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HomeMy WebLinkAboutCVS Pharmacy - 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: RETAIL FOOD 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:. CVS PHARMACY Whose place of business is: CVS PHARMACY #1866 261 CHAUNCY STREET PERSON(S) IN CHARGE: ERIC FURTADO, STORE MANAGER Permit Expires: December 31, 2019 Food Fee: $100.00 License Number: RF-2 BOARD OF HEALTH Milk & Cream AichaeCHeatey, Chairman il FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) .. , Establishment Name: j� ( c ,w C P t L Establishment Address: r .(° J r-( � pharmacyNOV 201 Establishment MailingAddress if different): One ( ) One Cv5 Drive -Mail Code 1160 bvoonsorket, RI 02895- Establishment Telephone No.: rU, ""` ----- --.. Applicant Name & Title: Stephanie Cadorette CVS/pharmacy One CVS Drive Applicant Address: Licensing Coordinator Mail Code 1160 Woonsocket, RI 02895 Applicant Telephone No.: �k f=1 t 24 Hour Emergency No.: Applicant E-mail: `" i _ ^, ` - ( Owner Name & Title (If different from applicant): Owner Address: Cv5/pharmacy One Cv5 Drive Owner Telephone No.: Mail Code 1160 Woonsocket, R1 02895 Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ea.Elpartner. Corporation Name Title Address El An Individual El A Partnership 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title t-'". f Address: Telephone No: _3 �Yx ">` ( `Z / 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name &Title. `J - �tib, Nt r / ` ' i ( _ Address: Telephone No: rGf �-, ���, 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: Cad (( — Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: ermanent Location Esta ishment Type is Caterer$35.00 ❑`�-. Moblie Mobile Start Date: Retail ( Sq. Ft) [ Ivttlk & Cream $10.00 Mobile End Date: Q Food Service up to 100 INCLUDING Q Mobile Food Consession Moblie Comments: FOOD TRUCKS $175,00 NO PHF PREPARED ON SITE $100.00 r-,i Manufacture Frozen Desserts/ice Cream Length of Permit: Food Service up to 101 -200 $250.00 $25.00/freezer Annual E] Food Service up to 201 + $300.00 EJ Supermarkets $400 -1 Pushcart $50.00 # of Pushcarts: 0 Re idential Kitchen $100.00 --- E Seasonal Seasonal Dates: Retail Food $125.00 Retail Snack Food $50.00 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: — Food O Definitions: PHF- Potentially hazardous food (fimeRemperature controls required) Nan-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready-lo-eat foods (Ex. sandwiches, salads, mums which needno furtherprocessing) al€ of Commercially Pre -Packaged Non-PHFs i] PHFCooked To Order E] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And E PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service :ie Delivery of Packaged PHFs Q Sale of Raw Animal Foods Intended to be Prepared by Consumer E Reheating of Commercially E3 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours s3 Use of Process Requiring A Variance — ❑i Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health control) — El Ice Manufactured and Packaged for Retail Sale E Preparation of Non-PHFs Other Food Operations E Juice Manufactured and Packaged for E] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service i Retail Sale of Salvage, Out -Of -Date —_—__--_- or 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 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 10LCCMR 590.000 ahe federal Food Code. o e A W Signature of Applicant: 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 stale taxes required under law. o Signature of Individual or Corporate Name: Social Security Number or Federal ID: 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. rr; 4 Signature of Individual or Co orate Name Corporate Officer (Mandatory, if Applicable) Melanie K. Luker Assistant Secretary "*Social Security No. (Voluntanj) 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\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc '\ The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: C i1i,_-) < 7 Address: City/State/Zip: Phone Ar y-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. 