HomeMy WebLinkAboutSimple Amenities - 12/31/2021l2 A,
Town of Mansfield - Board of Health
Town of MOns� ld
6 Park Row
Mansfield, MA 02046) '? .
PERMIT NUMBER: ` t
Application for the Sale of Tobacco Products
I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation
Affecting Smoking and the Sale, Vending and Distribution of Tobacco. By signing this application, I declare that I
have read the regulation and am responsible for tobacco product sales regarding federal, state and local laws.
This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or
revocation of this permit.
NAME OF BUSINESS:
LOCATION OF SALE OF TOBACCO PRODUCTS:
TELEPHONE AT LOCATION: // Y&'� �33 9 C1n2 �>
OWNER OF BUSINESS:
ADDRESS OF OWNER:
TELEPHONE OF OWNER:
FAX NUMBER:
If a corporation or partnership, give name, title, and home address of officers or
a'11
Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training
documentation
* Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00
CT-3T NUMBER: / ?i z) .3 , C�
FEDERAL ID/SS NUMBER: a 613
SIGNATURE:
DATE:
A check mark signifies your understanding and agreement. I understand and agree that:
d It is against the law to sell any tobacco product and/or nicotine delivery product (e.g. e-cigarettes) to anyone
Jess than 21 years of age, regardless of how old the person looks.
C( Anyone selling tobacco products and/or nicotine delivery products must conclusively establish the customer's
age as over 21 years old, by means of government -issued photographic ID.
p/Anyone selling tobacco products and/or nicotine delivery products must check and verify official government
photo ID for anyone less than 27 years of age.
0 1 must consent to unannounced, periodic inspections and compliance checks of the permitted retail
establishment.
Flavored tobacco products and vape products (including mint, menthol and wintergreen) can only be sold in
licensed smoking bars, for onsite consumption only.
,V( Unflavored E-cigarettes with nicotine content over 35 mg/per ml can only be sold in adult -only retail tobacco
/ stores and licensed smoking bars.
PJ Flavored e-cigarettes with any strength of nicotine content can only be sold in licensed smoking bars, for onsite
consumption only.
Self-service tobacco product and/or nicotine delivery product displays from which the customer may select
products are prohibited.
V1 The sale of single or loose cigarettes or cigarettes in packages of fewer than 20 cigarettes is prohibited.
0 I may not distribute any free samples of tobacco products or nicotine delivery products (e.g. e-cigarettes) and I
may not accept any means, instruments or devices that allow for the redemption of tobacco products for free or
cigarettes at a price below the minimum retail price determined by the Massachusetts Department of Revenue.
Tobacco vending machines are prohibited.
011, Non-residential Roll -Your -Own machines are prohibited.
CS/ Blunt wraps are prohibited.
C� Penalties for violation of the regulation include monetary fines and/or suspension of this permit for seven or
thirty days.
0 I may not allow any employee to sell tobacco products or nicotine delivery products (e.g. e-cigarettes) until such
employee reads this regulation, state and federal laws regarding the sale of tobacco and signs a statement, a
/copy of which will be placed on file, that he/she has read the regulation and applicable state laws.
2 1 must prominently display a copy of the "Permit to Sell Tobacco and Nicotine Delivery Devices".
C/ I must provide the Board of Health with proof of a current "Cigarette Retailers License" from the Massachusetts
Department of Revenue (DOR) and my DOR business permit (Attach a copy of each permit/license).
Z_ 1 must display Department of Public Health signs stating, "Sale of tobacco to Minors is prohibited".
IK' I must display signs provided by the Board of Health that discloses referral information about cessation.
ET' If I sell nicotine delivery devices (e.g. e-cigarettes) I must display signs stating that sale of nicotine delivery
devices to anyone below the minimum legal sales age is prohibited and that the used of e-cigarettes at indoor
establishments is prohibited by local law.
I have received, read and understand the Board of Health regulation "Regulation Affecting Smoking and the Sale,
Vending, and Distribution of Tobacco and Nicotine Delivery Products" and agree to abide by it.
Signature — Date /
Print Name
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name
piTd?�uy ` Establishment Address
�l�l �� IC)_
C-n / c�. pe 44P UL
Establishment Mailing Address (if different)
Establishment Telephone No f
Applicant Name & Title: �Liriio c
Applicant Address -2ry1 L�� �r Z.(
Applicant Telephone No.: '5 0v 6 5' XLy) 24 Hour Emergency No.: Yvy G 7Y u_Ly /
Applicant Email
y1(SN-Y)', c eA 01i Q me '
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
ED An Association
partner.
D'A Corporation
Name Title Address
An Individual
%l un c� �' ���riio[-wi 2 �u1 �� ��o� Ile Stir
f (o _f it- /d J/J
O A Partnership
a
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: X-/O"m/UVhrar- 0
Address: J7C
U�
Telephone No: j V I 24 Hour Emergency No: 5 U 6 cl
FAX:
E-mail: Y-now),Vj r�
Alt E-Mail: U
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
tjW
/03
t/F
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS:
Name of Persons) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in
Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. 0 Yes
Does this establishment require a FOG permit? _ If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Lu Annual
[ etail Food $125.00
(] Mobile Food Consession
Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
r Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
[?i Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
(7 Food Service up to 201 + $300.00
Ell Pushcart $50.00 # of Pushcarts:
Temporary Time:
IN Supermarkets $400
®Residential Kitchen $100.00
Rain Date:
"ilk & Cream $10.00
,c Caterer $35.00
Food Operations: Definitions:PHF - Potentially
hazardous food(timeRemperature controls required)
(Chock all that apply): Non-PHFs- non -potentially hazardous/ood(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing)
0 Sale of Commercially Pre -Packaged Non-PHFs
PHFCooked To Order
[] Hot PHF Cooked and Cooled or Hot Held
f?7 Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
for More Than a Single Meal Service
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended
Susceptible Population Facility
❑��.. Reheating of Commercially
to be Prepared by Consumer
Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
0 Customer Self -Service
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only
kJ Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs
Retail Sale
� Offers Raw Or Undercooked Food Of
Il Juice Manufactured and Packaged for
Animal Origin
Other Food Operations
Retail Sale
�1 Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
s1 Prepares Food/Single Meals for
Irt Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
to ' Commonwealth of Massachusetts Letter to; L0913958208
"� Department of Revenue Notice Dale: January 14,?021
Geoffrey E. Snyder, Commissioner Aetu m t ID: CRL-10719457.016
s9e4mass.guv/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
�I�Id��bhllLdlldl��ddlll�uu�Idpulr�ptl�l�luldp�I
SHAHMIR.INC
9
SIMPLE AMINITIES
4250 E RENNER RD APT 1915
.�
RICHARDSON TX 75082-2853
Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut
along the dotted line and display at your business location. At any time, you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license.
If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at
(800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
6 Ose� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
�trkyry.o4� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 21 years of age is prohibited.
SHAHMIR INC Account ID: CRL-10719457-016
SIMPLE AMINITIES License Number: 1955039232
214 RUMFORD AVE STE 103
MANSFIELD MA 02048-2176
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts Gencral Laws to
sell at retail at the address shown above. This license is non-transferablc and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: January 14, 2021 Expiration Date: September 30, 2022
Commonwealth of Massachusetts Letter ID: LI987700032
Department of aevrnne Malice Date: January 14. 2021
"dt Geoffrey E. Snyder, Commissioner Account ID: EDL-10719457-018
cN mass,gov/dor
LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS
t1lIIrIItIInlPthrrlvttulid1,11,11fill lldhuupltdlrpll
SIIAHMIR INC
8SIMPLE AMINITIES
$ 4250 E RENNER RD APT 1915
10 RICHARDSON Tx 75082-2853
Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut
along the dotted line and display at your business location. At any time, you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this
license.
If you have any questions about your license, call us at (617) 887-6367 or toil -Gee in Massachusetts at
(800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p,m.
DETACH HERE
a s cuUSE MASSACHUSETTS DEPARTMENT OF REVENUE
n Retailer License for Sale of Electronic Nicotine Delivery Systems
This license must be posted and visible at all times. The sale of
tobacco products to anyone under 21 years of age is prohibited.
SIIAHMIR INC
SIMPLE AMINITIES
214 RUMFORD AVE STE 103
MANSFIELD MA 02048-2176
Account ID: EDL-10719457-018
License Number: 1283950592
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts
General Laws to sell electronic nicotine delivery systems at the address shown above. This license is
non -transferable and may be suspended or revoked for failure to comply with state laws and regulations.
Effective Date: January 14, 2021 Expiration Date: September 30, 2022
Commonwealth of Massachusetts
Department of Revenue
Geoffrey E, Snyder, Commissioner
pv*
nross.gov/dor
Letter to: L1265558948
Notice bate: January 15, 2021
Account it): CCL-10719437-013
RETAILER LICENSE FOR SALE OF CIGARETTES
111huIlPinllhutitttllddttllhlllttPdlhlthdllllnri
SHAHMIR INC
SIMPLE AMENITIES
i
4250 E RENNER RD APT 1915
®
RICHARDSON TX 75082-285.3
Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line
and display at your business location. At any time, you can log into your MassTaxConnect account at
mass.govlmasstaxcounect to view and re -print a copy of this license,
If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at
(800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH. HERE
6 °sF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
o Retailer License for Sale of Cigarettes
9 13
�I Rx t.orrw This license must be posted and visible at all times. The sale of tobacco
products to anyone under 21 years of age is prohibited.
SHAHMIR INC Account ID: COL-10719457-013
SIMPLE AMENITIES License Number: 1549834240
214 RUMFORD AVE STE 103
MANSFIELD MA 02048-2176
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transterabie and may be suspended or revoked for
failure to comply with state laws and regulations,
Effective Date: January 15, 2021 Expiration Date: September 30, 2022
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
Nf-1 have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
0�_il have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature _Date: 02-- Dq —2 l
Applicant Name (please print clearly)— N0.81�10MA-P
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Sd l0\ mm l r. / N C
Address: 211.l �N` )mp-P AVENUE ; SOl (E 10-3 MMDEL P
City/State/Zip: [,<j•i, E)2-0PI Ci' Phone #: SDE— & lid— 8 2 LI i
Are yop an employer? Check the appropriate box: Busing s Type (required):
1 • 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] g• ❑ 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 100 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.j 12.❑ Other
*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 #l.
I ant an employer that is providing workers'
Insurance Company Name: o &PS
Insurer's Address: 3 q R T E 1 3 Y
insurance for my employees. Below is the policy information.
City/State/Zip: ;500-rw
r1,�,CIVNIS' mii�) r 02-%bb
Policy # or Self -ins.
��r
Lic. #
/'
W V �.0 ` 5-0-0- 5 �%Z �-1,3% _3 -2(�Z1&Expiration
Date: T li Z
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
Investieations of the DIA for insurance coverage verification.
I do hereby certify, unde the pains and penalties of peljuly that the information provided aboveis true and correct
07�//0 i Signature: //,, Date: Z2
Phone #: 5D' 42yS ' K2` l
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 Person: Phone #:
www.mass.gov/dia
Age -Restricted Products Policy & Procedures: Tobacco
LOCATION
Every Employee at this location has the legal and moral responsibility to control
the sale and distribution of age -restricted items to ensure these items do not get
sold to minors!!
TOBACCO PRODUCT SALES POLICY
Objective: That all store Employees follow all laws`
related to the sale of tobacco products including; c
loose tobacco, pipe tobacco, rolling papers, cigars'
The minimum age to purchase tobacco products is
It is our responsibility as a retailer at
sale of tobacco to anyone under the
PROCEDURES:
e and lighters.
years of age.
community to prevent the
1. This policy will be.reyiewed With all new'Employees before they can
operate a cash register and sell`tobacco products.
2. All store Employees to take computer based training and successfully pass
with 100% prior to starting on a register. This certification to be updated
on an annual basis prior to previous year expiration.
3; A valid form of identification will be required for all tobacco purchases
regardless of age or frequency of customer visits.
id are as follows:
Valid Massachusetts License
Valid Massachusetts state id
Valid US passport
Valid Out of State License
No expired identification will be accepted.
Photos must be visually matched to the customer purchasing and licenses
scanned into the register.
Driver's License is to be scanned into the register system. All other
identification from the acceptable list will require manual entry of the date
of birth listed on the documentation.
4. If it is suspected that someone is purchasing tobacco for anyone under the
age of twenty-one (21) a valid Id will be required from all members of the
party.
I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco
and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I
fail to follow store policy and local and state laws about the sale of tobacco or nicotine delivery products to
any person under the legal age, I could lose my job or be fined.
I agree to the following rules about the sale of tobacco products:
I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form
of tobacco, or any nicotine delivery product to any person under the age of 21. If any person regardless of
age attempts to make a tobacco purchase without an acceptable, I will not make the sale. ) will not accept
a note from an adult giving permission to a person under the age of 21 to buy tobacco products.
In turn, management agrees to support my judgment not to make the sale in any of the cases described
above.
Failure to follow this policy may result in disciplinary action up to and including
termination,.
Employee Signature Date
Store Operator Signature
Date
(This form will be maintained in your personnel file as a part of your permanent
employee record)
Photos must be visually matched to the customer purchasing and licenses
scanned into the register.
Driver's License is to be scanned into the register system. All other
identification from the acceptable list will require manual entry of the date
of birth listed on the documentation.
4. If it is suspected that someone is purchasing tobacco for anyone under the
age of twenty-one (21) a valid Id will be required from all members of the
party.
I have read and understand the Mansfield Board of Health Regulations which prohibits the sale of tobacco
and nicotine delivery products to anyone under the age of twenty-one (21) years. I also understand that if I
fail to follow store policy and local and state laws about the sale of tobacco or nicotine delivery products to
any person under the legal age, I could lose my job or be fined.
I agree to the following rules about the sale of tobacco products:
I will not sell any tobacco products, including cigarettes, cigars, chewing tobacco, bidis, or any other form
of tobacco, or any nicotine delivery product to any person under the age of 21. If any person regardless of
age attempts to make a tobacco purchase without an acceptable, I will not make the sale. I will not accept
a note from an adult giving permission to a person under the age of 21 to buy tobacco products.
In turn, management agrees to support my judgment not to make the sale in any of the cases described
above.
Failur
termi
up to and including
✓ this policy may result in disciplinary action
� o
Empl ee Signature Date
lA/a�v
Store Operator Signature Date
(This form will be maintained in your personnel file as a part of your permanent
employee record)
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
I have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature
Applicant Name (please print clearly)
eHAH"U"B'
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'�414� p CERTIFICATE OF LIABILITY INSURANCE
DATE(MM2D21�)
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
NCRM1 CT
RogersGray, Inc.
434 RIG 134
South Dennis, MA 02660
ia°c, No, E.t): (800) 653-1801 jac, Nel:(877) 816-2156
no al�ss: mail@rogersgray.com
INSURERS AFFORDING COVERAGE
NAIC If
INSURER A: Associated Employers Insurance Company11104
INSURED
INSURER B :
INSURER C:
Shahmir Inc.
INSURER D:
214 Rumford St, Suite 103.
Mansfield, MA 02048
INSURER E
INSURER F:
COVFRAOFS CFRTIFICATE NUMBER- 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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
TYPE OF INSURANCE
ADDLSUBR
POLICY NUMBER
POLICY EFF
POLICY EXPLTR
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
EACH OCCURRENCE
$
DAMAGE TO RENTED
PREM12ES (Ea � nce
$
MED EXP (Any oneperson)
$
PERSONAL B ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY D IPC')T LOC
OTHER:
GENERAL AGGREGATE
$
PRODUCTS - COMPIOP AGO
$
$
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
SSWN
AUTOS ONLY AUTOS ONLY
COMBINED tSINGLE LIMITEa
$
BODILY INJURY Perperson)
$
BODILY INJURY Per accident
$
PPeOacGtlenl AMAGE
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMSMADEAGGREGATE
EACH OCCURRENCE
$
$
DIED I I RETENTION$
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
OFFICEWMEMB RRqIEXC UOEDPECUTIVE ❑
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
WCC-600-5024313-2021A
112912021
1129/2022
iSTAPERT E OTH-
E.L. EACH ACCIDENT
1,000,000
$
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
11000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Mansfield
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
c/o Board of Health
6 Park Row
AUTHORIZED REPRESENTATIVE
�-
Mansfield, MA 02048
ACORD 25 (2016/03) @ 1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD