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Home My WebLink AboutFood and Friends - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit# FOOD ESTABLISHMENT PERMIT APPLICATION.' (Application must be submitted at least 30 days before the planned opening date) • . 0 k Establishment Name f noA S Fr ll e YLt -i I ,-tc 4 c,/, Ftr sr v s Z;-/ � 3 6? � Establishment Address a A r%C DTII /Vf �/ e 7 �-� %iG�r6�'j�ld NA D� d Establishment Mailing Address (if different) Establishment Telephone No v d& - Applicant Name&Title: '�Dovork 0y�rn� VV_ Applicant Address ) %t �h � 54- O'Z Iy8 Applicant Telephone No.: , j p e -3341 _ �� 9� 24 Hour Emergency No.: 6'�O-e� c6� Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. O A Corporation Name Title Address IN An Individual A A Partnership Ed Other legal Entity I 1-1v Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: rfJcr�� E •r- e'f5"q�rd Address: /'G a' w(l +7 ) Telephone No: ��.. Jr��v �d 9°f 24 Hour Emergency No: FAX:�� E-mail:!�`t�?' Alt E -Mail: C�� 1 U Pirf 2=0yt , t 1 4e, District Or Regional Supervisor (if applicable) pQW %'czreA& Name & Title: Az4W _Apra - Address: /g7T/2Ao�iw 4sy L'avw, 4 / Pf ui' vrGlc� 93 P,n sT civ Telephone No: sD 2 2 Z - ,Z 24 Hour Emergency No: ) FAX: d? �zm� ems? E-mail: GU GVUl� (�/%Ip�jO/QCfJLG97G/IO F C�Ur�ie¢S �0�� 2 Food Establishment Information WATER SOURCE: �OCCJ N �� (^ ` SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge C fied in Food Protection Management: L'AVA-7, Name of Peerson(s)In..Charge Certified in Allergen Awareness Training fn@iLL/D L [ � �2.Q,.��12i2 Name of pest control company routinely inspecting the premises for evidence of pests �� e✓�� 77j1J If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. J Yes Does this establishment require a FOG permit? /f/O If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual Retail Food $125.00 c Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $ 25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 0 Pushcart $50.00 If of Pushcarts: Temporary Time: OSupermarkets $400 Residential Kitchen $100.00 Rain Date; Milk &Cream $10.00 Q Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(fimeRemperature controls required) (Cheek all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs IA PHFCooked To Order [2d Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs (J Preparation of PHFs For Hot And for More Than a Single Meal Service 1°❑1 Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly I] Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Susceptible Population Facility Q Use Process Requiring A Variance Processed Foods for Service Within 4 Hours of and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation Pre Retail Sale IUI of Non-PHFs p r_ � Offers Raw Or Undercooked Food Of C Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale G's Vacuum Packaging / Cook Chill i] Offers RTE PHF In Bulk Quantities Prepares Food/Single Meals for ed Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply Wth 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. X Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I ceWfy under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: F(Y,�jy� 02�T!'f5T LtVG14, Rf =1d. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Food Establishments Fee Caterer $35 Milk & Cream $10 Pushcart $50 Manufacture Frozen Desserts/Ice Cream per freezer $25 Mobile Food $100 Residential Kitchen $100 Retail Snack Food, no PHF $50 Retail Food $125 HACCP review and approval $100 Restaurants Seating up to 100 $175 Restaurants Seating 101-200 $250 Restaurants Seating 201+ $300 Supermarket $400 Farmer's Market $25 Temporary (per day) $50 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) Any establishment that generates FOG and does not have FOG containment $50 Critical Violation re -inspection fee $100 Plan review $100 Tobacco and Nicotine Delivery Products $150 Town of Mansfield 6 Park Bow, Mansfield, Massachusetts 02048 Health Department Amy Donovan -Palmer, MPH, BS, Health Agent Food Service Establishment Renewal To renew your permit, please submit the following documents and payment to the Health Department. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. 1. Food Establishment Permit Application (Attached) 2. ServSafe / Food Safety Manager Certificates 3. Allergen Awareness Training Certificates 4. Tax Certification Form (Attached) 5. Workers' Compensation Insurance Affidavit: General Business (Attached) 6. 1Merlee =y ration page 7. hed) Please note, the Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address for all positions. If there are any changes in contact information (i.e. new PIC, new email address), the Health Department must be notified within 10 business days. �The following documents must be on site during inspections. 