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HomeMy WebLinkAboutHoliday Inn - 12/31/20214:t::- 1306 ® 35'0, Town of Mansfield Health Department 6 Park Row, Mansfield, MA 02048 508-261-7366 APPLICATION FOR HOTEL/MOTEL LICENSE Motels & Hotel License valid January 1st through December 31st 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)I� DBA (if Different) 1—&JIlrkul 1�/d Business Address Mailing Address r,.3 Business Phone `J73 ; - t j Alternate Phone Owner/President Name Manager/Agent/Operator Name Business Phone r)�' i3� - �� �JJ Alternate Phone E-mailAklyl-G. 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: u J / # Swimming Pools: # Saunas: # Spas: # Whirlpools: _# Hot Tubs: / Name of Certified Pool Operator: Pest Control Manager: ;/7/Jr / r'Y) Trash/Garbage Collector and Schedule: /71<ual' Is Wate MunicpafjorPrivate Well: Is SewerM� micipaborPrivate 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 Social Security Number (Voluntary) or Federal Identification Number** 6 hu,lg.,n 51)az7n% Px5l @e/z-1 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. 10 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYY Y) 11/6/2020 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 CONTACT NAME: Bdanna FOertschbeck Diversified Insurance Industries, Inc. PHONE . 410-433-3000 a N.); 410-433-3440 307 International Circle EMAIL ADDRESS: brianna.foertschbeck@dii-ins.com Suite 610 INSURERS AFFORDING COVERAGE NAIC If Hunt Valley MD 21030 INSURERA: Endurance Amer Spec Ins* .41718 INSURED GLOBVI"I INSURER B: SOm o America Insurance CO* 11126 Vision Hampshire, LLC Ua Holiday Inn Mansfield, MA INSURER C: Allied World Assurance Co* 19489 INSURER D: Continental Insurance* 35289 c/o Hospitality Cover Plus, LLC INSURER E: P.O. Box 1572 Cockeysville MD 21030 INSURER F: COVERAGES CERTIFICATE NUMBER: 535879990 REVISION NUMBER: 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 TR WIRE OF INSURANCE ADDL SUBR POLICY NUMBER MMfDDYEFF POLICMMIDDYEXP LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE � OCCUR EmpI Benefit GLOBVIS-GL 11/1/2020 11/1/2021 EACH OCCURRENCE $1,000,000 'PREMSES Ea orcwence $1,000.000 X MED EXP An one person) $EXCLUDED X Liquor Liability PERSONAL B ADV INJURY _ $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JET N LOC OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS - COMP/OPAGG $2,000,000 Empl BenflLiquor $1,000,000 8 AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X AUTOS ONLY HIRED X AUTO ONLY X $2.000 wmp X $2.000 toll GLOBVIS-AU 11/1/2020 11/1/2021 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (Per acddenDAMAGE $ $ D X UMSRELLAIJAB EXCESS LIAB X OCCUR CLAIMS -MADE CUE 5094764769 1111/2020 11/1/2021 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 LED X RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFCEWMEMB RPEXCLUDED?ECUTIVE ❑ (Mandatory In NH) If yes, desaibe antler DESCRIPTION OF OPERATIONS below N/A IPER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ C Excess Liability GLOBVISAS 11/1/2020 11/1/2021 UmIVAggregate 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD101,Addltlonel RemarksSchedule,meybeaUechedifmorespaceiaraggired) Re: Holiday Inn Mansfield - 31 Hampshire Street, Mansfield, MA 02048 General Proof of Coverage CERTIFICATE HOLDER 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. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street y` Boston, MA 02,111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: im Phone #: ��9 rig" Are you an employer? Check the appropriate box: Business Type (required): S. Retail 1. I am a employer with employees (full and/ _R)— orpart-time).