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HomeMy WebLinkAboutTGI Fridays - 12/31/2020IN1-20-�6 0d FOR BOARD OF HEALTH USE ONLY Permit # Issued II FOOD ESTABLISHMENT PERMIT APPLICATION 1 (Application must be submitted at least 30 days before the planned opening date) Establishment Name TGI FRIDAYS Establishment Address 280 SCHOOL STREET, SUITE A100 MANSFIELD, MA Establishment Mailing Address (if different) PO BOX 781898, WICHITA, KS 67278 Establishment Telephone No 508-261-4021 Applicant Name & Title: GC FRIDAYS BOSTON, LLC Applicant Address 133 SEVILLA AVE, CORAL GABLES, FL 33134 Applicant Telephone No.: 305-567-3852, 24 Hour Emergency No.: Applicant Email ----------- ---- Owner Name & Title (If different from applicant) SAME Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or Ll An Association partner. n Name Title Address A Corporation An Individual ALFONSO FERNANDEZ, COO 133 SEVILLA AVE, CORAL LABELS FL 33134 R Partnership I FERNANDO ANON, CFO 133 SEVILLA AVE, CORAL GABELS FL 33134 GX Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: NICOLE CLIFFORD Address: Telephone No: 508-261-4021 24 Hour Emergency No: 774-281-3005 FAX: E-mail: 0655@fridays.com Alt E -Mail: tsingleton@fridays.com; licensingandpermits@fridays.com; mjboler86@yahoo_com_ District Or Regional Supervisor (if applicable) Name & Title: ANNE BIRON Address: Telephone No: 24 Hour Emergency No: 603-553-1832 FAX: E-mail: abiron@fridays.com Food Establishment Information WATER SOURCE: TOWN OF MANSFIELD I SEWAGE DISPOSAL: TOWN OF MANSFILED r Water Supply No: (If applicable) i No. of Food Employees: 45URS: 7 DAYS A WEEK 11AM-1AM erson(s) In Charge Certified in Food Protection Management: MATTHEW BOILER BRANDI M. WIMMER NICOLE L. CLIFFORD STEPHEN P SILLUP Name of Person(s) In Charge Certified in Allergen Awareness Training NICOLE L. CLIFFORD Name of pest control company routinely inspecting the premises for evidence of pests Eco Pest If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. [A Yes Does this establishment require a FOG permit? YES If yes, please attach the FOG permit application Length of Permit: Establishment Type: [A Annual IT] Retail Food $125.00 ID Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Temporary [ Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 E]Manufacture Frozen Dessens/Ice Cream Temporary Start Date: L Food Service up to 101 -200 $250.00$25.00/(reezer Temporary End Date: IRj Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: 0 Supermarkets $400 L] Residential Kitchen $100,00 Rain Date: ;: XI Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations Pefinifions:PHF - Potentially hazardous food(fimeRemperature wntrois required) Non-PHF's - non -potentially hazardous fcodfno time/lemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sanowvlc)1es, sateds, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs LXj PHFCooked To Order Xl {or More Thao a Single Meal t PHIF Cooked and Cooled or HoHeld Hotce [X Sale of Commercially Pre -Packaged PHFs E] Prearation of Hot And Cold Holding For iSingle Fis rMeal Service F,.] PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFsSusceptible Population Facility U Sale of Raw Animal Foods Intended IXj Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand El Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) %J Preparation of Non-PHFs Retail Sale Ll Offers Raw Or Undercooked Food Of I] Juice Manufactured and Packaged for Animal Origin I Other Food Operations Retail Sale E] Vacuum Packaging! Cook Chill [-I Offers RTE PHF in Bulk Quantities IT] Prepares Food/Single Meals for Retail Sale of Salvage Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cops of 106 CMR 590.800 and1hf federal Food Code. Signature of Applicant: (�> X i rvy —Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal to' 47-4670785 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. J�� 0 lL !/ Signature of Individt al or Corporate Name 47-4670785 *"Social Security No. (Voluntary) or Federal Identification Number TERRI.CARMAN By: Corporate Officer (Mandatory, if Applicable) *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\sicite\Dcsklop\Scott's Documents\Food Fstab1W,,n009-"re1"p\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Ap llicant Information Please Print Legibly Business/Organization Name: Address: GC FRIDAYS BOSTON, LLC ,)an tzi-wonl RT #A100 City/State/Zip: MANSFIELD, MA 02048 Are you an employer? Check the appropriate box: L❑ I am a employer with 45 employees (full and/ or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]* 4.0 We are a non-profit organization, staffed by volunteers with no employees. [No workers' comp. insurance req.j *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' compwrsation policy is required end such an organization should check box # I. I ant an employer that is providing workers' compensation insssrassce far nsi, employees, Below is the policy infarmation. .,AFFTY NATIONAL CASUALITY CORPORATION Insurance Company Phone M 508-261-4021 Business Type (required): 5. Retail 6, Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. nNon-profit 9. O Entertainment 10.0 Manufacturing 1 I.0 Health Care 12.0 Other 1832 SCHUETZ ROAD Insurer's ST LOUIS, MO 63146 City/State/Zip: P I' # r Self -ins Lie 9 PRA4060323 Expiration Date: 4/01/2020 o Icy o 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 tip 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. Ido hereby certify, n//liter the pains andenahies of perjury that the information provided above is true (slid correct. /i. awl) 11 12/16/2019 316-685-1622 X31 Offleial use only. Do not write lit 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 Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on rile for future permits or licenses. A new affidavit trust be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to buns leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Fonn Revised 5-26-05 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: TGI FRIDAYS Address: 280 SCHOOL ST #A100, MANSFIELD, MA 02048 Mailing Address: PO BOX 781898, WICHITA, KS 67208 Phone/Fax Number: 316-685-1622 FAX 316-681-4666 Contact Person/Title for Grease Traps: MATT BOLER, GM Name of Company scheduled to pump internal grease trap(s) monthly: BAKER COMMODITIES Name of Company scheduled to pump external grease trap quarterly: BAKER COMMODITIES Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $SO ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledg s that the information submitted in these documents is true, accurate and complete. Signed f If I _ Date 12/16/2019 Print Name TERRI M. CARMAN Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): 240 Seating Capacity (Actual Count): 235 Normal Hours of Food Preparation/Service: Monday 11 AM -1 AM Tuesday 11 AM -1 AM Wednesday 11 AM -1 AM Thursday 11 AM -1 AM Friday 11 AM - 1 AM Saturday 11 AM -1 AM Sunday 11 AM - 1 AM Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 3 3 compartment sink 4 4 Handwashingsink 1 1 Commercial Dishwasher 3 3 Bar sink 1 1 Mop Sink 0 0 Garbage Disposal 2 0 Ice Making Machines 3 0 Fryolators 4 0 Grills or Ovens 0 0 Exhaust Hoods 25 25 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): HOOD VENTS ARE CLEANED IN A 3 BASE SINK DAILY WITH THE ENTIRE SYSTEM BEING PROFESSIONALLY CLEANED ONCE A MONTH is dinnerware pre -rinsed before being washed? X Yes No If yes, at what station/sink? DISH SINK 19 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? I Please list fixtures attached to each grease trap Grease Trap 1 DIRTY DISH RINSE SINK Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? X Yes No S1Ze 3000 gallons Where is the existing outdoor GRU located? IN PARKING LOT REAR OF BUILDING If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: N/A Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? YES Where is the grease storage unit located? OUTSIDE PARKING LOT How often is this grease storage unit emptied? QUARTERLY Please list the vendor who removes the waste: BAKER COMMODITIES 3 Iii h.a R CERTIFICATE OF LIABILITY INSURANCE DA1 /06/00IYYYYI 11/06/2019 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, ANDTHE 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 MCGRIFF, SEIBELS & WILLIAMS, INC. 3400 Overton Park Drive BE Suite 300 Atlanta, GA 30339 CONTACT Cary Cowart PHONE 404 497-7500 FAX c xINC, Not: E-MAIL ADDRESS: ccowart@mcgriff.com INSURERS AFFORDING COVERAGE NAIC p INSURER A:Safety National Casualty Corporation 15105 GI -053854 INSURED RMET Holdings, Inc. INSURER e INSURER C: DBA Gold Coast Holdings GC Fridays Boston LLC 13 Sevilla Avenue INSURER D: INSURER E: Coral Gables, FL 33134 INSURER F: y7;iIIIItlLNa]I:11W 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 Lm TYPE OF INSURANCE ADDLSUBR INSD Me POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMOILD YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCURAMA GI -053854 04/17/2019 04/01/2020 EACH OCCURRENCE $ 1,0110,000 ET RENTE 1,000,000 PREMISESBe occurrence $ MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO- � LOC JECT GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY CAF4053855 04/17/2019 04/01/2020 EOsBINEDISINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ ( ) HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERWEMBER E%CLUDED? FNJN/A PRA4060323 04/17/2019 04/01/2020X PER OTH- UTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Liquor Liability GL4053854 04/17/2019 04/01/2020 Aggregate S 2,000,000 Each common cause $ 1,000,000 $ $ $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space N required) Locations: #2733-1 Worcester Road, Framingham, MA 01701; #2736 - 240 Fortune Boulevard, Millford, MA 01757 #2737 - 750 Providence Hwy, Dedham, MA 02026 #2738 - 601 Donald Lynch Boulevard Suite 4258, Marlborough, MA 01752 #2740 - 33 Mystic View Road, Everett, MA 02149 #2742 -70 Worcester Providence Tpke, Millbury, MA 01527 #2746 -9 Orchard HIII Park Drive, Leominster, MA 01453 92747 - 49 Newbury Street, Danvers, MA 01923 continued next page) CERTIFICATE HOLDER CANCFI I ATinbd Page 1 of 4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE Page 1 of 4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: Abs ADDITIONAL REMARKS SCHEDULE Page 2af4 PRODUCER MCGRIFF, SEIBELS & WILLIAMS, INC. INSURED RMET Holdings, Inc. DBA Gold Coast Holdings GC Fridays Boston LLC POLICY NUMBER CARRIER NAIC CODE ISSUE DATE: 11/06/2019 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: (continued from previous page) #2750 - 280 School Street Suite A100, Mansfield, MA 02048 #2751 - 1385 South Washington Street, N Attleboro, MA 02760 #2754 - 455 State RoadNorth Dartmouth, MA 02747 #2755 - 6 Mozzone Boulevard, Taunton, MA 02780 All rights The ACORD name and logo are registered marks of ACORD GtK I INUAI G IVUIwom": J V JOJJYJ A p® EVIDENCE OF PROPERTY INSURANCE Dnre 1 SVJ6534S 1 11/06/201906/2019 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST. AGENCY AICN o Ex 404 497-7500 COMPANY MCGRIFF, SEIBELS & WILLIAMS, INC. See Attached 3400 Overton Park Drive SE Suite 300 Earthquake Atlanta, GA 30339 $100,000 Cary Cowart $10,000,000 FAX E-MAIL CCOWart g AIC No: ADDRESS: @mC rlff.com CODE: SUB CODE: AGENCY CUSTOMER ID INSURED RIVET Holdings, Inc. POLICY NUMBER DBA Gold Coast Holdings 7EEFFECTIVE See Attached GC Fridays Boston LLC EXPIRATION DATE133 CONTINUED UNTIL Sevilla Avenue Coral Gables, FL 33134 06/01/2020 TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: #2733 - 1 Worcester Road, Framingham, MA 01701; #2736 - 240 Fortune Boulevard, Milford, MA 01757; #2737 - 750 Providence Hwy, Dedham, MA 02026; #2738 - 601 Donald Lynch Boulevard Suite 4258, Marlborough, MA 01752; #2740 - 33 Mystic View Road, Everett, MA 02149; #2742 - 70 Worcester Providence Tpke, Millbury, MA 01527; #2746 - 9 Orchard Hill Park Drive, Leominster, MA 01453; #2747 - 49 Newbury Street, Danvers, MA 01923; #2750 - 280 School Street Suite A100, Mansfield, MA 02048; #2751 - 1385 South Washington Street, N Attleboro, MA 02760; #2754 - 455 State RoadNorth Dartmouth, MA 02747; #2755 - 6 Mozzone Boulevard, Taunton, MA 02780. 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 EVIDENCE OF PROPERTY INSURANCE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, COVERAGE I PERILS I FORMS AMOUNT OF INSURANCE DEDUCTIBLE Building See SOV for Limit $25,000 Business Personal Property/Contents See SOV for Limit Business Income/Extra expense See SOV for Limit I Written At Replacement Cost Earthquake $10,000,000 $100,000 Flood $10,000,000 $100,000 Flood - Zones A & V $ 2,500,000 $100,000 Schedule of Insurers, AM Best Rating, Policy Number, (% Risk): Certain Underwriters at Lloyds, A XV AMR -67050 (18%) Indian Harbor Insurance Company, A+ XV AMP7536569-00 (6%) QBE Speciality Insurance Company, A XV MSP -28167 (25%) Steadfast Insurance Company, A+ XV CPP1062728-00 (17.5%) General Security Indemnity Company of Arizona, A+ XV 10T029659-11916-19-00(7%) (continued next page) 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. AQUI I IUINAL IN I CKC51 NAME AND ADDRESS ADDITIONAL INSURED MORTGAGEE LENDER'S LOSS PAYABLE LOSS PAYEE LOAN # Evidence of Insurance AUTHORIZED REPRESENTATIVE I ACORD 27 (2016/03) Page 3 of 4 ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: A` R ® ADDITIONAL REMARKS SCHEDULE Page 4 of 4 PRODUCER MCGRIFF, SEMELS & WILLIAMS, INC. INSURED RMET Holdings, Inc. DBA Gold Coast Holdings GC Fridays Boston LLC POLICY NUMBER CARRIER NAIC CODE ISSUE DATE: 11/06/2019 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: (continued from previous page) REMARKS United Specialty Insurance Company, A IX USI -25127-00 (7%) Lexington Insurance Company, A XV LEX-014714548-00 (7%) Safety Specialty Insurance Company, A+ XV SSI -16409-00 (4.5%) FILI Global Specialty BE, A XV HAN-22485-00 (6%) Old Republic Union Insurance Company, A VII ORAMPR007398-00 (2%) 101 All rights The ACORD name and logo are registered marks of ACORD UtKI INUra t INUIMotn: avaowvo