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HomeMy WebLinkAboutStop & Shop #7 - 12/31/2019v V FOR BOARD OF HEALTH USE ONLY Permit # Issued g^' X' FOOD ESTABLISHMENT PERMIT APPLICATION a (Application must be submitted at least 30 days before the plan rai g Establishment Name: 6 i Shop � 1 n � � 1 Establishment Address:317 GhouklagSir02i 5 2`�a8 r: Establishment Mailing Address(if different): BY. 1385 l4awack- Si- A4n: i.iee.vtsiviq , QuWa) MA ozvo9 Establishment Telephone No.: (plq qq0 8gQg I Applicant Name &Title: SV;,anrte_ ±�tSiC�, OU�UrVLLb7 I t �ICQYli1r79 Applicant Address: si , Ounne-q MA 0maq Applicant Telephone No.: (o 1-1 '770 $%O$ 24 Hour Emergency No.: 617 gq�✓ 53��J Applicant E-mail: 5UZgytY1L'.ICES}P.r@Ye�(lilh�ylnnS55eVr�c¢S,COrrt� Owner Name & Title (If different from applicant): -TV* 5FoPt Shop SUNvvY ulv R_V Lo • LLC _ Owner Address: )3S5 �nmock- St, Ouiv1CyMtn OzUoo Owner Telephone No.: (PI-7 'lqo 9703 1_ Owner E-mail: s vnrin'L Usde✓@ no�oo I YJU51 ✓I 55erylu 5 . C_NY Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. 11 A Corporation Name Title Address O An Individual v 11 A Partnership 19`6ther legal Entity I,Le, Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: 377 ChRVv1CN Sf, 0ctnsklck8 MA ac�vNS 77 �0i3 Telephone No: (j0$ - ?,37. R`%� 24HourEmer enc No: 9 Y g 53 l3 FAX: 41A E-mail: SS, sbo .coon. '�h,-emanay( ah,01a. aonjL AltE-Mail: SULQnVI�. )CCSiP @ V�(Q)(%USruI(SSS /l(QS , COINi District Or Regional Supervisor (if applicable)'7'0m Mp'(P foL) Name & Title: bts�tio 1�. 1y-00"4— Address: c915 e F Chn 5f CT Telephone No: �(�O ��Pq_a� 24 Hour Emergency No: 977 N3 S3at�J FAX: 4A E-mail: N% �\O Food Establishment Information OURCE: •�W� SEWAGE DISPOSAL: `- -wrt ater Supply No: (If applicable) E No of Food Employees: 1 95 DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management file. 1 If more than 3 individuals are certified, complete list is on Person Trained in Anti -Choking Procedures (If 25 Seats or more): 11 )f/A Q C toter $35.00 Location: .: Permanent Location Establishment Type Moblie Mobile Start Date: *Retail (4fjl�✓ Sq. Ft) " Milk & Cream $10.00 Moblie End Dale: E3 Food Service up to 100 INCLUDING Q Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: g Q Manufacture Frozen Desserts/Ice Cream Annual rood Service up to 101 -200 $250.00 $25.00/freezer ---- --------- - — LJ rood Service up to 201 + $300.00 EJ Pushcart $50.00 # of Pushcarts: Seasonal ,.,./ 0 en Residential Kitch$100.00 Seasonal Dates: _ Ljv Supermarkets $400 E] Retail Food $125.00 ❑ Temporary C ^.flail Snack Food $50.00 Temporary Start Dale: Tobacco Products $150.00 Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, mums which need no furtherprocessing) Q'Sale of Commercially Pre -Packaged Non-PHFs 0 PH FCooked To Order ' Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs PrPreparation of PHFs For Hot And [] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Q Delivery of Packaged PHFs E] Sale of Raw Animal Foods Intended - _ ❑ Vacuum Packaging / Cook Chill " Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours E] Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Customer Self-Srvice of Non PHF and Non- 0 e Customer Self -Service Perishable Foods Only contact alternative, time as a public health contra Ice Manufactured and Packaged for Retail Sale _._- Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Q Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Ej Retail Sale of Salvage, Out-Of-Dateor Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that lhefood 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 copied-'1�05 CWFR 5,W:000 and the federal Food Code. Signature of Pursuant to MGL Ch.62C, sec. 49A, f&rtifyfunder lhWpenalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. ,� L /� Signature of Individual or Corporate Name: /{7Q �'r'/' -F _ShW &eeVYVi oA, ( Pl ��-- Social Security Number orFederal ID: ©q—'.�GYo%yL%% 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. �Y7e S r 3bw (%.wY"YYIL(&l C,0 u--e �—� Signature of Individual or Corporate Name By: C ora e ffi er (Mandatory, if Applicable) ay- 30(0 / L/q 7 "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. C:\Osm\sleite\Desktop\Scoa's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of'Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street y` Boston, MA 02111 wrvw. niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �e clpe_rlmorw Co t i,C- Address: City/State/Zip: 001`440- 1 /1 1703 Phone #: 07 9770 970Y Are you an employer? Check the appropriate box: Business Type (required): 1. Pf I am a employer with employees (full and/ 5. [11.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 a 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]** 1 I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 ant (iit employer that is providing workers' compensation iasaraiiee for my employees. Below is the policy information, Insurance Company Name: )rldQrYlll4kj jY)5t1MnC_ec> UM mCJd,' Amerlm_ Insurer's Address: U . Qy); loop City/State/Zip: — r Policy # or Self -ins. Lic. # WLk C�J �377�(� Expiration Date: %Oz7 n 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 cg dify, raider tpe pajns and penalties ofpeijaiy that the information provided above is brae and correct. /o// k/18 C] Official rise 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 I3ealth 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Page L of 2 A, 40 �® L`w►�'"J„�{, CERTIFICATE OF LIABILITY INSURANCE DATE 27/2018 ) D9/27/2olB 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: Willis of North Carolina, Inc. c/o 26 Century Blvd y P.O. Box 305191 PHONE FAX AIC No Ext: 1-877-995_7378 (AID Nr). 1-688-467-2378 E-MAIL ADDRESS: certificates@willis.com INSURER(S) AFFORDING COVERAGE NAICN Nashville, TN 372305191 USA _ I_NSURERA: ACE American Insurance Company 22667 INSURED The Stop and Shop:. Supermarket Company. LLC 1149 Harrison Pike INSURERS: American Guarantee and Liability Insurance 26247 INSURER C: Indemnity Insurance Company of North Ameri 43575 INSURER D: ACE Fire Underwriters Insurance Company 20702 Carlisle, PA 17013 USA INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: W8226394 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 OFINSURANCE ADDLSUBR SD POLICYNUMBER POLICY EFF MMIDDIYYYY POLICYEXP MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 � CLAIMS -MADE OCCUR .' � DAMAGE TO RENTED PREMISE�aoccurrence E $ 2,000,000 MED EXP (Any one person) $ A PERSONAL& AD_V INJURY $ 2,000,000 HDO G71210650 10/01/2018 10/01/2019 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 2,000,000 X _ POLICY ❑ PRO- ❑ LOC JECT S OTHER: AUTOMOBILE LIABILITY COMBINEBINED S Ea nt INGLE LIMIT $ 10,000,000 BODILY INJURY (Per person) _ S X ANY BODILY INJURY (Per accident) $ A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ISA H25268349 10/01/2018 10/01/2019 PROPERTYDAMAGE Per resident $ B X UMBRELLA LAB EXCESS LIAB X OCCUR CIAIMS-MADE AUC08249868-07 10/01/2018 10/01/2019 EACH OCCURRENCE S 5,000,000 AGGREGATE 5 5,000,000 DED X RETENTIONS 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORNARTNERIEXECUTIVE YIN OFFICEIIMEMBEREXCLUDED7 (Mandatory in NH) NIA WLR C65437740 10/01/2018 10/01/2019 X PER FIR STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEES 1,000,000 E.L. DISEASE -POLICY LIMIT 1, OVO, 000 S If yes, describe under DESCRIPTION OF OPERATIONS below D Workers Compensation -WI SCP C6543782A 10/O1/2018 10/01/2019 E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Bari $1,000,000 E.L. Disease-Pol Lim $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 09/26/2018 WITH ID: W8128287. Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED CERTIFICATE HOLDER CANCELLATION 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 The Stop & Shop Supermarket Company LED 1149 Harrisburg Pike Carlisle, PA 17013 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16804499 BATCH: 885616 AGENCY CUSTOMER ID: LOC M A CORD® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMEDINSURED Willi. of North Carolina, Inc. The Stop and Shop Supermarket Company LLC 1149 Harrison Carlisle, PA Pike 17013 USA POLICY NUMBER See Page 1 CARRIER NAIL 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 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WCU C65437788 EFF DATE: 10/01/2018 EXP DATE: 10/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Excess Workers Comp. E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAICN: 22667 POLICY NUMBER: WLR C65437867 EFF DATE: 10/01/2018 EXP DATE: 10/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation -MA E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 16804499 BATCH: 885616 CENT: W8226394 ANS/ 7680 Universal Blvd., Suite 550. Orlando, Fl- 32819 (B00) 446-0257 F (407) 3523603 v .NRFSP.Com dational Registry of Food Safety Professionals® Notification of Test Result ID##: xxx-xx- Scaled Test Score: 88 Candidate Status: Pass Test Date: August 24, 2016 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below, Preventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls In a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product Time and Temperature (Competent) Conducting Cleaning and Sanitizing (Competent) Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered) i � r ,Ayi�z NATIONAL EOISTRY OF FOOD SAFETY P _ OFESSIONA PATRICK J c , HAS SUCCESSFULLY SATISFIED THE REQ E�gENTS FOR THE 5r ice, FOOD SAFETY MANAGER UNDERTHE CONFERENC FOR FOOD PROTECTION STANDARDS & PR 51DNT: LAWRENCE J. LYNCH, CAE ISSUE DATE: AUGUST 24, 2016 EXPIRATION DATE: AUGUST 24, 2021 CERTIFICATE NO: 21262740 TEST FORM: EZS34 ni,,,ranate 4 not valid Wane. ,ban rive rare froth data of Wua National Registry of Food Safety Professionals(E CERTIFIED FOOD SAFETY MANAOER VP � H �';, w ' Wes` 44 240 x;. ; InGale i�afa' :Z�S2W AOgust 3DIe" Expiration Date: August 24, 2021 PATRICK J HICKEY 43 HARRIETT AVE BURLINGTON, MA 01803 National Registryof Food Safep- Professionals@ 1 7680 Universal Blvd Ste 550 1 Orlando, FL 32819 I Phone: 407.352.3830 I Fax: 407352.3603 n0-t-- x Ratan Business Services IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THIS PAYMENT PLEASE CONTACT: Suzanne Kester - Coordinator 1, Licensing (617) 770-8708 suzanne.kester@retailbusinessservices.com or Susan Fox —Coordinator I, Licensing (617)770-6010 susan.fox@retailbusinessservices.com FAX: 717-960-1932 PLEASE FORWARD ANY CORRESPONDENCE & LICENSES/PERMITS TO THE FOLLOWING ADDRESS: RETAIL BUSINESS SERVICES, LLC An Ahold Delhaize Company LICENSING DEPARTMENT 1385 Hancock Street Quincy, MA 02169 The Stop & Shop Supermarket Company LLC Officers and Managers Title Name President Mark J. McGowan Treasurer Derk-Jan Terhorst Secretary Mark Messier Assistant Secretary Maria Silvestri Managers: Mark J. McGowan Steven Kienzle Derk-Jan Terhorst Stacy Wiggins Robert Yager M vwcers a iwanayers ui i ne otop a Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 Page 1 of 2 aA DATE (MMIDDIYYYYI 09/26/2018 CERTIFICATE OF LIABILITY INSURANCE 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 ondorsementlsl. PRODUCER Willie of North Carolina, Inc. c/o 26 Century Blvd P.O, Box 305191 Nashville, IN 372305191 USA INSURED The Stop 6 Shop Supermarket Company LLC Attn: Rick Shaughnessy 1385 Hancock Street Quincy, HA 02169 USA 1-877-945-7378 1IePA m,A, 1-888-467-2378 ACE American Insurance Company 22667 American Guarantee and Liability Insurance 26247 Indemnity Insurance Company of North Ameri 43575 ACE Fire Underwriters Insurance Company 20702 COVERAGES CERTIFICATE NtIMRER' W8127120 RFVISI(TN 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUHANCE 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 - -- -- �ADDLSUOA - --- POLICY EF-F POLICY EXP..I -- - - ---- LTR TYPE OF INSURANCE POLICY NUMBER flMM1DMYYYY1MMTD/YYYY LIMITS X COMMERCIALGENERA�L LIABILITY CACIIOCCURRCNCC $ 2,000,000 r^ RDAMAI L O CLAIMS -MADE OCCLUR J ENT -PREMISES (a occur cs) _ _$ 2,000,000 _ A MCD rXP IA�one pa a q c � Ron G71210650 10/01/2018 10/01/2019 PERSONAL P, ADV INJURY $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: GENLRAL AGGREGATE L $ 2,000,000 -XI POLICY jfLl I LOC PRODUCTS-COMP/OP ACC 1 $ 2,000,000 S OTHER' AUTOMOBILE LIABILITY COMBINED SINGLE II MIT $ 10,000,000 X I ANY AUTO BODILY INJURY IPm perean) A OWNED r ISCIIEDHITO AUTOS ONLY I AUTOS ISA H25268349, 10/01/2018 10/01/2019 BODILY INJURY feel ncrl ienp,j _$ 5 �II RULE NON -OWNED PROPERTY �AMAGL K AUTOSONLY AUTOS ONLY fps g00ep11 S B X UMBRELLA LIAR X 1 OCCUR CACHOCCURRCNCC S 5,000,000 E %CESS LIAB CLAIMS -MADE AUC08249866-07. 10/01/2018 10/01/2019 AGGREGATE. g 5, 000,000 LED I X I RETENTION $ 10, 000 1 S WORKERS COMPENSATION X PERTUT-E..__., OR11-_,__,_______,.,_____,__ AND EMPLOYERS' LIABILITY YIN _ C ANYIHUPHIE I OHIPAH INEPJLIXECUI WE FI FACT $ 11000,000 CRICLR,MLMBEREXCt.UDED7 NIA WLR C65437740 10/01/2018 10/01/2019 ,., (Myandatory In NH) CL DISEASE -CA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below C 1 DISEASE - POLICY UMIT $ 1,000,000 D Workers Compensation -WI 9CF C6543702A 10/01/2019 10/01/2019 E.L. Each Accident $1,000,000 Per Statute E.L. Disease-Ga Espl $1,000,000 E.L. Disease-Pol Lim $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is requlmd) RE: Store #007. Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED Mansfield Health Dept. 6 Park Row Mansfield, 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 lo 1988-2016 All rlahf5 rC6ervpd. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD so io: 16771903 BATCH: 882153 2 of 2 857 WILLIS TOWERS WATSON� 26 CENTURY BLVD. 6TH FL NASHVILLE, TN 37214 857 1 MB 0.421 �nrIII�I�II��h6lnmh��P�IIIrPhmlhlln�IlP�gllrll MANSFIELD HEALTH DEPT 857 6 PARK ROW MANSFIELD, MA 02048-2433 >K>x*>k TICE>k*>k>k In order to expedite distribution of certificates to Certificate Holders, we would like to begin using electronic distribution for future issuances. Also, we would like to remove any certificates that are no longer needed. If you would like to receive electronic copies in the future or no longer require a certificate for this Insured, please note as such below. Please complete this form and submit with a copy of your current certificate to the contact information below: Do you wish to receive renewal certificates: Yes [ ] No [ ] Require a hard copy be mailed: Yes [ ] No [ ] Email Address or Fax Number: SIR ID: 16771903 If you require additional information or have further questions, please feel free to contact: Willis Towers Watson Global Certificate Center Email: Certificates@willistowerswatson.com Fax: 888-467-2378 Phone: 877-945-7378 Please note that it is your responsibility to provide up-to-date contact information to assure correct distribution of any future renewal certificates. 1 of 2 857