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Home My WebLink AboutTedeschi's/7-Eleven 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 Establishmen 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: TEDESCHI FOOD SHOPS 37484H/7-ELEVEN, INC. 242 CHAUNCY STREET License Number: FS-102 Permit Expires: December 31, 2018 Food Fee: $125.00 Milk & Cream ICI BOARD OF HEALTH MicfiaeCMcCCean, 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: TEDESCHI FOOD SHOPS 37484H/7-ELEVEN, INC. 242 CHAUNCY STREET License Number: FS-102 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, 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: 7-ELEVEN, INC. having a place of business at: TEDESCHI FOOD SHOPS 37484H/7-ELEVEN, INC. 242 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 112212018 , unless previous to that time is suspended or revoked. Expires 112212018 License No.: FS-102 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 FS-101 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be ubmitted at least 30 days before the planned opening date) 1) Establishment Name 7484H17-ELEVEN, INC. 2) Establishment Address 242 CHAUNCY STREET 3) Establishment Mailing Address (if different) 242 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5421 5) Applicant Name & Title: 7 —_ t"e4l (vG r o Y v l I Q v- 6) Applicant Address PO BOX 219088,DALLAS, TX 75221 7) Applicant Telephone No.: 24 Hour Emergency No.: (267) 616-3449, TORRANCE CRAWFORD 8) Owners Name & Title RIICHKEN REALTY TRUST 9) Owner Address (If different from applicant) 636 COUNTY STREET, TAUNTON, MA 02780 Owner's telephone number 5088229740 10) Establishment Owned By: ❑ An Association WJ A Corporation 11 An al A Partnership g n Elt'ity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: DONALD AMES, MANAGER Address: 170 HIGHLAND STREET #23., TAUNTON, MA 02780 Telephone No: (508) 339-5421 24 Hour Emergency No: (267) 615-3449, TORRANCE CRAWFORD FAX: E-mail: 7� —Y Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Ti It e ; S�o�hP,r r®Sc ., /MKf A k- Address: I <J® ivy, ^� �� f �"j Telephone No: 24 Hour Emergency No: FAX: �] Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 8 17) DAYS/HOURS: 7AAYS/6:00 AM - 11:00 PM 18) Name of Person In Charge Certified in Food Protection Management: DONALD AMES 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 /r 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ / v� "'' 20) Location: [V] Permanent Location 22) Establishment Type - ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Food Service up to 100 or ❑ Mobile Food & Consession $75,00 Moblie Comments: 21) Length of Permit: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑./ Annual or up to 25' PHF display $150.00 ❑ Pushcart $25.00 # of Pushcarts: ❑ Seasonal Seasonal Dates: ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time0amperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furfherprocessing) 0 Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held [] Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ r H PHF and RTE Foods Prepared Foighly Susceptible Population Facility ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service --------- ❑Sale of Raw Ay C oods Intended to be Preparedd bby Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours ❑Vacuum Packaging /Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ---— Customer Self -Service of Non PHF and Non- Perishable Foods Only❑Ice ----- [_] Customer Self -Service Manufactured and Packaged for Retail Sale CI Preparation of Non-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 to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.Q00 and all other applicable law. I have been instructed by the board of health on how to obtain f 10.5 CMR 00Q and the federal Food Code. 24) Signature of Applicant: }}..�� - - Pursuant to MGL Ch.62C, sec. 49Ft"IIednder t e i p ies o rury t ai o m bes knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 75-1085131 '�� C, A^ I� 26) Signature of Individual or Corporate Name: "'r''u! Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Perinit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31 st of each year. NAME OF BUSINESSS4t V004 shape, r ADDRESS: 2q q- TELEPHONE AT LOCATION: S L p FAX NUMBER: iit-q1-9- ISp / OWNER OF BUSINESS: �j QxI{!l'� l VK- I TELEPHONE OF OWNER: `� 1 ~ -70 1 FEDERAL ID/SS NUMBER: �S - [�S i FEE: $10.00 PERMIT NUMBER: SIGNATURE: DAT : ��i Toi-vn of Mansfield - Board of Health PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 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 noof�this Regulation may1 result in fines, suspension or revocation of this permit. NAME OF BUSINESS: '�� Op1t J�S -, t D if )4 LOCATION OF SALE OF TOBACCO PRODUCTS: ,i/ t (�� CJ TELEPHONE AT LOCATION: OWNER OF BUSINESS: 1 G ADDRESS OF OWNER: TELEPHONE OF OWNER: f �il _(1/� TO I � JJ FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. -T5Lb3 License. FEE: $25.00 CT-3TNUMBER: Ic��3�`( FEDERAL IDISS NUMBER: SIGNATURE: 1 } ` � DATE � �� M sncrrosF Commonwealth of Massachusetts 4 l Department of Revenue C. Harding, Commissioner �Yy 'r,,�i1 Christopher gin' rum mass.gov/dor Letter ID: LI89822280.8 Notice Date: October 27, 2017 Account ID: CGL-10196336-110 RETAILER LICENSE FOR SALE OF CIGARETTES II'�I'�I�IIJ��I'�'III�IIII�"II'I�I�IIIuIInh61iII1�IJl�lllt 7 ELEVEN INC 7-ELEVEN 3MNK PO BOX 711 DALLAS I'X 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 ctiti c,,,55P , SF, J MASSACHUSETTS DEPARTMENT OF REVENUE Form - b p Retailer License for Sale of Cigarettes y 11� �Tt'f'Nr u `l` 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-10196336-110 7-ELEVEN 37484H Location ID: 10196336-0772 242 CHAUNCY ST License Number: 998928384 MANSFIELD MA 02048-1256 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 27, 2017 Expiration Date: September 30, 2018 CoInnanweai4lt or Massaclusens Lcucr I D: L 160499400 Doinnonem a F Itevenno Notice Dune: October 26, 2017 Christopher C. I larding, Coiningssioncr Account ID: Cid, 10196336 113 5 'EVr OMB Iim,govdor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I'�Ilddlll�u4l1lhlllt1'111uluIeIII IIIIIIIII [1411111'14r1'1 EEO 7 CLCVGN INC 7-CLGVBNg3g444R h0 BOX 711 DALLASTX 75221.11711 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 raasstaxconneet 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 JSs"` 'sr MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco 017Y �' �'�A r oFsw 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 7-ELEVEN 37484H Location ID: 10196336-0773 242 CHAUNCY ST License Number: 594929664 MANSFIELD MA 02048-1256 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: 0ctobcr 26, 2017 Expiration Date: September 30, 2018 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. -7-La�w E Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number �� Amw� / By: Corporate Of (Mandatory, i pplicable) ( _s , 5V� ctj��K-- *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\Seott's bomimentMood Establishments-Temp\TAX CERTIFICATION EORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ivww.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information y Please Print Legibly Business/Organization Name:�t d /� Address: 'It- City/State/Zip: !►IAvis �b�1 it: Soy 33q_ 5:T . Are you an employer? Check the appropriate box: Business Type (required): 1. am a employer with _0L employees (full and/ 5. etail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (me]. 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I L❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box # 1 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 ant an employer that is providing rfpt•hers' compensation insurance for my employees. Below is Ilse policy information. Insurance Company Insurer's Addrt City/State/Zip: Policy # or Sell 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 certifr, tntder file pains and penaties of perjury that lire information provided above is true and correct. www.mass.gov/dia Ac Ro D® CERTIFICATE OF LIAMLITY INSURANCE DATE (10/05)17 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 CONSITUTE A CONTACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endarsement(s). PRODUCER AON Risk Services Southwest, Inc. Dallas Location 2711 North Haskell Ave, Suite 800 Dallas, TX 75204 CONTACT NAME:PHONE ANC, No. Ext): 866 283.7122 FAX (A/C, No): (847) 963-6390 E-MAIL ADDRESS INSURERS AFFORDING COVERAGE NAICN (214) 989.0000 INSURER A: INSURED Inc. One Arts One Arts Plaza INSURER B: I ACE American Insurance Company j 22667 INSURER C: I Indemnity Insurance Cc of North America 143575 1722 Routh Street, Suite 1000 Dallas, TX 75201 INSURER D: 1 INSURER E: �.cRIIr-KWH1C NUMBER oOVlronxl u,,�.n.-.. IY V IYIpGR 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP INSR WVO DATE(MMIDD/YYI DATE(MM/DD/YY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE -RENTED $ CLAIMS MADEQX OCCUR. DAMAGET $ OWNERS' 8 CONTRACTOR'S PROT. PREMISES Ira occun-ence) MED EXP (Any One Person) $ LIQUOR LIABILITY PERSONAL B ADV. INJURY $ $E SELF INSURED RETENTION GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGO g AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMITALL $ ED AUTOS (Ea accident) CHEDU SCHEDU LEDAUTOS BODILY INJURY $ HIRED AUTOS (Per Person NON -OWNED AUTOS BODILY INJUR $(Per Accident) PROPERTYDAMAGE $ EXCESS LIABILITY (Per Accident) X UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ G WORKERS COMPENSATION AND 10/1/2017 10/1/2018<. X WC STATU-TORY LIMITS Other B EMPLOYERS' LIABILITY LRC6441561A EL EACH ACCIDENT $ 1,000,00E ANY PROPRIETOR/ Yes LRC64406578 ELDISEASE- POLICY LIMIT $ 1,00DOW PARTNERS/EXECUTIVE X No SCFC64415657 OFFICER EXCLUDED EL DISEASE -EA EMPLOYEE $ 1.000.000 B OTHER HDOG27870636 10/1/2017 10/1/2018 Ea. Common Cause $500,000 Liquor Liab Cvg Aggregate $500,000 DESCRIPTION OF OPERATIONS/LOCp110NSNEHICLE$/SPECIAL ITEMS Workers Compensation and Liquor Liability coverage applicable for all corporate operating 7.11 stores in the State of Massachusetts r:FRTIFIr:ATF wni nCR .....__.. ._._.. commonwealth of Massachusetts Division of Standards Ashburton Place SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN on,MA 02108 ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE �� w.I VIUO) I ne Auurcu name and logo are registered marks of ACORD £k \ ka.. ** - f U.U) \ \ B >c\ 0 <