10 Written Illness Reporting Policy with respect to diseases transmissible through food // (example attached) T� /2. Vomit and Diarrhea Clean up Procedure (example attached) V1. Pest Control contract and/or receipts from routine inspections of the premise The Plastics Waste Reduction bylaw is now fully in effect. According to this by-law, no retail establishment, including food service establishments, shall provide thin-film, single -use plastic check-out bags. Check-out bags can only be a 100% recyclable paper bag containing at least 40% post -consumer recycled content or a reusable check-out bag. Please contact the Health Department if I can be of any further assistance. Phone (508)261-7366 Fax (508)261-7425 Emailadpalmer(✓ic mansfieldma.com Mansfield Board of Health Request for Fee Waiver for Food Permit Date We, �rjv ��a,r c i 57� /(restaurant/ organization) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: We are not charging a fee for food/drink being served. We are a religious organization. ❑ Other: Thank you, Signature C�aerd ai �"�r Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: 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 O cer Wafidnt T ij'tlpplicable) �II re.�5 , Gti P.yvL GYI b1) "N,5�2 PS/�1 s`✓v� c,e (-�^w+ : EI e e D y -3o = o 42 "Social Security No. (Voluntan/) 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents J Office of Investigations 6/" 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Get Applicant Information .,e Print Legibly Business/Organization Name: �1�r�T' �1'�! �1�/ �1 Address: City/State/Zip: 4 � 9 6Y 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. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I 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. [No workers' comp. insurance required] 8. P�,Non-profit 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 4.[Ano employees. [No workers' comp. insurance required]** 11.❑ Health Care We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing woo insurance for my employees. Below is the policy information. Insurance Company Name:r�cQ,. �e 1r e^ Los,� m at t i 4,W �' n S tt ✓m rtc� _��__ Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Attach a copy of the workers' compensation policy declaration page (showing the policy number and 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 cert`" 'under the pr rt andpenalties ofperjury that the information provided above is true and correct. 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: www.mass.gov/dia Phone #: ------------------------------------------------------------ Certificate # 18369552ServSafe ; I e € SUed 9114/2019 I r I i I I I CERTIFICATION i I i 1 b I t Name: CHARLOTTE I I Expires 1 a 1 i t iaY 1 I a I i 1 a I o f 1 ettnSG M ♦«®.. ..W� P � P 1 I MOM w0l�%V WDlfifQW IO11°VDWM5 P unuaiquoways I i I I I Y I 1 1 ? I i I + 1 e I r I w I •sluawaiinbai uolle3ggloo aol AwaBe Aioleln6aj ilunoi Jno'A Lillm poLlo -Aldde smel le:)ol I P I t I uoilepossy luemels@8 leuOWN aql to MJeutapeJj e si aleSnuaS of ixau buueadde o6ol aq j 0ll `suoilnjos uoileposw luejnelsaa leuolleN hq asuaoil aapun Pasn '33"N aql to NJewapejl Palalsi6w e eSAJ,3S si aleSnJaS paAIOS@A slg6u ll'd (j3Vi AN) uoilepuno j leuoileonP3 uotlepossy luemelsaa leuolleN 9 WZ O -------------------------------------------------------------- Ad E, 1 No W 0 W z .a � Opti O 0 U RRR'. W � m a ?4 p v 3 0 u n y m ¢ M M A v y Q O p .a N � .4 .a Z � y V p S. 0 W .a � Opti O 0 RRR'. ?4 p v 3 u n y � 0 •hl Opti y � r O A v y x 5 ti.b�o N � � y PREFERRED MUTUAL INSURANCE COMPANY Preferred One Preferred Way New Berlin NY 13411 Mutual COMMERCIAL GENERAL LIABILITY COVERAGE PART L`censsumd" DECLARATIONS DIRECT BILL RENEWAL BUSINESS Policy Number: CPP 0190 60 22 75 Named Insured: FIRST BAPTIST CHURCH Address: 52 NORTH MAIN ST MANSFIELD MA 02048 Replacement or Renewal Number of CPP 0180602275 Agent: BATES INSURANCE AGENCY INC 20 34600 Address: MEDFORD MA 02155 Policy Period: From 11/05/19 to 11/05/20 12:01 A.M. standard time at the mailing address of the named insured as stated herein. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT (Other than Products -Completed Operations) 4 1 , 000,000 PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT S 1 1000,000 PERSONAL AND ADVERTISING INJURY LIMIT S 500,000 EACH OCCURRENCE LIMIT $ 500,000 DAMAGE TO PREMISES RENTED TO YOU LIMIT (Any One Premises) $ 100,000 MEDICAL EXPENSE LIMIT (Any One Person) S 5,000 The Named Insured is: NOT FOR PROFIT Business of the Named Insured is: CHURCH Audit Period: FORMS & ENDORSEMENTS ATTACHED TO THIS POLICY CG2022(1001) CG2283(1194) R10020 0193) R10021(0193) R10022(0193) R10023(0193 R[0009( 1931 CG2147((1207) CG9506 0709) CG0203((0308) R10490(0413) CG2151(04 3 CG2187 011 6) CG2109 0615) CG2171(0115) CG2108(0514) CG0001(0413) CG2186(1204) CG24240413) CG2132(0509) IL0003(0908) IL0021(0908) CG2167(1204) CG9505(0104) TOTAL ADVANCE PREMIUM 852.00 THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. PMD7 (10-14) Includes copyrighted material of Insurance Services Office, Inc., with permission @ Insurance services Office, Inc., 2000. 