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Home My WebLink AboutHoliday Inn 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. GAUTAM SHARMA, PRESIDENT Whose place of business is: HOLIDAY INN MANSFIELD 31 HAMPSHIRE STREET PERSON(S) IN CHARGE: ZACHARY FRANGOS, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -39 Food Fee: $137.50 Milk & Cream V BOARD OF HEALTH wlichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: GAUTAM SHARMA, PRESIDENT having a place of business at: HOLIDAY INN MANSFIELD 31 HAMPSHIRE STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -39 Scott Leite, 3--1'eaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -39 FOOD ESTABLISHMENT PERMIT APPLIGA I IUN pp ica ►on mus esu mi e a eas ays a ore e p anne open►ng a e 1) Establishment Name HOLIDAY INN MANSFIELD 2) Establishment Address 31 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 31 HAMPSHIRE STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-2200 5) Applicant Name & Title: VISION HAMPSHIRE LLC - 6) Applicant Address 31 HAMPSHIRE STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-2200 24 Hour Emergency No.: (508) 339-2200 8) Owners Name & Title GAUTAM SHARMA, PRESIDENT 9) Owner Address (If different from applicant) Owner's telephone number (508) 339-2200 10) Establishment Owned By: ❑ An Association ❑ A Corporation ❑ An Individual 0 A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Name & Title: 121 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: ZACHARY FRANGOS, GENERAL MANAGER Address: 31 HAMPSHIRE STREET, MANSFIELD, MA 02048 Telephone No: (508) 339-2200 24 Hour Emergency No: (508) 339-2200 FAX: E-mail: ZFRANGOS(cD-HIFOXBORO.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 30 DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: MARTIN O'SHEA If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: W Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) n Milk & Cream $5.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer 21) Length of Permit: Annual or up to 25' PHF display $75.00 Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Pushcart $12.50 # of Pushcarts: 0 ❑ Residential Kitchen $50.00 E]Retail Food $50.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs iVJ PHFCooked To Order W Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs (. Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility �/❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ iCe Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale iV Prepares Food/Single Meals for Catered Events or Institutional Food Service E] Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $137.50 Payment is due with application ❑ waived 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_�nd the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under Fhe penalties o rjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 47-3112140 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: HOLIDAY INN MANSFIELD ADDRESS: 31 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 339-2200 FAX NUMBER: OWNER OF BUSINESS: GAUTAM SHARMA, PRESIDENT TELEPHONE OF OWNER: (508) 339-2200 FEDERAL ID/SS NUMBER: 47-3112140 FEE: $5.00 PERMIT NUMBER: FS -39 SIGNATURE: DATE: M aH /,1) 2O l 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. VISI ON HPrrhPSr►Ett C -- Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) L17- 311 2140 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts DI 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:` Address:�- City/State/Zip: r4AC-1k �, Phone Are you an employer? Check the appropriate box: 1. F1 am a employer with employees (full and/ or part-time).* 2. ❑ 1 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. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'_comp. insurance req.] Business Type (required): 5. ❑ Retail 6, ❑ Restaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (incl 8, ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11.❑ Health Care 12,❑ Other real estate, auto, etc.) *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 am 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. Lic. #_ Expiration Date; 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, tinder the Ains ajld penalties of perjury that the information provided above is true and correct 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: www,mass.gov/dia Phone GLOBVIS-01 JHOGAN ACO�Q" CERTIFICATE OF ,LIABILITY INSURANCE �,� DATE'MMIDDIYYYY) 1/29/2016 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 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 Roblin Insurance Agency 144 Gould Street Suite 100 Needham, MA 02494 CONTACT NAME: PHONE Ext): (781) 455-0700 ac No : (781) 449-8976 E-MAIL ADDRESS: certificates@roblininsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers Insurance Co 36161 INSURED Vision Hampshire LLC dba Holiday Inn 31 Hampshire Street Mansfield, MA 02048 INSURER B : INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE 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 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 TYPE OF INSURANCE ADDL INSD S B WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 11 OCCUR EACH OCCURRENCE $ DAMAGET PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E PRO- JECT D LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? F (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PAUB-OG64525.0-15 06/01/2015 06/01/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Issued as evidence of Insurance. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Issued as Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE > X ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD GLOBVIS-01 JHOGAN ACORO� �� CERTIFICATE OF.IABILITY INSURANCE DATE (MMIDDIYYYY) 5/19/2016 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(les) must 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 Roblin Insurance Agency 144 Gould Street Suite 100 Needham, MA 02494 CONTACT NAME: PHONE (781) 455-0700 AX N, ; (781) 449-8976 ac No Ext E-MAIL DRESS: certificates@roblininsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers Insurance Co 36161 INSURED Vision Hampshire LLC dba Holiday Inn 31 Hampshire Street Mansfield, MA 02048 INSURER B: INSURER C : INSURER D : INSURER E: INSURER F: rnvl=RAr,FS rFRTIFICATE 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 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 TYPE OF INSURANCE L INSD S WVD POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR XLiq Liability $11$2M P -630 -9C747111 -TIL -15 06/24/2015 06/24/2016 EACH OCCURRENCE $ 1,000,000 -DAMAG ° RENTED 300,000 PREMISES Ea occurrence $ � MED EXP (Any one person) $ 5,000 X No 1,000,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PJRECT LOC X POLICY F—] OTHER: GENERAL AGGREGATE $ 20,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS COMBEa acciINED eSINGLE LIMIT $ dnt BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? LJ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Issued as evidence of Insurance. '.rr1� 1^A•r unr MOO C-ANCFI I ATinN V '18iSt3-ZU"14 AV//ICU I.VKYVRH I IVIY. HII �Il�lll5 Ir5G1 VtlU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Issued as Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V '18iSt3-ZU"14 AV//ICU I.VKYVRH I IVIY. HII �Il�lll5 Ir5G1 VtlU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD GLOBVIS-01 JHOGAN CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 5/19/2016 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(les) must 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 Roblin Insurance Agency CONTACT NAME: PHONE (781) 455-0700 FAX No : (781) 449-8976 Ext 144 Gould Street Suite 100 Needham, MA 02494 -M IL E-MAIL certificates@roblininsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Travelers Insurance Co 36161 INSURED INSURER B: INSURER C : Vision Hampshire LLC dba Holiday Inn AlP-630-9C747111-TIL-15 CLAIMS -MADE OCCUR X Liq Liability $1/$2M 31 Hampshire Street INSURER D: INSURER E : Mansfield, MA 02048 INSURER F: MED EXP (Any one person) $ 5,000 rcorlClrATC Al11MRC0• REVISION NUMBER: %1 V V Gr[N%7 CJ v..... � .. . v .... ...........-... 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. ILTR TYPE OF INSURANCE AUDE INSD SIM WVD POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY ION All ' ht ed EACH OCCURRENCE $ 1,000,000 _DAMAGE T° IR 300,000 PREMISES Ea occurrence $ AlP-630-9C747111-TIL-15 CLAIMS -MADE OCCUR X Liq Liability $1/$2M 06/24/2015 06/24/2016 MED EXP (Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 X NoDed/SIR GEN'L AGGREGATE LIMIT APPLIES PER: PRO- D LOC X POLICY F] GENERAL AGGREGATE $ 20,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY Eec accidentSINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO EDULED AUNAUTOS AL4AUTOS OW OWNED HI BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMOCCUREACH OCCURRENCE $ AGGREGATE $ EXCLAIMS -MADE $ PER OTH- STATUTE I ER DED I I RETENTION $ WORKERS COMPENSATION E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Issued as evidence of Insurance. CERTIFICA I E MULUER T SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Issued as Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ION All ' ht ed @ 1988-2014 ACORD CORPORAng s resery ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD �® ® Z LL u E '1 OHO t �® ® Z LL u E '1 OHO N C N E N n O 'a U U N � O O O N p� C O 0 0 N 7 N Q C U O m �y � 7 ><.,.` W QLL O ca O ' w Wit �� .• ).. T jFJ i T i W 0 pill 5! i W