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HomeMy WebLinkAboutVillage @ Willow Crossing 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:. BENCHMARK SENIOR LIVING Whose place of business is: VILLAGE AT WILLOW CROSSINGS 25 COBB STREET PERSON(S) IN CHARGE ANNE DEMINICO, EXECUTIVE DIRECTOR Permit Expires: December 31, 2016 License Number: FS -69 Food Fee: $67.50 Milk & Cream W BOARD OF HEALTH MichaeCvlcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: BENCHMARK SENIOR LIVING having a place of business at: VILLAGE AT WILLOW CROSSINGS 25 COBB STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 -69 Scott Leite, Health 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 -69 - - - FOOD ESTABLISHMENT PERMIT APPLICATION -Ap-puc-ation musrue--suYm-utfedaf >easf 3u days -before the plannedopening use) 1) Establishment Name VILLAGE AT WILLOW CROSSINGS 2) Establishment Address 25 COBE STREET 3) Establishment Mailing Address (if different) 25 COBB STREET MANSFIELD, MA 02048 t s 4) Establishment Telephone No (508) 261-1333 x203 I 5) Applicant Name & Title: ANNE DEMINICO, EXECUTIVE DIRECTOR -------- ----- 6) Applicant Address 25 COBB STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (339) 222-8479 24 Hour Emergency No.: (339) 222-8479 8) Owners Name & Title BENCHMARK SENIOR LIVING 9) Owner Address (If different from applicant) 40 WILLIAMS STREET, SUITE 350, WELLESLEY, MA 02 481 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation Name Title Address j ❑ An Individual - - - -- O A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: ANNE DEMINICO, EXECUTIVE DIRECTOR Address: 25 COBB STREET, MANSFIELD MA 02048 Telephone No- I(508) 261-1333 X203 24 Hour Emergency No: (sss) 222-8479 FAX (508) 3374663 (781) 489-721 -_ - - - -- E-mail: ADEMINICOCaDBENCHMARKQUALITY.COM Alt E -Mail � 13) District Or Regional Supervisor (if applicable) Name & Title: I j Address: Telephone No: 24 Hour Emergency No: FAX: 1 E-mail: i Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) L 16) No. of Food Employees: 130 17) DAYS/HOURS: MON-SUN 6 AM -8 PM 18) Name of Person In Charge Certified in Food Protection Management: 77"1 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 J certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: W Permanent Location ❑ Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: 0 Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations n PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Preparation of PHFs For Hot And -- Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly _ __- -_ _---- Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended -- - to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill _ - _ - - - - ❑ Use of Process Requiring A Variance ❑ Customer Self Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Origin Animal Ori i A Retail Sale nmg --- - -- ❑ Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date- - - — --1 or Reconditioned Food �To be completed by the Board of Health Total Permit Fee: $62.50 I 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 copse f 1, 05•C�MQR�5 0 0 and �federal Food Code. 24) Signature of Applicant: (', r �"' �C� 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. 25) Social Security Number or Federal ID: 20-86698- `� S 3®�N� 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: VILLAGE AT WILLOW CROSSINGS ADDRESS: 25 COBB STREET TELEPHONE AT LOCATION: (508) 261-1333 x203 FAX NUMBER: OWNER OF BUSINESS: TELEPHONE OF OWNER: (508) 337-4663 BENCHMARK SENIOR LIVING FEDERAL ID/SS NUMBER: z4- 38 a1_ y4 !�2` Lj0 FEE: $5.00 PERMIT NUMBER: FS -69 A i SIGNATURE: DATE: q11 S-/6 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** 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 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 d / , / Please Print Legibly Business/Organization Name: 6-X �fCll;�7 (���� a�6�a �eS V t l as e 4� 601116a Oow;q`� S I Address: A5 }Nbbb W e2� n City/State/Zip: I `(O/4,-'latl'"(f� 020'(� Phone #: Are you an employer? Check the appropriate box: I . [ I am a employer with 1� employees (full and/ or part-time).* 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 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. real estate, auto, etc.) 8, ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.0 Health Care 12.[.Other % �l �I✓� /7t f 1 !/l *Any applicant that checks box N I must also till out the section netow snowing melr worxers cumpensmiuu PUIJ >y uu 111 uvn, **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 providin�j_w��or`kersr' compensation insurance for my employees. Below is the policy information. Insurance Company Name: � Tl'GJ/j Insurer's Address: 3 6 Gz �_ I City/State/Zip: �C Lti` 1 1qAf S �y Policy # or Self -ins. Lia # L1i Expiration-Date:-- Attach xpiration 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 DTA for insurance coverage verification. I do hereby cerci y, under the pains andpenalties of perjury that the information provided above is true and correct. ^•-�----. ��,9•-alp Phone #: SSR', _ .k/ /333 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, guviu is Phone BENCASS-02 BURRAU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D16 DNYYY) 416120 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS f- ^-ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES :LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED r<EPRESENTATIVE 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 Willis of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE (877 945-7378 FAX, CNo : 888 467-2378 A/c Ext): )( ) IL ADDARIESS: certificates@willis.com Nashville, TN 37230-5191 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Lloyd's B7874 INSURED INSURER B: INSURER C : Benchmark Senior Living LLC EACH OCCURRENCE $ 1,000,000 201 Jones Road Suite 300 West INSURER D: INSURER E : Waltham, MA 02451 INSURER F: 04/01/2016 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. -IN -SR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X CLAIMS -MADE 1-1 OCCUR X SB-LTCA-01462-16 04/01/2016 04/01/2017 pREMISESOEaoc," ante $ 100,000 MED EXP (Any one person) $ 10,000 X Retention: $100,000 X Professional: Incl. PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY ❑PROJEcr N LOC Policygg' A $ 15,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 A X EXCESS LIAB X CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A E.L. DISEASE - POLICY LIMIT 1 $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Included as an Additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Coverage includes Liquor Liability per the attached Endt #19 - ESS009, 052011 ed. CFRTIFICATF HOI nFR 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE B -X Mansfield LLC d/b/a The Village at Willow Crossings 25 Cobb Street CJI*�CU Mansfield MA 02048 �Y ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BENCASS-02 WARRENPA 7 ,A ® CERTIFICATE OF LeIA91LITY INSURANCE DATE (MMIDDIYYYY) 3/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF' INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 2TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LLOW. 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 Willis of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 CONTACT Willis Towers Watson Certificate Center -NAME: PHONE 877 945-7378 FAX Ne : 888 467-2378 AIA Ext : ( ) ( ) IL E-MAIL Certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Arch Insurance Company 11150 INSURED Benchmark Senior Living LLC 201 Jones Road Suite 300 West Waltham, MA 02451 INSURER B: Lloyd's B7874 INSURERC: INSURER D: INSURER E: INSURER F: rnvGaer_Gc C-ERTIF!C- TF N IMRFR' REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE INSD IVSD WVD WVD POLICY NUMBER MMIDDIIYYYY MM DDIY'M LIMITS Mansfield MA 2048TH COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 11 OCCUR DAMAGE TO PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ POLICY PRO LOC JECT OTHER: AUTOMOBILE LIABILITY Ea acc dentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO X 41CAB4987703 04/01/2016 04/01/2017 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOSAUTOS PROPERTY DAMAGE $ Per accident $ X Coll Ded $1,000 x Comp Ded $1,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 B X EXCESSLIAB X CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE [-N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA 41WC14987903 04/01/2016 04/01/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Business Auto 41CAB4987803 04/01/2016 04/01/2017 Any Auto/CSL 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is included as an Additional Named Insured. 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE B -X Mansfield LLC d/b/a The Village at Willow Crossings 25 Cobb Street C�� Mansfield MA 2048TH �' ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BENCASS-02 WARRENPA CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 3/30/2016 T41S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES oi�LOW. 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 Willis of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONT ACT ME, Willis Towers Watson Certificate Center -NAME, PHONE (877) 945-7378 ac No): (888) 467-2378 A/c E-MAILExt Dess: Certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC It Nashville, TN 37230-5191 INSURER A: Lloyd's 87874 INSURED INSURER B: INSURER C: Benchmark Senior Living LLC X 201 Jones Road Suite 300 West INSURER D: INSURER E: Waltham, MA 02451 INSURER F: MED EXP (Any one person) $ 10,000 rnX/PPAnFc rIPRTIFIrATF NIIMRFR: 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 SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YM LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 OCCUR X CLAIMS -MADE 1:1 OCCUR X SB-LTCA-01462-16 04/01/2016 04/01/2017 ETORENTED 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 X Retention: $100,000 X Professional: Incl. PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS -COMP/OP AGG $ 1,000,000 POLICY F PRO FX] LOC JECT Policy Agg. $ 15,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOSAUTOS F PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 A X EXCESS LIAB X CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE� PER OTH- STATLITE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Included as an Additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Coverage includes Liquor Liability per the attached Endt #19 - ESS009, 052011 ed. PCOINCIPA-rc unl n9:0 rANCFI I_ATION (0 1988-2014 AGUKL) GUKF L)KA I wN. All ngnts reservea. 