10/16/19 SJL AP INSURED COPY CPP GLO 0190602275 867016322 00017 Preferred Mutual Live Assured" PREFERRED MUTUAL INSURANCE COMPANY One Preferred Way New Berlin NY 13411 COMMERCIAL GENERAL LIABILITY SCHEDULE Policy Number: CPP 0190 60 22 75 DIRECT BILL RENEWAL BUSINESS Location and Item Description of No. Hazards Code No. Premium Basis Rates Advance Premium OTHER PR/CO OTHER PR/CO 001A CHURCHES OR OTHER HOUSES OF WORSHIP INCLUDING PRODUCTS AND/OR COMPLETED OPERATIONS CG2022 CG2283 52 NORTH MAIN ST MANSFIELD MA 02048 BRISTOL CO 030 003B R10020 -DIRECTORS & AREA PER THOUSANDS . FT. 41650 10000 0027.557 276 INC MA -517 OFFICERS LIABILITY 73145 COVERAGE PART - MA -517 CLAIMS MADE 004B R10021 -PROFESSIONAL LIABILITY COVERAGE 73444 PART MA -517 005B R10022 -SEXUAL MA -517 MISCONDUCT OR SEXUAL 41650 ABUSE ENDORSEMENT MA -517 006B R10023 -RELIGIOUS INSTITUTION HIRED 44444 AUTO AND NON -OWNED MA -517 AUTO LIABILITY (PER FORM SCHEDULE) 001C SOUP KITCHENS 22222 MA -517 SOUP KITCHEN 1-75 MEALS PER WEEK 0 0000.000 0000.000 $ 117 0 0000.000 0000.000 $ 60 0 0000.000 0000.000 $ 200 0 0000.000 0000.000 $ 132 0000.000 0000.000 $ 67 TOTAL ADVANCE OTHER AND PR/CO $ 852 TOTAL ADVANCE PREMIUM $ 852 GL -S1 (10.14) Includes copyrighted material of Insurance Services Office, Inc., with its permission @ Insurance services Office, Inc., 2000. 10/16/19 SA AP INSURED COPY CPP GLO 0190602276 857316322 010001 PREFERRED MUTUAL INSURANCE COMPANY One Preferred Way New Berlin NY 13411 Preferred POLICY ISSUED ON THE CO-OPERATIVE PLAN Mutual Live Assured" COMMERCIAL LINES POLICY COMMON POLICY DECLARATIONS Policy Number: CPP 0190 60 22 75 Named Insured and Mailing Address (No., Street, Town or City, county, State, Zip Code) FIRST BAPTIST CHURCH 52 NORTH MAIN ST MANSFIELD MA 02048 Policy Period: From 11/05/2019 to 11/05/2020 named insured as stated herein. DIRECT BILL RENEWAL BUSINESS Replacement or Renewal Number of CPP 0180602275 12:01 A.M. standard time at the mailing address of the IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Properly Coverage Part Commercial General Liability Coverage Part Commercial Crime Coverage Part Commercial Inland Marine Coverage Part Owners & Contractors Protective Liability Coverage Part Commercial Auto Coverage Part (Not Applicable In Massachusetts) Countersigned: 10/15/2019 By PTIMTIrtat] BATES INSURANCE AGENCY INC 92 HIGH STREET - SUITE B1 MEDFORD MA 02155 (781)396.4985 $ 2,995.00 $ 852.00 TOTAL $ 3,847.00 Authorized Representative THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVER- AGE FORMS(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. CD -1 (10-14) Includes copyrighted material of Insurance Services Office, Inc., with its permission @ insurance Services Office, Inc., 2006 INSURED COPY MASSACHUSETTS CHANGES - LEAD POISONING ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. With respect to the premises listed in the Declarations of this policy, for each "unit" on such premises for which you have either a "Letter of Interim Control" or a "Letter of Full Compliance", and for the adjacent common areas which are covered under the policy and to which the "Letter of Interim Control" or "Letter of Compliance" applies, we will provide coverage under COVERAGE A - BODILY INJURY AND PROPERTY DAMAGE LIABILITY (Section I - Coverages) for liability arising out of an "occurrence" of lead poisoning, as described below. This insurance applies to "bodily injury" which occurs during the policy period and arises out of lead poisoning from lead in a covered "unit", or adjacent common areas, for which one of the following applies: A "Letter of Interim Control" or a "Letter of Compliance" is in effect at the time the "bodily injury" occurs; 2. The "bodily injury" occurs within 14 days after you, or your managing agent, have been notified by an au- thorized lead inspector that the "unit" or adjacent common areas on your premises is not in conformance with an already existing emergency lead management plan and the "Letter of Interim Control"; or 3. The "bodily injury" occurs during any extension of the 14 day period described in paragraph 2. above, as granted by a lead poisoning control director, local code enforcement agency or board of health, or by judicial order, except no coverage is provided for "bodily injury" for which you are strictly liable under the Massachusetts Lead Law. ' This insurance does not apply to "bodily injury" which is the result of your gross or willful negligence. Subject to the General Aggregate Limit shown in the Declarations of this policy, the most we will pay for all "bodily injury" arising out of any one "occurrence" of lead poisoning shall not exceed the Each Occurrence Limit shown in the Declarations. For each "unit" for which you obtain a "Letter of Interim Control" or a "Letter of Full Compliance" during the policy period, you