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HomeMy WebLinkAboutRIte Aide 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:. MAXI DRUG, INC. Whose place of business is: RITE AID #10141 243 CHAUNCY STREET Permit Expires: December 31, 2018 License Number: RF-15 Food Fee: $100.00 Milk & Cream ICI 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: RITE AID #10141 243 CHAUNCY STREET License Number: RF-15 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: MAXI DRUG, INC. having a place of business at: RITE AID #10141 243 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.: RF-15 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 RFRF15 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openin d __----- ,A 1) Establishment Name 2) Establishment Address RITE AID #10141 243 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 3165 ATTENTION: HARRISBURG, PA 17105 4) Establishment Telephone No 5) Applicant Name & Title: MAXI DRUG, INC. (508)337-8800 6) Applicant Address P.O. BOX 3165, HARRISBURG, PA, 17105 7) Applicant Telephone No.: (717)761-2633 8) Owners Name & Title 24 Hour Emergency No.: (508) 725-3549 MAXI DRUG, INC. 9) Owner Address (If different from applicant) P.O. BOX 3165, HARRISBURG, PA 17105 Owner's telephone number (717) 761-2633 10) Establishment Owned ey: 11) If a corporation or partnership, give name, title, and home address of officers I J An Association or partner. l A Corporation Name Title Address CJ An Individual _ Ll A Partnership -�I Other le al Entit — -- __... 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title WILLIAM PEREIRA, MANAGER Address: 31 BOW STREET, PLAINVILLE, MA 02762 Telephone No: FAX: E-mail: Alt E-Mail: 695-4013 24 Hour Emergency No: (500) 725.3549 !(508) 337-6193 iBI LL0905@COMCAST. N ET 13) District Or Regional Supervisor (if applicable) Name &Title: VINNI PIZZI Address: I4 WASHINGTON STREET, CANTON, MA Telephone No:'(781) 821-6038 24 Hour Emergency No. (401) 626-7099 FAX: (781) 821-1448 ' E-mail Food Establishment Information �4) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 16) NO of Food Employees. 17) DAYS/HOURS: MON-FRI 8 AM-10 PM SAT 8 AM-10 PM SUN 8 AM-10 PM 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ 20) Location: [] Permanent Location 22) Establishment Type ] Moblie Moblie Start Date: Retail ( Sq. Ft) Moblie End Date: [) Food Service up to 100 or Moblie Comments: up to 10' PFIF display $125.00 21) Length of Permit: ] Annual ❑ Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 j Food Service - Institution Meals/Day) ❑ Caterer $25.00 j] Milk & Cream $10.00 El 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 23) Food Operations Definitions: PHF- Potentially hazardous food (tune temperature controls required) 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) [] Sale of Commercially Pre Packaged Non-PHFs L] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- - - - - - r/] Sale of Commercially Pre -Packaged PHFs I ---- - ---- - --------- ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service _-.._.._..._..... _- - --- ---- [_] Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly -- -------- ----- --1--1---- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer --""- c Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ------------ -------- ❑ Customer Self -Service of Non PHF and Non- ------------ - [ .j Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ___ - --- -- --- - Ice Manufactured and Packaged for contact alternative, time as a public health ❑ Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service _i Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Eoobe completed by the Board of Health l Permit Fee: $100.00 ment 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 and the federal Food Code. 24) Signature of Applicant: 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: 04-2960944 26) Signature of Individual or Corporate Name: 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: RITE AID #10141 ADDRESS: 243 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-8800 FAX NUMBER: (508) 337-6193 OWNER OF BUSINESS: MAXI DRUG, INC. TELEPHONE OF OWNER: (717) 761-2633 FEDERAL ID/SS NUMBER: 04-2960944 FEE: $10.00 PERMIT NUMBER: RF-15 SIGNATURE:iCLI DATE: Town of Mansfield Town of'Mansfield - Board of Health 6 Park Row 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. NANIE OF BUSINESS: RITE AID #10141 LOCATION OF SALE OF TOBACCO PRODUCTS: 243 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-8800 OWNER OF BUSINESS: ADDRESS OF OWNER: MAXI DRUG, INC. P.O. BOX 3165, HARRISBURG, PA 17105 ATTN LICENSING TELEPHONE OF OWNER: (717) 761-2633 FAX NUMBER: (508) 337-9966 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 Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 1367855104 FEDERAL IDISS NUMBER: 04-2960944 SIGNATURE: '/v DATE: 1%2710 tign� iU,cFr, MASSACHUSETI:S DEPARTM ENT OF REVENII'. [xim ID: 1,0957211648 PO BOX 7044 Notice Date: Octobei 5. 2016 BOSTON, MA 02204-7044 Account ID: CG],-11371248-007 CONTACT CENTER �.4�„ • e4: (617) 887-6367 h�OF RETAILER LICENSE FOR SALE OF CIGARETTES nr°Illr�rlu'11P�Phl4ld�lpldggl„Ilpbl�llghlul MAX] DRUG INC BROOKS PHARMACY 200 NEWBF.IU0' CMNS ETTERS PA 17319-9303 Attached below is vour 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.govhnasstaxconnect to view and rc-print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -flee in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o iAj Retailer License for Sale of Cigarettes ��✓ y: This license must be posted and visible at all tunes. The sale of tobacco products to anyone under 18 ,years of age is prohibited. MAXI DRUG INC Account ID: CGL-I 1371248-007 RITE AID N. 10141 Location ID: 1 1371248-0207 243 CHAUNCY ST License Number: 1367855104 MANSFIELD MA 02048-1247 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 5, 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 Individua or Corporate Name By: Corporate Officer (Mandatory, if Applicable) . 0:1 - a 9coo9'4�( *"Social Security No. (Voluntary) 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. R\Hl RhVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doe \ The Commonwealth of Massachusetts UVDepartment of IndustrialAccidents Office ofInvestigations- I Congress Street, Suite 100 Boston, MA 02114-2017 w ww. mass. gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: Are you n employer? Check the appropriate box: 1. I am a employer with 15 + employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Business Type (required): 5. Rjlr5tail 6. ❑ Restaurant/BarMating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Mannfacturing 11.❑ Health Care 12. ❑ Other _.__ *Any applicant that checks box 41 nmst 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' conpensation policy is required mid such an organization should check box ti 1. lain an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: ('fine_s,,,re -- City/State/Zip:r���---- Policy # or Self -ins. Lic. #TR- KU 17 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 pensl�es ofyeijury that the information provided above is true and correct. • _ w_ OA. Phone#• 7/7-e2.1` —S-S— l) Official use only. Do not write in this area, to be completed by city or town official. City or Town: Perntit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.ntass.govidia Corporate Officers and Directors of Maxi Drug, Inc. Incorporated in the State of Delaware on 1112811990 Federal ID# 042960944 Kenneth Black, President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone:717-214-2550 Michael Podgurski, Vice President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone:717-975-5888 Susan Lowell, Vice President Office Address: Rite Aid Corporation, 200 Newberry Commons, Etters, PA 17319 Office Phone: 717-975-5744 Ghislaine Lespinasse-Bond, Vice -President Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone:717-975-5768 Daniel Miller, Vice President & Secretary Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-214-2541 Matthew Schroeder, Vice President & Treasurer Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-214-8867 AFRO® CERTIFICATE OF LIABILITY INSURANCE DATE ovos/2017 YY) zon 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 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 MARSH USA, INC. 501 MERRITT 7 CONTACT NAME: P"CONNo E 1 - AIC No): NORWALK, CT 06856 Aftn Norwalkoedrequest@marsh.com l Fax: 212-948-0929 E-MAIL -" AooRlsss: INSURER S AFFO_RDING COVERAGE NAIC p _ INSURER A: NIA_ NIA 416752-DRUG-GAWXW-17-18 GLU RITE AID INSURED AFFILIATES _ INSURER B: Travelers Property Casualty Company of America -- 25674 INSURER C :The Travelers Indemnity Company 25658 165 - PO BOX 165 3 HARRISBURG, PA 17105 INSURER D INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-008226771-09 REVISION NUMBERS 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 SUER POLICY NUM BER POLICY EFF MMIDD/YYYY) POLICY EXP (MMMDNMI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE El OCCUR EACH OCCURRENCE DAMAGE TO RENTED PREMISES Ea occurrencel_ is GENT MED EXP(Any one person) $ PERSONAL B ADV INJURY $ AGGREGATE LIMIT APPLIES PER POLICY �] JECOT `JILOG OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NONOWNEDPROPERTY HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ _ DAMAGE Per ac=tlen(L $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE _ $ DED I RETENTION$ $ B D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y� OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes. dascriba antler DESCRIPTION OF OPERATIONS below N/A TC2JUB-7442L10A-17 (ADS) TRKUB-7442L111-17 (AZ,MA) 0110112017 01/0112017 0110112018 :§ci 0110112018 X SPER TATUTE EOTR E.L. EACH ACCIDENT $ 2,000xff EL DISEASE S 2,000,W0 _-EA_EMPLOYE EL DISEASE -POLICY LIMIT $ 2.6-oxi DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION Rile Aid Corporation P O Box 3165 Harrisburg, PA 17105 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Nancy Kalbfell ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY MARSH USA, INC. POLICY NUMBER CARRIER AGENCY CUSTOMER ID: 416752 LOC #: Norwalk ADDITIONAL REMARKS SCHEDULE Page 2 of 2 NAIC CODE NAMED INSURED RITE AID AND AFFILIATES PO BOX 3165 HARRISBURG, PA 17105 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance COVERAGE AFFORDED BY THE PROVISIONS OF THIS CERTIFICATE ARE NO MORE THAN REQUIRED BY LEASE OR CONTRACT, •""'•'•"—--- 'IMPORTANT NOTICE TO TENANTMNDLORD/LESSOR""•'•^••^"•^^^'""••"^"•• A COPY OF THIS CERTIFICATE/EVIDENCE OF INSURANCE FOR THE 1112017 TO 11112018 POLICY PERIOD SHOULD BE FORWARDED TO THE APPROPRIATE PARTIES (MORTGAGE COMPANIES, FINANCIAL INSTITUTIONS, ETC,) UPON REQUEST. WHEN THE REQUESTING PARTY IS IN QUESTION, PLEASE CONTACT RITE AID @ 717-761-2633 IF EVIDENCE OF COVERAGE IS NO LONGER REQUIRED, KINDLY RETURN THE CERTIFICATE MARKEDNO LONGER REQUIRED, AND WE WILL ADJUST OUR FILES ACCORDINGLY. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All riohts reserved The ACORD name and logo are registered marks of ACORD