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HomeMy WebLinkAboutHome Depot 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 Establishment Type: RETAIL SNACK FOOD 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:. HOME DEPOT USA, INC Whose place of business is: THE HOME DEPOT #2609 390 WEST STREET PERSON(S) IN CHARGE: AL DEAK, STORE MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-16 BOARD OF HEALTH MichaeCMcCCean, Chairman A FOR BOARD OF HEALTH USE ONLY Permit #Issued S-16 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name THE HOME DEPOT #2609 2) Establishment Address 390 WEST STREET 3) Establishment Mailing Address (if different) 2455 PACES FERRY ROAD B 12 ATLANTA, GEORGIA 30339 4) Establishment Telephone No (508) 337-2050 5) Applicant Name& Title: HOME DEPOT USA, INC. 6) Applicant Address 2456 PACES FERRY ROAD NW, ATLANTA, GA 30339 7) Applicant Telephone No.: (770) 433-8211 24 Hour Emergency No.: C (774) 312-3194 8) Owners Name & Title HOME DEPOT USA, INC 9) Owner Address (If different from applicant) 2455 PACES FERRY ROAD, ATLANTA, GA 30339 .. ... ... ... --- .. ..... Owner's telephone number 7704338211 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1. 1 ­J An Association or partner, A Corporation Name Title Address 1_1 An Individual A Partnership _L] Other legal Entity_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: AL DEAK, STORE MANAGER Address: '390 WEST STREET, MANSFIELD, MA 02048 Telephone No: 1(401) 744-5744 24 Hour Emergency No: C (774) 312-3194 -4 - FAX: 1(508) 851-6013 E-mail: Alt E-Mail: !JO EY-S-HARRISPHOM E. DEPOT, CO M 13) District Or Regional Supervisor (if applicable) Name. P TRIP- Food Establishment Information 14) WATER SOURCE. TOWN 16) SEWAGE DISPOSAL TOWN PEP Public Water Supply No: (If applicable) 16) No of Food Employees 1 17) DAYS/HOURS: MOWSAT 6 AM-10 PM SUN 7 AM-0 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 Seals or more): f j 20 Location Ili Permanent Location ) 22) Establishment Type Mobile Mobile Start Date: IJ Retail ( Sq. Ft) Mobile End Date: n Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: ❑ Food Service up to 101 -200 V1 Annual or up to 25' PHF display $150,00 ' I Seasonal i. 1 Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: Temporary L. I Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Dale: Temporary Time: Rain Date: -- _ ---- - _ -- U Caterer $25.00 IJ Milk & Cream $10.00 [� Mobile Food & Consesslon $76,00 i_ Manufacture Frozen Desserts/Ice Cream $25.00/freezer 1 i Pushcart $25,00 # of Pushcarts: 0 [_I Residential Kitchen $100.00 tJ Retail Food $100.00 [✓J Retail Snack Food $25.00 Tobacco Products $25.00 I I '23)Food Operations Definitions:PHF- Potentially hazardous food (flmeRempandure controls required) Non-PHFs - non -potentially hazardous food(no tima/lemperalure controls required) I(Check all that apply): RTE- ready4o-oaf roods (Ex. sandwiches, salads, muffins which need no furtherprocessing) (y1 Sale of Commercially Pre -Packaged Non-PHFs 1 Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours V, 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 Ill Customer Self -Service I: I Ice Manufactured and Packaged for Retail Sale (_I Juice Manufactured and Packaged I Retail Sale Offers RTE PHF in Bulk or Reconditioned Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service h PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill L Use of Process Requiring A Variance - j and/or HACCP Plan (including bare hand contact alternative, time as a public health control) J Offers Raw Or Undercooked Food Of Animal Origin ,J Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health I Total Permit Fee: $26.00 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 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: �- I "/[/� Pursuant to MGL Ch.62C, se 49A, ertify 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: 5e-1853319 26) Signature of Individual or Corporate Name: Home Depot U.S.A., Inc. 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 Individual or Corporate Name ."Social Security No. (Voluntary) 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. RaHe It6Ve ds Dw=en(APERMIT APPLICATIONS\TAX CBRTIFICATION FORM.doc dN The Commonwealth ofMassacliusetts r Department oflndustrialAccidents Office of investigations 600 Washington Street Boston, MA 02111 wiminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib[y Name (Business/Otganizatiou/Individual): Nome Depot U.S.A., Inc. 2455 Paces Ferry Road NW Atlanta GA 30339 Pholie #: 7704338211 Are you an employer? Check the appropriate box: 1. ® I am a employer with 4. © I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insuratice.t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MOL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10,❑ Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ay applicant that checks box #1 must also fill out the section below shoving their workers' compensation policy information. omeovners who submit this affidavit indicating they are doing aft work and then hire outside contractors must submit it new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lain an employer that Is providing workers' compensation insurance for my eniplgyees. Below Is the policy and job site information. Insurance Company Name: National Union Fire Insurance Company Policy 9 or Self -ins. Lie. M 175 Water Street 18th Floor Expiration Date: 3/1/2018 Job Site Address: XWC6583145 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing fire policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL e. 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 tdo hereby cent y underthe his andpenaUles ofpeijury that the irrforn:ation provided above is true and correct. Sienaritre: 111 17 I Date: 11/9/2017 770-433-8211 Official use only. Do not write in this area, to be completed by city or town official. or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other _ Contact Person: Phone 0: coRtS® CERTIFICATE OF LIABILITY INSURANCE oATE(MMIOaYYYVi o2mr2oa 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 Dartilloate holder to an ADDITIONAL INSURED, the pollcyjles) must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endQmement. A statement on this certificate does not confer rlghte to the certificate holder In lieu of such endorsament(s). PRODUCER WSH USA, INC TWOAWANCECENTER 3500 LENOX ROAD, SUITE 2400 ATLANTA, GA 303326 DT NAME: ENh iic net RIP, D 1 INSURERISI AFFORDING COVENAOE - NAICN INSURER A : CH RspubTro Insurance Co 2047 100492•NDmeO•GAW'•17-18 INSURED HOME DEPOT USA. INC. WBIA THE HOME DEPOT INSURER 8; h9d Oeaerel Insuram Company - ----------- 42757 INSURER c: NOW HBm1361140 ins CO 23841 2455 PACES FERRY ROAD BUILDING 020 INSURER b: INSURER E: ATLANTA, GA 30330 INSURER Pt COVERAGES - CERTIPICATENUMRER: ATL-OD3739316-14 PrVIAInN Nl lnnara•t THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWTHSTANDING 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 POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, L [NOR TYPEOFINSURANCa POLIOYNUMOEft POLICY YY WDD� LIMITS A 1 X COMMERCIAL GENERAL LIABILITY CLAWS.MAOE M OCCUR MWZY310022 .IMITSOFPOLICYXS -SIR:SIMPEROCC 0001220t7 03A)ffi0t0 EACHDCCURRENCE s 9,000,000 DA51A5 SYCTBBNTEu "'� S ),Oi10A00 MED EXP (An ono anon) B EXCLUDED PERSONALSADVIWURY B -� 91000,000 GENLAGOREOATE�UqMpIT.APPLIESPER: X POLICY ❑,IECT �LOC Ot HER: GENERALAGGREGATE S 9,000,WO PRODUCTS-COMP S 0,000.000 S AUTOMOBILE X LIABILITY ANY AUTO AUTO�EO �oWU:O HIRED AMOS NONOWNED AUTOS MW(8310021 SELF INSURED AUTO PRY DMG 0310112017 0310112016 COMBINED SINGLE LIMIT Ea a de B 11000,000 BODILY INIURY(Pelpee:on) _ B BODILY IWURY(Por amfdwl) S PROPERTYDAMAGE S S UMBRELLA LIAO EXCESS LIAO v OCCUR CWMS-MADE EACHOCCURRENCE S AGGREGATE $ DEO RETENTIONS y B D G WORKERS COMPENSATION AND EMPLOYERS' MAOILIIY ANY PROPAIETOFIPgRTNENEXECUOVE YIN OPRCEIVMEMBER EXCLUDED? (Mmdaloryln NR) Ifyc5de TIONOtler OESCRIPTNNI DE OPERATIONS bNow NIA WI.RC40112300(TN) WC 023102423(AKNH,NJ,YT) WC 023102424(WI) Can6nued on AddiNOmfPe Be 03NiYID17 031012017 OMW017 WA12010 +. OXOI12018 0XV2010 % STATUTE Bri E.L.EACHACCIDENT B 11000,000 EL.bISEASE-FAEMPLOYF B LOODSIX) E.L.DISEASE •POLICY LIMIT B 1,000,000 DESCRIPTION OP OPERATIONS I LOCATIONS I VEItICLRS tADOR0101, AtldPlonei RamaMe BaAeQele, may Aq Mleched If moro apace N rogVlredi CITYOFBURRANK BUILDING DIVISION P.O. BOX 6450 SURBANK, CA 9161H-0491 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE bELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ZED REPRESENTATIVE USA ine, ;ORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD ACO/i D® L./ AGENCY CUSTOMER ID: 100492 LOC M: Atlanta ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA, ING, HOME DEPOT U.S.A., INC. 0181ATHE HOME DEPOT 2455 PACES FERRY ROAD ._ POLICY NUMPER BUILDING 0.20 ATIANTA, GA 30339 CARRIER NAIL Done EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, DnGM MI IMFGD- 25 Pnose TITI w. Certificate of Llab)lity Insurance WOdICm DIXnpalleflpem CgnILelBd: Cartier lmiemn4p Irma w Compsnyol NedBAn orka PoruyNumbor WLRG49112M(AL,ARFL,ID,IA,K8,KY,I4,MS,MO,NE,NM,NO,OYySC,SD,WV,WY) EOMrwo Dale: 03101017 Expire0an Data: 03101 018 (EL)Umu 51,000,000 Cinder. Now Hampshire InPN6abCpn+pany PdkY Number: WCO23102422 (00, DE,HI,IN,MD,MN,MT,NYAti) Dfedvo DalwON112017 Etppauou Date: 0310I018 IEgUmib$L0D0,0W Camas ACEAmodcan lnsuronw Company Po" Number. WCU 0491t2282(OSp(A7, CAdI,NC,ORVA,WA ) EBective Date: 0101,2817 Exte rso n Dale: =12018 (110 UM0Sf,000,,000 SIR: $1,000,000 SIR for 91a etelacol Az, CAIL.NC,ORVA,WA Carder. National Union Foe Insurance Company Poky Number. XWC 6503144 (0S0 (CO,CT,GA,ME4M4NV,ORPA,UT) Effective Dale: 030112017 Expfraibn Data: 03*1018 (RI WIL 51,000,00) $1,000,000 SIR fa the slates otCCME,NV,MI, OH^ LIT $760,000 SIR fa [be alai u1 GA S35M00 SIR for IAo stale of CT Carder Na1bIMl Unbn Flea Insmmlw Company Polley Number. XWC 6503145 (OSI) (MA) EremNEData:o3Glnoo EaPiralbn Oam:03N12018 (Couro LsLOM W SIR: SwIl.0011 TX Employos XS Indemnly: CemerllNlxs Unbn lovarr w, Company Paley Number. THS046810202(TX) EBetlhre Dale:03gin017 FYplratbn Date: 03/012018 (ELI Until: 610,000,000 8IR:SI,ODD,000 0 2008 ACORO Tire ACORD name and logo are registered marks of ACORD 1 ACORU AGENCY CUSTOMER ID: 100492 LoC e: Atlanta ADDITIONAL REMARKS SCHEDULE Page 3 Of 3 AGENCY NAMED INSURED MARSH USA, INC, HONE DEPOT USA, INC. DIBIA THE HOME DEPOT 2455 PACES F@RRY ROAD POUDY NUMBER ' BUILDINGC-20 ARANTA, GA 30330 CARRIER NAIL CODE EFFECTIVE DAM THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER, 25 FORM TITLE: Certificate of Liability Insur '**HOME DEPOTINSUREDS" The Home Depm.Inc. The Home Depot USA,, In Home Owl USA. In dba The Home Depot Home DepoIU.SA Ina dba Home Demraom Wooten Home DapoIDSA, lem doe YourONerWmetmmm, LW; Homo Depolor lyedo Idea, In Ohbalcustom Commerce, Ira HOMO Depot Roduc9 Au01Npy, LLC Home Depot &Oro S PPUL In Red Boston, LLC mleaw Brands, In InodMe Rlsnds, Iladbn: Ramell CopporNeld Esga Malnlenance supoy Hedmve Express Leon Maolenenoo USA RenuvaOOm Rua Smppl"'Im Us Loth Wimer donPml AmSen Soxsmi Traym ➢p Tadaioogos The ACORD name and logo are registered marks OT ACORD reserved. THE HOME DEPO'T',' USA INC. ' Officer Listing PERSONAL AND CONFIDENTIAL Craig A. Menear, Chief Executive Officer'. 770-433-8211 2455 PACES FERRY RD NW ATLANTA GA 30339 and President Carol Tome', EXP, Corporate Services and Chief Financial Officer 770-433-8211. 2455 PACES- FERRY RD NW ATLANTA GA 30339 Karen Dewalt, VP Corporate Controller , 770.433-8211 2455 PACES FERRY RD NW ATLANTA GA 30339 and Tax r ti. Copy of THD Officers LlsLxlsx 3/13/2017