must, as soon as practicable, notify us and provide a copy of the letter. Coverage for that "unit" and the adjacent common areas to which the letter applies shall take effect on the date the letter becomes applicable to the newly complying "unit". B. With respect to the premises listed in the Declarations of this policy, for each "unit", and its adjacent common areas, for which you do not have a "Letter of Interim Control" or a "Letter of Compliance", the insurance under this policy does not apply to "bodily injury" arising out of lead poisoning from lead in such covered "unit" or its adjacent common area, unless, for an additional premium, you purchased such coverage for which, if so pur- chased such coverage for which, if so purchased, an endorsement is attached to your policy. C. If you are a new owner of a premises covered under this policy, and you bring such premises into conformance with the Massachusetts Lead Law within 90 days from taking title, the coverage described in paragraph A. above applies. Coverage for this period shall apply to all conforming "units" and their adjacent common areas from the date you took title to the premises or from the inception date of this policy, whichever is later. D. For the purposes of this endorsement, the DEFINITIONS Section is amended by the addition of the following: 1. "Letter of Compliance" means a Letter of Lead Abatement Compliance or other equivalent "letter of compli- ance" issued by a licensed governmental or private lead inspector in accordance with applicable laws and Department of Public Health regulations on lead poisoning prevention and control. A "Letter of Interim Control" is not a "letter of compliance". 2. "Letter of Interim Control" means a letter, other than a "letter of compliance", which has been issued by a licensed lead inspector: a. In accordance with the applicable laws and the Department of Public Health regulations on lead pre- vention and control: and CG 22 83 (11-94) Copyright, Insurance Services Office, Inc., 1994 Page 1 of 2 CPP GLO 0190802275 2277 19268 INSURED COPY 00019 b. In connection with an emergency lead management plan which has been established to address an ur- gent lead paint hazard until a "Letter of Compliance" is obtained. 3. "Unit" means a room or set of rooms, let to an individual or household for use as living and sleeping quarters, which: a. Is located in any building, premises, dwelling, or in the residential portion of such building or premises which includes both commercial and residential accommodations; and b. Was constructed prior to 1978. CG 22 83 (11-94) Copyright, Insurance Services Office, Inc., 1994 Page 2 of 2 CPP GLO 0190602276 2277 19288 INSURED COPY 00020 CLAIMS MADE THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY. POTENTIAL COVERAGE GAPS MAY ARISE UPON THE EXPIRATION OF CLAIMS MADE COVERAGE. DIRECTORS AND OFFICERS LIABILITY COVERAGE PART This endorsement modifies insurance provided under the following: RELIGIOUS INSTITUTION COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule Policy Period: (Same as Policy Period shown in the Policy Declarations unless otherwise shown.) Retroactive Date: 11/05/2010 COVERAGE PROVIDED UNDER THIS ENDORSEMENT IS SUBJECT TO A SEPARATE LIMIT, STATED BELOW. THIS SEPARATE LIMIT MAY BE HIGHER OR LOWER THAN, AND IS NOT IN ADDITION TO, THE LIMIT PROVIDED BY THE RELIGIOUS INSTITUTION COMMERCIAL GENERAL LIABILITY COVERAGE PART. Limits of Insurance $ 500,000 Each "Wrongful Act" $ 1,000,000 Aggregate Various provisions of this policy restrict coverage. Read b. We will have the right and duty to defend any the entire policy carefully to determine rights, duties "suit" seeking damages, even if any of the and what is and is not covered. This coverage part has "suit's" allegations are groundless, false, or a limited time period to report a wrongful act or claim. fraudulent, but: The provisions in this form are in addition to the Com- mon Policy Conditions and the Religious Institution Commercial General Liability Conditions. The word "insured" means any person or organization qualifying as such under Section III - Who Is An Insured contained in this Coverage Part. Words and phrases that appear in quotation marks in this Coverage Part have special meaning. Refer to Section VII - Definitions of this Coverage Part or Section V - Definitions of the Religious Institution Commercial General Liability Coverage Form. SECTION I - COVERAGE 1. Insuring Agreement 1) The amount we will pay for damages is limited as described in Section IV - Limits oflnsurance. 2) We may investigate and settle any claim or "suit" at our discretion; and 3) Our right and duty to defend ends when we have used up the applicable Limit of Insurance to pay judgments or settle- ments; and c. This insurance applies to a "wrongful act" only if a claim for damages because of the "wrongful act" is first made during the policy period or any extended reporting period. a. We will pay those sums that the insured be- 1) A claim by a person or organization comes legally obligated to pay as damages seeking damages will be deemed to have because of a "wrongful act" to which this in- been made when written notice of such surance applies. The insurance provided by claim is first received and recorded by us, this Coverage Part does not apply to a whether such claim is reported to us by "wrongful act" which occurred before the Ret- any insured or by the person or organiza- roactive Date, if any, shown in the Schedule tion seeking damages. above or which occurs after the policy period. 2) All claims for damages because of a The "wrongful act" must take place in the "wrongful act" causing loss to the same "covered territory"; and person or organization will be deemed to RI 0020 (01-93) Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. CPP OLD 0190602275 2277 19288 INSURED COPY 00021 ,�4 4 have been made at the time the first of those claims is made against any insured. 2. Exclusions All of the exclusions of the Religious Institution Commercial General Liability Coverage part which are not specifically excepted by the terms of this coverage part apply to this coverage part. In ad- dition, this insurance does not apply to: a. Any dishonest, fraudulent, malicious or crimi- nal act and related fines and penalties; b. "bodily injury", "property damage", "personal injury", "advertising injury" or "professional lk ability"; c. Claims based upon or arising out of any actual or alleged violation of the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment Company Act of 1940, amendments thereto, or regulations promulgated thereunder; or any similar provisions of state statutory law or common law; d. Salaries or other compensation of employees, directors, officers or religious leaders; e. Failure to secure and maintain insurance or bonds for the proper amounts of coverage; f. Damages from any transaction for personal gain or advantage which is not shared equally by all members; g. The violation of any civil rights statute or ordi- nances; h. Any claim, "suit", or damages arising directly or indirectly from "contaminants or pollutants" including clean up or removal costs; I. Any claim based on the Employee Retirement Income Security Act of 1974 and amendments to it, or similar Federal, State or local laws; J. Any claim or "suit" of one or more "directors and officers" and/or "committee members" against any individual or group of "directors and officer" and/or "committee members"; k. Any claim or "suit" alleging libel or slander; I. Any claim or "suit" arising out of any actual or alleged conduct of a sexual nature; m. Any claim or "suit" arising out of an insured's joint venture with any entity or ownership of a controlling interest in any subsidiary. How- ever, we will provide coverage to the "direc- tors and officers" and "committee members" of a subsidiary acquired or created after the inception date of this coverage part subject to RI 0020 (01.93) written notice thereof being given to us within 60 days of acquisition or creation. This cover- age applies only to "wrongful acts" occurring after your acquisition or creation of the sub- sidiary, and only for claims made within the first 60 days following such acquisition or cre- ation. We may requiest additional information about the subsidiary, and after review we may exclude or include coverage under this endorsement. SECTION II - SUPPLEMENTARY PAYMENTS We will pay, with respect to any claim or "suit" we de- fend: 1. All expenses we incur. 2. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earning up to $100 a day because of time off from work. 3. All costs taxed against the insured in the "suit". 4. Prejudgment interest awarded against the insured on that part of the judgment we pay. If we make an offer to pay the applicable limit of insurance, we will not pay any prejudgment interest based on that period of time after the offer. 5. All interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, offered to pay, or deposited in court the part of the judgment that is within the applicable limit of insurance. These payments will not reduce the limits of insurance. SECTION III - WHO IS AN INSURED Each of the following is an insured for a "wrongful act": 1. You. 2. Your "directors and officers" as a group and each director and officer as an individual, but only with respect to their duties as directors or officers. 3. Your "committee members" as a group and each member as an individual, but only with respect to their duties as a committee member. 