HomeMy WebLinkAboutHoliday Inn - 12/31/2020556 - >
r Town of Mansfield Health Department
' c 6 Park Row, Mansfield, MA 02048
508-261-7366
APPLICATION FOR HOTEL/MOTEL LICENSE`
Motels & Hotel License valid January 1st through December 31st Annually
Fee Schedule: Payment is due with application
Application Fee
$50 v
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
n.
Legal Business Name (Corp., LLC. Etc) I J I
DBA (if
Business Address 0/
Mailing Address �_kl ee
Business Phone \07d— Alternate Phone
Owner/President Name
Manager/Agent/Operator Name,f/ �? L/ l)U
Business Phonnew/' l///° Alternate Phone
E-mail rY (G77 9%�/L�(i d//tG l� t/�r /J
l
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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: '320 / # Swimming Pools:
# Whirlpools: # Hot Tubs:
Name of Certified Pool Operator: _
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i# Saunas: I# Spas:
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(, Pest Control Manager: co /S /7zS��f-�j17' G- )l1701/y7
Trash/Garbage Collector and Schedule: /l�f�� �y- ~ ✓�'��iL/� �; ��ti
Is Water E7ipa)loPrivate Well: 11l e �ls Sewer 4unicipal or Private Septic: Gif r
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.
61 ' ''-
Signature of Individual or Corporate Name
Social Security Number (Voluntary) or Federal
Identification Number"
By: Corporate Officer (Mandatory, 17 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.
Department ofltidustrfal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
w irminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: i,_31
City/State/Zip:
UdeXIFPhone
Are an employer? Check the appropriate box:
Business Type (required):
,you
L,.I am a employer with /Li-"3 employees (full and/
5. ❑ Retail
orpart-time),*
6.[Xestaurant/Bar/EatingEstablishment
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]
$• ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp, insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
11.❑ Health Care
with no employees. [No workers' comp. insurance req.]
12.0Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' contpensmi[ ins raneee for my employees. Below is the policy information.
Insurance Company Name: � � / /L > 1i�6r t74-$ , ee)
Insurer's Address: /'y%aG' 104116VI),m-
6 (a lc, % fCIG� C_Y(lk AN
City/State/Zip:_ CA0_rld / 6, �,
Policy # or Self -ins, Lic. # �Ic r2 % 3 D Expiration Dater
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains aanndpenalties ofperjriry that the information provided above is/trit eand correct
S�nature: /rtllo Date. 1`W1a/ 1y
-_d0 3. 33-?5
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
www.mass.gov/dia
Phone
EMPUIVERT
Workers' Compensation and Employers Liability
Insurance Policy
EMPLOYERS PREFERRED INS. CO.
Policy Number From olicy PeriodTo
A Stock Company
EIG 26-16163 01
06/2412019 06/24/2020
t 2:01P.MS[and rtl i'me at theaddress M.
1 Insured as statedehereln
Transaction
AMENDED DECLARATIONS
Effective: 06/24/2019
NCCI Carrier # 31283 WCIRB CARRIER#
PRIOR POLICY NUMBER EIG265616300
1. Named Insured and Address
Agent
VISION HAMPSHIRE LLC
DIVERSIFIED INS INDUSTRIES ING 6465200
DBA HOLIDAY INN MANSFIELD
307 INTERNATIONAL CIR #610
31 HAMPSHIRE ST
HUNT VALLEY, MD 21030
MANSFIELD MA 02048-1113
Telephone: 41'04333000
Customer #
Carrier #
FEIN #
Risk ID #
Entity or Insured
3.1283
473112140
001033835
LIM LIABILITY CO
Additional Locations:
2. The Policy Period is from 06/24/2019 to 06/24/2020 12:01 a.m. Standard Time at the Insured's mailing address.
3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A.
The limits of our liability under Part TWO are:
Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit .
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here:
All states except HI, ND, OH, WA, WY and states listed in item 3,A.
D. This policy includes these endorsements and schedules: See attached schedule.
t. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, anq Rating Plans.
Alt infurrtratiou required below 'rs subject to Veriflcation and charfgo by audit. .
Minimum Premium $
Assessments and Taxes $
SI=E EXTENSION OF INFORMATION PAGE
231 Expense Constant $ 338
Premium Discount $ -1,440
Total Estimated AnnualPremium $ 26,439
❑ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: M Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly
f
:ountersigned this Day of
ssued Date: 06/28/2019 Authorized Representative
ssuing Office EMPLOYERS PREFERRED INS. CO.
14120 BALLANTYNE CORPORATE PLACE, SUITE 100
CHARLOTTE, NC 28277-2685
;sued Date 06/28/2019 INSURED COPY
IC990630 (5/98 Ed.)
0
�I
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
POLICY INFORMATION PAGE ENDORSEMENT
The following item(s)
WC 89 06 00 A
(Ed. 07-87)
[ ] Insured's Name (WC 89 06 01)
[ ] Item 3.A. States (WC 89 06 11)
[ ] Policy Number (WC 89 06 02)
[ ] Item 3.B. Limits (WC 89 06 12)
[ ] Effective Date (WC 89 06 03)
[ ] Item 3.C. States (WC 89 06 13)
[ ] Expiration Date (WC 89 06 04)
[ ] Item 3.D. Endorsement Numbers (WC 89 06 14)
[ ] Insured's Mailing Address (WC 89 06 05)
[x] Item 4.* Class, Rate, Other (WC. 89 04 15)
[ ] Experience Modification (WC 89 04 06)
[ ] Interim Adjustment of Premium (WC 89 04 16)
[ ] Producer's Name (WC 89 06 07)
[ ] Carrier Servicing Office (WC 89 06 17)
[ ] Change in Workplace of Insured (WC 89 06 08) [ ] Interstate/Intrastate Risk ID Number (WC 89 06 18)
[ ] Insured's Legal Status (WC 89 06 10)
[ ] Carrier Number (WC 89 06 19)
is changed to read:
EFFECTIVE 06/24/19 AMEND TO INCREASE PAYROLL FOR CLASS CODE 9052 FROM 1,045,440
TO 1,057,000; CLASS CODE 9058 FROM 828,026 TO 1,010,000 AND CLASS CODE 8810 FROM
118,800 TO 310,000 PER THE AGENT'S REQUEST.
*Item 4. Change To:
Premium Basis
Rate Per $100
Classifications
Code
Total Estimated
of
Estimated
No.
Annual
Remuneration
Annual Premium
Remuneration
Total Estimated Annual Premium $ 26,439
Minimum Premium $ 231 Deposit Premium $ 2,413.30
All other terms and conditions of this policy remain unchanged.
This endorsement changes the policy to which it is attached and is effective on the.date issued unless otherwise stated.
(The information below is required only when this endorsement is Issued subsequent to preparation of the policy.)
This endorsement, effective 06/24/2019
Policy No, EIG 2656163 01
Issued to VISION HAMPSHIRE LLC
Premium $26,439
Countersigned at
at 12:01 AM standard time, forms a part of
Of the EMPLOYERS PREFERRED INS. CO.
Carrier Code 31283
Endorsement No. 001
on By: �v ��
Authorized Representative
WC 89 06 00 A
(Ed. 07-87) ® 1987 National Council on Compensation Insurance, Inc.
lntormation 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 a joint 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 fill 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 permit/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 file for future permits or licenses. A new affidavit
must 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 bum 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
jmt Revised 5-26-05