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HomeMy WebLinkAboutSunoco 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Retail 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:. SUNOCO, INC. (R&M) Whose place of business is: SUNOCO #6035 70 COPELAND DRIVE Permit Expires: December 31, 2018 License Number: RF-51 Food Fee: $100.00 Milk & Cream ',1 BOARD OF HEALTH 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: SUNOCO #6035 70 COPELAND DRIVE License Number: RF-51 Permit Expires: December 31, 2018 BOARD OF HEALTH AichaeCMcCCean, 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., SUNOCO, INC. (R&M) having a place of business at: SUNOCO #6035 70 COPELAND DRIVE 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.: RF-51 Board of Health .MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 4696461273 PRK 348 12:04:52 12-28-2017 1/11 f`? FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at leastdays betcre Me planned opening a e 1) Establishment Name () r _#�_ DS5 2) Establishment Address 0 do s �� 3) Establishment Mailing Address (if different)j?m Wrid!ah 81,.(/ ( ,-:'A 19�1 4) Establishment Telephone No 5M3-9 -23a / .yZu/i-e-,2AOf D 5) Applicant Name & Title: G A-o 5 _ i_lense jtznor 6) Applicant Address gt7Z0 $r _ A- 7az3 7) Applicant Telephone No(iOq 0t 4b_ / 0 0 E5 24 Hour Emergency No.: 10C- 6) Owners Name & Title ,u � Q C ! $ 9) Owner Address (if different from applicant) Owner's telephone number 10) Establishment Owned By: ® An Association " Corporation ® An Individual IN A Partnership ® Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 5z,P— affaC A4 12) Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager etc.) J Name &Title: -r' r� �` .J OS h Uu//'O (P s - J� DYE 9ge. Address: pzand hr AllanspieGd,ozac Telephone No: Jf� �� _ 30 24 Hour Emergency No; ��%� >V 59j 1S41 - 6iV'1 p8 33y- Sri FAX: E-mail: Alt E-Mall: 13) District Or Regional Supervisor (if applicable) Name &Title: `l Address: Telephone No: 74_10( 24 Hour Emergency No; FAX: �9' 56 E-mail: 4696461273 PRK 348 12:05:22 12-28-2017 2111 Food Establishment Information 14) WATER SOURCE: —FOW 1,I 1 15) SEWAGE DISPOSAL: 16) No. of Food Employees: DEP Public Water Supply No: (if applicable) 17) DAYS/HOURS: 2f/ 18) Name of Person In Charge Certified in Food Protection Management p� n nh �, u rr pug If more than 3 Individuals are certified, complete list Is on file. 7' Required as of 10112001 In accordance with 105 CUR 590.003(A) Please attach copy of certificate t9) Person Tmined in Anti -Choking Procedures (If 25 Seats or more): ❑® 20) Location: 56ammment Locallm I] Mobile Mobile Start Date: �22) /Establishment Type } Ratoll ( H 5 t? Sq. Ft) ® Cal rer $25.00 Ilk & Cream $10.00 Mobile End Date: ® Food Service up to 100 or np Mobile Food & Consesslon $75.00 Mobile Comments: up to 10' PHF display $125.00 ® Food Service up to 101-200 Manufacture Frew Dessertsllce Cream $25.00/hazer 21 ength of Permit: Annual druid to 25' PHF display $150.00 ❑® Food Service up to 201 + or 2T+PHF display $275.00 © Pushcart $25.00 # of Pushcarts: Residential Kitchen $100.00 Vetail Food $100.00 I] Seasonal Seasonal Dates: t] Food Service - Institution ( Meals/Day) ,®, Retail Snack Food $25.00 ram, Tobacco Products $25.00 ® Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Dale: 23) Food Operations (ock all that apply): Definitions: PHF- Polentlasthazardous food ffimeRemperafum cunholsrequNed) Non-PHFs- nonpo(anf7alfy hazardous food(no flma/temparalure conho/srequked) RTE-ready-to-sal foods (Ex.sandwiches, salads muffins which nsadno falherprocessing) ,,C,h Lai Sale of Commercially Pm -Packaged Non-PHFs ❑B PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Delivery of Packaged PHFs ❑ ® Sale of Raw Animal Foods Intended to be Prepared by Consumer to Reheating of Commercially Processed Foods for Service Within 4 Hours IN Vacuum Packaging / Cook Chill Use of Process indi Vadn end/or HACCP Pllanan (including bare ce hand contact alternative, time as a public health control) ® Customer Self -Service of Non PHF and Non- Perishable Foods Only ® Customer Self -Service ® Ice Manufactured and Packaged for Retail Sale ® Preparation of Nan-PHFs Other Food Operations ® Juice Manufactured and Packaged for Retail Sale ❑® Offers Raw Or Undercooked Food Of Animal Origin (] Prepares Food/Single Meals for Catered Events or Institutional Food Service ® Offers RTE PHF In Bulk Quantities ❑® Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed By the Board of Health Total Permit Fee: Payment Is due with application ® waived I, the undersigned, attest a accuracy of the formalion provided in this application and affirm that the food establishment operation II cumply with t06 R 590.000 and all other applicable law. I have been Instructed by the board of health on how to o 6 CMR 690.000 and the federal Food Code. 24) Signature ofAp nt: Pursuant to MCL Ch.62C, sec. 49A. I certify under the penalties of perjury that I, to my best kno a ge-au helief, have glad all state tax returns and paid stale laces required under law. 25) Social Security Number or Federal to: 26) Signature of individual or Corporate Name: 4696461273 PRK 348 12:06:52 12-28-2017 5/11 Town of Mansfield - Board of Health Application for Milk and Cream Permit Town of Mansfield 6 Park Row Mansfield, MA 02048 I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: 11& L1 hL 0 Gt7 *,{o o 35 ADDRESS: "Trj Cop -anj jr, TELEPHONE AT LOCATION: (.5500-55f-'Ogol FAX NUMBER: OWNER OF BUSINESS: SI.It bcb1 J,-4u0-(Y+PA) TELEPHONE OF OWNER: 0)55Q 0 20 FEDERAL ID/SS NUMBER:-ll�l�ff� FEE: $10.00 PERMIT NUMBER: 13r51 r SIGNATURI DATE: �' 4696461273 PRK 348 12:05:56 12-28-2017 3111 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 Ones, suspension or revocation of this permit. NAME OF BUSINESS: SUi.! OGQ LOCATION OF SALE OF TOBACCO PRODUCTS: 7d Cop.LGand Dr. TELEPHONE AT LOCATION: OWNER OF BUSINESS: 45UuaGo lme «�M� ADDRESS OF OWNER: TELEPHONE OF OWNER: (toID) g5q-ZW9 or X,610 FAX NUMBER: 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 RetaY Excise Unit License. FEE: $25.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: SIGNATURE: DATE: bsnetRtrr Commonwealth of Massachusetts Letter to: L0602314240 Department of Revenue Notice Date: May 17, 2017 '' Michael J. Heffeman, Commissioner Account ID: CRL-10916694-047 '1u\TOµ ntass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I10101IIIIII11111111111111111gIlgIgIIIIIIIIIIIIIIIIIIIIIIIIIII TAX DEPARTMENT SUNOCO RETAIL LLC 3801 WEST CHESTER PIKE NEWTOWN SQUARE PA 19073-2320 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 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 1Q5 ""t'SFp MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T y Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SUNOCO RETAIL LLC Account ID: CRL-10816694-047 SUNOCO 6035 Location ID: 10816694-0042 70 COPELAND DR License Number: 1560276992 MANSFIELD MA 02048-1221 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: May 17, 2017 Expiration Date: September 30, 2018 4696461273 PRK 348 12:07:07 12-28-2017 6111 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. or Corporate Name By: Corporate Officer (Mandatonj, if Applicable) "Social Sdetlrity No. (Voluntanj) 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. C:\Usm\sleite\Desktop\SwWs Dowmenis\Food Estabtishmcnts. Tcmp\TAX CERTIFICATION FORMAne 4696461273 PRK 348 12:06:19 12-28-2017 The Commonwealth of Massachusetts UIVDepartment oflndustrialAccidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.niass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 15g46(. 1 6,. (—Wl+M ) Address: 099- MAdd ran RV4 I S 6 , 0601 /y City/State/Zip: VJVPM(SSIr)j iTA�4ip�1L Phone #:�IalQUS-'U19 4/11 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail orpmt-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. S. ❑ 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 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 1 12.0 Other 'Any applicant that checks box # I most also fill out the section below showing their workem' compensation policy infmmation. **If the corpomte officem have exempted themselves, but the corporation has other employees, a workers' compensation policy is requimd and such an organization should check box #1. lam an employer chat isprovidiag workers' cotnpcnsation hisarance for my employees Beloit, is the policy information. Insurance Company Insurer's City/State/Zip: (gritpact, b qi T it 0UI C 27VQZ 'Ito(,o— Policy # or Self -ins. Lie. # MM W z-Y 2 AZ 9 (5 Expiration 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 1yst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investial of the DIA r insurance coveraee verification. 1 do hereby cerh r the pains io eats ofperjury that the information provided above is trite and correct K Signaturey� K Date: l 2V l/,T )(Phone#: la2z- 11 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/Lice tse # 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 #: www.mass.gov/dia 4696461273 PRK 348 12:09:11 12-28-2017 10/11 ACORO® CERTIFICATE OF LIABILITY INSURANCE �i. 9/15/2018 DATE (MMmomvYl 9/7/2017 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 pollcy(les) 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 LOCKTON COMPANIES COMA" NAME: 5847 SAN FELIPE, SUITE 320 HOUSTON TX 77057 866-260-3536 _ PHONE aC N•: a 11, E-MAIL ADDRESS, INSURERS AFFORDING COVERAGE NAICy IN9URERA:OId Republic Insurnnce Coin an 24147 INSURED Sunoco Retail, LLC 1389322 3801 West Chester Pike INSURER 6: INSURER C: INSURER 0: Newtown Square PA 19073 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 13995767 REVISION NUMBER: XXXXXXX 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 BYPAID CLAIMS. IEXP LTR TYPEOFWSURANCE DIED ADDL eVDBIR POLICYNUMBER usamYI'YY MMMDNYY UNIT A X COMMERCIAL OENERAL LIADWTY CLAIMS -MADE � OCCUR Y Y MWZY 59829-17 9/152017 9/IS/2018 EACH OCCURRENCE f 10000000 OA PREMISES e T $ 10,000,000 MEDEXP An ono raon S XY,)CK) Y PERSONAL B ACV INJURY S 10.000.000 GEN'L AGGREGATE UMR APPLIES PER: }{ POLICYE],ECT MLUC OTHER: GENERALAGGREGATE S IOOOO= PROOUMS•COMPIOPAGG s See Below S A AUTOMODILEMARILITY NX X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY MCS-90 y y MWTB2171117 9/15/2017 9/15/2018 (CSOaacddenl GLEU $ 10i000000 BODILY INJURY (Par panon) 5 )CXXXXX- )( BODILY INJURY (Par acddanl) $ XX)CXY t PROPERTYDAMAGE Per arcIdeni S XXXXXXX S XXXXXXX UM8119"LIAB IXCE99 LIAR