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HomeMy WebLinkAboutLonghorn Steakhouse 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. RUAIRI BYRNE, MANAGING PARTNER Whose place of business is: LONGHORN STEAKHOUSE #5296 390 WEST STREET PERSON(S) IN CHARGE., RUAIRI BYRNE, MANAGING PARTNER Permit Expires: December 31, 2016 License Number: FS -33 Food Fee: $75.00 Milk & Cream F%-]* BOARD OF HEALTH MichaeCMCCCean, 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: RUAIRI BYRNE, MANAGING PARTNER having a place of business at: LONGHORN STEAKHOUSE #5296 390 WEST 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 12131/2016 License No.: FS -33 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred May 23 16 06:28p FOR BOARD OF HEALTH USE ONLY p,3 Date received: Date Inspected: Approved By: Permit# Issued j FS -33 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at (east 30 days before the planned opening date) 1) Establishment Name LONGHORN STEAKHOUSE #6296 2) Establishment Address 390 WEST STREET 3) Establishment Mailing Address (if different) P.O. BOX 695016 u � Y, ORLANDO, FL 32869-5016 4) Establishment Telephone No (508) 261-8810 5) Applicant Name & Title: RARE HOSPITALITY INTERNATIONAL, INC. i 6) Applicant Address P.O. BOX 695016, ORLANDO, FL 32859-3330 7) Applicant Telephone No.: (900)248-4918 x9787 24 Hour Emergency No.: (401) 886-4525 (401) 374-4953 S.SCOTT CELL (781) 733-2511 8) Owners Name & Title - - - - - JAPI - y► 9) Owner Address (If different from applicant) 31.;' j 5 �4S f 1Z4 20-102— Owner's telephone number wct Y -W 1`LKl 10) Establishment Owned By: i 11) If a corporation or partnership, give name, title; and home address of officers El An Association i or partner. lVI A Corporation Name Title Address ❑ An Individual Vic..it�•oe/ ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Tk %_Aet i V, y y n e., Al,�A'"5) Address:._. .. 11S_ 14&)VC_ Telephone No: BOJ— %2 (oDcPo FAX: (407) 872-3775 E-mail: RHAYWARD(u)DARDEN.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: STEPHEN SCOTT 24 Hour Emergency No: (401) 986-4525 (401) 374-4953 S.SCOTT CELL (781) 733-2511 Address: 1000 DARDEN CENTER DRIVE, ORLANDO, FL 32837 Telephone No: (407) 245-4000 24 Hour Emergency No: (900) 2484918 x6797 FAX: (407) 872-3768 E-mail RHAYWARD@DARDEN.COM May 2316 06:28p Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN i - DEP Public Water Supply No: (If applicable) 16) NO. Of Food Employees: 17) DAYS/HOURS: SUN-THURS 11 AM -10 PM FRI-SAT 17 AM -11 PM 18) Name of Person In Charge Certified in Food Protection Management: 51?-IbVe4� r'� ,� q � mqil&qq e_v- It more than 3 individuals are certified, complete list is on file, Required as of 7(!9/2007 in accordance with 905 CMR 590.003(A) Please attach copyof certificate j 19) Person Trained in Anti -Choking Procedures (if 25 Seats or more): N4 20) Location: :21 Permanent Location 22 Establishment Type yp I Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq, Ft) M,Ik & Cream $5.00 Moblie End Date_ ❑ Food Service up to 100 or r (^ Mobile Food & Consession $37.50 Moblie Comments: -- --- --J up to 10' PHF display $62.50 I Manufacture Frozen Dessertslice Cream 21) Length Of Permit: Food Service up to 101 -200 $12.50/freezer I U Annual or up to 25' PHF display $75.00 ❑ Pushcart S12.50 # of Pushcarts: Seasonal r❑ Food Service u to 201 + r ❑Residential Kitchen $50.00 Seasonal Dates: or 26+ PHF display $137.50 1 [] Retail Food S50.00 ❑ Temporary ❑ Food Service - Institution ❑ Retail Snack Food $12.50 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products S12.50 Temporary End Date: Temporary Time: i ; Rain Date: ..._.._.. ... _. .. .. -._ I --_... 23) Food Operations j Definitions: PHF - Potentially hazarwous food (tfma4emperature controls required) `` Non-PHF's - non-porentially hazardous food(no time4emperature controls required) :(Check all that apply): I RTE -ready-to-eaf foods (Ex. sandy.9ches, salads, muffins which need no further processing) J Sale of Commercially Pre -Packaged Non-PHFs © PHFCooked To Order �[,j Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs ,Cil Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For H ghly (�i Reheating of Commercially ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility Processed Foods for Service Within 4 Hours to be Prepared by Consumer `, ❑ Vacuum Packaging f Cook Chill I .• ❑ Customer Self -Service of Non PHF and Non- m ; ❑ Custoer Self -Service ❑ Use of Process Requiring A Variance Perishable Foods Only lice Manufactured and Packaged for and/or HACCP Plan (including bare hand contact alternative, time as a public health i] Preparation of Non-PHFs Retail Sale control) Other Food Operations �__ Juice Manufactured and Packaged for © Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for ❑ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Hoard of Health Total Permit Fee: $75.00 Payment is due with application -- waived 1, 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 obtaiWopies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I cern 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. 25) Social Security Number or Federal ID: 5&1493312 _® 26) Signature of Individual or Corporate Name: /,41 / 1_11Z .I'/ May 2316 06:28p 'own of :kfansfield - Board of Health Application for Milk and Cream Permit Town of Mansfield 6 Park Raw Mansfield, MA 02048 I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: LONGHORN STEAKHOUSE #5296 ADDRESS: 390 WEST STREET TELEPHONE AT LOCATION: (508) 261-8810 FAX NUMBER: (508) 261-8812 OWNER OF BUSINESS: 1rn V-4 -S1 TELEPHONE OF OWNER: q6 oto 0 FEDERAL ID/SS NUMBER: 58-1498312 FEE: $5.00 PERMIT NUMBER: FS -33 SIGNATURE: DATE: May 23 16 06:29p I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. " A k 4 -5,0 J -4/1 5� * Signature of Indi dual or Corporate Name (Mandatory) By: Co orate Officer (Mandatory, if applicable) ��(- Py- 7 Y"3/ ;�- ** 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 fumished 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. May 2316 06:29p p•7 The Commonwealth of Massachusetts Department of Industrial Accidents Office aflnvestigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Rcikc- t '�t' �, �'— m�r'-6imS Address:_ 3?d e�c3 �L S PC City/state/Zip: i4 �a ,S�7 e /� IA 4 oa ora Phone #: Are y an employer? Check the appropriate box: 1,el am a ertlployer with _A -,2i employees (full and/ or parttime),* 2, ❑ 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 requiredl* 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp, insurance req.) Business Type (required): 5, ❑ Retail 6. festaurant/BarBating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 4. Entertainment 10,17 Manufacturing I I. ❑ Health Care 12,❑ Other *Any applicant That checks box # 1 must also fill out the section below showing their workers' eompensatlon policy information. *117the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 91. I am an employer that is providing workers' compensathion Insurance far my employees. Below is the policy Information, Insurance Company Name: cam.' Insurer's Address:_ �f Xeiti i 'Q— u e— . 50 U�6 City/State/Zip: 41►'rln P� /_l 6 /1 '51 A_j Al Policy # or Self -ins. Lic. R —TW 61-1- /( / _ Expiration Date: :_,v Attach a copy of the workers' compensation policy declaration page (showing thq policy number and expiration date), Failure to secure coverage as required under Section 25A of MGL Q. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andlor 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, rtify, under the pains an pen///alfi�ies of perjury that the information provided above is true and correc4 t S ignature: 16-t , Iti�2Q �— Date: Official use only, Do not write in this area, to 6e completed by city or town official City or Town: PermitlUcense # 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 #• c"R�® Ac aaa...---..v CERTIFICATE OF LIABILITY INSURANCE DATE (MM1DD/YYYY) 05119/2016 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 Marsh USA, Inc. 3031 N. Rocky Point Drive West, Suite 700 Tampa, FL 33607 Attn: Tampa.certrequest@marsh.com CONTACT NAME: Al No. Ext): FAX No : EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American Guarantee & Liability Ins Cc 26247 CN101737850-DARDE-GAWU-15- 5296 LONG INSURED Darden Restaurants, Inc. GMRI, Inc. INSURER B : Liberty Mutual Fire Insurance Company 23035 INSURER c: Liberty Mutual Insurance Company 23043 INSURER D: Arch Insurance Company 11150 P. 0. Box 695011 Orlando, FL 32869 GENERAL AGGREGATE $ 5,000,000 PRODUCTS - COMP/OP AGG $ 5,000,000 INSURER E: INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X NON OWNED HIRED AUTOS AUTOS IX rr)VFRAnI7A r 1=PTIFIrATF NIIMRFR• ATL -003966891-01 REVISION NUMBER:2 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 I LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY DIYEYYY MMIDDY� LIMITS B X COMMERCIAL GENERAL LIABILITY OCCUR X LIQUOR LIABILITY of Marsh USA Inc. E82C41004161395 06/01/2015 06/01/2016 EACH OCCURRENCE $ 1,500,000 DAMAGE TCLAIMS-MADE PREMSESOEaoccurrDence $ 1,500,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY 0 PRO D LOC JECT OTHER: GENERAL AGGREGATE $ 5,000,000 PRODUCTS - COMP/OP AGG $ 5,000,000 SIR $ 500,000 B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X NON OWNED HIRED AUTOS AUTOS IX AS2C41004161055 06/01/2015 06/01/2016 COEaMBINED accidentSINGLE LIMIT $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE AUC547165403 06/01/2015 06/01/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED RETENTION $ $ C C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WA5C4D004161105 (AOS) WC5C41004161115 (WI, MN) WCX003376106 (OH, WA) SIR: $500,000 (OH, WA ) 06/01/2015 06/01/2015 06/01/2015 06101/2016 06/0112016: 06/01/2016 X ISTATUTE OERH E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYE $ 2,000,000 E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: LongHorn #5296 - 390 West Street, Mansfield MA 02048 This certificate cancels and supersedes all previously issued certificates. ro0T1r1r'A•rc unt nGo CANCFI I OTIr]N Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee (0 1988-2014 ACORD GUKPL)KA I IUty. AU rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD May 2516 09:36a d' ri � N gem0 Z Iwo � Q z W F cd a a u pN LL LL tAm F/ E F Q � � LU W LU U ;o LLM W 0 N p.3 O 0 E °- LL W v. p y' L v °- V o3 v � LL � � a v- � u � o � a w a .ro T1 C A � v O r E W U w N a� N .A O N °' tv U) W 3 U O a N p.3 O May 2516 09:36a p,2 kt x r Q NNNXW9- LL m U Iii Iii N W?y w i'- O a(n � U: c N 0 W` w 0 rL ='Q ;� F CL U mi w Z Iw- o LL [w-HUr 4� Z A w �-- M O O UI N w L., u n 1 C O� pt7 Q In m z a p,2 12 1! Na c Q NNNXW9- LL m U Iii Iii N W?y a U UN O a� N <RZIL u � U mi w Iw- � [w-HUr % > c pow 1 C O� pt7 Q U z CL Ck p,2 Na c LL m O O a a N :n 0 w ti o � tL m `L % > c 1 C O� pt7 Q o CL p,2 May 2516 09:36a p.4 6 May 25180 85 ........... f o c k m a , 2 f |. 7 2 7a7 � \ $. !RN � \ % LJJ (D 2)( .■ qCIA :2 m p V- |, 0 \ 9 .§ § \f �\ ° � ƒ k Im �1 )+ )\) * c k m f 2 & 7a7 � \ % LJJ (D 2)( ■ p.! RARE HOSPITALITY INTERNATIONAL, INC. OFFICERS AND DIRECTORS Address all official correspondence to any of the Corporate Officers below to: P.O. Box 695016, Orlando, FL 32869-5016 Name Title Residence William R. White, III President, 4035 Glider Rose Treasurer and Place Director Winter Park, FL 32792 Joseph G. Kem Vice President 112 Kennison Drive and Secretary Odando, FL 32801 Colleen M. Hunter Assistant Secret 11762 Aurelio Lane Orlando. FL 32827 (RARE Hosoitalitv International. Inc. is a w holiv owned subsidiary of GMRI. Inc.. which is wholly owned by Darden Restaurants, Inc., a publicly traded company) ® ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/27/2016 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 Marsh USA, Inc. 3031 N. Rocky Point Drive West, Suite 700 Tampa, FL 33607 Attn: Tampa.certrequest@marsh.com CONTACT NAME: PHONE FAX A/c o Ext): AIC No): ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: ACE Property & Casualty Insurance Company 20699 CN101737850-DARDE-GAWU-16- 5296 LONG INSURED Darden Restaurants Inc. GMRI, Inc. P.O. Box 695011 INSURER B ; Greenwich Insurance Company 22322 INSURER C : XL Insurance America, Inc. 24554 INSURER D: XL Specialty Insurance Company 37885 INSURER E Orlando, FL 32869-5011 INSURER F nnamoAnmo CGRTICIr:ATF KI MBER• ATL -003890622-05 REVISION NUMBER:O 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. /NSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY of Marsh USA Inc. RGE3001137 06/0112016 06/01/2017 EACH OCCURRENCE $ 1,000,000 PREMISES (Ea occurrence) $ 300,000 CLAIMS -MADE 111 OCCUR MED EXP (Any one person) $ X LIQUOR LIABILITY PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 PRODUCTS - COMP/OP AGG $ 5,000,000 PRO- X POLICY ❑ JECT LOC SIR $ 1,000,000 OTHER: B AUTOMOBILE LIABILITY RAD94377960 06/01/2016 06/01/2017 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident BODILY INJURY (Per person) $ XANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOSAUTOS X X NON -OWNED HIRED AUTOS AUTOS (PerOaccidenl DAMAGE $ $ A X UMBRELLA LIABX OCCUR X00 G28123383 001 06101/2016 06/01/2017 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION$25,000 $ C WORKERS COMPENSATION RWD3001138 (AOS) 06/01/2016 06/01/2017'" X STATUTE �RH E.L. EACH ACCIDENT $ 2,000,000 D D AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORlPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA RWR3001139 (WI, AK) RWE9435480 (OH, WA ) SIR: $1,000,000 (OH, WA) 06/0112016 06/01/2016 05/0112017 0610112017 E.L. DISEASE - EA EMPLOYE $ 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) #5296 LongHorn, 390 West Street, Mansfield, MA 02048. This certificate cancels and supersedes all previously issued certificates. r — —M CANCELLATION vctc r rrwrr c nvw"" Mansfield U 18Stf-2U94 ACORD CUKrUKA I IUIV. All ngnts febel VOU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Board of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Six Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 2048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee .J U 18Stf-2U94 ACORD CUKrUKA I IUIV. All ngnts febel VOU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 0004669 SP 0297-COt-P04671-1 Mansfield Board of Health Six Park Row Mansfield, MA 2048