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HomeMy WebLinkAboutRed Roof Inn 12/31/2013Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health to Operate a Swimming Pool E�_ PERMIT NUMBER: 10 Pool/SPA Certification Date: June 09, 2010 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: June 09, 2015 Person Certified: KELLY GIL Pool/SPA Certification Date: Pool/Spa Certification Expires: Person Certified: In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: FMW RRI NC LLC #10274 for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: F./I Semi -Public 60 FORBES BLVD. AUTOMATIC CHLORINE 55 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health .Agent ❑ Special Purpose Pool None Date Issued Town of Mansfield Fowl, of Mansjield - Board of Hearth 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 10 NAME OF OWNER: FMW RR) NC LLC #10274 ADDRESS: THE RED ROOF BUILDING 605 S. FRONT ST CITY: COLUMBUS STATE: OH ZIP: 43215 TELEPHONE: (506) 339.2323 FAX: VMAIL: i4cy FED ID/SS NO: 45.2910865 FEE PER POOL: $75.00 Certification Expires Evert/ 5 Years. Permit EXDires December 31st Year, PERSON CERTIFIED: KELLY GIL PoollSPA Certification Date: 6/9/2010 Pool/SPA Certification Expires: 6/9/2015 PERSON CERTIFIED: PoollSPA Certification ©ate: P001/SPA Certification Hxpiros: certification remarks(if necessary): REMARKS: 'NO LIFEGUARD ON DUTY,, sign is required. PER DAILY TESTING POOL MAINTAINED [] Public POOL OPERATION: $emi-Public Special Purpose Pool POOL LOCATION_ 60 FOR82S BLVD, TYPEIPOOL: CONCRETE IN -GROUND LENGTH: 40' WIDTH: 20' VOLUME: 22,000 MINIMAX DEPTH: T to 8' SWIM AREA: $00 sq. ft. DIVE AREA: NONE WATER SOURCE: TOWN WIW DISPOSAL: TOWN SEWER TYPE OF FINISH: GUNITE SCUM GUTTER: NONE DECK TYPE: NONE SKMMR WEIR LENGTH: TWO BASKETS TREATMENT SYSTEM; DIATOMAOEOUS DISINFECT METHOD: AUTOMATIC CHLORINE CHEMICAL TREATMI=NT: MANUALLY AS REQUIRED NUMBER OF BATHERS: 55 SIGNATURE: _ DATE: Please make appropriats changes. Sign, date and enclose check payable to -"own of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 42048. 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) C ** S o—c i Wd 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 Indostrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Red Roof Inn #10274 Address: 60 Forbes Blvd City/State/Zip: Mansfield, MA 02048 Phone #:508.339.2323 Are you an employer? Check the appropriate box: 1. R I am a employer with 20 employees (fill 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.❑ Manufacturing 11. F-1 Health Care 1210 Other Hotel *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy intormallon. **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 isproviding lvorliers' compensation insurance for my employees. Beloty is the policy information. Insurance Company Name: Liberty Mutual Fire Ins Co Insurer's Address: 175 Berkeley Street, MS 06D City/State/Zip: Boston, MA 02116 Policy # or Self -ins. Lic. # WC2-641-437760-012 Expiration Date: 09/06/2013 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. Ido hereby certify, under the pains andpenalties ofpeijury that the information provided above is true and correct. 05.13.2013 (614) 225-5172 Official use only. Do not write in this area, to be completed by city or tolvn official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: «�vw.mass.gov/dia / 1 ® AC"R® CERTIFICATE OF LIA81LITY INSURANCE DATE(MM/DD/YYYY) 12/5/2012 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 teras 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 Oregon, Inc. g CALIC#0464609 (503) 224-4155 222 SW Columbia St., Suite 600 Portland OR 97201 CONT NAMEACT Amy Blake PHONE AIC No Ext :503-224-4155 arc No :503-274-2155 E-MAIL ADDREss:Am .Blake willis.com INSURERS AFFORDING COVERAGE NAIC # INSURER A:Liberty Mutual 23043 INSURED 4REDROOF INSURER B : INSURERC: Red Roof Inns, Inc. INSURER D: RRI West Management, LLC 605 South Front Street Columbus OH 43215 INSURER E : INSURERF: /+COKCVIJIUIV IVUIYIOCR. 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 INSR I SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ CLAIMS -MADE El OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S $ POLICY PRO LOC Cj AUTOMOBILE LIABILITY 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 $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $$ A WORKERS COMPENSATION WC2641437760012 /6/2012 /6/2013 X TORY LI ITS OT _ E.L. EACH ACCIDENT 51,000,000 AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE $1,000,000 OFFICER/MEMBER EXCLUDED? [—]N (Mandatory in NH) NIA E.L. DISEASE -POLICY LIMIT $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: The following Red Roof Inn locations 855 State Route 46, Parsippany, NJ 07054 603 Fellowship Road, Mt. Laurel, NJ 08054 3203 Brunswick Pike, Lawrenceville, NJ 08648 15 Meadowlands Parkway, Secaucus, NJ 07094 11 Centre Plaza, Tinton Falls, NJ 07724 GERTIFIL:A 1 t HULULK VMIY­L I.— The Commonwealth of MA, Dept of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 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 t1l e_. lJ 17700 -LV IV F1wrw vvly vlv-I I Ivl.. nu I.U.— ............... ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 11/10/2010 15:28 FAX 1 508 337 6733 274 MANSFIELD 0004/004 m