OCCUR CLAIMSMAOE NOTAPPLICABLE EACH OCCURRENCE 5 XXXXXXX AGGREGATE S )CXXX)CXX DEO I IRETENTIONS S XXXXXXX A WORKERS COMPENSATION Rs ANDEMPLOYE'MANUTY ANY PROPRIETORMARTNIouixECUTIVE !N OFFICERIMEMBER EXCLUDEO? N (Mandabry In NN) OERIPTIONOFOPERATIONSbelow NIA Y MWC 117949-17(AOS MWC 311172-00 (TX ONLY) 9/15/2017 9/15/2017 9/15/2018 9/15/2018 PER OTH- X STATUTEER FL EACH ACCIDENT $ 10000000 EL DISEASE• EA EMPLOYEE S 10000000 EL DISEASE -POLICY LIMIT S 10000000 A *Excess Workers Compensation N Y MWXS 300313-17 9/15/2017 9/152018 EL Each Ace $I OMM EL Disease -Policy Lim S10MM EL Disease -Each Empl SIOMM DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES IAnDRD 101, AddlUonal RemarW Schedule, may be anached II mem epaee u mqulmdl EXCESS WORKERS COMPENSATION -• POLICY APPLIES TO STATES: OH and NM. Products/Completed Operations Aggregate Limit Subject to the General Aggregate Limit. All policies (except Workers'Compensation/EL) contain a special endorsement with"Primary and Noncontributory"wording. 13995767 For Informational Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, !-1L[5L•]:ItIK•]:11•]:faV1{•1:IIe{I ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 4696461273 PRK 348 12:08:19 12-28-2017 9/11 Sunoco, Inc. (R&M) 1 Hirm"`:mluvg= „an` n. t?.,r_: wriltek„ s i ...:xis}zvmxf - � amw-3`t"``.".�is Asher, Cynthia A Vice President 1?731/2999 Perpstuat ,"...ur�s."`,c.s•3-v:-rs�r-•v. " ^i .. "'-2^- .c ^,x .,Gennai Caunsel6Secretwyi s , c . z#1713111999 x" <"—" PdPGh1?7 r'^'-I Donne0y, Mard K. Assistarl Secretary 12/312999 pmmh al ' .t., r �" L s a� r{n F 2 as i H'•-cs�-ucw�,_; ,f n. .ig£3: iss:.':... ux� y'i °. }.. «=.r,. e ...r:r=- xi `µ,t,.:f•br i•i5�''�W.:•.1 �'F'my..z y� ,,M }., 7iye+y�Pey�v�(e:'i'� �Green, Pat&im J. Vice President 1?I31f2999 Perpetual riw�,wa,yS i'' J iLT't;s e '"'-ili iVICO pn F fi 'Y`"MS "r`R A.i,Re rn„ °i"*.M1.>s. �i{ .Mj �7"^kt+'. in+ ��_,...•. .�.�c.,:..,. ,..y +r--a2F rr=.c. '• ,.;...lw.��'ui:Csi.J..7.,':: :.•S"viC'iL.1:s �.`:S�.s.. Hess, Sheryl Vice President i?73V3999 Peryeluat 7 -p i Ai ea �, i � 5i ai .. -,{ •Si+�' y d'+1 +�tFF i a4 �t.aa�, x',}�,--• x-�•/E�'.�tusa 1A.. �,k Owens, RoW W. Sole Director 12131MAO P"luoi kt Td,? ^J� � � s h r '. y s "'�"„t�� nxL �h srix`tX�°' zr•Tv^-`-2�.M"�"irMp+ SLrol, John P. Mes President 1213MM Parpetual WegrKr''kJamesF SS:¢t. .rsmmill '^ ;•�?.•. .. t rx ,;t y $ r:., f='•4--15-xeSu,a.:-.-i .L>�.a'- ,:�. }^ .F' wwams,AnOmyM. We President IMI/2999 Peipeprai 01MV2016 Pape i of 1 4696461273 PRK 348 12:09:50 12-28-2017 11111 All policies (except Workers' Compensation/EL) Include a blanket automatic additional Insured endorsement [provision] that confers additional insured status to the certificate holder only if there Is a written contract between the named Insured and the certificate holder that requires the named Insured to name the certificate holder as an additional insured. In the absence of such a contractual obligation on the part of the named Insured, the certificate holder Is not an additional Insured under the policy. All policies include a blanket automatic waiver of subrogation endorsement [provision] that provides this feature only when there Is a written contract between the named Insured and the certificate holder that requires it. In the absence of such a contractual obligation on the part of the named insured, the waiver of subrogation feature does not apply. Miscellaneous Attachment: M490201 Master ID: 1389322, Certificate ID: 13995767