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Home My WebLink AboutRed Roof Inn - 12/31/2019a \eh�rt'/ 0 `3C;" y Town of Mansfield Health Department B1\ 6 Park Row, Mansfield, MA 02048 �n � . 508-261-7366 APPLICATION FOR HOTEL/MOTEL LICENSE Motels & Hotel License valid January 1 st through December 31 st Fee Schedule: Payment is due with application Application Fee $50 Inspection fee: 0-50 units $200 51 or more units $300 MAKE CHECK PAYABLE TO: Town of Mansfield RETURN TO: Health Department, 6 Park Row, Mansfield, MA 02360 Legal Business Name (Corp., LLC. Etc) pe'( QD0L 1rw' 60sd-vn - �2I—S 1i e1� DBA if Different Business Address -mpo,V j2ot.'AQZ04e Mailing Address Business Phone sa' 33 Aj 23�2 3 Alternate Phone Owner/President Name ry(ir'16y,. 10GlC,8(,0 knl) IXT L_L(- Manager/Agent/Operator Name Business Phone E-mail i Uc)'-It4 Alternate Phone Please note: the Health Department will do the majority of communications through email. It is essential that you provide the department with the best address(es) for the both local operations and business communications. # Rooms: 1;4— # Swimming Pools: # Saunas: # Spas: # Whirlpools: i # Hot Tubs: Name of Certified Pool Operator: Pest Control Manager: Trash/Garbage Collector and Schedule: Is Water Municipal or Private Well: Is Sewer Municipal or Private Septic: 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 Corporate Officer landalory, if Applicable) L11— � i.o �Lm "*Social Security No. (Voluntary) or Federal Identification Number tLV S W ! L LC 0W11ot *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. 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 Applicant Information Please Print Legibly Business/Organization Name: ' ROb �h Address.- City/State/Zip: Phone #: Are yo I an employer? Checl t e 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. ❑ 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (me]. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp, insurance required] g• ❑ 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12. P Other _[[DV,( _ *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy buiumalion. **It the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. lam an employer that is providi ig workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Name: �� AVf (.C1M&An t� ) Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. A Expiration Date: i a2 ICC 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. a61:M I do hereby c'erdl.p, under the pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town ojfrcial. 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 www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE DAM(MMIDDrIY(Y) 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 endorsements . PRODUCER Lockton Insurance Brokers, LLC CONTACT S Centeryointe Drive PHONE "-- _-- - FAX — Suite 400 BEM ______ i INK Nq� .MAIL —' Lake Oswego OR 97035 ADDRESS _ __ (213)689-0065 INSURER(S) AFFORDING COVERAGE NAIC# INSURED Red Roof Inns, Inc, 1447203 7815 Walton Parkway New Albany OH 43215 COVFRAC.FR RPnPnnl CFMTICICATC MIDaeeu. 1cv-ruenr .. �,,,..,.... ............. .............. 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 — _.-- _ _-.— — _ IDOL sues UM LTR TYPE OF INSURANCEIBM POLICY NUMBER MMfD�Y� MMIDD�Y� LIMITS COMMERCIAL GENERAL LIABILITY NOTAPPLICABLP. EACH OCCURRENCE S XXXXXXX --- �CIAIMS-MADE CI OCCUR - DAMAGITTORENTED PREMISES Lu recce) --- $_XXXXXXX _ MED SKIT (Anyone person) $ XXxXXXX_ PERSONAL B ACV INJURY $XXXXXXX_ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ XXXXXXX POLICY PROS ECT OC PRODUCTS GOMPIOP AGG $ XXXXXXX -- OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT _tE..c dnnl) _.. $ X_X_XXXXX__ O BODILY INJURY (Par person) $ XXXXXXX OWNED OWNED EDULED AUTOS ONLY ac<menq $HIRED XXXXXXR OWNED AUTOS ONLY S ONLY PROILVMJUA AG Pm.cridYOAMAGE Larnccldenh_ $XXXXXXX W—AUTOS $XXXXXXXUMBRELLA LIARCCUR NOTAPPLICABL6EACH OCCURRENCE S XXXXXXEXCESS LIARLAIMS.MADE _._ AGGREGATE $_XXXXXXX DED RETENTIONS _ $ XXXXXXX A WORKERS COMPENSATION N X STATUTE_„ AND EMPLOYERS' LIABILITY YIN WCC-641-437760-018 9/6/2018 9l6/2019 IERH ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERNEMBER EXCLUDED? NI NIA E L EACH ACCIDENT _.. g._) QQQsQQQ (Mandatory In NH) EL DISEASE -EA EMPLOYEE $ ),000,Q00 If yes. doscdbe under -- — ---..._— DESCRIPTION OF OPERATIONS haloes E.L. DISEASE- POLICY LIMIT E I QQQ QQQ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Addalonal Remorse Schedule, may be aHaehad If more apace le required) Red hoof Inn 60 forties Blvd; Mansfield, MA 02048 15778501 Evidence of Insurance ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The ACORD name and logo are registered marks of ACORD All rights