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Home My WebLink AboutRed Roof PLUS + -12/31/2021Town of Mansfield Health Department 6 Park Row, Mansfield, MA 02048 a 508-261-7366 / APPLICATION FOR HOTELiMOTEL LICENSE. Motels & Hotel License valid January 1st through December 31st Annually Fee Schedule: Payment is due with application Application Fee $50 inspection fee: 0-50 units $200 51 or more units $300 INTAKE CHECK PAYABLE TO: Town of Mansfield RETURN TO: Health Department, 6 Park Row, Mansfield, MA 02360 Legal Business Name (Corp., LLC. Etc) BW M III LLC DBA (if Different) Red Roof PLUS+ a Business Address --�� — Mailing Address 7815 Walton Parkway New Albany, 013 43054 Business Phone 3�"a Alternate Phone Owner/P esiden Name / t Manager/AgenVOperator a ne _rm Business Phone a Alternate Phone —------- - - Please note: the He 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: -Lb 4 # Swimming Pools: —A— # Saunas: # Spas: # Whirlpools: # Hot Tubs: Name of Certified Pool Operator: hMny' -7 0 ckaz Pest Control Manager: Ecolab Pest Control ` Trash/Garbage Collector and Schedule: Republic Services��_ Is Water Municipal or Private Well: Municipal Is Sewer Municipal or Private Septic: Municipal 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. Z�a,ct. , llaev Pue44erL Signature of Individual or Corporate Name 47-3368497 -Social Security No. (Voluntary) or Federal Identification Number Authorized Officer Rep 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. Tile Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations IN 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: general Businesses Business/Organization Name:Red Roof PLUS+ 60 Forbes Blvd City/State/Zip: Mansfield, MA 02048 Phane #: 508-339-2323 ' d• Are y ,,On an employer? Check the appropriate box: 1. R I am a employer with i it employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for Inc in any capacity. [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §I(4), and we have no employees. [No workers' comp. insurance required]' 4.0 we are a non-profit organization, staffed by volunteers, 1 ees [No workers' comp. insurance req.] Business Type (regmre ). 5. [] Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. Office and/or Sales ('net' real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.[] Manufacturing 11.❑ Health Care 12.9 Other H b ' with no emp oy eAny ir workers' compensation policy imor applicant that cks box #1 must also fill out the section below showing the **Ifthe corporate officers have exempted themselves, but the corporation has otter employees, a workers' compensatonolicy Policy is required and such an che organization should check box A. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Everest National Insurance Company Insurer's Address: 3 Centerpointe Drive City/State/Zip: Lake Oswego, R # IZ1Vll vv euuuoa- Expiration Date: 9/6/2021 Policy # or Self -ills. Lie. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the of a imposition Wof ORK penalties a i fine up to $1,500.00 and/or the one-year imp violator, Be advised that a copy penalties ttement the form be forwGarded ro theGOffice d a fine in of up to $250.00 a day against PY Y Investigations of the DIA for insurance coverage verification. ve is true and correct I do hereby certify, _ _.._w.... s..a>•:,,ru ehat ehe information provided abo 1 V Phone #: b � ✓ 3 � a3 r6.O al use only. Do not write in this area, to be completed by city or town official Permit/License # r Town: g Authority (circle one): rd of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's office er — Contact wvnv.mass.gov/dia Phone AC ® CERTIFICATE OF LIABILITY INSURANCE DATEMI (MODA'YYY) 1 9/15/2020 9/6/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. must have ADDTIONAL INSURED provisions or be endorsed. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) the certain policies may require an endorsement. A statement on If SUBROGATION IS WAIVED, subject to the terms and conditions of policy, this certificate does not confer rights to the certificate holder in lieu of such endorsements . CONT r PRODUCER Lockton Insurance Brokers, LLC ME: FAX 3 Centerpointe Drive PHONE No Suite 320 EMAIL ADD ESS: Lake Oswego OR97035 INSURERIS)AFFORDING COVERAGE NAIC# (213)689-0065 INSURER A: Everest National InsuranceCom an 10120 INSURED Red Roof Inns, Inc. INSURERS: 1447203 7815 Walton Parkway INSURER C : INSURER D : New Albany OH 43054 INSURER E INSURER F: ocTncl/lAl Al11AlIRFR• XXXXXXX COVERAGES REDR001 CERTIFICATE NUMHt:K: I048LoOo •-^••-•-- BEEN ISSUED TO THE INSURED -----_- NAMED ABOVE FOR THE ----- POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS ADDL SUER POLICYEFF POLICY EXP OMITS INSR LTR TYPEOFINSURANCE RM VWDPOLICY NUMBER MM/LID 1MUuaDNYYY1 $ XXXXXXX COMMERCIAL GENERAL LIABILITY NOTAPPLICABLE EACH OCCURRENCE A E O R 'tTEU PREMISES aoccu ence $XXXXXXX CLAIMS -MADE ❑ OCCUR MED EXP (Any one person) $ XXXXXXX PERSONAL B ADV INJURY $ XXXXXXX GENERALAGGREGATE $ XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: 0 PRODUCTS -COMP/OPAGO $XXXXXXX POLICY ❑ jEOT LOC OTHER: NOTAPPLICABLE COMBINED SI OLE LIMIT Ea acatlent $XXXXXXX AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ j{�{XXXXX ANY AUTO BODILY INJURY (Per accident) $ XXXXgVM OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE $ XXXXX3 x HIRED NON -OWNED Per aceident AUTOS ONLY AUTOS ONLY $ X(�{XX){ UMBRELLA LIAB OCCUR NOTAPPLICABLE EACH OCCURRENCE $XXXXXXX AGGREGATE $XXXXXXX EXCESS LIAB CLAIMS -MADE $ XXXXXXX DED RETENTION$ X PEROR WORKERS COMPENSATION N RMSWC00068-201 9/6/2020 9/6/2021 E.L. EACH ACCIDENT $ 1000000 A AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOWPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? N NIA E.L. DISEASE -EA EMPLOYE $ 1 000000 E.L. DISEASE -POLICY LIMIT $ 1 000 000 (Mandatory in NH) It es, desrnbe under below DESCRIPTION OF OPERATIONS DESCRIPTION OFOPERATIONS I LOCATIONS/VEHICLES (ACORDlot. Additional Remarks Schedule, may be amehed if more apace le required) for non-payment, in which case, 10 days will be provided.* ItF- #10274 Red Roof Inn Q 60 Forbes *30 Days Notice of Cancellation will be given, unless cancelled 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 reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Attachment Code: D567517 Master ID: 1447203, Certificate ID: 16482656 Town of Mansfield Health Department 6 Park Row Mansfield, MA 02048 To whom it may concern: In our continuing effort to provide timely certificate delivery, Lockton Companies is transitioning to paperless delivery of Certificates of Insurance, thus, this is your final hard -copy delivery. To ensure electronic delivery for future renewals of this certificate, we need your email address. Please contact us via one of the methods below, referencing Certificate ID 16482656. • Email:l'Gicificet7e;livc(�lockfon.corn • Phone: (213) 689-2300 If you received this certificate through an internet link where the current certificate is viewable, we have your email and no further action is needed. In the event your mailing address has changed, will change in the future, or you no longer require this certificate, please let us know using one of the methods above. The above inbox and phone number below are for automating electronic delivery of certificates only. Please do NOT send future certificate requests to the above inbox or call into the number below. Thank you for your cooperation and willingness in reducing our environmental footprint. Lockton Insurance Brokers, LLC - Pacific Series Lockton Insurance Brokers, LLC 1,icoiiw i70F 1 5.707 71l , Fi�tan'o i ` trcct, i i ( i F I % Los Awm ,clrs. CA 900I7_�'52 -4 213-689-0065 / FAX: 21.3-689-0550 lockton.com