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HomeMy WebLinkAboutSunoco #6035 06/01/2013Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. Whose place of business is: Permit Expires: SUNOCO, INC (R&M) SUNOCO #6035 70 COPELAND DRIVE June 01, 2013 License Number: RF-54 BOARD OF HEALTH Food Fee: $50.00 Milk & Cream W MichaeCHeaCey, 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: License Number: Permit Expires: BOARD OF HEALTH SUNOCO #6035 70 COPELAND DRIVE RF-54 June 01, 2013 .MichaeCHeaCey, 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: SUNOCO, INC (R&M) having a place of business at: SUNOCO #6035 70 COPELAND DRIVE 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 June 01, 2013, unless previous to that time is suspended or revoked. Expires: June 01, 2013 License No.: RF-54 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 03/31/12 10:52AN Coop 6035 508-339-8766 p.03 FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF-54 FOOD ESTABLISHMENT PERMIT APPLICATION 1) Establishment Name SUNOCO #6036 2) Establishment Address 70 COPELAND DRIVE 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 5) Applicant Name & Title:- TO 6) Applicant Address 999 BERK: _____.._._.._.......... _....... ..... ...... _.._ 7) Applicant Telephone No.: (610) 913-2610 999 BERKSHIRE BOULEVARD, SUITE 100 WYOMISSING, PA 19610-1268 339.2301 CE COORDINATOR BOULEVARD, SUITE4W WYOMISSING, PA 19610-1258 24 Hour Emergency No.: (800)766.5644SUNOCO SECURITY (508) 8) Owners Name & Title SUNOCO, INC (R&M) .__.__—___..____.._____..._-.---- ........ ___.__._..._._..__......_._-.... ._--- .... .-........... ..-.---..._...........__.._.--_--.__._...___-__...— 9) Owner Address (If different from applicant) 999 BERKSHIRE BOULEVARD, SUITE 100, WYOMISSING, PA ---....._...— - --- -- ---- - ._..... --- .........._......._M_........ -... _.__...-._.._......_.. _...._.__.._.__.._.. ......_..._... Owner's telephone number (610) 988-2619 OR .2620 _._...._..-......_.__-. 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 0 An Association or partner. N11 A Corporation Name Title Address ❑ An Individual(._�_Ld 1�-.___.....__._......._.........._..---_...._...._....__.............._...._.._--.._. O A Partnership O Other legal Entity _..__._...._.. --- - _._...-----... - ---- p-erat....--- - ---- - - __- --...------...__ - ---..... e- -- -- ......_._._._.. 12) Parson Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: - ---------- --- ----- --- -- -- - - Telephone No: FAX: 24 Hour Emergency No: n r Alt &Mail: _ 13) District Or Regional Supervisor (if applicable) 03/31/12 10:52AM Coop 6035 508-339-8766 p.04 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees; 0 17) DAYS/HOURS: 2417 ----------- __._..__-__.._._._ 18) Name of Person In Charge Certified in Food Protection Management: JOSEPH T. BURROUGHS If more than 3 individuals are certified, complete list is on file. 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 Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: Annual ....._._.._....__.._...._....._...._..... _..._------- ___._._—__._..._.. Seasonal Seasonal Dates: [� Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type [JJ Retail ( 480 Sq. Ft) Food Service uto 100 or up to 10' PHF display $75 [] Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 26+ PHF display $125 [) Food Service - Institution ( Meals/Day) ❑ Caterer $25 jy Milk & Cream $2 Mobile Food & Consesslon $50 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer [J Pushcart $25 1t of Pushcarts: [_J Residential Kitchen $25 Retail Food $50 Retail Snack Food $10 n Tobacco Products No Fee 23 Food Operations thefinftlons: PHF- Potentially hazenfw$ food (rlma4empenuUM controls required) p Non-PHFs - non -potentially hazardous foodino time4emperatum controls required) Check all that apply): RTE- leady-to-eat foods (Er. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs _......._._....._._._....._..__.._._.__._.._..—.__.._...._...-__ De ........ Sale of Commercially Pre -Packaged PHFs - -_..._._..__....._...._—. livery of Packaged PHFs 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 [) Preparation of PHFs For Hot And Cold Holding For Single Meal Service [� Sale of Raw Animal Foods Intended to be Prepared by Consumer 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 ____.._....._...__......__.-__-. .......... Vacuum Packealno / Cook Chill ❑ Customer Self -Service and/or HACCP Plan (including bare hand Ice _.._._..__...._....ac_t ...._.ur.e.d ..__ and _....__.Package._.__.........d .._for .._... contact alternative, time as a public health ❑ Manuf Retail Sale control) Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin_ _ ..._._.�._.........._..._.................anti—_...._. []Prepares Food/Single Meals for ---_...._._._..... [j Offers RTE PHF in Bulkulk Quantities .._..__.._._._.._.__.._._..___._...___..__......_..__.___ Catered Events or Institutional Food Service r' Retail or Reconditioned To be completed by the Board of Health Total Permit Fee: $50.00 Payment Is due with application F1 waived 1, 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 c es of 105 CMR 690.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, i certify r der the Pena li of perjury at 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: 23.1743283 26) Signature of Individual or Corporate Name: §\ \\ zQ4 a wy ©J co « § \ ) � : «\ 03/31/12 10:52AN Coop 6035 508-339-8766, p.05 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 June 1 st of each year. NAME OF BUSINESS: SUNOCO #6035 ADDRESS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 FAX NUMBER: (508) 339-8766 OWNER OF BUSINESS: SUNOCO, INC (R&M) TELEPHONE OF OWNER: (610) 988-2619 OR -2620 FEDERAL IDISS NUMBER: 23-1743283 FEE: $2.00 PERMIT NUMBER: RF-54 SIGNATURE: DATE: z1 .._.-.._.-. 03/31/12 10:52AM Coop 6035 508-339-8766 p.06 Town of Mansfield Town of Mansf eld - Board of Health 6 Park Row Mansfield, MA 02048 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 June 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: SUNOCO #6035 LOCATION OF SALE OF TOBACCO PRODUCTS: 70 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-2301 OWNER OF BUSINESS: SUNOCO, INC. (R&M) ADDRESS OF OWNER: 999 BERKSHIRE BLVD., SUITE , WYOMISSING, PA 44/1 TELEPHONE OF OWNER: (610) 988,449- vCe� c FAX NUMBER: (508)-339-8766 If a corporation or partnership, give name, title, and home address of officers or partner. FEDERAL ID/SS NUMBER: 23-1743283 PERMIT NUMBER: RF-54____------- SIGNATURE: DATE: 03/31/12 10:52AM Coop 6035 508-339-8766, p.07 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. Sunoco, Inc. (R&M) * Signature of Individual or Corporate Name (Mandatory) _ 6� 93--/ - ';?I IYI�3 ** Social Security Number (Voluntary) or Federal identification Number * This license will not be Issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A, 03/31/12 10:52AM Coop 6035 508-33,9-8766. p.08 The Commonwealth of Massachusetts Department of industrial Accidents Office of investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses Applicant Information uneeeme.Please Print Le bI Business/Organization Name: 999 Rairkshire Blvd. Suite 100 Address: Wy=icginn, PA 19610 Are you an employer? Check the appropriate box: I. ❑ I am a employer with 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]' A. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Phone #: Business Type (required): S._aRetail 6. [1 Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales line]. real estate, auto, etc.) 8. © Non-profit 9. [] Entertainment ME] Manufacturing 11.0 Health Care 12.