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HomeMy WebLinkAboutRed Roof Inn - 12/31/20207 OV 6t� 6�-nto��S-So,= Town of Mansfield Health Department 6 Park Row, Mansfield, MA 02048 508-261-7366 APPLICATION FOR HOTEL/MOTEL LICENSE Motels & Hotel License valid January Ist through December 31s t Application Fee $50 [ns eetion 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) -44-- (O � 71f DBA Business Address Mailing Address Business Phone �.�� �j `i `d3a3 Alternate Phone Owner/President Name --P W A R T ;U LLC- _ Manager/Agent/Operator Name m rt V bcz 5 r Business Phone 5—TA --S - a'JaA3 Alternate Phone E-mail 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: ( 3 # Swimming Pools: 11 # Saunas: # Spas: # Whirlpools: # Hot Tubs: Name of Certified Pool Operator: _ Pest Control Manager: -av,\ V, k Co 16JO Trash/Garbage Collector and Schedule: P b� 4 ( ✓ Q/� I CC �— Is Water Municipal or Private Well:ow✓ is Sewer Municipal or Private Septic: f o w o 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: R-e-d R0 -T_it7 # 16 a 7 V Address: 60 Nr_/aes avj City/State/Zip: MonEj-i�(k MA OaOV- Phone#: 50E-33Q-2323 Are you an employer? Check the appropriate box: Business Type (required): 1. Z 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. [No workers' comp. insurance required] 8. ❑ 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]* 1 l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.® Other 1�6ae� *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **lf 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 ff I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: p 6 &y 8 -,3 0 City/State/Zip: Policy # or Self -ins. Lie. ff f 6 q& 2 6 5 Expiration Date: 9 % 612 o Zo 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 of perjury that the information provider/ above is true and correct -?4-4-a693 Official use only. Do not write in this area, to be completed by city or town oflieial. 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 www.mass.gov/dia Phone TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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 **Social Security No. (Voluntary) or Federal Identification Nurnber By: Corporate Officer ( ndatory, i 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. All CERTIFICATE OF LIABILITY INSURANCE 9/6/2020 OATE(MMI2001 S Y) 12/30/2019 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, 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 Lockton Insurance Brokers, LLC CONTACT NAME: 5 Centerpoinle Drive $Ulle 400 Lake Oswego OR 97035 PHONE FAX INC. No Ext : AIC No E AL ADDRESS: (213)689-0065 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Everest Denali Insurance Company 16044 INSURED Red ROOF Inns, Inc. INSURER B: INSURER C: 1447203 7815 Walton Parkway _ INSURER D : New Albany Oil 43054 INSURER E: INSURER F : COVERAGES REDRO01 CERTIFICATE NUMBER: 16487656 REVISION NUMBER: XXXXXXX 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 rypE OF ADDLSUBR INSD. WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYV LIMITS COMMERCIAL GENERAL LIABILITY NOT APPLICABLE CLAIMS -MADE EOCCUR EACH OCCURRENCE $ XXXXXXX PREMISES Ea occurrence $ XXXXXXX MED EXP(Any one person) $ XXXXXXX PERSONAL &ADV INJURY $ XXXXXXX GENERALAGGREGATE $ XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- ECT OC PRODUCTS - COMPIOPAGG $ XXXXXXX $ OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE EOa MB deD SINGLE LIMIT $XXXXXXX BODILY INJURY (Par person) $ XXXXXXX ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) _ $ XXXXXXX HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ___,,,,_,,, PROPERTY DAMAGE Peraccidenl $ XXXXXXX $XXXXXXX UMBRELLA LIAB OCCUR NOTAPPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE_ s XXXXXXX EXCESS LIAB CLAIMS -MADE DED I I RETENTIONS $ XXXXXXX A WORKERS COMPENSATION N AND EMPLOYERS' LIABILITY YIN CCIWC00032-191 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICEWMEMSER EXCLUDED' �.N/A' 9/6Y2019 9/6YL020 X PER OTH- STATUTE ER E.L. EACH ACCIDENT _ $ 1000000 E.L. DISEASE - EA EMPLOYEE 1,000,000 5If (Mandatory in NH) yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) *30 Days Notice of Cancellation will be given, unless cancelled for non-payment, in which case, 10 days will be Provided.* RE: #10274 Red Roof Inn @ 60 Forbes Blvd; Mansfield, MA 02048, 16482656 Town of Mansfield Health Department 6 Park Row Mansfield MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1088-201 S'"ACO'RD CORPORATION. All rights reserved_ ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD