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HomeMy WebLinkAboutSunoco 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 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:. 7-ELEVEN, INC. Whose place of business is: SUNOCO #40082H 70 COPELAND DRIVE Permit Expires: December 31, 2018 License Number: RF-31 Food Fee: $125.00 Milk & Cream !l 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 #40082H 70 COPELAND DRIVE License Number: RF-31 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: 7-ELEVEN, INC. having a place of business at: SUNOCO #40082H 70 COPELAND DRIVE 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 112312018 , unless previous to that time is suspended or revoked. Expires 112312018 License No.: RF-31 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 RF j c FOOD ESTABLISHMENT PERMIT APPLICATION - (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name SUNOCO #40082H- z 2) Establishment Address 70 COPELAND DRIVE t JAN 2 3 29°o3 3) Establishment Mailing Address (if different) P.O. BOX 219088 DALLAS, TX 75221 4) Establishment Telephone No (508) 339-2301 5) Applicant Name & Title: 7-ELEVEN, INC. 6) Applicant Address 3200 HACKBERRY ROAD, IRVING, TX 75063-0131 7) Applicant Telephone No.: (972) 828-7011 24 Hour Emergency No.: 8) Owners Name & Title 7-ELEVEN, INC. 9) Owner Address (If different from applicant) 3200 HACKBERRY ROAD, IRVING, TX 75063-0131 Owner's telephone numberTo I - -� 10) Establishment Owned By: 1 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. V! A Corporation An Individual Name l/ KWv-XT1�V1 rr�� bTitle // _wS(AVa, vP vC SCG Address 32� ►cK fYy f'�1�lYV( T%v A Partnership b Nj d sQVj-jQr UP Tres' gz— 0 4Lt %ey� -PQ y ✓t j,,1 Other legal Entity - - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: JOE BURROUGHS Address: 70 COPELAND DRIVE, MANSFIELD, MA 02048 Telephone No: I(508) 339-8766 24 Hour Emergency No: FAX:- E-mail: J , Alt E-Mail: 13) District Or Regional Supervisor (if applicable) - Name &Title:-T,6TC(4PC Q, C%ravvf-o V-4 - Address: I oS�Z-- Telephone No: Z 1„-7 „ b `S _ 3 VLt t, q 24 Hour Emergency No: FAX: �'�N21�Z$�7b;E-(mail: Q vVm ek74, a/� Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 8 ICI 17) DAYS/HOURS. 24 HRS./7 DAYS A WEEK 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 ��AA 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more). 20) Location: jam!, Permanent Location ! 22) Establishment Type -'. Mobile Mobile Start Date:;'.`. Retail ( Sq. Ft) Mobile End Date: ' Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 12 1) Length of Permit: �'_ J Food Service up to 101 -200 j Ili Annual or up to 25' PHF display $150.00 I Seasonal i..J Food Service up to 201 + -. or 254 PHF display $275.00 !! Seasonal Dates: 1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: ] Food Service - Institution ( Meals/Day) Rain Date: i_........... Caterer $25.00 111/" Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream -' $25.00/freezer [l Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 [ Retail Food $100.00 [._I Retail Snack Food $25.00 IV, Tobacco Products $25,00 i 23 Food Operations Definitions: PHF- Potentially hazardous food dime/femperature controls required) p Non-PHFs -non-potentially hazardous food(no time/temperature controls required) ,(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Vj Sale of Commercially Pre -Packaged Non-PHFs -j Sale of Commercially Pre -Packaged PHFs -_, Delivery of Packaged PHFs i 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 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 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 ! acuum Packaging / Cook Chill ] U f A --- Self-service -- -- -- Self �� se o Process Requir ng variance ;1..,✓Customer -Se ! and/or HACCP Plan (including bare hand (fie Manufactured and Packaged for 1 contact alternative, time as a public health I Retail Sale , _ control) ,mice Manufactured and Packaged for J Offers Raw Or Undercooked Food Of Retail Sale Animal Origin r J OtfersRTE PHF in Bulk Quantities f_J Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health -- _-- - - - - -- - - Total Permit Fee: $100.00 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 w' comply with 105 CMR 590. 0 and all other applicable la I have been instructed by the board of health on how to b copies of 105 5 .0 0 and the federal ood Co 24) Signature of Applicanti: Pursuant to MGL Ch.62C, sec. 49A, I certify and enalties of perjury that I, 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: 75-1035131 —� 26) Signature of Individual or Corporate Name: Y V l-- Town of Town of Mansfield - Board of Health 6 Pak Rowansfield 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: SUNOCO #40082H ADDRESS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 a-t FAX NUMBER: _ \b 6 OWNER OF BUSINESS: 7-ELEVEN, INC. TELEPHONE OF OWNER:on-'� -% - \ i FEDERAL ID/SS NUMBER: 75-1085131 FEE: $10.00 7i PERMIT NUMBER: RF-r SIGNATURE: DATE: Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 3t PERMIT NUMBER: RF0_ 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: SUNOCO #40082H LOCATION OF SALE OF TOBACCO PRODUCTS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 OWNER OF BUSINESS: 7-ELEVEN, INC. ADDRESS OF OWNER: P.O. BOX 219088 TELEPHONE OF OWNER: (972) 828-7011 FAX NUMBER: TA Z l 0 If a corporation or partnership, give name, title, and home address of officers or partner. SEE APPLCATION * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 1564379136 FEDERAL ID/SS NUMBER: 75-1085131 0 SIGNATURE: DATE: 1 /2017 sss�;?ReF� Commonwealth of Massachusetts Letter ID: L0154855680 K 3 A Department of Revenue Notice Date: August 31, 2017 Christopher C. Harding, Commissioner Account ID: CRL-10196336-I l3 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IIII III '1'111111'11'I1II111'IIII III IIIII III d]III III IIIII III IIII 7 ELEVEN INC 7-ELEVEN 3"� PO BOX 711 DALLAS TX 75221-0711 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 MassTaxCofinect 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 r�s5'" ,i"r<T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T yA\ Retailer License for Sale of Cigars and Smoldng Tobacco Pr , ;'//.. This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CRL-10196336-113 SUNOCO #40082I-I Location ID: 10196336-0705 70 COPELAND DR License Number: 1629587456 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: August 31, 2017 Expiration Date: September 30, 2018 essr"w,f. Commomvealth of Massachusetts Letter 1D: L0667801856 v,= Department of Revenue Notice Date: August 31, 2017 Christopher C. Harding, Commissioner Account ID: CGL-10196336-110 IiET.ipcv`�` mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 'llll'I'll'lllll""IIII"III'II"IIII'llJhlllllltlilnlllll�ll 7 ELEVEN INC 7-ELEVEN PO BOX 711 DALLAS TX 75221-0711 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 snc"'"t 5n MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ^4Prl�a l y Retailer License for Sale of Cigarettes T ',F,vr o�,.�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. 7 ELEVEN INC Account ID: CGL-10196336-I 10 SUNOCO #40082H Location ID: 10196336-0704 70 COPELAND DR License Number: 1564379136 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: August 31, 2017 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. M Signature of Individual or Corporate Name By: Corporate tser (Mandatory, Applicable) S� _�,��5 ► 3 I **Social Security No. (holuntanj) 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:\Users\sleite\Desktop\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMI TING AUTHORITY. pplicant Information PI Business/Organization c- d fJ 0-1k14 -L Phone M Z30 Are --you anan employer? Check thh appropriate box: Business Type (required): 1. [tj-r am a employer with employees (full and/ S. etail or part-time).* 6. 1-IRestaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no - y, ❑ 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. El manufacturing no employees, [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. [� Health Care with no employees. [No workers' comp, insurance req.] 12.0 Other *Any applicant that checks box #] 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 wor ers' compensation insurance for my employees. Below is the policy information. Insurance Company Name—: 4-Po A t q Insurer's Address: City/State/Zip; V k A + t , 1 (''� `(t,_� —O Policy #or Self-ins.Lic.#- �W L C/ V S 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 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. 9 Id R A.►�o _A 'LA- n,ea, I -- 22A q 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 Phone w mass.gov/dia A� CERTIFICATE OF LIABILITY INSURANCE DATE 00/05)17 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT' WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE IRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY CLAIMS.' INSR LTR I TYPE OF INSURANCE GENERAL LIABILITY ADD[ IN5ft SUB R WVD POLICY NUMBER POLICYEFF GATE (MM/OD/YY) POLICY DATE (MM/OD/DDI YY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE XQ OCCUR. OWNERS' & CONTRACTOR'S PROT. DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED E%P (Any One Person) $ LIQUOR LIABILITY PERSONAL B ADV. INJURY S $500,000 SELF INSURED RETENTION GENERAL AGGREGATE $ AUTOMOBILE LIABILITY PRODUCTS-COMP/OP AGO $ ANYAUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS (Ea accident) SCHEDULEDAUTOS BODILY INJURY $ HIRED AUTOS (Per Person) NON -OWNED AUTOS BODILY INJUR $ (Per Accldenq PROPERTY DAMAGE $ EXCESS LIABILITY (Per Accident) X UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELIA FORM AGGREGATE $ C B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY NY PROPRIETOR/ Yes PARTNERS/EXECUTIVE X No OFFICER EXCLUDED LRC6441581A LRC64405578 SCFC64415657 1D/1/2017 70/i/2018 x WCSTATuTORY LIMITS Other CCID- EL EAEASE—POLI $ 1,000,000 EL DISEASE -POLICY LIMIT ELDISEASE—EAEMPLOYEE $ $ 1,000,000 1,1300,000 Ea. Common Cause Aggregatemm $500,000 B JOTHER Liquor Liab Cvg HDOG27870638 70/1/2017 10/1/2018 DESCRIPTION Workers OF OPERATIONSILOCATIONSNEHICLES/SPECIAL Compensation and Liquor Liability coverage ITEMS applicable for all corporate operating 7-11 stores in the Slate of Massachusetts CERTIFICATE HOLDER I Ashburton Place SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ten,MA 02108 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE AON RISK SERVICES SOUTHWEST, Inc. ©1900-ZUIU ACORD CORPORATION. All rights reserved. • ­ ­$ „dnad dnu 1u9O are registered marks of ACORD