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HomeMy WebLinkAboutVillage at Willow Crossing - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health : Permit to Operate a Food Service Establishment Type. FOODSERVICE ESTABLISHMENT 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:. BENCHMARK SENIOR LIVING Whose place of business is: VILLAGE AT WILLOW CROSSINGS 25 COBB STREET PERSON(S) IN CHARGE. ANNE DEMINICO, EXECUTIVE DIRECTOR Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -81 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream N �tl FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planneda . Establishment Name: v, �IGt c A+ W i (Ic7Gt1 �rossoO Establishment Address: 2S 00(k S'�'�`ef �avts�ietah Mil- U , Establishment Mailing Address (if different): ¢6 Establishment Telephone No: �JQ 2 tot f 33�J n Applicant Name & Title: Aim im beHl nico, &IeC"✓e �t�eClN' Applicant Address: 25 cabiq Sleet-, kanS6,e(d kt+ C)2zgv Applicant Telephone No.: S og_ zw-133 3 24 Hour Emergency No.: 508$ .2L1 _ 1333 Applicant Email: actP[Ntiil,cv @ bC✓tcl?mavkojucrt!iy. Cor" Owner Name & Title (If different from applicantt):"�5YnCG7Mark- c5erbl� 140j25 Owner Address: 2„01 104e5 r?00d ww ti 3`1 Rodd No Nkcw IY� 62c s l Owner telephone number: 7$11-W7--7100 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. a A Corporation Name Title Address IN An Individual IQA Partnership IDEA Other legal Entity Person Directly Responsible For Operations (owner, person in charge, supervisor, manager etc.) /Daily Name & Title: Aviv l�. be ql I o, ��CGGI�iy� �i/CG�Of Address: -25 &Yeet kaAsGe td A4 o w qg Telephone No: 5R)8'. ul, /.333 24 Hour Emergency No: 241-1333 FAX: rJVg-,337 • tl�to3 E-mail QLi2iM[/l��C.� � �f�h.FL1['!'fG+��GICt�['/+�,LO✓H 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: %pWh I SEWAGE DISPOSAL: 7-oWo DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYSMOURS: p" Name of Person In Charge Certified in Food Protection Management: 1 I&MCe A. 60W If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: X.Permanent Location Establishment Type: F{ Caterer $35.00 Q Moblie Moblie Start Date: N Retail -NO FOOD PREP ( Sq. Ft) $125 KMlIk & Cream $10.00 Moblie End Date: f%.. Mobile Food Concession . Food Service up to 100 seats Mo PHF PREPARED ON SITE $100.00 Moblie Comments: INCLUDING FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Length Of Permit. Food Service for 101 -200 seats $250.00 x -x $25.00/freezer Annual -- Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: Ea Seasonal r3 Residential Kitchen $100.00 Seasonal Dates: 1/) Supermarkets $400 H Temporary -- L1 Tobacco Products $150.00 Temporary Start Date: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF- Potentially hazardous food(timenemperature controls required) Non-PHFs - non -potentially hazardous foodiro timeRemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Fd Sale of Commercially Pre -Packaged Non-PHFs XPHFCooked To Order i§ Hot PHF Cooked and Cooled or Hot Held Q Sale of Commercially Pre -Packaged PHFs OK Preparation of PHFs For Hot And for More Than a Single Meal Service Ei Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility FJ Sale of Raw Animal Foods Iniended eheati of Commercially to be Prepared by Consumer K3 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- L Customer Self -Service '1 Use of Process Requiring A Variance Perishable Foods Only and/or HACCP Plan (including bare hand Q Ice Manufactured and Packaged for contact alternative, time as a public health reparation of Non-PHFs Retail Sale control) Other Food Operations fg Juice Manufactured and Packaged for iR Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Q Offers RTE PHF in Bulk Quantities (Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned FoodTo be completed by the Board of Health Total Permit Fee: Payment is due with application IH 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 CMR590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copie