The URL can be used to link to this page

Home My WebLink AboutCumberland Farms - 6/1/2010Commonwealth 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: CUMBERLAND FARMS, INC. CUMBERLAND FARMS #0187 30 CHAUNCY STREET June 01, 2010 License Number: RF-42 Food Fee: $50.00 Milk & Cream W BOARD OF HEALTH Dr. Raymond Martin, Chairman I 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: CUMBERLAND FARMS #0187 30 CHAUNCY STREET License Number: RF-42 Permit Expires: June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman Town of Mansfield Town of Mansfield - 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 ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CUMBERLAND FARMS, INC. LOCATION OF SALE OF TOBACCO PRODUCTS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: OWNER OF BUSINESS: CUMBERLAND FARMS, INC. ADDRESS OF OWNER: 777 DEDHAM STREET, CANTON, MA 02021 TELEPHONE OF OWNER: (781) 828-4900 FAX NUMBER: 8 t" Y"'� 1- If a corporation or partnership, give name, title, and home address of officers or partner. FEDERAL ID/SS NUMBER: 04-2843586 PERMIT NUMBER: RF-42 SIGNATURE: DATE: i AA 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 1st of each year. NAME OF BUSINESS: CUMBERLAND FARMS #0187 ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 330� c�, CG+ k -- q � � -T FAX NUMBER: (`f fa' t ) -*2 ;� \ — (') & S '-� OWNER OF BUSINESS: CUMBERLAND FARMS, INC. TELEPHONE OF OWNER: (781) 828-4900 FEDERAL ID/SS NUMBER: 04-2843586 FEE: $2.00 PERMIT NUMBER: RF-42 SIGNATURE: DATE: it 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 (Mandatory) ,,-- dA By:'Corporate Officer (Mandatory, if applicable) ** 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1F www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: CUMBERLAND FARMS INC. Address: 777 DEDHAM STREET City/State/Zip: CANTON MA 02021 Phone #: Are you an employer? Check the appropriate box: 1.0 I am a employer with 6, 092 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no emolovees. rNo workers' comn. insurance rea.] (781)828-4900 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I L❑ Health Care 12.® Other RETAIL CONVENIENCE STORE/GAS S A *Any applicant that checks box # I must also fill out the section below showing 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 boo: 91. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ILLINOIS NATIONAL INSURANCE COMPANY Insurer's City/State/Zip: AON SERVICES/5 KENNEDY PLACE/LOTH FLOOR PROVIDENCE,RI 02903-2393 Policy # or Self -ins. Lie. # WC 60168572 Expiration Date: 04 /01 / 10 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 andpenqhiieqfperjury that the information provided above is true and correct. Signature: Date: Phone #: (781)828-490(� TAX MANAGER 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.mass.gov/dia FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF-42 FOOD ESTABLISHMENT PERMIT APPLICATION (Aoolication must be submitted at least 30 days before the planned opening date) 1) Establishment Name: CUMBERLAND FARMS #0187 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) TAX DEPT. 777 DEDHAM STREET Dy (1 CANTON, MA02021 tE U 4) Establishment Telephone No: (508)339C UD :� �!A{ 1 ZOOS 5) Applicant Name & Title: CUMBERLAND FARMS, INC. 6) Applicant Address 777 DEDHAM STREET, TAX DEPT., CANTON, MA 02021 7) Applicant Telephone No.: (781) 828-4800 24 Hour Emergency No.: (808) 388.7097 8) Owners Name & Title CUMBERLAND FARMS, INC. 9) Owner Address (If different from applicant): 777 DEDHAM STRET, TAX DEPT., CANTON, MA 02021 10) Establishment Owned By: ❑ An Association V A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If corporation or partnership, give name, title, and home address of officers or partner. - Name Title Address E c� Q 7 12) Person Directly Responsible For Daily Operations (owner, person in charge(supervisor, manager etc.) Name & Title: Address: Telephone No: Q 24 Hour Emergency No: c =� `�- v FAX: 13) District Or �egionafSupervisor (if applicable) Name & Title: n ...-- Address: Telephone No: FAX: 24 Hour Emergency No - A CORD,M CERTIFICATE OF LIABILITY DATE(MM/DD/YYYY) INSURANCE 04/01/2009 PRODUCER ADD Risk services Northeast, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY Providence RI Office AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 50 Kennedy Plaza CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE loth Floor COVERAGE AFFORDED BY THE POLICIES BELOW. Providence RI 02903-2393 USA — INSURERS AFFORDING COVERAGE NAICH PHONE-(866 283-7122 FAX- 847 953-5390 INSURED INSURER A: National union Fire Ins Co of Pittsburgh 19445 INSURERB: ACE American Insurance Company 22667 CUMBERLAND FARMS, INC. 777 DEDHAM ST INSURER C: Illinois National Insurance Co 23817 CANTON MA 020211484 USA INSURERD: New Hampshire Ins Co 23841 INSURERS: COVERAGES I SIR applies per terms and conditions of the o Tz.: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED INSR CM AIRYI INSHE TYPE OF INSURANCE POLICYNUMBER POLICY EFFECTIVE DATE(MMBHAVY) POLICY EXPIRATION DATEIhIMWD\YV) LIMITS A G NMAL LIABILITY 0907312 04/01/09 04/01/10 EACH OCCURRENCE $1,500,000 DAMAGETORENTLD $1,500,000 x COMMERCIALGENERALUABILITY CLAIMSMADE ® OCCUR PREWSE (EeARY MIT)ESESIEa mePenee) EXP ee..nee) EXC U 2 PERSONAL& ADV INJURY $1,500,000 GENERAL AGGREGATE $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E4, 000, 000 ❑X POLICY ❑ PRO- ❑ LOU ECT A A AUTOMOBILE X LIABILITY ANY AUTO CA0919338 ADS CA0919339 04/01/09 04/01/09 04/01/10 04/01/10 COMBINED SINGLE LIMIT (Eaeeaiden) $3,000,000 BODILY INJURY ( Per Verson) (N"erson) A ALL ONVNED ALMS SCHEDULED AUTOS MA CA0919340 NH 04/01/09 04/01/10 X BODILY INJURY HIRED AUTOS X NON OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT ANY AUTO OTHERTHAN EA ACC e AUTO ONLY: AGO B EXCESS NMBRELLA LIABILITY G23886480 04/01/09 04 O1 10 EACH OCCURRENCE MOCCUR ❑ CLAIMS MADE AGGREGATE $8,000,000 ®DEDUCTIBLE RETENTION $500,000 D C WORICERSCOMPENSATION AND EMPLOVERS'LIABILITY 60168571 CT,DE,NH,N3,PA,RI,VT 60168573 4 04/01/09 04/01/10 X WC STATU- TORYLIMITS I OTH- ER E.L. EACH ACCIDENT $2,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEILMEMBEREXCLUDEDl Ifyea. describe under, SPECIAL PROVISIONS below FIL 60168572 MA,ND,NY,OH,WA,WV,WY 04/01/09 04/01/10 E.L. DISEASCEA EMPLOYEE $2,000,000 E.L DISEASE -POLICY LIMIT $2,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEMCLESME CLUSIONS ADDED BY ENDORSEMENT'SPECIAL PROVISIONS The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. CERTIFICATE HOLDER -CANCELLATION Town Of Mansfield Six Park ROW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Mansfield MA 02048 USA 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE .41 ��o�a .mil"mAACOORD ✓`1988 ACORD 25 5' 2001 08 CORPORATION L e000 cUlf;F'1b d Fams'- Date of Incorporation: State of Incorporation: Principal Address: Federal ID NO: Ti DEDHAM STREET, CANTON. MASSACHUSETTS 02021.9118 Law Department PHONE: 781-828-4900wEasrm:imV_k�6.-9.^N' = com Joseph H. Petrowski 66 Arnold Road Wellesley, MA 02481 Mark G. Howard, Esq. 15 Greylock Road Wellesley, MA 02481 John T. Daly 22 Thomas Road Berkeley, MA 02779 September 14, 1984 Delaware 777 Dedham Street, Canton, MA 02021 04-2843586 PRINCIPAL OFFICERS: eff, 1011108 President Secretary Assistant Treasurer fa ate€ BRANDED PRODUCTS umbe;Nn Farms - Cumberland HEW MAY o 4 2c:;3� Oil L.P. G We are pleased to announce that the Corporate Offices of Cumberland Farms, Inc. and Gulf Oil L.P. are consolidating and relocating to their Business Support Campus located at: 100 Crossing Boulevard Framingham, Massachusetts 01702 (800) 225-9702 Cumberland Farms, Inc. (508) 270-1400 Gulf Oil L.P. (508) 270-8300 Gulf Oil L.P. is expected to commence business operations at the Business Support Campus on Monday, May 4, 2009 Cumberland Farms, Inc. is expected to commence business operations at the Business Support Campus on Monday, May 18, 2009 Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 117) DAYS/HOURS: SUN -SAT 5AM - 12PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 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: Rj Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: ❑d Retail ( 3,500 Sq. Ft) Mobile End Date: ❑ Food Service up to 100 or Mobile Comments: up to 10' PHF display $75 21) Length of Permit: ❑d Annual ❑ Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution Meals/Day) ❑ Bakery$25 ❑ Caterer $25 ❑ Food Delivery $25 ❑J Milk & Cream $2 Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 Retail Food $50 Retail Snack Food $10 Tobacco Products No Fee 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑� Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ 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- Perishable Foods Only ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health I, the undersigned, attest to the accuracy of the information provided in this application establishment operation will comply with 105 CMR 590.000 and all other applicable law. board of health on how to obtain copies of 105 CMR 590,000 anomie federal F(ooc Cod4 24) Signature of Applicant: r' `"' Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury theI, t i and paid state taxes required under law. 1 25) Social Security Number or Federal ID: 04-284358rr. 26) Signature of Individual or Corporate Name: t t_-Y'YV Total Permit Fee: $50.00'T ra Payment is due with application ❑ waived m that the food been instructed by the ED knowledge and belief, have filed all state lax returns C__ 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: CUMBERLAND FARMS, INC. having a place of business at., CUMBERLAND FARMS #0187 30 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 June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 License'NoRF-42 Scott Leite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred