Loading...
HomeMy WebLinkAboutTrattoria Della Nonna - 12/31/2020*Oi� S6 gly FOR BOARD OF HEALTH USE ONLY Permit# Issued",', 20 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name L N\ Establishment Address Nu Establishment Mailing Address (if different) Establishment Telephone No ti>"YNC\ Applicant Name & Title: Applicant Address Applicant Telephone No.:SiA 24 Hour Emergency No.: Applicant Email Owner Name & Title (if different from applicant)� Owner Address ' Owner telephone number 'j Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. 12 A Corporation Name Title Address 0 An Individual E A Partnership H Other legal Entity Person Directly Responsible For Daily Operations (o ner, person in charge, supervisor, manager etc.) Name & Title: rA t7 Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL ' No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: �.`,_' Name of Person(s) In Charge Certified in Food ProtectionanagM ement: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests - 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. D Yes Does this establishment require a FOG permit? 1Q If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual H Retail Food $125.00 Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 `❑'t Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Fli Supermarkets $400 ❑`i Residential Kitchen $100.00 Rain Date: ,`Milk & Cream $10.00 ❑'f Caterer $35.00 Food Operations: Definifions:PHF - Potentially hazardous food(lime/temperatum controls required) (Check all that apply): Non-PHF's-non-potenfially hazardoustood(no fire/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) !'=7 Sale of Commercially Pre -Packaged Non-PHFs WPHFCooked To Order ❑8 Hot PHF Cooked and Cooled or Hot Held [I Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service 0 Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Q Sale of Raw Animal Foods Intended Susceptible Population Facility E7 Reheating of Commercially to be Prepared by Consumer ❑-3 Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service J Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Ct Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of E] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill 0 Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for 0 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 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. Signature of Applicant: L`-� .,- - "`'• Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: r Signature of Individual or Corporate Name:t"-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. Si ture of Individ}t or Corporate Name By: Corporate Officer (Mandatonj, if Applicable) "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:\UsersWeite\Desktop\Scott's DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: \;,s� \ Address: Phone #: , c �)LN' L, t , an employer? Check the appropriate box: A�re-. LE I (full Business Type (required): F]5. Retail LLJ am a employer with employees and/ or part-time).* 6.0 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. 8. ❑ Non-profit 3.❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § I (4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* Health Care 4. ❑ We are a non-profit organization, staffed by volunteers,11.❑ 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 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 workers' compensation insurancefor my employees. Below is the policy information. Insurance Insurer's Policy # or Self -ins. Lie. # .'1'*,`a 1`ta °`-�, '-3,� �,. "i. Expiration Dater 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 lire 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: Phone #: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Cor \1�Oi Address: Mailing Address: V-A ' e!\71 fix\ A NX\ t `i y Phone/Fax Number: lc t , ti `0 E 4Y�v '30 Emai Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date k/ ! ` 1E,)1 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): \\� Seating Capacity (Actual Count):'" Normal Hours of Food Preparation/Service: ` 4 Monday Tuesday Wednesday Thursdaye- Friday Saturday Sunday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher Barsink Mop Sink Garbage Disposal Ice Making Machines .f Fryolators t,1 Grills or Ovens Exhaust Hoods t Floor drains \ Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): s Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? Grease Trans and Grease Removal Internal Grease Traps aa How many indoor Grease Removal Units (GRU/trap) are on site? f External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: _ Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: Please list fixtures attached{{to each grease trap Grease Trap i <,S 4 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: _ Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: I dNSI rv5afe TIFICATION DEVIN SHENKAR for successfully compleling Iho standards sel fadh for the Ser Safe® Food Protection Manager Certificalion Examination, which is mcmiited 6y the Amerimn National Standards Institute IANSIKonlererroa (or Food Proleclion (CFP). 11/1 DATE OF E L.1 laws apply. BER 5110 EXAM FORM NUMBER 11/16/2020 DATE OF EXPIRATION racvtiticatioa regairemenls. rauonu...Maveu�m�a 1)sWbd.on&.d.3e 1500. Chkop.a6060eas...sfdatrnmr.an�- O C 6 LL _ x � w o 'oc - o � _ Y o = a V W LL � w w m V Z a E o a ! N w N o w O w v 2 O O 0.0 Ln s W = v> a o .+ z a 4 ° W v s Q w m — Q= o W Lna� aw 4 w Q U') p x� s -> Z . m -2> C) i g LU Z -2C-4 "g w mC `oU Q W jS of K \ w H � c °E Z Y s N w � QP S iu � ec xa4 1 � pq \ �.® 141 \f}\ \ \ § § 3 ( § ) e } \ / \ § t ® CIS 2 z 2 0 ( t U 0 2 \ \ \ pq \ �.® 141 \f}\ \ \\\ 2 a\}@B 2u \\\\ \ � \ \ �.® 141 \f}\ \ \\\ 2 \ 2u \\\\ \ E\©§ ) � / � \ CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: OE JN SHENNAH Certificate Number: 2147353 Date of Completion: '"O's Date of Expiration: lmM 7lie above nanned person is hereby issued this;ruifiwfe for tompleling au allergen awareness training program recognized by the Wassarhnsetts Deparnonnt of Public Heallb in accordance with 105 CAM 590.009(G)(3)(a). Diis teitipmte willbe vrtlidf6{five(5)yearsfrom date ofrompletion. hwu dBy: NATIONAL RESTAURANT � ASSOCIATION,,, blassadwsctrs Restmvant A..d. imt 800.765.2122 333 T.vnp6;c Road, Suitu 102 wtv .tnrantorg Southborough, AIA 01772 508-303-9905 navv.maresraurentassocorg I'Y „” ,,, Massachusetts Department of Revenue MT -9 Data Integration Bureau f goo Cambridge street �� 2 �� 0 ��) O Boston, NIA 02204 CERTIFICATE NUMBER 1 l ® d I ® d F. d ® ® d The vendor herein named is registered to sell meals and all beverages pursuant to the General Laws, Chapters 62C and 64H. This registration is effective only for the registrant at the location specified herein. Any change of name or address renders this registration null and void. t� 04'-461-876 IDENTIFICATION K_I`It'!isTH f DE;FAZi0 NUMBER -l' %'A fFJi?IA LA CUC.INA JIi`aJitHA 1 i ?=iT iI %iAIN 3T 0517IJ0 ISSUE DATE inti J(Li) P-0 ii U2LI4u HE DERICK A. LASKEY This registration must be displayed for customers to see and is not assignable or transteraoie. COMMISSIONER OF REVENUE �� o® CERTIFICATE OF LIABILITY INSURANCE EMY DAT/11912019 111/19/2019 Y) 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 endorsement(s). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. PHONEFA% AIC No Ext: AIC Not: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# 1 Adp Boulevard INSURERA: Travelers Indemnity Company of Connecticut 25682 Roseland NJ 07068 INSURED INSURERS: INSURER C: KENNETH MITCHELL DEFAZIO INSURER D: DBA: TRATTORIA DELLA NONNA INSURER E: 160 N MAIN ST _ 1 INSURER F: MANSFIELD MA 02048 COVERAGES CERTIFICATE NUMBER: 1312906 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. INSR LTR TYPE OF INSURANCE DD IISO S WVD POLICY NUMBER POLICY EFF MM/DD/YYYV POLICY EXP MMIOD/YYYV LIMITS Mansfield MA 02048 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1-1 OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ _ MED EXP (Any one person) $ GENT PERSONAL &ADV INJURY $ AGGREGATE LIMIT APPLIES PER: PRO -❑LOC POLICY ECT OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEO RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS YIN LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? FYI (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A N U84N22667019 69/06/2619 09/06/2020 PER OTH- STATUTE ER EL EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,666.666 E.L. DISEASE - POLICY LIMIT $ 1,666,066 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN KENNETH MITCHELL DEFAZIO ACCORDANCE WITH THE POLICY PROVISIONS. 160 N MAIN ST AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HEARTAVER CPR AED Heart HVOr"a' t American Heart CPR AED ro Association. STACEY JARVIS Do above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AIA Headsaver CPR AED Produce, Optional completed modules are Nose NOT refund out 03/I710F mtant" 03/2626 ___ -a.-_.-D_,. Issue Date Recomme!Med Renewal Rale HEART A V E R CPR AED Heartsaver" American Heart CPR AED 60 Association. KELLIE SIMPSON The above individual has successfully completed the objectives and skills evaluations in accordance with the couemu a of the ANA Heartsaver CPN AED Program. Optional completed modeles am have NOT marked out: QuId CPR AED Inlaot CPRExam 0311 03[20_2_0 _ _ _ `7/20 .1& _ _ _ Issue Date�� � � � Recommended Renewal Bala HEARTSAVER CPR A E D Heartsaver" American Heart CPR AED Association. DEVIN SHENKAR The above Individual hos sUceasslulty completed the objectives and skills evalea em s in accordance with Ole cuidwlu a of the ARA Heartsaver CPR AED Program, Optional completed modules am Ihose NOT marked out: 03AVAIT mamCPe 03MID Issue Date Recommended Renewal Bale HEARTSAVER CPR A E C Heartsaver" American Heart CPR AED Associatio) KENNY DEFAZIO The above Individual has successful/ completed the objectives and skills evaluations in accordance with No Cwrlwfmn el the ARA Headsaver CPR AED Program. Optional completed modules are Own NOT marked out. 03/026ff' Infant CPR 03/2626 Issue Date Recommended Renewal Bale HEAHT'AV EH CPR AEC Heartsaver" PO American Heart CPR AED Go Associatio YVONNE DEFAZIO The above Individual line succosefelly completed the objectives and Who evaluations In accordance with the emdcuklm of the AIA Headsaver CPR AED Program. Optional completed modules am those NOT marked out: 03/liftilk"0 Infant CPR 03/2aV I— -------- _.. _... ------ ssue Data Pecomman---d—ad Renew ---al Bato HEART A V E R CPR A E C Heartsaver"' a American Heart CPR AED Associatio MELANIE TREMBLAY The above Individual has successfully completed Vie objectives and sidle ovaluadms in accordance with the curdcoluen of the ARA Headsaver CPR AED Program. Optional completed modules am those NOT marked out: 03/I'%6va" Infant CPR 03/20W Issue Date Recommended Renewal Dale HEARTSAVERCPQ Raining � TC ID #�� Center Name SOUTHEASTERN NEW ENGLAND TC Info -_- ATTLEB0R0,MA-02703 (508)236-7151 Course Location STURDY MEMORIAL HOSPITAL Instructor DEBRA WALSH 1110MEA9 Name _ Holder's Signature 02016Ame6H r1As lath. Tem/,N1,1gvhh Ns card wtllalferrla appoarencre. 151810 NEARTSAVER CA=R AEC Training Center Name TC ID # # SOUTHEASTERN I`IF--Li!.EN-GLANq_ _ TC Into_ r AITLEBORO MA02703 ,(SOSZ'236.7151 _ Course Location -r_ STURDYMEI�I_QRJALJtOSPITAI,___ Instructor Inst. ID # Name DFBR_A WALSH_ 11102130249 Holder's ®2015 Pmerjcari rtfasoclagw Tnmpedrg mN lhk uprntl alfaxlhapPxars 15-1810 Training SOUTHEASTERN NEW NPRAND Center Name TC Info ,NQ�LEBORO MA.02703 (50$)236-7151 _ _� Course STURDY MEMORIAL HOSPITAL Location Instructor DEBRA WALSH i 1J0Mma9 Name Holder's Signature ®20m5 e, "eM odagon Tarrywrfrg with lMs cerdrnifal(erlG apPasmrrtt. 15-1010 Training Center Name SOUTHEASTERN NEW &IRAND Info A771'LEB0R0, MA 02703 (08) M-7151 Course Location STURDY MEMORIAL HOSPITAL Instructor DEBRA WALSH 1110MR49 Name Holder's j Ptc c 02015"en HeM Assn Tampering wi0lMsc� wi➢elle mnrh 16 -tel Training SOUTHEASTERN NEW NUAND Center Name Tc AT, Info LEBORO, MA 02703 008)236-7151 - __-._____ Course STURDY MEMORIAL HOSPITAL Location Instructor DEBRA WALSH l I10E4°3R 49 Name Holders / ®2gt5MlErlcaOxa'W Pssw1n0o6 TengaMrg wrlh thkw ltwilx gq»amnce 15-101 Training SOUTHEASTERN NEW kWAND Center Name TC _ Al LEBORO,M/}02703 (5(10236 -71St Info i _—__,�.-...._ Course STURDY MEMORIAL HOSPITAL Location _ _ __.._..---_�.__. __._— . Instructor DEBRA WALSH 1110�ft &49 Name Signature _ -- ®2015Pme aHeanmwdalron iemperiM x+lh ✓ui caAwllellelrfs appearance 15-101 h*Coto® CERTIFICATE OF LIABILITY INSURANCE DATE(MxvoomyVl TYPE OF INSURANCE 10/09/2019 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 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 endorsement(s). PRODUCER CONTACT Kim Sylvestre NAME: Bright Agency, Inc pHCNNO Ezt: {508)473-0556 Pnlc No: (508)478-6709 6 Congress St. E -MA ksylvestre@brightinsurance.com ADDRESS: P.O. BOX 424 INSURER(S) AFFORDING COVERAGE NAIC# Milford MA 01757 INSURERA: NY Marine & General Ins Co INSURED INSURER B: Arbella Protection Ins 41360 Dewey Service Corp INSURER C : StarStone National Ins Co 1 Condon Way#D INSURER D: Zurich -America INSURER E: Hopedale MA 01747 1 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1992712111 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, INSR LTR TYPE OF INSURANCE AVOLBURR INSR We POLICY NUMBER POUCYEFF MMIDD/YYYY POLICYEXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX -1 OCCURAGE X Pollution PK201900011407 07/31/2019 07/31/2020 EACH OCCURRENCE $ 1,000,000 TO KIN; 1 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY PRO- F—]3,000,000 JECT LOC OTHER: GENERALAGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGG $ Employee Benefits $ 1,000,000 B AUTOMOBILE X LIABILITY ANYAUTO OWNED XSCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY X AUTOS ONLY 102006410103 07/24/2019 07/24/2020 GGIAWNBERINGLE LIMIT $ 1,000,000 Ea accident) BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident)$ Comp Bi s 20,000 C X UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE 73168Z192ALI 07/31/2019 07/31/2020 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X1 RETENTION $ 10,000 $ D WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) I DESCRIPTIObe N OF DESCRIPTION OF OPERATIONS below NIA 6ZZUB-4N59350-1-19 09/14/2019 09/14/2020 OTH- X STATUTE X ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) n 19AA_2n16 Ar.ORn RORPnPATInN 411 rLKm meer,.ed ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Trattoria Della Norma ACCORDANCE WITH THE POLICY PROVISIONS. 160 N Main St AUTHORIZED REPRESENTATIVE Mansfield MA 02048 n 19AA_2n16 Ar.ORn RORPnPATInN 411 rLKm meer,.ed ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD