HomeMy WebLinkAboutReservoir Hotel - 12/31/2021L �
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Town of Mansfield Health Department R j
ao 6 Park Row, Mansfield, MA 02048 &
m` 508-261-7366
APPLICATION FOR HOTEL/MOTEL LICENSE
Motels & Hotel License valid January 1 St through December 31st Annually
Fee Schedule: Payment is due with application
A lication 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) Reservoir Hotel Partners, LLC
DBA (if Different) Fairfield Inn &Suites by Marriott
Business Address 50 Reservoir Street, Mansfield, MA 02048
Mailing Address P O Box 248, 66 State Road, Westport, MA 02790
Business Phone
508-452-0700
Owner/PresidentName Richard Lafrance
Manager/Agent/Operator Name Michael Dougherty
Business Phone 508-452-0700
Alternate Phone
Alternate Phone
E-mail tburkhardt@lafrancehospitality.com
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: 108 # Swimming Pools: 1 # Saunas: 0 # Spas: 0
# Whirlpools: 0 # Hot Tubs: 0
Name of Certified Pool Operator: Sean Lafrance
Pest Control Manager: Robert Ablondi - Ecolab
Trash/Garbage Collector and Schedule: Republic - twice weekly
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.
s
i ahire of Iddividual or Corporate Name
84-3716007
"Social Security No. (Voluntary) or Federal
Identification Number
Jeffrey P. Pineault
By: Corporate Officer (Mandatonj, 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.
C:\Users\sleite\Desktop\Scotts DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc
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: Reservoir Hotel Partners, LLC
Address: 50 Reservoir Street
City/State/Zip: Mansfield, MA 02048
Are you an employer? Check the appropriate box:
1. Q I am a employer with 30 employees (full and/
or part-time).*
2.n I am a sole proprietor or partnership and have no
employees working for me 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, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. n
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #: 508-452-0700
Business Type (required):
5. Retail
6. Fj Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. REntertairiment
10.R Manufacturing
I LF] Health Care
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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. #
Expiration
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 ertify{/(hider the
/pains
(a��}dypenalties of peijuur..y.+that the information provided above/ is true and correct.
SianatnrP• ,C €l V ..�°^"'°*°"�--��+v�i! Date- ��7
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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