 101112001 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: [J Permanent Location 22) Establishment Type Mobile Mobile Start Date: ' U Retail ( S Ft) Mobile End Date: Moblie Comments: 21) Length of Permit: IV Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: 1 q ] 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 254 PHF display $275.00 L_1 Food Service - Institution ( Meals/Day) TOWN ❑ Caterer $25,00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [J Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 j Retail Food $100.00 ICJ Retail Snack Food $25.00 Tobacco Products $25,00 Rain Date: --_-_--------------- _____ 23)Food Operations Definitions:PHF- Potentially hazardous food(time/lemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ;Check all that apply): RTE -ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) i EV Sale of Commercially Pre -Packaged Non-PHFs 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 Other Food Operations I PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service [.1 Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service [Ice Manufactured and Packaged for Retail Sale [- I Juice Manufactured and Packaged 1 Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or FIACCP Platt (including bare hand contact alternative, time as a public health [„] Offers Raw Or Undercooked Food Of Animal Origin - _ - - I ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities 'I ____ __ —.__ Catered Events or Institutional Food Service Retail Sale of Salvage Out -Of -Date I ..._._.- -- __ --_ or Reconditioned Food i r To be completed by the Board of Health --- -- "----"___—� Total Permit Fee: $25.00 Payment is due with application waived 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 an "A federal Food Code. 24) Signature of Applicant: t ./, (( 4 `� YPt-1 /'�✓ ----- _, Pursuant to MGL Ch.62C, sec. 49A, 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: 04-3061447 '� ,,,111 //, 26) Signature of Individual or Corporate Name: �7i`f'r'Yinle2.v-�-�E'- Town of Town of 'Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 PERMIT NUMBER: 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: STOP & SHOP SUPERMARKET, CO., GAS STATION #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: (508) 337-6791 If a corporation or partnership, give name, title, and home address of officers or partner. SEE ATTACHED LIST Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 274968576 FEDERAL ID/SS NUMBER: 04-3061447 SIGNATURE: H_\I4 >�'uF MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L0297882624 ?� �s PO BOX 7044 Notice Date: October 17, 2016 BOSTON, MA 02204-7044 Account ID: CGL-10044051-295 a9/6 CONTACT CENTER �4 (617) 887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES �l�1ii11hduh�P�uhPidlpI�PIPPdIPIIIIIP�III�ulhl� ATTN LICENSING DEPT STOP & SHOP SUPERMARKET CO LLC STOP & SHOP #001 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. DETACH HERE rsSPO iosi,� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T qA Retailer License for Sale of Cigarettes 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 FUEL #007 377 CHAUNCY ST MANSFIELD MA 02048-1169 Location ID: 10044051-0228 License Number: 274968576 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 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 nffirarc R Mannners of The Stoo & Shop Supermarket Companv LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708