4. "Directors and officers" and "committee members" of any subsidiary, but only to the extent specified under the exception to Exclusion 2.m. SECTION IV - LIMITS OF INSURANCE 1. The limits of Insurance shown in the Schedule of this Coverage Part and the rules below fix the most we will pay regardless of the number of: a. Insureds; Includes copyrighted material of Insurance Services Office, Inc. with Its permission. CPP GLO 0190602276 2277 19288 INSURED COPY Page 2 of 4 GUI IN b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 2. The Each "Wrongful Act" Limit is the most we will pay for all damages arising out of the same act or "interrelated wrongful acts" of one or more of the insureds and shall be considered as one "wrongful 4• act". 3. The Aggregate Limit is the most we will pay for damages as a result of "wrongful acts" for all claims that are made during each annual policy period. 4. You shall be liable to pay the first $100 of damages per individual "officer, director" or "committee member" arising out of each "wrongful act". 5. The maximum you shall be liable to pay for each "wrongful act" is 1,000, except that the individual retention amount in 4. above shall in no event be reduced below $75 per individual. 6. We shall be liable to pay 99.9% of the damages in excess of the amount determined under 4. and 5. above, but: a. We will not be liable for more than the Limit of Insurance shown in the Schedule for this Coverage Part; and b. You shall be liable for: 1) 0.10% of damages in excess of the amount determined under 4. and 5. above; and 2) for the full amount of any such damages remaining after we pay the amount shown for the Limits of Insurance in the Schedule for this Coverage Part. SECTION V - CHANGES TO RELIGIOUS INSTITUTION COMMERCIAL GENERAL LIABILITY COVERAGE PART CONDITIONS Paragraphs 2.a. and 4.b. of SECTION IV - RELIGIOUS INSTITUTION COMMERCIAL GENERAL LIABILITY CON- DITIONS of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM are deleted and replaced by the fol- lowing: 01 a. You must see to it that we are notified as soon as practicable of a "wrongful act" which may result in a claim. To the extent possible, no- tice should include: 1) How, when and where the "wrongful act" took place; RI 0020 (01-93) CPP OLO 0190602275 2) The names and addresses of any dam- aged persons and any witnesses; and 3) The nature of any damages arising out of the "wrongful act". Notice of a "wrongful act" is not notice of a claim. b. Excesslnsurance This insurance is excess over any of the other insurance, whether primary, excess, contigent or on any other basis: 1) That is effective prior to the beginning of the policy period shown in the Declara- tions of this insurance and applies to a "wrongful act" on other than a claims - made basis, if: a) No Retroactive Date is shown in the Schedule of this Coverage Part for this insurance; or b) The other insurance has a policy pe- riod which continues after the Retro- active Date shown in the Schedule for this Coverage Part. When this insurance is excess, we will have not duty to defend any claim or "suit" that any other insurer has a duty to defend. If no duty to defend any claim or "suit" that any other insurer has a duty to defend. If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. When this insurance is excess over other in- surance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: 1) The total amount that all such other in- surance would pay for the loss in the ab- sence of this insurance; and 2) The total of all deductible and self-insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Schedule of this Coverage Part. However, this insurance will be primary to other insurance bought specifically to apply in excess of the Limits of Insurance shown in the Schedule of this Cov- erage Part. Includes copyrighted material of Insurance Services Office, Inc. with its permission. 2277 19288 INSURED COPY Page 3 of 4 00023 SECTION VI - EXTENDED REPORTING PERIOD 1. We will provide one or more Extended Reporting periods, as described below, if: a. This Coverage Part is canceled or not re- newed; or b. We renew or replace this Coverage Part with insurance that: 1) Has a Retroactive Date later than the date shown in the Schedule of this Coverage Part; or 2) Does not apply to a "wrongful act"on a claims -made basis. 2. A basic Extended Reporting Period is automatically provided without additional charge. This period starts with the end of the policy period and lasts for 60 days. The Basic Extended Reporting Period does not ap- ply to claims that are covered under any subse- quent insurance you purchase, or that would be covered but for the exhaustion of the amount of insurance applicable to such claim. 3. A Supplemental Extended Reporting Period of one (1) year is available, but only by an endorsement and for an extra charge. This supplemental period starts 60 days after the end of the polcy period. You must give us a written request for the endorsement within 60 days after the end of the policy period. The Supplemental Extended Re- porting Period will not go into effect unless you pay the additional premium promptly when due. The additional premium for the Supplemental Ex- tended Reporting Period will be 50% of the annual premium for the Coverage Part. 4. Extended Reporting Periods do not extend the pol- icy period or change the scope of coverage pro- vided. They apply only to claims for a "wrongful RI 0020 (01-93) act" that occurs before the end of the policy period (but not before the Retroactive Date, if any, shown in the Schedule of this Coverage Part). Claims for such "wrongful acts" which are firs re- ceived and recorded by us during the Basic Ex- tended Reporting Period (or during the Supplemental Extended Reporting Period, if it is in effect) will be deemed to have been made on the last date of the policy period. Once in effect, Extended Reporting Periods may not be canceled. S. Extended Reporting Periods do not reinstate or in- crease the Limits of Insurance applicable to any claim to which this Coverage Part applies. SECTION VII - DEFINITIONS When used in this Coverage Part: 1. "Committee members" means your members ap- pointed to serve on a commitee to perform specific management duties for you. 2. "Directors and officers" means those persons who now form or previously formed your administrative body, including their legal representatives. Each such person must be or has been selected by your institution, according to your bylaws. 3. "Occurrence" means "wrongful act" when it ap- pears in Religious Institution Commercial General Liability Coverage Part Conditions or Exclusions applying to this Coverage Part. 4. "Wrongful act" means any negligent act, error or omission, misleading statement, breach of duty, or misstatement committed by "directors and officer" or "committee members" while acting in their ca- pacity as such. 5. "Interrelated wrongful acts" means wrongful acts which have as a common nexus any fact, circum- stance, event, transaction or series of facts, cir- cumstances, situations, events or transactions. Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 4 of 4 CPP GLO 0190602275 2277 19288 INSURED COPY 00024 PROFESSIONAL LIABILITY COVERAGE PART THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE RELIGIOUS INSTITUTION COMMERCIAL GEN- ERAL LIABILITY COVERAGE PART. COVERAGE PROVIDED UNDER THIS ENDORSEMENT IS SUBJECT TO A SEPARATE LIMIT, STATED BELOW. THIS SEPARATE LIMIT MAY BE HIGHER OR LOWER THAN, AND IS NOT IN ADDITION TO, THE LIMIT PROVIDED BY THE RELIGIOUS INSTITUTION COMMERCIAL GENERAL LIABILITY COVERAGE PART. Limits of Insurance $_500,000 Each Claim $ 1,000,000 Annual Aggregate SCHEDULE OF POSITIONS COVERED 1. CLERGY - 2 2. 3. 4. 5. 6. 7. 8. 9. 1. We will pay those sums that the insureds becomes 1) The amount we will pay for damages is legally obligated to pay as damages because of limited as described in Limits of Insurance any acts, errors, or omissions arising out of "pro- for Professional Liability Coverage. fessional services" to which this insurance applies. 2) We may investigate and settle any claim No other obligation or liability to pay sums or per- or "suit" at our discretion; and form acts or services is covered unless explicitly provided for under paragraphs (b) and (c). 3) Our right and duty to defend a claim or "suit" ends when we have used up the a. This insurance applies only: applicable limit of insurance in the pay- ment of judgements or settlements for 1) To acts, errors, or omissions: such claim or "suit", or when we have used up the annual aggregate limit of in - a) That are committed during the policy surance in the payment of judgments or period; settlements. b) That take place in the "coverage ter- c. Coverage Extension - Supplementary Pay- ritory"; and ments c) Arising out of "professional services" In addition to the limit of insurance, we will "suit" in the conduct of your operations, as pay, with respect to any claim or we described in the Declarations. defend: 1) All expenses we incur. b. We will have the right and duty to defend any claim seeking those damages, even if any 2) The cost of bonds to release attachments, allegations are groundless, false, or fraudu- but only for bond amounts within our Limit lent. However: of Insurance. We do not have to furnish these bonds. RI 0021 (01-93) Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc. with its permission. CPP OLO 0190602276 2277 19288 INSURED COPY 00025 3) All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the "claim" or "suit", including actual loss of earnings up to $100 a day because of time off from work. 4) All costs taxed against the insured in the "suit". 5) Prejudgment interest awarded against the insured on that part of the judgment we pay. If we make an offer to pay the Limit of Insurance, we will not pay any pre- judgement interest based on that period of time after the offer. 6) All interest on the full amount of any judgment taht accrues after entry of the judgment and before we have paid, of- fered to pay, or deposited in court the part of the judgment that is within our Limit of Insurance. 