* 6. [].A(estaurant/Bar/EatingEstablishment 2. ❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales (iacl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* 4. We are a non-profit organization, staffed by volunteers, I 11.Q Health Care 12.0 Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **rf 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 providijn�g workers! compensaattion insurance fogey entpli ees. Insurance Company Name: Insurer's Address:() ���yl�t ht3Yl CiV2i° �/ City/State/Zip: C� !U'3t-) is the policy information. C Policy # or Self -ins. Lic. # � a(p`rj 161J O � Expiration Date: / :2�oL% 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 ofpeijury that the inforination provided above is true and correct Signature: (J`--'YI,C Date• 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 Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: Wiril:J0174So4l Workers' Compensation and Employers Liability Insurance Policy EMPLOYERS ASSURANCE CO. Policy Number From olicy PeriodTO A Stock Company EIG 2656163 02 06/24//20tl20 06/24/2021 Inso eJ M.si1ied%er In a al (he address of the 1 Transaction RENEWAL DECLARATIONS NCCI Carrier # 36870 WCIRB CARRIER# PRIOR POLICY NUMBER EIG265616301 1. Named Insured and Address Agent VISION HAMPSHIRE LLC DIVERSIFIED INS INDUSTRIES INC 6465200 DBA HOLIDAY INN MANSFIELD 307 INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer# Carrier# FEIN # Risk ID # Entity of Insured 1 36870 473112140 001033835 LIM LIABILITY CO Additional Locations: 2. The Policy Period is from 06/24/2020 to 06/24/2021 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 ND, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ Assessments and Taxes $ SEE EXTENSION OF INFORMATION PAGE 231 Expense Constant $ 338 Premium Discount $ Total Estimated AnnualPremium $ 8,966 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly Countersigned this Day of e& Issued Date: 06/19/2020 Authorized Representative Issuing Office EMPLOYERS ASSURANCE CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 Issued Date 06/19/2020 WC990630 (5198 Ed.) AGENT COPY Page 1 of 4 1:MPLOYERS0 EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG265616302 Named IDSUred: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Code No. Classification Description Massachusetts Rating Period: 06/24/2020 through 06/24/2021 Site 00001 8810 CLERICAL OFFICE EMPLOYEES NOC 9052 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9058 HOTEL: RESTAURANT EMPLOYEES Site 00001 Total Total of Sites for Rating Period Rating Period Total Rating Period: 06/24/2020 through 06/24/2021 9037 RATE DEVIATION ADJUSTMENT 9812 INCREASED COVERAGE II 9898 EXPERIENCE MODIFICATION 0277 ALL RISK ADJUSTMENT PROGRAM 0900 EXPENSE CONSTANT 9740 TERRORISM PREMIUM 0986 DEPARTMENT OF INDUSTRIAL ACCIDENTS ASSESSMENT Rating Period Total State Total Policy Total Issued Date 06/19/2020 AGENT COPY WC990630 (5/98 Ed.) Page 2 of 4 Premium Basis Rate Per Estimated Total Est. Annual $100 of Annual Remuneration Remuneration Premium 0 0.070000 0.00 350,000 1.490000 5,215.00 150,000 1.380000 2,070.00 $ 7,285.00 $ 7,285.00 $ 7,285.00 7,285 0.080000 -583.00 6,702 0.020000 134.00 6,836 1.100000 684.00 7,520 0.090000 677.00 338.00 500, 000 0.030000 150.00 8,014 0.035100 281.00 $ 1,681.00 $ 8,966.00 $ 8,966.00 .MPLOYERS' EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 State MA VISION HAMPSHIRE LLC 31 HAMPSHIRE ST MANSFIELD MA 02048-1113 WORKERS'COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 SITE LOCATION SCHEDULE Issued Date: 06/19/2020 AGENT COPY WC990410 (7/06 Ed.) Page 3 of 4 EMPLOYERS EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 NT SCHEDULE State Form Nbr. Ed. Date Description MA WC000000C (1/15) WC/EL INS. POLICY FORM BOOKLET MA WC000115 (1/20) ENDT OF PEND LAW CHG TO TRIPRA MA WC000403 (4/84) EXPERIENCE RATING MOD FCTR MA WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT MA WC000414 (7/90) NOTIFICATION OF CHG OWNERSHIP MA WC000422B (1/15) TERRORISM RISK INSURANCE PROG MA WC000424 (1/17) AUDIT NONCOMPLIANCE CHARGE END MA WC000425 (1/17) EXP RATING MOD FACTOR REV ENDT MA WC200301 (4/84) MA LIMITS OF LIABILITY ENDT MA WC200302A (9/08) MA ASSESSMENT CHARGE MA WC200303D (8/10) MA NOTICE TO POLICYHOLDER ENDT NIA WC200405 (6/01) MA PREMIUM DUE DATE ENDT MA WC200601A (7/08) MA CANCELLATION ENDORSEMENT MA WC200604 (11/02) MA POLICY DEFINITION ENDT MA WC99040SA (3/07) INSTALLMENT PAYMENT ENDT issued Date: 06/19/2020 AGENT COPY WC990633 (5/98 Ed.) Page 4 of 4