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HomeMy WebLinkAboutMansfield Xtra Mart 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:. DRAKE PETROLEUM COMPANY, INC. Whose place of business is: MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET Permit Expires: December 31, 2018 License Number: RF-13 Food Fee: $100.00 Milk & Cream 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: MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET License Number: RF-13 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: DRAKE PETROLEUM COMPANY, INC. having a place of business at: MANSFIELD-MA XTRA MART 905 SOUTH MAIN 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•13 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Manufacture Frozen Desserts and/or Ice Cream Mix The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made hereunder, hereby issues MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31 st of each year. License Number: RF-13 Freezers: 1 TOTAL: $25.00 MANSFIELD BOARD OF HEALTH AichaecMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued RF-13 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planne p'&rfmg`d_aQ-"1!"' 1) Establishment Name 2) Establishment Address MANSFIELD-MA XTRA MART 905 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 800 SOUTH STREET, P.O. BOX 9161 ATTN: LEGAL WALTHAM, MA 02454 4) Establishment Telephone No 261-2812 5) Applicant Name & Title: DRAKE PETROLEUM COMPANY, INC. 6) Applicant Address 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 7) Applicant Telephone No.: (781) 398-0419 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: DRAKE PETROLEUM COMPANY, INC. 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 (781)398-4419 10) Establishment Owned By: 111) If a corporation or partnership, give name, title, and home address of officers An Association or partner. lei, A Corporation Name Title Address El An Individual awc" 1 1 A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'iJIM BRODEUR, MANAGER Address: Telephone No: 05 SOUTH MAIN STREET, MANSFIELD, MA 02048 261-2812 FAX: I(781) 398-7261 E-mail: MP€TZ0GLO' - - —_— Alt E-Mail: iLENNYA(a)XTRAMART.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: �vxtirn�crvc . )0 SOUTH STREET, WALTHAM, MA 02454 744)-222-552-7 'i > Y124 Hour Emergency No: E-mail: KK HLEEN:BISBEE@GLOBALP C-OM (781) 398-7261 Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 7 DAYS PER WEEK 24 HRS. 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: W Permanent Location Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: n Annual [_1 Seasonal Seasonal Dales: -I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑J Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $125.00 ❑ 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 ❑ Food Service - Institution Meals/Day) ❑ Caterer $25.00 �1 Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 V Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 W Retail Food $100.00 ❑ Retail Snack Food $25.00 W Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous rood (timelfempmature controls required) Non-PHFs - non -potentially hazardous food(no time/femperature controls required) ;Check all that apply) I - RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing) [] Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ------ ---------- -- --- for More Than a Single Meal Service [] Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And Delivery of Packaged ----- — Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs 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- ❑d Customer Self -Service ❑ Use of Process Requiring A Variance and/or FIACCP 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) Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities r Catered Events or Institutional Food Service L Retail Sale of Salvage, Out -Of -Date __. or Reconditioned Food 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 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 and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-22360E 26) Signature of Individual or Corporate Name: _ of perjury that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mans field - 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: MANSFIELD-MA XTRA MART ADDRESS: 905 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-2812 FAX NUMBER: (781) 398-7261 OWNER OF BUSINESS: DRAKE PETROLEUM COMPANY, INC. TELEPHONE OF OWNER: (781) 398-4419 FEDERAL ID/SS NUMBER: 04-2236089 FEE: $10.00 PERMIT NUMBER: RF-13 SIGNATURE: DATE: I v13 f/ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF-13 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: MANSFIELD-MA XTRA MART LOCATION OF SALE OF TOBACCO PRODUCTS: 905 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-2812 OWNER OF BUSINESS: ADDRESS OF OWNER DRAKE PETROLEUM COMPANY, INC. DRAKE PETROLEUM COMPANY, INC. TELEPHONE OF OWNER: (781) 844-8800 FAX NUMBER: (781) 674-7799 If a corporation or partnership, give name, title, and home address of officers or partner. PLEASE SEE ATTACHED * Provide a copy of current Department of Revenue C CT FEE: $25.00 FEE: CT-3T NUMBER: 288632832 1362374656 FEDERAL ID/SS NUMBER: 04-2236089 SIGNATURE, Retail Excise Unit License. DATE: 1 V1,5 V- S�cHt<r4. MASSACHUSE'rIS DEPARTMENT OF REVENUE Letter ID: L1021875200 - PO BOX 7044 Notice Date: October 18, 2016 BOSTON, MA 02204-7044 Account ID: COL-11154405-069 A CONTACT CENTER (6I7) 887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES I'I.,h111111111Jill 111i111111pill ll1111jj1611111111 o� DRAKE PETROLEUM CO INC MILLBURY XTRA MART o� 800 SOUTH ST STE 500 WALTHAM MA 02453-1439 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 -flee in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACIi HERE �Ps56c"Osa MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o w Retailer License for Sale of Cigarettes � a 9,eN7.ofe This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CGL-11154405-069 MANSFIELD XTRA MART Location ID: 11154405-0203 905 S MAIN ST License Number: 288632832 MANSFIELD MA 02048-3149 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 18, 2016 Expiration Date: September 30, 2018 MASSACHUSETTS DEPARTMENT OR REVENUE Letter ID; L2095617024 PO BOX 7044 Notice Date: October 18, 2016 BOSTON, MA 02204.7044 Account ID; CRL-I 1154405-072 CONTACT CENTER $lyr pVp' (617)887-6367 RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO �dlpl6l'I'III"��"III'h�I�b11Jl�lhl�d1111����111�11�1' DRAKE PETROLEUM CO INC MILLBURY XTRA MART 800 SOUTH ST STE 500 WALTHAM MA 02453-1439 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 MassTaxConnecl 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 �Psy�c"urE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m Retailer License for Sale of Cigars and Smoking Tobacco 'Fvro.Q� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DRAKE PETROLEUM CO INC Account ID: CRL-1 1154405-072 MANSFIELD XTRA MART Location ID: 11154405-0204 905 S MAIN ST License Number: 1362374656 MANSFIELD MA 02048-3149 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 18, 2016 Expiration Date: September 30, 2018 Town of Town of Mansfield - Board of Health 6 Pak Ro tansfield Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board of Health at the Town of1fansfield. In accordance with the provisions of section 65H of Chapter 94 of the General Lauri, as most recently amended, and the regulations made thereunder, the undersigned hereby applies fits a license for a WHOLESALEIRETAIL manufacture offrozen desserts and ice cream In& and submits the following information: I. FUII name of applicant: MANSFIELD-MA XTRA MART 2. Business address 800 SOUTH STREET, P.O. BOX 9161 ATTN: LEGAL MA 02454 3. If applicant is nn individual: Fullname: DRAKE PETROLEUM COMPANY, INC. Residence: 800 SOUTH STREET P.O. BOX 9161 WALTHAM, MA 02454 3a. If applicant is a partnership, full name and residence of all partners: 3b. hi'applicant is a corporation: State of incorporation: MASSACHUSETTS Date of incorporation: APRIL 16 1958 Fall name and address qf: Principal office: 800 SOUTH STREET, P.O. BOX 9161 ATTN: LEGAL president PLEASE SEE ATTACHED Treasurer: Clerk: 4. Location gfPlants: IN STORE SOFT SERVE MACHINE S. Names of brands.and trade or corporation name, if any, under which the products care to be sold. - UNBRANDED 6. Number and capacity of f eezers and lees: Z is the nrix purchased? YES 8. Is the mix pasteurized? YES Fee: ($25.00 perfr•eezer) $ 25 ffso, from whom purchased? 9. Number ofgallons of frozen desserts and/or ice cream mix to be sold in Massachnseus during the licensing period 600 111, Number of gallons oljrozen desserts andlor ice cream mix sold in Hassachuseas during the previous licensingperiod 11. Is the plant corvstructed and equipped as provided in the regulations? Yes NSF/approved T 12. Is the water supply public or not? YES 13. Have you received a copy q/ the regulations? NO I hereby certify that the frozen dessetts and/or ice cream mix Ise// in Massachusetts will be manufactured in comp/lance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary condib'ons. I attest that the information stated in this application is true and accurate under the pains and penalties ofperjury. (.jC/oT'mp n ow jn^�e)'rylopff/icegr's�p!/sJi�gf'�yr'a�t�u(DAT �re) jul" /I )9 (Title) (City or Town) 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. dile, �� t,JFCLi'�C3 qJ,Q4 ratWame By: Corporate Officer (Mandatory, if Applicable) **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:\FIealthVane's DoGu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORMA= The Common npealth of Massachusetts Department oflndustrialAccidents Office of Investigations 1 Cougress Street, Suite 100 Boston, AM 02114-2017 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ! )t (Z V' C t P t 1 �(t I l 0 J n L ` Address: i ) a)o — City/State/Zip: t ) T�P -L A a f Phone #: Are you an employer? Checic the appropriate box: Business Type (required): L� I am a employer with employees (full and/ 5. ©'hetail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g, M Non-profit [No workers' comp. insurance required] 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]*' 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box gl must also fill out the section below showing theirworkers' 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 fA 1. I am an employer that is providing workers' comperq tr don insurance for illy employees. Belot, is thepolicy htforruatlou. Insurance Company Insurer's City/State/Zip: ill? f' Policy # r Self -ins. Lic. # % g ll`t ! ���K L � Expiration Dater!® -1-19 t ach 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 ceit &, undertthe pains and penalties ofperjury that the iufornratlou provided above is true and correct. official use only. Do not I,rite in this area, to be completed by ci0y 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 Contact Person: Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty Mutual. INSURANCE INFORMATION PAGE 176 Berkeley Street Boston, MA 02116 Issued by Liberty Insurance Corporation (a stock company) 21814 Policy Number WA7-69D-460066-017 Issuing Office Lewiston, ME Renewal Of WA7-69D-460066.016 Issue Date 10/1812017 Account Number 9-460066 1. Insured and Mailing Address Global Partners, LP 800 South Street, Suite 500 PO Box 9161 WALTHAM MA 02453 Sub Account 0000 FEIN 74-3140887 NJ TIN 141924242000 Risk ID 911385333 Status Limited Partnership Other workplaces not shown above: See Item 4. Premium - Extension of Information Page 2. Policy Period: The policy period is from 10/0112017 to 10101/2018°12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law of the states listed here: CT FL GA IN IA ME MD MA MT NH NJ NY NC OR PA RI TX VT VA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A and the States of: ND OH WA WY D. This policy Includes these endorsements and schedules: See Item 3. Coverage D - Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per $100 Estimated Annual See Minimum Premium Premium will be billed Annual Producer 0002 000499 LOCKTON COMPANIES LLC (DALLAS SERIES) 2100 ROSS AVE STE 1400 DALLAS TX 752016706 Total Estimated Annual Premium Deposit Premium Deposit Tax/Surcharge/Assessment Countersigned by Authorized Rep. (FL) WC 00 00 01 A ©1987 National Council on Compensation Insurance, Inc. WC 00 00 01 B (CA) Ed. 07101/2011 Al Rights Reserved Page 1 of 1 Global Montello Group Corp CORPORATE OFFICERS Name Address & Phone No Title Eric Slifka Director, President and Chief Executive Officer 800 South Street, Suite 500 Waltham, MA 02543 781-894-8800 Andrew Slifka Executive Vice President 800 South Street, Suite 500 Waltham, MA 02543 781-894-8800 Edward J. Faneuil Secretary, Executive Vice President and 800 South Street, Suite 500 General Counsel Waltham, MA 02543 781-894-8800 Charles A. Rudinsky Chief Accounting Officer and Executive Vice 800 South Street, Suite 500 President Waltham, MA 02543 781-894-8800 Daphne Foster Chief Financial Officer 800 South Street, Suite 500 Waltham, MA 02543 781-894-8800 Mark Romaine Chief Operating Officer 800 South Street, Suite 500 Waltham, MA 02543 781-894-8800