2. Exclusions Applicable to Professional Liability Coverage g. Any dishonest, fraudulent or criminal act or omission of the insured, including the violation of any penal statute, ordinance, or regulation. h. Liability arising out of "personal injury" or "advertising injury". I. Acts, errors or omissions of the insured as a proprietor, superintendent, or executive officer of any hospital, sanatorium or medical clinic, or while acting for a professional counseling service organized for the sole purpose ofpro- viding counseling, referral, educational, or similar services. 3. Who is an insured for Professional Liability Cover- age a. Each of the following is an insured for Profes- sional Liability Coverage to the extent set forth below: 1) Each of the following is an insured for Professional Liability Coverage to the ex- tent set forth below: a) You; All of the Exclusions of the Religious Institution Commercial General Liability Coverage Part which b) Any executive officer, volunteer reli- are not specifically excepted by the terms of this gious instructor, member of the board Coverage Part apply to this Coverage Part. In ad- of trustees, member of the board of dition, this insurance does not apply to: directors, member of the board of governors, or similar board of yours a. Liability due to the rendering or failure to ren- but only with respect to their duties der medical, surgical, dental, x-ray or nursing as such; and services or treatment. This includes, but is not limited to shock therapy, and the prescription, c) Any employee occupying a position utilization, furnishing or dispensing of drugs scheduled in the SCHEDULE OF PO - or medical, radiological, surgical, dental or SITIONS COVERED shown above. nursing supplies or appliances. 4. Limits of Insurance for Professional Liability Cov- b. Liability arising out of the insured's commit- erage ment of a patient to a hospital or psychiatric institution, or drug or alcohol abuse clinics or a. The Limits of Liability shown in this endorse - institutions of the like. ment and the rules below fix the most we will pay regardless of the number of: c. Liability arising out of acts, errors or omis- sions of the insured as a member of a formal 1) Insureds; accreditation or similar professional board or committee of any hospital or professional so- 2) Claims made or "suits" brought; or ciety. 3)Persons or organizations making claims d. Liability arising out of the insured's accept- or bringing "suits". ance and/or undertaking of custodial care or responsibility of a person at the request, in- b. The most we will pay for the sum of all dam- struction, authorization or direction of any ages because of each claim or "suit" covered governmental agency, authority, board or offi- by this insurance is the Professional Liability cer. limit shown above applicable to "each claim". e. Liability arising out of any actual or alleged c. Two or more claims arising out of one act, er- conduct of a sexual nature. ror or omission in "professional services" or related acts, errors or omissions in "profes- f. Damages caused by the insured while under sional services" shall be deemed to constitute the influence of intoxicants or narcotics. one claim for the purpose of applying the Pro - RI 0021 (01.93) Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc. With its permission. CPP OLO 0190602275 2277 19288 INSURED COPY 00026 fessional Liability limits shown above applica- ble to "each claim". d. Aggregate Limits The most we will pay for the sum of all dam- ages because of acts, errors or omissions arising out of "professional services" covered by this insurance is the Professional Liability limit shown above as "annual aggregate". The limits of this insurance apply separately to each consecutive annual period and to any re- maining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the limits of Insurance. 5. Definition Applicable to Professional Liability Cov- erage RI 0021 (01-93) "Professional Services" means, solely for use un- der this coverage: a. Guidiance or counseling activities; b. Activities arising out of the ownership, opera- tion, use or maintenance of cemeteries; or c. Teaching activities arising out of the faculty or teaching staff of any school, religious educa- tion facility, day care center or nursery school owned or financially controlled by you. 6. Conditions Applicable to Professional Liability Coverage a. All General Liability Conditions (Section IV) and Definitions (Section V) of the Religious In- stitution Commercial General Liability Cover- age Form are applicable to this insurance. b. Duties in the Event of Occurrence, Claim or "suit' do not apply to this insurance to the ex- tent that they refer to expenses incurred by the insured for first aid. Includes copyrighted material of Insurance Services Office, Inc. with its permission. CPP GLO 0190602275 2277 19266 INSURED COPY Page 3 of 3 00027 MAR