The URL can be used to link to this page

Home My WebLink AboutFour Corners Citgo 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 i 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:. ANJANA D. PATEL, PRESIDENT Whose place of business is: FOUR CORNERS CITGO 4 SOUTH MAIN STREET Permit Expires: December 31, 2018 License Number: RF-7 Food Fee: $100.00 Milk & Cream Cal BOARD OF HEALTH Mich.aeCMcCCean, 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: FOUR CORNERS CITGO 4 SOUTH MAIN STREET License Number: RF-7 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: ANJANA D. PATEL, PRESIDENT having a place of business at. FOUR CORNERS CITGO 4 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-7 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 RF-7 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening dad 1) Establishment Name FOUR CORNERS C11 ;O '" 2) Establishment Address SOUTH MAIN STREET OCT 3) Establishment Mailing Address (if different) 4 SOUTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-6111 5) Applicant Name & Title: DINESH PATEL 6) Applicant Address 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: 15081261-1532 24 Hour Emergency No.: (608)982-8177 8) Owners Name &Title ANJANA D. PATEL, PRESIDENT 9) Owner Address (If different from applicant) 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 Owner's telephone number (508) 982-8177 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. L A Corporation Name Title Address ❑ An Individual ❑ A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title �DINESH (JACK) PATEL Address: 14 OLD STABLE DRIVE, MANSFIELD, MA 02048 Telephone No: 1(508) 337-6111 FAX: (508)337-6112 E-mail: Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title 24 Hour Emergency No: (508) 982-8177 24 Hour Emergency No: E-mail: PDINISH68@YAHOO.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 3 17) DAYS/HOURS: 7 DAYS 5 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: �J Permanent Location 22) Establishment Type Caterer $25.00 J' Moblie Moblie Start Date: ❑ Retail ( So Ft) 1(-11 Milk & Cream $10 00 Moblie End Date: Moblie Comments: 21) Length of Permit: rJ Annual El Seasonal Seasonal Dales: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain narP ❑ 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) L I Mobile Food & Consession $75.00 F 1 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ( J Residential Kitchen $100.00 I] Retail Food $100.00 ❑ Retail Snack Food $25.00 [] Tobacco Products $25.00 23) Food Operations Definitions: PHF - Potentially hazardous food (tlmeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre Packaged Non-PHFs J Sale of Commercially Pre -Packaged PHFs J Delivery of Packaged PHFs J Reheating of Commercially Processed Foods for Service Within 4 Hours _. Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non PHFs Other Food Operations ❑ PHFCooked To Order FT Preparation of PHFs For Hot And Cold Holding For Single Meal Service r i Sale of Raw Animal Foods Intended to be Prepared by Consumer I j Customer Self -Service ❑I Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service �❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility I!❑. -Vacuum Packaging / Cook Chili i�' J Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Odom Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for _— __ ._._—----- I Catered Events or Institutional Food Service J Retail Sale of Salvage Out -Of -Date ----- ----- -i 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 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: 204-68-4806 N, ,uf�� 26) Signature of Individual or Corporate Name: ` QS h \ Mlp� SUBHLAI ACORO I �� RTIATE flF LIABILITY INSURANCE DATE(MWDD/YYYY) 10/25/2017 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 have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER 508-947-1818 J.K. Olivier! In&,Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivier! fi2mwEAcT Kenneth W. Olivier! PHONE 508-947-1818 FAX ac, No, EXI : A/c, Na Mss- INSURERS AFFORDING COVERAGE NAICt INSURER A, NGM Insurance Co. 14788 INSURED SubhLaxm! Inc. dba Four Comers Citgo�--- 4 South Main St Mansfield, MA 02048 Cum 8r Forster Special Ins INSURED a: i P y INSURE C: Ms. Retail Merchants We Group INSURER D : 16URER E : INSURER F : onA rr hunmco. RPVISInid NijMRER. 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 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`OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OFINSURANCE OL BOB POLICY NUMBER POLICYEFF POUCYEXP LIMITS A X COMMERCIAL GENERALLimiLrry EACH OCCURRENCE $ 1,000,0O0 X CLAIMS MADE ❑ OCCUR BPB9026H 07/14/2017 07/14/2018 DANEUSET2EN9 $ 500,0Dg MEDEXP An one m(n) $ 10,00D PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ wof D LOG GENERALAGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY CMe amman!) OMBINED SINGLE LIMIT $ BODILY INJURY Perperson) $ ANY AUTO BODILY INJURY Peraccident AUTOS EDONLY AUTOSULEO HIRED NOTNOO NED AUTOS ONLY AUTOS ONLY H 11 Rra Ide AMAGE Per accitlent $ S UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS MADE DED I I RETENTION$ C B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANNYICERRAEMBEREXCTNERE ECUTIVE - (Mandatory in NH) Oyes, desaibe under DESCRIPTION OF OPERATIONS below Pollution [lab. N/A 014005033710117 STP115094 01/01/2017 11/28/2016 01N1f20'IB' 11/28(2018 X PER U OTH- EL EACH ACCIDENT 100,000 $ E.L. DISEASE - EA EMPLOYE $ 1D0,D00 El DISEASE-POLICYLIMIT aggregate 500,000 2,000,000 Claims Made ded/claim 5,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, AddiBonal Remarks Schedule, may be attached it more space Is required) nAhlr•ri I ATI%N LIEN I IriGm I C HO W ER "MANST02 rr� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE <:�- L— ACORD 25 (2016103) 01988-2015 ACORD GOHPOHA 110N. AR rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents y 1 Congress Street, Suite 100 Boston, MA 02114-2017 r, www mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Ltgjb1 Business/Organization Name: �ls-z�ti � Qe,/po'/--t � F.l� Address: n1 Sys City/State/Zip: gv. V �t2� 6101-ff Phone#: ol8 fl 1,1 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. �RestaurantBar/EatingEstablishment 2.0 1 am a sole proprietor or partnership and have no ?, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ 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, 12. ❑ Other with no employees. [No workers' comp. insurance req.] *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 thcmedv s, but the corporation has other employees, a workers' compensation policy is required and such ao organization should check box #I. I am an employer that is providing workers' ompensation insurance for my employees. Below is the policy information. Insurance Company Name: i'c .pp, l tJ-wYl-Nr-t. Insurer's Address:-,binSn- 1 City/State/Zip: Policy# or Self -ins, Lie. #- '�--� ��,Q`2.(� Expiration Date: l� yk—N o 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 penalties ofperjury that the information provided above is true and correct Sivnatum Date: Phone #: C n eg y 82 11'1 Official use only. Do not write in this area, to be completed by city 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#: www.mms.gawwn 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: FOUR CORNERS CITGO ADDRESS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 337-6111 FAX NUMBER: (508) 337-6112 OWNER OF BUSINESS: ANJANA D. PATEL, PRESIDENT TELEPHONE OF OWNER: (508) 982-8177 FEDERAL ID/SS NUMBER: 204-68-4806 FEE: $10.00 PERMIT NUMBER: RF-7 SIGNATURE DATE: 1O-26`kI Town of Town of Mansfield - Board of Health 6 Park Rowansfield Mansfield, MA 02048 PERMIT NUMBER: RF-7 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: FOUR CORNERS CITGO LOCATION OF SALE OF TOBACCO PRODUCTS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 337-6111 OWNER OF BUSINESS: ANJANA PATEL, PRESIDENT ADDRESS OF OWNER: 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 982-8177 FAX NUMBER: (508) 337-6112 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: 680710144 FEDERAL IDISS NUMBER: 204-68-4806 SIGNATURE: F^�� DATE: to-26-C 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 By: Corporate Officer (Mandatory, t 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: HmItbUane's Doc=ents\PERM r APPLICATIONS\TAX CERTIFICATION FORM.doc