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HomeMy WebLinkAboutCold Stone Creamery - 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: FOOD SERVICE 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:. ASHWANI RATHOR Whose place of business is: COLD STONE CREAMERY 280 SCHOOL STREET PERSON(S) IN CHARGE: ASHWANI RATHOR Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-10 BOARD OF HEALTH -%lichaeCHeatey, Chairman Milk & Cream V, 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: Cold Stone Creamery Establishment Address: 280 School Street, D160, Mansfield, MA 02348 Establishment Mailing Address(if different): 11 White Oak Way, North Attleboro, MA 02760 Establishment Telephone No.: Applicant Name & Title: 11 White Oak Way, North Attleboro, MA 02760 Applicant Address: 11 White Oak Way, North Attleboro, MA 02760 Applicant Telephone No.: 5085986841 24 Hour Emergency No.: 5085988841 Applicant E-mail: coldstonemansfieldma@gmail.com Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 0 An Association partner. O A Corporation Name Title Address El An Individual a 1( r.rsfh L` C .-- 11 C.Ls {e`' G:C 1 .11' X A Partnership--- Qe -VoLe_ fin O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 11 White Oak Way, North Attleboro, MA 02760 Address: 11 White Oak Way, North Attleboro, MA 02760 Telephone No: 7 r=_ a t ; 6 24 Hour Emergency No: 5085988841 FAX: E-mail: coldstonemansfieldma@gmail.com 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: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management Ashwani Rathor If more than 3 individuals are certified, complete list is on file. Meenakshi Rathore Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: ❑ Permanent Location Establishment Type n Caterer $35.00 E3Moblie Mobile Start Date: 0 Retail ( Sq. Ft) ❑N Milk & Cream $10.00 Mobile End Date: E] Food Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 ❑ Food Service up to 101 -200 $250.00 a Manufacture Frozen Desserts/ire Cream $25.00/freezer Length of Permit: g Q Annual E] Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: — 0 Seasonal Seasonal Dates: 0 Supermarkets $400 ❑ Residential Kitchen $100.00 (] Retail Food $125.00 E] Retail Snack Food $50.00 —ETTemporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Dale: _ Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food (tlmOemperatuie controls required) Non-PHFs - non-potenhaly hazardous food(no dwAomperature controls required) RTE -ready-toeaf foods (Ex. sandwiches, salads, muffins, which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs E] Preparation of PHFs For Hot And Cold Holding For Single Meal Service _ I] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Ej Delivery of Packaged PHFs — n Sale of Raw Animal Foods Intended to be Prepared by Consumer Ej Reheating of Commercially Processed Foods for Service Within 4 Hours _ 0 Vacuum Packaging I Cook Chill -- E] Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health _control) _ Customer Self -Service of Non PHF and Non- Perishable Foods Only Lj Customer Self -Service _ Q Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities _ Q 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 E] 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 105 CMR 590.000 and the federal Food Code. 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 lax returns and paid state taxes required under law. i +f Signature of Individual or Corporate Name: Social Security Number or Federal ID: , --- C( "��+� 7), 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 (Mandatory, 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. C:\Users\.sleite\Duktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address. 2 Lb o& I D i f o Phone #: e 4 n A. `i"� ` ?? q / Are you an employer? Check the appropriate box: Business Type (required): 1. Er I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. O 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. S. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § I (4), and we have M ❑ Manufacturing no employees. [No workers' comp. insurance required]* I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 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 insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip Policy # or Self -ins. Lic. # t 3 7 l C Vt'_NExpiration Date: f l 2 - 011� 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 ofperjuty that the above is true and correct. Sinnature• = uk"'i" - Date: d 1� t 4I - "4 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 Heath 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mass.gov/dia SWEETOO-01 PEERCIN lh o CERTIFICATE OF LIABILITY INSURANCE �� D03119ATE /2 8 I 03119/2018 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 C T CT Amy Shock Hyylant- Toledo 811 Madison Ave. Toledo, OH 43604 PHONE FA% AIC No Ext: A/C, No: E- oAIL . Amy.Shock@Hylant.com INSURER(S) AFFORDING COVERAGE NAICa INSURER A:Ohio Security Insurance Co 24082 INSURED INSURER B: Traveler's Casualty & Surety CO 19038 INSURER C : Sweet Tooth, LLC dba Cold Stone Creamery INSURER D: 11 White Oak Way North Attleboro, MA 02760 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 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 ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Ek] OCCUR X X BZS67709462 01/01/2018 01101/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 11000,000 MED EXP An ndpasorn $ 15,000 PERSONAL a ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOP AGO S 2,000,000 EPLI 100,000 A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOppSyy Ep X AUTOS ONLY X AUTOS ONNLY BZS57709462 01101/2018 01101/2019 COMBINED SINGLE LIMIT Ea code 1,000,000 $ BODILY INJURY Per arson BODILY INJURY Per acudenl $ PeOaccRden DAMAGE UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRgqO��PRIIETgO�RRiPARTNERIEXECUTIVE YIN 'Mande 0 In NHI EXCLUDED? If yes, described under DESCRIPTION OF OPERATIONS below NIA UBOJ368779 01/0112018 01101/2019- - X PER ISTATUTE OTH- E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE 1,000,000 $ E.L. DISEASE - POLICY LIMIT 11000,000 A A BI/EE ALS 12 Months BZS67709462 BZS67709462 01101/2018 0110112018 01/0112019 01/01/2019 Bus Pars property Spoilage 306,000 10,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may lue attached if more space is rectivredd Kahala Franchising, L.L.C., Kahala Brands, Ltd., their subsidiaries, officers, directors, and employees, 9311 E. Via a Ventura, Scottsdale, Arizona 85258 are listed as additional insured/grantor of franchise in regards to covered location 280 School St, Mansfield, MA 02048 and effective 411/2018; 174 S Franklin St., Holbrook, MA 02343 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Kahala Brands, Ltd., Kahala Franchising,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 9311 E. Via de Ventura Scottsdale, AZ 85258 AUTHORIZED RE1/PRRESENTAATIIIVVE'\L ` /YI lY IF--It 'Y— `-� ACORD 25 (2016103) @ 1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board of Health at the Town of D4coasfteld. In accordance with the provisions of seelion 65H ofChapler 94 of the General Laws, as most recently amended and the regulations made thereunder. the undersigned hereby applies for a license for a WHOLES.I Ld:,'12C'T-IIL nran facuu•e of fi-o_en desserts and ice cream mix and subinils the firdlowing h?formation: 1. Full name of applicant: meenaksbi Ratko e- 2. Business address Z20 SCA001 SZfett- / D J90 , �QhSFit lri M_[ OZ 3y8 3. /f applicant is an individual.: Full name: S Lo el!.0 ) Ooe- Residence: W 6t-e QC+� bnEL) 3a. lfapplicam it a partnership, fidl name and residence ofall partners: A.S�i,)ant 1',),1LAr II U)kAe -, /-)IxWWCLU l\) AF-bjohnfd ,n'MAOZW6 e 3b, fopplicani is a corporation: State of incorporation: Date of incorpe Full nine and address of: Principal office: President Treasurer: Cleric 4. Location of Plants: 5. Names gl'brands and trade to corporation name, if any, under which the products tire to he sold: 6. Number and capachy of�•ee_ers and fees: Fee: ($25.00 perfi•eeaer) $ #Type! 7• is the mix purchased? YVfsojii•i n whoa purchased? -SY 9 la NC-tU)60< v N. Is the inir pusteuri❑ed? ri t"s 9. Number gfgallons of fi-m_en desserIs ardor ice ararn mix to be sold in Massachusetts during the licensing period 'I vl41 10. Niuriber ofgallons of frozen desserts ardor ice cream mix sold in rl to,ssachu,sets during the previous licensing period L � cil . 11. Is the plant coitstrncted and equipped as provided iin the regulations? Y 12. Is the water supply public or rot? v X15 13. Hare yoit received a cogv of ilte regitictlions? I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with ail law of the Commonwealth ofMassaschusetts pertaining theretnder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured tinder sanitary conditions. I attest that the information stated in this application is true and accurate under the pains and penalties of perjury. w 106119 (Company owner/officer's signature) (DATE) (Title) �- (City or Town) W 0� O r � ry � U) Q Z W W 2 M[3 2@ co z` 0 � � � � R %dam $/� f§ /\ z 0 LAW �A I w O W u z Mai z .4 z W r l K sF LL 0 � Z Q i O m N v N O v W in o 0 Q _N ri W .9 p Q cu � You yyy V N �1 U Lek HYLANT hylant.com LOW, STONE n . C R E.A M E R Y iolodo Office P.O. Box 1687 Toledo, OH 43603 Offered For UOLD o C H E A M E P Y E 0 This program has been designed to satisfy all the requirements of your franchise agreement at a very competitive price. In addition to the basic Property, General Liability, Auto and Workers' Compensation coverage, we also offer Life, Employment Practices Liability, Employee Benefits Liability and Personal Insurance. Your Program Manager is: Amy Shock Toll Free 800-249-5268, ext. 6047 Phone 419-259-6047 Fax 419-259-6099 Amy.Shock@hylant.com Please contact her with any questions, or to request a quote. s Confidentiality Statement. The information and concepts provided to you by Hylant Group are strictly confidential. The w HYL,AN"L information and concepts are solely for your Internal evaluation and no other use or distributor is permllled or authorized. Ali trademarks are the property of their respective owners. "Insurance 101" for COLDATONEO Franchisees Property Insurance • You should insure your property for the full replacement value of your inventory, furniture, fixtures, equipment, and build -out. Improvements and betterments include installed equipment, fixtures, and the build -out. Ask yourself what it would cost to rebuild and replace everything in the event of a total loss. Check your lease to see if you need Building coverage. For example, you may be responsible for insuring your heating and air conditioning equipment. Some leases require you to insure items such as doors or floor coverings. These are not considered Business Personal Property unless they were installed at your expense, but they can be covered by adding Building coverage. • Flood and earthquake are excluded under this policy. Earthquake can be added in most states, subject to underwriter approval. We can offer you a quote for Flood coverage under a separate policy. General Liability Insurance The "Per Occurrence" limit is the most the company will pay for any one claim. • The "Aggregate" limit is the most the company will pay in any one policy year for all claims combined. • Most policies exclude coverage for Employment Practices Liability, such as discrimination, sexual harassment, wrongful termination, failure to promote, etc. We can offer you a separate quote for this important coverage. Hired & Non -Owned Auto Liability Protects your business against liability arising out of your employees' use of their personal vehicles on company business. • Provides liability coverage for vehicles rented in the business name. Physical damage coverage for vehicles rented in the business name is available for an additional premium. Umbrella Liability • Provides an additional layer of Liability coverage in addition to your Primary General Liability and Hired & Non -Owned Auto Liability. • Check your lease to see if an Umbrella is required. Workers' Compensation • In Ohio, Washington, North Dakota, and Wyoming this must be purchased from the State. In addition, you need to carry "Stop Gap", or Employer's Liability Coverage from your General Liability insurer. This covers you as the employer for an intentional workplace or work -related injury to an employee. It is rated on your total annual payroll. • The rules regarding the inclusion or exclusion of owners vary by state. Owners or corporate officers who do not take any salary are assigned a minimum payroll according to state rules when they are included for coverage. Before deciding to exclude owners, check the provisions of their health insurance, as it may exclude work -related injuries. • The policy is auditable at the end of the policy term. If the actual payroll varies from the estimate established at the beginning of the term, an additional or return premium is generated. • If you employ any subcontractors or independent contractors, you will need to maintain copies of their Workers' Compensation insurance certificates, or you may be charged an additional premium at audit. �,' j` A !. Confidentiality Statement. The information and concepts provided to you by Hyland Group are strictly confidential. The \' V l information and concepts are solely for your Internal evaluation and no other use of distribution is permitted or authonzed. All trademaro are the property of their respective owners. "Insurance 101" for COUSTONEO Franchisees (Continued) Employment Practices Liability • Protects your business against suits brought by employees or potential employees due to discrimination, harassment, wrongful termination, and unfair hiring practices. • Many policies allow you to purchase third -party coverage which will protect your business from suits brought by patrons that felt harassed or discriminated against. • $100,000 sublimit available (in most states) for the Fair Labor Standards Act (FLSA) which protects you from litigation due to wage and hour disputes. Employee Benefits Liability • This endorsement covers oversights and errors the named insured makes in administering its various employee benefits programs. It does not cover improper or inadequate advice regarding investments or the actual investment decisions the retirement plan or pension administrator makes. Cyber Liability/Data Breach • Most states mandate that when a data breach occurs, whether it stems from the work of an outside hacker or innocent errors made by the staff, the business must notify the affected individuals and offer them credit monitoring services. This coverage reimburses you for the notification and credit monitoring fees incurred due to a disclosure of Personally Identifiable Information or Personal Health Information. Trade Name Restoration • This coverage provides business interruption for your loss of income due to an incident of food borne illness, contamination or extortion, and extra expenses for incident response. It includes the impact of an actual or alleged outbreak involving the same trade name even if it does not directly involve you. Incident response expenses include the cost of marketing efforts, overtime of regular staff and cost to remove contaminated product. • Crisis management support is provided to help you anticipate, prepare for, and respond to an evolving food borne illness and associated media event. e"Ap H >r I ANT 1. Confidentlalily Statement. The Information and concepts provided to you by Hylant Group are strictly confidential. The V information and concepts are solely for your internal evaluation and no other use or distribution is permitted or authorized. All trademarks are the property of their respective owners. Franchise Insurance Program Application Contact Name Ashwani Ranthor OLDpSTON Email coldstonemansfieldma@gmail.com Business Name Sweet Tooth, LLC Year Business Started 2016 Mailing Address 11 White Oak Way, North Attleboro, MA 02760 Location Address 280 School St, Mansfield, MA 02048 Home or Mobile Phone 5085988841 Store Phone Effective Date of Coverage Jan 1 st 2017 Federal ID Number 81-4511843 Form of Business: Corp. _ Partnership Sole Prop._ Estimated Receipts 300,000 Sq. a 1200 Year Built 2006 Alarm System Type Any losses in the last 3 years? Standard Coveraqes Included Sprinklers? LLC X Other Construction Type nOn-Cobu s it bl a -steel # of Employees FT PT, Please attach 3 years of current loss history. Business Personal Property Limit (Recommended Minimum)* $300,000 If $300,000 is not sufficient, indicate limit: $ Equipment Breakdown Included General Liability Per Occurrence $1,000,000 General Liability Aggregate $2,000,000 Products Liability Per Occurrence $1.000,000 Products Liability Aggregate $2,000,000 Fire Damage Legal Liability $300,000 Medical Payments $10,000 Hired & Non -Owned Auto Liability $1,000,000 Spoilage $10,000 'The Business Personal Property Limit should reflect 100% replacement cost of your furniture, fixtures, equipment, inventory and build -out. This limit will include your Improvements and Betterments. Options Umbrella Liability $1,000,000_ $2,000,000_ Other Workers' Compensation: Yes X No_ (If yes, complete supplemental information on next page.) signing (his application does not bind (he company to complete the insurance. All information requested in this application is considered malenal and important. If the company agrees to be bound under the (erns of this semitrailer, your policy is void it you hide any important information from us, or attempt to depend or /to to us about any matter contained in this application. Any changes an your opeation must be reported to your agent A certificate of insurance will be automatically sent to Nahala Corp. in compliance with your franchise contract. Digitally signed by Ashwani Rather Ashwani Rather Date: 2016.12.07 11:21:34-05'00' Insured's Signature Date I Confidentiality Statement. The information and concepts provided to you by Hylant Group are strictly confidential. The I j I ,` i * V information and concepts are solely for your Internal evaluation and no other use or distribution Is permitted or authorized. All trademarks are the property of their respective owners. Franchise Insurance Program Application Do you have a Regional Developer? If so, please provide name and address: ■ 10 . E A MEa YI. � . Do you operate any other business under this entity name? If so, please provide details: Estimated Annual Payroll: Workers' Compensation Supplemental Information :I 1 Ownership Information Complete for all owners, corporate officers, members, or partners. Indicate the estimated annual payroll for each, and if they should be included or excluded under the Workers' Compensation coverage. PLEASE NOTE: The rules regarding the inclusion or exclusion of owners, as well as the minimum and maximum payroll charged for owners, vary by state. Before deciding to exclude owners, check the provisions of their health Insurance, as It may exclude work -related Injuries. Any changes in ownership during the term of the policy must be reported so the policy can be adjusted accordingly. Name Title Ashwani Ranthor Meenakshi Rathore °% Ownership Payroll 50 50 This form must be completed in its entirety and signed by an owner or corporate officer. Ashwani Manager / Owner Insured's Signature Title I would also like a quote for: _Flood _Earthquake _Employment Practices Liability Food Borne Illness Trade Name Restoration _Employee Benefits Liability Cyber Liability/Data Breach _Other Include Exclude x X 12/07/2016 Date Confidentiality Statement, The information and concepts provided to you by Hylant Group are strictly confidential. The I, AN F Information and concepts are solely for your Internal evaluation and no other use or distribution is permitted or authorized. All trademarks are the property of their respective owners, HYLAN T Individual Life Insurance Referral Form Email requests to: info@benefitsbrokerage.net Do you have enough life insurance to protect your business and your family if something happens to you? This is a critical need if you have a SBA loan or other debt obligations. Name Address Male _ Female _ Date of Birth Phone Fax Height Weight Tobacco Use? Y_ N _; If QUIT last used was when mm/yy. Type?, Are you currently being treated for elevated blood pressure Wor cholesterol? Y _ N If so, what year were you diagnosed? Average total cholesterol Average blood pressure reading Average HDL Have you ever sought treatment or been advised to seek treatment for use of drugs or alcohol? Y _ N _ In the past 5 years, have you been convicted of driving under the influence of alcohol? Y _ N In the past 3 years, have you been convicted of 3 or more moving violations? Y _ N _ Have you been treated or sought treatment for: diabetes, heart disease, cancer, stroke, asthma, lupus, depression, epilepsy, crohn's, murmur, sclerosis, arthritis, parkinson's or cardiovascular disease within the last 10 years? Y N Medications Quote amount: $100,000 _ $250,000 _ $500,000 _ $1,000,000 Term desired: 10 years _ 15 years _ 20 years _ 30 years Other Permanent Life What would happen if you could no longer earn an income? Would you like a disability insurance quote? y/n What would happen if you needed long term care or home health care? Would you like a long term care quote? y/n Confidentiality Statement. The Information and concepts provided to you by Hyland Group are surely confidential. The HYLANT information and concepts are solely for your Internal evaluation and no other use or distribution is permiltetl or authorized.