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE B -X Mansfield LLC d/b/a The Village at Willow Crossings 25 Cobb Street Mansfield MA 2048 1 C' (0 1988-2014 AGUKL) GUKF L)KA I wN. All ngnts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD co (71 C% It 9 IS I qj � � I �� � � �. E 0 � ! § � ¥ \ •g � � \ / / ƒ}/\ � \ ® � N N o � � I \ j) ( 0 : : { /•§ 5 � w 6 � � � W 0 � O _ g � � Q Q � �. E ! § \ •g � � \ ƒ}/\ � \ ® � I \ j) ( { /•§ 5 � � �. \ •g � � \ ƒ}/\ � ® ® � { /•§ 5 � w 6 � � �. BENCASS-02 WARRENPA ,�c'oez CERTIFICATE OF LIABILITY INSURANCE ATE (MM/DD/YYYY) P3/30/2016 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 Willis of Illinois, Inc. c/o 26 Century BlvdWC,No P.O. Box 305191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE 877 945-7378 AX No : 888 467-2378 Extl: ( ) ( ) E-MAIL Certificates@willis.com INSURERS) AFFORDING COVERAGE NAIC # Nashville, TN 37230-5191 INSURERA:Arch Insurance Company 11150 INSURED INSURER B: Lloyd's 87874 INSURER C: Benchmark Senior Living LLC 201 Jones Road Suite 300 West INSURER D: INSURER E: Waltham, MA 02451 INSURER F: MED EXP (Any one person) $ t1n11C0Ar1_C0 r`CATIRIr'ATF IVIIMRFR• REVISION NUMBEK: 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY P OLICY EXP MM/DD/YYYY LIMITS 6 Park Row COMMERCIAL GENERAL LIABILITY Mansfield MA 2048 O' EACH OCCURRENCE $ CLAIMS -MADE D OCCUR REN PREMISES (-DAMAGE ToEa occu D nce $ MED EXP (Any one person) $ PERSONAL& ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY FJ PRO- JECT ❑ LOC OTHER: AUTOMOBILE LIABILITY =BINLIMIT $ 1,000 000 BODILY INJURY (Per person) $ A X ANYAUTO X 41CAB4987703 04/01/2016 04/01/2017 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ X Coll Ded $1,000 X Comp Ded $1,000 UMBRELLA LIAB EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 B X EXCESS LIAB HOCCUR CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 41WC14987903 04/01/2016 04/01/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1 $ 1'e -mon If yes, describe under DES 'RIF' HON OF OPERATIONS below A Business Auto 41CAB4987803 04/01/2016 04/01/2017 Any Auto/CSL 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Included as an additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance CAIVCFI I ATIrIAI (U 1988-ZU14 AGUKU GUKYUKA I IUN. An ngnis reserveu. 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of Mansfield -Board of Health 6 Park Row 1 Mansfield MA 2048 O' (U 1988-ZU14 AGUKU GUKYUKA I IUN. An ngnis reserveu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD BENCASS-02 BURRAU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/6/2016 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 Willis of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 AME: r NWillis Towers Watson Certificate Center NAME: (PAH/C.ONE (877) 945-7378 FA/C No): (888) 467-2378 Ext IL E-MAIL certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # Nashville, TN 37230-5191 INSURERA:Arch Insurance Company 11150 INSURED INSURER B: Lloyd's B7874 INSURERC: Benchmark Senior Living LLC 201 Jones Road Suite 300 West INSURER D: INSURER E: Waltham, MA 02451 INSURER F: MED EXP (Any one person) $ 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 SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDrrM LIMITS ` CJ�KVJ-� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DA-MAGETO RENTED PMSES (Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS- COMP/OP AGG $ POLICY PRO- LOC JECT POTHER AUTOMOBILE LIABILITY COMBINED cciISINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO X 41CAB4987703 04/01/2016 04/01/2017 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNED HIRED AUTOS PROPERTY DAMAGE $ Per accident $ X Coll Ded $1,000 X Comp Ded $1,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 B X EXCESS LIAB X CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) N / A 41WC14987903 04/01/2016 04/01/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 1 000 000 E.L. DISEASE - POLICY LIMIT $ s If yes, describe under DESCRIPTION OF OPERATIONS below A Business Auto 41CAB4987803 04/01/2016 04/01/2017 Any Auto/CSL 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Included as an additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance !`Cl]TIMf-ATG unl DER 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of Mansfield -Board of Health 6 Park Row ` CJ�KVJ-� Mansfield MA 02048 ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BENCASS-02 BURRAU ,�CORI�r" CERTIFICATE OF LIABILITY INSURANCE �' DATE (MM/DD/YYYY) 4/6/2016 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 Willis of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT Willis Towers Watson Certificate Center -NAME: PHONE 877 945-7378 ac No : 888 467-2378 Alc Ext): ( ) ) IL E-MAIL certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # Nashville, TN 37230-5191 INSURER A: Lloyd's 87874 04/01/2017 INSURED INSURER B: INSURER C : Benchmark Senior Living LLC PERSONAL BADV INJURY $ 1,000,000 201 Jones Road Suite 300 West INSURER D: INSURER E: Waltham, MA 02451 INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS nnvooAr±oe CCRTIF'ICATF til IMRFR• KEVISILLN NUftft!t'I'e: 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. INSRADDL LTR TYPE OF INSURANCE INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X1-1OCCUR CLAIMS -MADE X Retention: $100,000 C�� Mansfield MA 02048' SB-LTCA-01462-16 04/01/2016 04/01/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED PREMISES (Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 X Professional: Incl. PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 Policy Agg. $ 15,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BIN Ee a.,d.nlSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yee, deecr}be under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Host Liquor Liability �rr^A rc u^r noo r'AhlRFI I ATICIN U 1!JtW-ZU94 AL;UKU L UKYUKA I Ivry. Ali rlgnis reserved. 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE The Town of Mansfield 6 Park Row C�� Mansfield MA 02048' U 1!JtW-ZU94 AL;UKU L UKYUKA I Ivry. Ali rlgnis reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantwho has not produced acceptable evidence of compliance with the insurance coverage required," Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sufe that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog license or permit to bum leaves etc,) said person is NOT required to complete this affidavit. The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05