fyq 105 C 590,000 d t federal Food'Code. Signature of Applicant: /V/`��p'"���- Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 27 l t� Y--_ 4 q o Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandator, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. Ct\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street y` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information e ' / Please Print Legibly Business/Organization Name: �'X IvlalO eu{ � d/blQ-The V,I1Ve�'lMUlml-�t� Address: ;Z, b 5S e66yeef v City/State/Zip: X100SIR001 PA QZQI(g Phone #: JAB=�I- 333 Are ou an employer? Check the appropriate box: Business Type (required): I I am a employer with 1,30 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• ❑ 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 no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, q�� 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.fXOther Seoliy (lwkA. C Innwrl'' *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. lam an employer that c� is providingAvo�riters' compensation insuraan�ce for my employees. Below is the policy i' formation. Insurance Company Name: / " ch —t-risu L orniq lnoan q Insurer's City/State/Zip: Paaf a/ Policy # or Self -ins. Lic. # N l uJ6( g98'290 3 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 a 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, undo itZ to pai s� a,erI pe»trlti ofpe'jury that the information provided above is trite and correct. RiPnature- /�/ Q.r-�I�L_ o�V,(�• `>a]\-� natP. 12_1Z7J/5? Phone#: Sig -2&14333 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 www.mass.gov/dia Phone Page 1 of 2 41CC7R0°D CERTIFICATE OF LIABILITY INSURANCE DA7E(02 2'YYY' L _iR 04/02/2019 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 PRODUCER Hillis of Illinois, Inc. c/o 26 Century Blvd P.O. Be. 305191 Meadville, TN 372305191 USA INSURED Benchmark Senior .Living, LLC 201.. Jones Road, Suite 300 West' Waltham, MA 02451 77-945-7378 Arch Insurance Lloyd's 1-888-467-2378 11150 B7874 INSURER F: COVFRAOFS CFRTIFICATF NIIAARFR, WIDSIS970 RFVICION NIIMRFR• 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. INSfl ADDL BUBR-1 POLICY EFF POLICY EXP ._... TYPEOFINSURANCE LTR POLICY NUMBER MM1DDlYYYY MMMDIYYYY LIMITS Town of Mansfield -Hoard of Health COMMERCIAL GENERAL LIABILITY 6 Park Row ��[� Mansfield, MA 02048 VVtKV AI, EACH OCCURRENCE DAMAGETORENcurmnce) _$ _ _ )CLAIMSMADE ]OCCUR PREMIES(E occEO _ MED EXP (Any ono parson) $ PERSONAL & ADV INJURY $ GEN 'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ L PRO _ _I POLICY LOC PRODUCTS COM PIOP AGO _I' $ OTHER: IS AUTOMOBILE LIABILITY COMBINEUSINGLE LIMIT (En accident) $ 1, 000, 000 X ANY AUTO _ BODILY INJURY (Per person) 1$ A OWNED SCHEDULED Y 41CAB4987706 04/01/2019104/01/2020 BODILY INJURY (Per acwldent)l$ AUTOS ONLYNON HIREDS OWNED Hx PROPERTYDAMAGE y AUT9P.?VLY OE'tlTG61G,'Oile (Per accident) _.. $ _.. X UMBRELLA LIAR20,000,000 OCCUR i EACH OCCURRENCE $ x EXCESS LIAe. X CLAIMS MADE SB -LT CAX-01546-19 04/01/2019 04/01/2020 AGGREGATE_. $ 20,000,000 DED "�7 RETENTION$ $ WORKERS COMPENSATION XSTATUTE OER AND EMPLOYERS' LIABILITY YIN --. - A ANVPROPRIETORIPARTNERIEXECUTIVE E L EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED7 N/A;' 41WCI4987906 04/03/2019 04/01/207,0- - — _-- (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EI DISEASE -POLICY LIMIT $ 1,000,000 A Automobile. Liability - MA I 41CAB4987806 (04/01/2019104/01/2020 I Bee Below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) SEE ATTACHED CERTIFICATE HOLDER CANCFI_I_ATION ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR m: 17756164 BATCH1 1137843 2 of 2 769 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield -Hoard of Health AUTHORIZED REPRESENTATIVE 6 Park Row ��[� Mansfield, MA 02048 VVtKV AI, ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR m: 17756164 BATCH1 1137843 2 of 2 769 AGENCY CUSTOMER ID: LOC #: ASR" ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMEDINSURED Willie of Illinois, Ina. Benoheark Senior Living LLC 201 Jones Road, Suite 300 West POLICY NUMBER Walthae, MA 02451 See Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: _ 25 . FORM TITLE: Certificate of Liability insurance Automobile Liability - MA includes Any Auto and Scheduled Autos Combined Single Limit (Bach Accident): $1;000,000 Bodily Injury (Per Person): $20,000 Bodily Injury (Per Accident): $40,000 Property Damage (Per Accident): $1,000,000 Coll/Comp Deductible: $1,000/$1,000 Included as an additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 17756164 BATCH: 1137843 CERT: W10815970 _ Page 1 of 1 ® CERTIFICATE OF LIABILITY INSURANCE DATE (M2 04/02/2019/2019 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 riahts to the certificate holder In lieu of such endorsement(s). PRODUCER Willis of Illinois, Inc. c/c 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA INSURED Benchmark Senior Living LLC 201 Jonaa Road, Suite 300 West Waltham, MA 02451 INSURER E: 1-877-945-7378 Lloyd I COVFRAnFS CFRT[FICATF NIIMRFR- W10815965 REVISION NUMBER - 1-888-467-2378 B7874 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. SUCH -POLICIES. '- --... PODCV EFF. POLICY E%P- _- I -- -. IITH ] TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMOD/YYYY LIMITS The Town of Mansfield }( COMMERCIAL GENERAL LIABILITY 6 Park Row Mansfield, MA 02048 IM W//Vl.c��(A»A4L EACHOCCURRENCE $ 1,000,000 I 1 X I DAMAGETORENTED _ 100,000 CLAIMS -MADE —. OCCUR PREMISES(E_aocIT211Ice) _ $ 11 A x $100,000 Retention10,000 MED EXP (Any one person) $ X_ _ Professional IncludedSB-LTCA-01760-19 04/01/2019 04/01/2020 PERSONAL &_ADV INJURY $ 1,000 000 GEN 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE , $ 310001-000 _ POLICY PRO I _ I LOC ECT PRODl1CT5 _COMpIOP qGG_ I $ 1, 000, 000 OTHER: Policy Aggregate $ 15,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)__ $ ANY AUTO BODILY INJURY (Per parson) $ OWNED SCHEDULED BODILY INJURY (Per accident $ AUTOS ONLY AUTOS - HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Par accident).. $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ 20,000,000 A X EXCESS LIAB x CLAIMS MADE SB -LT CAX-01546-19 04/01/2019 04/01/2020 AGGREGATE i$ 20,000,000 _... ..__. _ _.. DED RETENTION$ $ WORKERS COMPENSATION PER OTH AND EMPLOYERS' LIABILITY YIN ._,_ STATIIT[. __ Efi_ ANYPROPRIETORIPARTNEH/EXECUTIVEF1 EL EACH ACCIDENT $ OFFICEREMBER E%CLUDE07 IM NIA _-- -- -" - (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ ifyes, describe untler - -- -- DESCRIPTIONOFOPERATIONSbelow E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS; VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Evidence of Host Liquor Liability CFRTIFICATr HAI r1PR CAMf.rI I ATInM 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD sR m: 17756164 CATCH; 1137843 202 771 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Town of Mansfield AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 IM W//Vl.c��(A»A4L 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD sR m: 17756164 CATCH; 1137843 202 771 Page 1 of 1 A`CWRi�V CERTIFICATE OF LIABILITY INSURANCE °04/23/2018 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, 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 Willie of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONE 1-877-945-7378 FAX 1-888-467-2378 Ext: C No: E-MAIL ADDRESS: ertificates@willis. tom c Nashville, TN 372305191 USA INSURERS AFFORDINGCOVERAGE NAICN INSURER A: Lloyd'. B7874 X COMMERCIAL GENERAL LIABILITY INSURED Benabmark Senior Living LLC INSURER 8: INSURER C: 201 Jones Road, Suite 300 West Waltham, NA 02451 INSURER D: INSURER E: X INSURER F: 1v ccniaveo CERTIFICATE NLiMEFR- W5931.08 oevlmnu xu rsaoee. 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, NISR LTR TYPE OF INSURANCE ADDL INSDMMIDDIYVVV) SUBR VIVO POLICY NUMBER POLICY EFF POLICY EXP (MMODNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY X EACH OCCURRENCE $ 1,000,000 PREMISES Eaoccur ante S 100,000 CLAIMS -MADE 0OCCUR A X $100,000 Retention MEDEXP(Anyaneperson) S 10,000 X Professional Included PERSONAL B ADV INJURY $ 1,000,000 SB-LTCA-01673-18 09/01/2018 09/01/2019 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 POLICY ❑ PRO- LOC ECT PRODUCTS - COMPIOPAGG 5 1,000,000 OTHER: Policy Aggregate g 15,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ O Ee accitlenl BODILY INJURY (Per person) S OWNED OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) 5 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE $ Per accident $ A UMBRELLALIAB OCCUR EACH OCCURRENCE $ 20,000,000 X EXCESS LIA8 X I CLAIMS -MADE SB-LTCAX-01486-18 04/01/2018 04/01/2019 AGGREGATE $ 20,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY VIN STATUTE ER E.L. EACH ACCIDENT S ANYPROPRIETORIPARTNERIEXECUTIVE OFFICEIUMEMBEREXCLUDED7 NIA (Mandatary in NH) if yes descdbe uOF nder E.L. DISEASE - EA EMPLOYEE $ E.L. DIBEASE- POLICY LIMIT $ DESCRIPTION OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Evidence of Host Liquor Liability The Town of Mansfield 6 Park Row Mana£ield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LMWUItiw I WtA.Cv ©1988-2015 ACORD CORPORATION. All riahte LD I4U Jolus) The ACORD name and logo are registered marks of ACORD SR ID: 16000676 BATCH: 681249 Page 1 of 1 4c4OR0 CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDDNWY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 04/23/2018 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 Inc. Willis of IllCentury NAME: PHONE . 1-877-945-7378 FAX 1-888-967-2378 AIC No: Blvd c/o 26 Century Hivd gEpOREMAIL SS' certificates@willis.com P.O. Box 305191 INSURERS AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA INSURERA: Arch Insurance Company 11150 INSURED eenchrnark Senior Living LLC INSURER B: Lloyd 87874 INSURERC: 201 Jones Road, Suite 300 West Waltham, NA 02451 INSURERD: INSURER E: INSURER F: IiVY CRAGES CERTi FICA E NDMHEH' wns51d1¢ OCVICinid KIIINADC0. 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 ADDLSUBR INSO MO POLICY NUMBER POLICY EFF MMIDDIYYYV POLICY EXP MMIDDIYYYV LIMITS COMMERCIAL GENERAL LIABILITY - CLAIMS -MADE 11OCCURD EACHOCCURRENCE S A T REN E PREMISES Ea occurrence $ MED EXP (Any one person) S PERSONAL B ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PROECT 1-1 JLOC PRODUCTS - COMPIOPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT Ea accident $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED y BODILY INJURY (Per accident) S AUTOS ONLY AUTOS 41CAB4987705 04/01/2018 04/01/2019 HIRED NON-OWNED 1000ONLY HX PROPERTDDAMAGECm/Co1LY $ Per aCcitlenl ..P/C.11 $, $ X D UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 20,000,000 X EXCESS LIAR X CLAIMS -MADE SB -LT CAX-01486-18 04/01/2018 04/01/2019 AGGREGATE $ 20,000,000 DED RETENTION$ $ WORKERS COMPENSATION X STATUTE AND EMPLOYERS' LIABILITY YIN EORH E.L. EACH ACCIDENT $ 1,000,000 A ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED NIA 41WCZ9987905 04/01/2018 09/01/2019 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) IVes, descre under E.L. DISEASE -POLICY LIMIT $ 1,000,000 SCRIPTI0ibOF OPERATIONS below A Buainess Auto 41CA114987805 04/01/2018 09/01/2019 Any Auto/CSL 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) Included as an additional Named Insured: a -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance CERT iFiCAIC HOLDER f`Anlrn I ATI 1M ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD sR Io: 16000676 anxcH: 681249 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield - Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 Ln'W/1 Le.c'-�P1lAN ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD sR Io: 16000676 anxcH: 681249 co N A V O N U t N vvi O ' W N v c L L p 3 m u Z N � =_ E W c u � T n � E � Q N A V U t N V_ J L p 3 Q LA !'i N Ln O N N N O N to N O O Z Z W F Q � v O LL LL E h a x W W U M u � n 1 C O Z o�n O E LL V X V W � O � i LL V o _ o m W 7 o � u c O � N C O U d oz VJ N Lu s a O V � � O O Um /�/� W O ' W -� Q M u � 3 Z o�n V N PA ;J M� � i4 r4