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HomeMy WebLinkAboutRIte Aide 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:. WALGREEN EASTERN CO. Whose place of business is: RITE AID #10141 243 CHAUNCY STREET Permit Expires: December 31, 2018 License Number: RF-32 Food Fee: $100.00 Milk & Cream f7 BOARD OF HEALTH NichaeCNcCCean, 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-32 Permit Expires: December31,2018 BOARD OF HEALTH Michae[AcCCean, 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: WALGREEN EASTERN CO. 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-32 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 (A N Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at leastdays before the p anne opening a e 1) Establishment Name P Ik i 4 1C I ) '\ 1 2) Establishment Address MI MCA. 3) Establishment Mailing Address (if different �j PO• _ l�l he(I.��. I�c�is 4) Establishment Telephone No �j31-��C) tJ �� f 5) Applicant Name & Title: \(�'r, m 'n V 6) Applicant Address � w,\ Vwwk-2))_As I I — 7) Applicant T``e11ll�epho��n""e No.: ' f 24 Hour Emergency No.: 8) Owners Name & Title 1� 9) Owner Address (If different from applicant) Owner's telephone number Qjq-l-uja-I! `4ULe 7 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers F1 An Association or partner. El A Corporation El An Individual Name Title Address El A Partnership El Other legal Entity - 9 z) rerson uirecuy Kesponsibie I -or Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �j �I'I Address: Telephone No: _`_�_�CfC) 24 Hour Emergency No: `b``c_I ` S�D __ l0 &C ��,pS�"� J J vlJ FAX: E-mail: Alt E-Mail: ` 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 17) DAYS/HOURS: t I lY ,_ q C, n I q 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): ❑ (JA 20) Location: '__ Permanent Location 22) Establishment Type lF] Caterer $25.00 I] Mobile Mobile Start Dale: IVJ Retail ( 13p927 Sq. Ft) ;'Milk & Cream $10.00 Mobile End Date: [j] Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 ❑Food Service up l0 101 -200 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21 Length of Permit: g Annual or up to 25' PHF display $150.00 ] Food Service up to 201 + [ Pushcart $25.00 # of Pushcarts: ❑ Residential Kitchen $100.00 Seasonal Seasonal Dates: or 25'+ pHF display $275.00 Retail Food $100.00 I] Food Service - Institution detail Snack Food $25.00 Temporary Temporary Start Date: ( Meals/Day) (Vrobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date:.-.-.----- 23) Food Operations Definitions:PHF- Potentially hazardous food(timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) .Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order FJ Hot PHF Cooked and Cooled or Hot Held F1 Sale of Commercially Pre -Packaged PHFs n Preparation of ­PHFs 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 ----- Susceptible Population Facility ----_ Sale of Raw Animal Foods Intended _ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Customer Self -Service — Perishable Foods Only n Ice Manufactured and Packaged far Retail Sale Other Food Operations F_] Juice Manufactured and Packaged Retail Sale l Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food I;;-- 1,ted by the Board of Health -- ee: e with application F] waived the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with� 1t05 �Mf2190.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies` v710 ,t;w 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify unde/de e 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: YoAGt ZifO-Y 26) Signature of Individual or Corporate Name: a 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 31 st of each year. NAME OF BUSINESS: r<'J�' ADDRESS: aL.Lt7� TELEPHONE AT LOCATION: c & 0U FAX NUMBER: �� 1 '� -� ( / OWNER OF BUSINESS: w GJ-a 0-Q_„Q,,_�'� / / v" '( /L. W j LAk--✓, TELEPHONE OF OWNER: oq,-y J -7 ®L4lQ fp FEDERAL ID/SS NUMBER: '�> (,, — I9 ZL_` 0 2Le FEE: $10.00 PERMIT NUMBER: SIGNATURE: DATE: t (� 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. NAME OF BUSINESS: 2a—,u Ain -4 I O 14 LOCATION OF SALE OF TOBACCO PRODUCTS: TELEPHONE AT LOCATION: 00 OWNER OF BUSINESS: ADDRESS OF OWNER: � ^ � f,_\jmo—F ` NSa r, i -- --- ---- - - — t- )--�J--1 --- - Y r l ✓ G c� ,mil TELEPHONE OF OWNER: (f 7 l [ FAX NUMBER: / , ct —is(, 8 / t' J — — — 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: $26.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: _1f2b-7�� SIGNATURE: A* DATE: SSM'.tture,. Commonwealth or.massnehusens b 4 Sst} Y Department of Revenue Hardin er C. Chrislo hCommissioner P 6. nip Leaur I D: 1.0639485696 I, Notice Dale: January 26, 2018 ©� AccnunlID: CGL-IIR16109-350 RETAILER LICENSE FOR SALE OF CIGARETTES ,III III III [111111111111111Iu111111111Ilnylr MS-3301 WALGREEN EASTERN CO INC: WALGREENS WALGREEN EASTERN CO INC 300 WILMOT RD DEERFIELD IL 60015-4614 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 P`^`; t'' y MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T p y(ge`2 Retailer License for Sale of Cigarettes b Ii`li'1 ��l . N rey. S;r"";c ` t,/;�.1.���e' This license must be posted and visible at all times. The sale of tobacco products to anyone tinder 18 years of age is prohibited. WALGREEN EASTERN CO INC Account ID: CGL-11816109-350 RITE AID 410141 Location ID: 1 1816109-0679 243 CHAUNCY ST License Number: 363057152 MANSFIEL,D 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: January 26, 2018 Expiration Date: September 30, 2018 Snu 'a s6 Commonwealth of Massachusetts Letter lD: 1_7303545600 Department of Revenue Notice Date: January 17, 2018 o { t 1 Christopher C. Harding, Commissioner Account ID: CRIA 1816109-370 PAT o4Q- mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO ' 1111111111111111111111111111111111111111111111111111111111111111 MS-3301 WALGREEN EASTERN CO INC WALGREENS 300 WILMOT RD DEERFIELD IL 60015-4614 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 ShC"USF�T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 9 ll, Retailer License for Sale of Cigars and Smoking Tobacco 3trFM o QF' This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. WALGREEN EASTERN CO INC Account ID: CRL-11816109-370 RITE AID #10141 Location ID: 1] 816109-0680 243 CI iAUNCY ST License Number: 1032767488 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: January 17, 2018 Expiration Date: September 30, 2018 v\A\ 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. - 04/Z - Signature o ivt or Corporate Name "Social Security No. (Voluntanj) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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 Docwneots\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Comno pealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 wwrv.i ass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business Address: Are you an employer? Check the appropriate box: 1. I am a employer with employees (full and/ orpart-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 TIypc (required): 5. Retail 6. RestauranUBar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10, Manufacturing 11. Health Care 12.Other *Any applicant that checks box #1 must also fill out the sectionbelow slowing 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 Nl. I am an employer that is providing tvorirers' compensation insurance for my employees. Below Is the poliey inforrmrtion. A Insurance Company Insurer's City/Statt Policy N or Self -ins. Lie. A W 64 10M;47—' 3 Expiration Date: 711 f [B__— 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 cerlifj; n f r lI aims and penalties ofperjury that the infornatiom provident above is true nad correct. t r(y� ,Q {r -Cd Signature: l ! !, A�F / 1d1i1,<n Date: M, City or Town: uAcfnd Id Permit/License# MEMORANDUM' OF LIABILITY INSURANCE' " ' " currgpp as of: �7une28 2017 PRODUCER THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY TO AUTHORIZED MARSH USA INC 540 W. MADISON CHICAGO, ILLINOIS 60661 UNITED STATES OF AMERICA VIEWERS FOR THEIR INTERNAL USE ONLY AND CONFERS NO RIGHTS UPON ANY VIEWER OF THIS MEMORANDUM OTHER THAN THOSE PROVIDE FOR IN THE POLICY, THIS MEMORANDUM DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW. THIS MEMORANDUM MAY ONLY BE COPIED, PRINTED AND DISTRIBUTED WITHIN AN AUTHORIZED VIEWER AND MAY ONLY BE USED AND VIEWED BY AN AUTHORIZED VIEWER FOR ITS INTERNAL USE. ANY OTHER USE, DUPLICATION OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS PROHIBITED. INSURED ..4COMPANIESrAFFORDING COVERAGE' �NAIC# COMPANY A ZUR(CH AMERICAN INSURANCE COMPANY 16535 WALGREEN CO. AND SUBSIDIARIES COMPANY 8 INDIAN HARBOR INSURANCE COMPANY 36940 300 WILMOT RD., MS #3108 "DEERFIELD, ILLINOIS 60015-5223 COMPANY C AMERICAN ZURICH INSURANCE COMPANY 40142 UNITED STATES OF AMERICA COMPANY SELF INSURANCE cove[�►Ges,�. 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 WI TIt RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. a M y,_; P r t SYPKQk iNBUMNCe ,, ., h(lU.CY.YiUM'BERI .. ➢tl}ICY S L f 4> N ao...t'w:6AT6'H`; ��pp�PO,t1C Nuin+"T3 . .: LXMrt'5 v jl, '- LiMl7s IN USD BN�BS =' "--:',. ...:�OTNEFSVI$E'11XPI. tG"B A GENERAL LIABILITY GLO 931009114 7/l/2017 7/1/2018 _ GENERAL AGGREGATE 5000000 X IM GENERAL U1Aa1LITY COMMERCIAL QU ARIS MADE OCCUR FILED 9310184 14 (Puerto Rlco) 7/1/2017 7/1/2018 PERSONAL&ADV INJURY 1000000 EACII OCCURRENCE E000,000 X Blanket Additional Insured FIRE DAMAGE Any One Hre) 500 000 X Per Policy MED EXP (Any One Person 0 X Blanket Contractual Liability X Liquor Liability A AUTOMOBILE LIABILITY BAP 931009611 7/1/2017 7/1/2018 % ANY AUTO COMBINED SINGLE LIMIT $ 5,000,000 ALL OWNED AUTOS BAP 9310183 14 (Puerto Rica) 7/1/2017 7/1/2010 BODILY INJURY (Per Person) $ 1 SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per Accident) $ NON -OWNED AUTOS PROPERTY DAMAGE $ B EXCESS LIABILITY US0007929SLI17A 7/1/2017 7/1/2018 PE 1 5000000 AGGREGATE 5,000.00 UMBRELLA FORM OTIIER TBAN UMBRELLA FORM C A A WORKERS COMPENSATION/ EMPLOYERS LIABILITY WC 9310092-14(AOS) WC 9310094-14(WI) ONE 9310093-14(IL & LA) 7/l/2017 I171112018 WORKERS COMPENSATION LIMITS STATUTORY A PARTNER$VFXECUTIVE X INCL EWS 9310447-14 (AZ) EL EACH ACC DENT 21000,00 A OFMCERS ARE: OEXCL EWS 9310448-14(MA &TN) EL DISEASE - POLICY LIMIT 2 000 00D EL DISEASE - EACH EMPLOYEE 2,000,00 D PRODUCT LIABILITY Se8-Insured 7/1/2U17 7/1/2018 EACH OCCURRENCE 2000 0 AGGREGATE 2 000 000 ADDITIONAL INFORMATION—' ' OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS, LENDERS, NIORTGAGEES, GROUND LESSORS, VENDORS, CUSTOMERS, CLIENTS, AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE, CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED [EASE, CONTRACI OR OTHER WRITTEN AGREEMENT, The Memorandum et insurance sees solelyto list nsuranca Policle9, llmlts and Gates O/ oovempe. Any modlflcaUon9 hereto' are not authorized. ) §2 k) \ )( ) %) {/ f/ f/ f/ f/ ° \} \\ \\ \\ \\ k }2 \ �} {/ ƒg )\ �\ ( m \6 ]{ o EK ({ \\ %/ )§ \ � 2! d § _ � ui c ( \ \ \ \ 3 k CL § §k W§ ;G ! u wz > of /U. ° °� \ ) § i qMo E¥ / \ a ) \ z { ! : E ) / ) ) ) uj � \ \ \ \} \ _ > e >, c January 11, 2018 Re: Change of Ownership Walgreen Co. Corporate Office 300 Wilmot Road, MS 3215 Deerfield, IL 60015 www.walgreens.com .BAN 16 261 Dear Sir or Madame, Please be advised that Walgreen Co. will acquire the attached Rite Aid location/s effective January 17, 2017. Enclosed you will find required applications and the fees associated with this ownership change. To clarify, this is an ownership change only. Upon Approval, please forward future mailings to the below address: Walgreen Eastern Co. Attn. Lisa Hansen PO BOX 901 Deerfield, Illinois 6001S If you have any further questions, please don't hesitate to contact me that the phone number provided below. Lisa Hansen Walgreen co. PO Box 901 Deerfield,1160015 847-527-4669 lisa.hansen@walgreens.com Enclosure Member of Walgreens Boots Alliance