[] Other *Any applicant that cheeks box 91 must also fill out the section below showing their workers' compensation policy summation. Off the corporate ofcen have exempted themselves, but the corporation has other employees, a workam' componsation policy is required and such an organization should check box #1. i am an employer that is providtng workers' compensation insurance for my employees. Below is the policy information. insurance Company Insurer's Address: City/State/Zip: Policy ff or Sell -ins. Lic. Expiration 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 cerl(fy, under the pains and penalties of perjury that the Information provided above is true and correct. Offlcial 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 A. Licensing Board 5. Selectmen's Office 6.Other Contact www.moss.gov/dia Phone A(C6Rh® CERTIFICATE OF LIABILITY INSURANCE DATEIM01`1 YVYI `/ oslzvzot t 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(les) 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 CONTACT NAME' MARSH USA INC. PHONE TWO LOGAN SQUARE , EXgL I (qAC Not: PHILADELPHIA, PA 19103-2797 SMAII. Ao REss: Alin: Philadelphia.cens@marsh.com INSURERS AFFORDING COVERAGE NNIC 9 INSURER A, Zurich American Insurance Cc _ 16535 J2335IALL-GAWPR-11.12 R&M GAW _ INSURED INSURER 9: American Zurich Insurance Company 40142 SUNOCO, INC. (R&M) ----- -- 1735 MARKET STREET INSURER C SUITE LL INSURER D: PHILADELPHIA, PA 19103 ----------- --- INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-003481924-04 REVISION NUMBER: 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. NTR TYPE OF INSURANCE INSRIAUDEg D POLICY NUMBER POLICYEFF POLICYEXPMIMIDD LIMITS A GENERALDABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE MOCCUR GLO 9308269-08 05/3112011 0513112012 EACH OCCURRENCE $ 1,0OQWO DAMA ETORENTED PREMISES Ea ocrerrence $ NIA MED EXP(Any one person) s NIA PERSONAL &ADV INJURY $ INCLUDED' GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG _$ $ INCLUDED' ----- $ ----� A AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED AUTOS AUTOS BAP 9308-11908 05)3112011 0513112012 COMBINED SINGLE LIMIT Ea eccitlent $ i,00QG00 X1HIRED BODILY INJURY(Per person) _ $ BODILY INJURY(Pcracclden0 $ PROPERTYDAMAGE Peraccider $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS�MADE EACH OCCURRENCE $ AGGREGATE DED I I RETENTION$ S g WORKERS COMPENSATION AND EMPLOYERS' LIABILITYYIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC 9308270 10 ( SELF INSURED IN PA, OK, OF, MI ) 0513112011 0513112012 X WC STATU- oTH. E.L. EACH ACCIDENT 1,000000 S E. L. DISEASE -EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,ODD,000 $ SEE ADDITIONAL PAGE DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) RE: EVIDENCE OF INSURANCE, CERTIFICATE HOLDER CANCELLATION SUNOCO, INC (R&M) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1735 MARKET STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PHILADELPHIA, PA 19103 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010106) The ACORD name and logo are registered marks of ACORD a Ln a 0 Z i fe 0 U. a X W ^ G � 60'd Y(b O U 'zo 008 EE—t,(nin M 0 Q�s a gg a pNd y aa� a U 4` dg O S sd� 99L8-6££-809 3£09 d003 XYZS:OT ZT/T£/£O 03/31/12 10:52AM Coop 6035 508-339-8766, p.10 CERTIFICATE OF .ALLERGEN AWARENESS TRAINING N,unc of Recipient: JOSEPH BURROUGHS C'enilicar'e Dumber: 182227 Dme dCompleri(m: 01/1312011 Datc of lspi(;rtiun: 01/13/2016 i.. Il/r /li x!'' NAIIONAI fin' nr/ b nr rlf rr r r /',rnn /'prrw /(f,l ;.� RLS1AURAN'i u,4r/rn; d/r < JLnxe/..r„l, IAnrnun, rrl rflrllk /l.nGh AS`d'XIAI'IONe, '//�i,;,�+ti/rv;,�::�ii/irrnfi,l rrulrrrlV rvmr!�on!r/,r/r o/'„nu/Jr/inrr. .u. ;e!rx". ] / ©) )2 /\o � - ® �