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, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing workers' compensation insurance for my employees. Below .nis.th,e policy information. Insurance Company Name: XL— �j}� �� 2'tJ�� � iTVIItEICH- _ Insurer's Address: �� ,� �J(/roe- '0 seck (-e -o-2- ' City/State/Zip: t �jf{'a yl'L`QFCC d7r �iO�Qc�' (06/ C 6 Policy # or Self -ins. Lie. # �LJ1 L�J� % as / 6 ( Expiration Date: 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, Phone #: 1461 that the information provided above is tr Doti• 1/// 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/01a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 12/2712.017 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. IMPURIAN I: It file Certificate holder is an ADDITIONAL INSURED, im If SUBROGATION IS WAIVED, subject to the terms an(J conditions of PRODUCER MARSH USA, INC. 99 HIGH STREET BOSTON, MA 02110 Ailh: Fax:212-948-5338 S02406 ALI,X E&OAS-19 NSU RED CVS HEALTH CORPORATION AND ITS SUBSIDIARIES AND AFFILIATES ONE CVS DRIVE -- WOONSOCXETI RI 02895 must have ADDITIONAL INSURED provisions or be endorsed. certain policies may require an endorsement. A statement on COVERAGES CERTIFICATE NUMBER: NYC 00914088613 REVISION NUMBER: 9 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. INSrt LTR: TYPE OFINSURANCE ADDL'SUDR POLICY NUMBER POLICY EFF MMIODIYYYY POLICY EXP IMMIDDI"Yyl LIMITS Ai X COMMERCIAL GENERAL LIABILITY CLAIMS.MADE X OCCUR jRGE300122001 OVD1120f6 0110W(Ug EACH OCCURRENCE UE OFY6R fD PREMISES, (Ea (xcyrrence) 5 4,500,000 _.. .__ S 10W,000 X SIR: $500,DW ''i MED EXP iAn one v 5 X _ _ LIQUORI.IABILiTYINCI.UDED PERSONAL B ADV INJURY $ 4,590,000 GEN'L GENERAL AGGHEGATE 5 2.8.000,000 AGGREGATE LIMIT APPLIES PER X -� POLICY 0 jE R ❑ LOC PRODUCT S_COMPIOP AGO 3 INCLUDED OTHER: A AUTOM091LELIAOILITY _,._. RAD943732301 _ 01b112018 _ 01,01i2019 COMBINED SINGLE LIMIT Fs 5,000,000 X ANYAUTO BODILY INJURY (Poi person) S F OWNED -- SCHEDULED AUTOS ONLY AUTOS X HIRED g NON-OWNEDPROPERTY _.._ AUTOSONLY - _7 AUTOS ONLY eni BODILY INJURY (Per amidene S Ol�Mi1GE--- PoracciEonB-.________ _ y------- S I SELF-INSUREOPHY.DMG. UMBRELLALIAB `. IOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMSIIADE AGGREGATE $ PEO RETENTIONS - - 5-----_����- B G _ WORKERS COMPENSATION AND EMPLOYERS'LIASIUTY ANYPROPRIETORWARTNEWEXECUTIVE YIN OFFICERIMEMSEREXCLUOEW 1(Mandatory In NH) NIA See Page I" far Policy NumCers i 01J01/2019 X PE DTIt, ___ STA TE Eft E L. EACH ACCIDENT EL DISEASE - EA EMPLOYEE $ 200000 5 2000,C00 I11 yyes, de,Wlao under OE SLIM PTION OF OPERATIONS bal.E, DISEASE. POLICY LIMIT 5 2.000,C00 D PBM E&O- PRIMARY MSPG24560533009 04/3012017 11111112118 LIMIT 15,ODD ,000 SIR Lxh Oatm (Inclusive of Defense Expenses) SIR 20.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 10f, Additional Remarka Sahedgle, may bo .Method Bmdre apace Is required) CERTIFICATE HOLDER CANCELLATION CVS HEALTH CORPORATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE AND I IS SUBSIDIARIES ANDAFFiUATES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ONE CVS DRIVE ACCORDANCE WITH THE POLICY PROVISIONS. WOONSOCKET, RI 02895 AUTHORIZED REPRESENTATIVE u— of Marsh USA Inc. Yevgenlya Muyamina '�euyeni'�a. /)'Zte�anx<n<a ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ƒ\\{\\00 \\ \\\\\> \\ /\//\\/ // C) 10 10 10 010101 < C $ ± ± / ƒ7\E 0 Ewu Ef`' {\ \\}\ )} \\\\}\\ \\ }\\}\}\ }\ \ ( / ƒ0u zz�oz / u ±\\§(f(§ +»2/###) ) / ) \ )®\�/j\ JJ [ ƒ\j\\ E y u F-- f \ / VCVSHealth RE: License Renewals Dear Sir/Madam: Enclosed please find completed application(s) and/or appropriate payment(s) for the License Renewal(s). Please note any changes made on the applications(s). When the new license(s) is/are issued, please send it to Mail Code #1160 at the address below. After making the necessary copied for my files I will forward to the originals to the stores for posting. Thank you for your cooperation in this matter. If you require additional information or have any questions, please contact me at 401-770-2112 or email Slascola@cvs.com. Sincerely, Stephanie Cadorette Licensing Coordinator 1 CVS Drive MC 1160 Woonsocket, RI 02895 Enclosure(s) ACORH GE°RTIFICATE OF LIABILITY INSURANCE TE D12/2712018 OrvyyV) 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 MARSH USA, INC. 99 HIGH STREET CONTACT NAME: PHeeN AX o Batt. AI No BOSTON, MA 02110 Attn: CVSCaremark.CertRequest@mamh.com Fm:212-948-5338 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAICk INSURER A: Greenwich Insurance Company 22322 GN101226639-ALL-GAW-19-20 INSUREDCVS HEALTH: CORPORATION INSURER B : XL Insurance America Inc 24554 INSURER C: XL S eclat Insurance Company37885 ONE CVS DRIVE MC2180 WOONSOCKET, RI 02895 INSURER D : INSURER E : _ INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-009367988-19 REVISION NUMBER: 5 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 ADDL SUER POLICY NUMBER POLICY SEE MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COM MESCAL GENERAL LIABILITY RGE300122002 01/01/2019 01101/2020 EACH OCCURRENCE $ 4,500,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 X MED EXP (Any one person) $ SIR: $500,000 X LIQUOR LIABILITY INCLUDED PERSONAL B ADV INJURY $ 4,500,000 GENT AGGREGATE LIMIT APPLIES PE R: GENERAL AGGREGATE $ 28,000,000 ROT POLICY PRO- ❑ LOG X PRODUCTS-COMP/OP AGO $ INCLUDED $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitleng__ $ BODILY INJURY (Per person) _ $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par accident) $ PROPERTY DAMAGE Per accitlent $ HIRED NON -OWNED AUTOS ONLY HAUTOS ONLY UMBRELLA LIAB 11 OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA See Page Two for Policy Numbers 0110112019 010112020; X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE -EA EMPLOYEE $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES IACORD 101, Additional Remarks Schedule, may be attached if mare space is required) RE: CVS STORE#01866-02, LOCATED AT 267 CHAUNCY STREET, MANSFIELD, MA 02048 TOWN OF MANSFIELD, MA IS NAMED AS AN ADDITIONAL INSURED (EXCEPT WORKERS COMPENSATION) AS THEIR INTERESTS MAY APPEAR, AS RESPECTS THE LEASED PREMISES, BUT ONLY TC THE EXTENT REQUIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT, CERTIFICATE HOLDER CANCELLATION 01866-02 TOWN OF MANSFIELD, MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 PARK ROW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MANSFIELD, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Yevgeniya Muyamina d ,'�cL /nz'war — ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1226639 LOC #: Boston ACORO® 11. _ , ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA, INC. NAMED INSURED CVS HEALTH CORPORATION ONE CVS DRIVE M02180 WOONSOCKET, RI 02895 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMPENSATION DEDUCTIBLE PROGRAM: POLICY DATES: JAN 1, 2019 TO JAN 1, 2020 (Coverage A) Policy # States Covered Carrier RWD300122102 AOS XL Insurance America RWR300122202 WI, AK XL Specially Insurance Company LIMIT: $2,000,000 DEDUCTIBLE: $2,000,000 EXCESS WORKERS COMPENSATION PROGRAM POLICY DATES: JAN 1, 2019 TO JAN 1, 2020 (Coverage B) Policy# States Covered Carrier RWE943548302 DC, MA, OH, RI XL Specially Insurance Company RWE943548402 CT, NC, NJ, VA XL Specialty Insurance Company LIMIT: $500,000 Excess Workers Compensation Self Insured Retentions: DC, MA, OR, RI: $500,000 CT, NG NJ, VA: $1,000,000 COVERAGE A: Workers Compensation: Statutory COVERAGE B: Employers Liability Limits: $500,0001$500,000/$500.000 COMMON POLICY CONDITIONS A. Cancellation 2. We (Camerl may cancel this policy by mailing or delivery to the first Named Insured written notice of cancellation at least: a.10 days before the effective date of cancellation if we cancel for non payment of premium 1) General Liability Additional Insured - Where Required Under Contract or Agreement language per endorsement CG 2026 (04113): SECTION 11-WHO IS AN INSURED, is amended to include as an additional insured: Any person or organization for whom the Named Insured has agreed to provide insurance prior to loss as provided by the General Liability Policy but only to the limit and scope of insurance agreed to by the Named Insured but only with respect to liability for'bodily injury", *property damage' or'personal and advertising injury' caused, in whole or in pad, by the Named Insureds acts or omissions or the acts or omissions of those acting on the Named Insured's behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 2) General Liability Earlier Notice of Cancellation Provided By Us language per endorsement CG 02 2410 93: ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1226639 LOC #: Boston ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY MARSH USA, INC. NAMEDINSURED CVS HEALTH CORPORATION ONE CVS DRIVE MG2180 WOONSOCKET, RI 02895 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS. FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Number of Days' Notice 90 For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. 3) GENERAL LIABILITY CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity (des) by the Carrier according to the notification schedule shown below: Name of Person(s) or EnRy(ies): Per the most current schedule maintained by Marsh USA, Inc. and furnished to XL Catlin no less than 45 days prior to the effective date of cancellation. Number of Days Advanced Notice of Cancellation: 90 ACORD 101 (2U(1ti101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD