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HomeMy WebLinkAboutTUP2022-0334P: (949) 2 87-8191 E : info @ cov idc l ini c .org January 25, 2022 We are requesting a permit to operate a temporary Covid testing site. 1. The request is for the surface parking lot located at: 3000 Grapevine Mills Parkway, Grapevine, TX 76051. 2. It is proposed to use this lot as a temporary testing site serving the local community. Patients purchase their test(s) and make their appointments on covidclinic.org. Upon arrival they are checked in and get tested at one of our mobile testing units by a healthcare professional that administers the test. Patients depart after their test and are sent results digitally. 3. Our drive through sites consist of (1) RV, (1) 20kw whisper watt generator, 1 portable toilet for staff only, and 1 dumpster 4. Patients remain in their vehicles for the duration of the testing for either site setup 5. Appointments are preferred, but drive-ups are welcome if we have availability. 6. The site plan details the traffic pattern and testing location within the site. 7. The testing site operates 7 days a week from 8:00AM-8:00pm and will run until 5/1/22. 8. Tests offered 1. Rapid Antigen 2. Rapid Antipbody 3. No Cost PCR 4. Rapid PCR 9. There will be between 4-5 on-site staff for either site Sincerely, Michelle Stansfield Director of Development Covid Clinic (760) 238-1249 |mstansfield@covidclinic.org 1 2 GRAPEVINE GRAPEVINE MILLS 3000 Grapevine Mills Pkwy Grapevine, TX 76051 REGISTRATION/TESTING (RV) DIRECTIONAL SIGNGE PATIENT TESTING TRAFFIC FLOW/QUEUE PATIENT EXIT TRAFFIC FLOW DUMPSTER RESTROOM GENERATOR WiFi HUB FIRE EXTINGUISHER Grapevine Mills SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 46204INIndianapolis 225 West Washington Street Simon Management Associates II, LLC The following is listed as additional insured on the policy Simon Management Associates II, LLC 3,000,000Aggregate 1,000,000Each Occurrence 08/04/202208/04/2021LHM843914X Professional Liability D \ 5,000,000 5,000,000 12/15/202212/15/2021PLM-CB-SVUCFS8KVX 8 88 C 1,000,000 12/10/202212/10/202172APB005114XX 8 8 8 8 B 2,000,000Cyber (Ea Occurrence) 5,000,000 5,000,000 2,000,000 10,000 50,000 2,000,000 11/14/202211/14/20210100132898-1XX 8 Cyber Liability8 8 8 A 33138Landmark American Insurance Company 15792Underwriters at Lloyd's, London 68102National Fire & Marine Insurance Company 38920Kinsale Insurance Company 92648CAHUNTINGTON BEACH 18800 DELAWARE ST Covid Clinic casey.paulson@insideinsurance.net (866) 672-9668 EZ Insurance 84003UTAmerican Fork 915 South 500 East #210 Inside Insurance 01/25/2022 DocuSign Envelope ID: 8C189098-2FEF-45DD-8CB2-C81E981505CF POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to li- ability arising out of your ongoing operations per- formed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occur ring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the addi- tional insured(s) at the site of the cov- ered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in perfor ming operations for a principal as a part of the same project. CG 20 10 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 o DocuSign Envelope ID: 8C189098-2FEF-45DD-8CB2-C81E981505CF Simon Management Associates II, LLC 0100132898-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Indianapolis, IN 46204 225 West Washington Street Simon Management Associates II, LLC The following is listed as additional insured on the policy Simon Management Associates II, LLC 6,000,000Aggregate 3,000,000Occurrence 08/04/202208/04/2021LHM843914X Professional Liability Abuse and MolestationC 5,000,000 5,000,000 11/14/202111/14/20200100132898-0X 100008 88 A 2,000,000 12/11/202112/11/202072APB004370Xx 8 8 8 B 4,000,000 4,000,000 2,000,000 10,000 500,000 2,000,000 11/14/202111/14/20200100132898-0Xx 8 Cyber Liability 8 Employers Liability8 8 8 A 33138Landmark American Insurance Company 20079National Fire & Marine Insurance Company 38920Kinsale Insurance Company 92648CAHUNTINGTON BEACH 18800 DELAWARE ST Covid Clinic casey.paulson@insideinsurance.net (866) 672-9668 EZ Insurance 84003UTAmerican Fork 915 South 500 East #110 Inside Insurance 10/07/2021 Extension of Form 25 for Covid Clinic Below is the list of additional insured that have been added to policy number 0100132898 -1 Ontario Mills Vacaville Premium Outlets Del Amo Fashion Center Brea Mall Great Mall Stoneridge Shopping Center Folsom Premium Outlets Camarillo Premium Outlets Petaluma Village Prem Outlets Las Americas Premium Outlets Napa Premium Outlets Denver Premium Outlets Colorado Mills Coral Square Tyrone Square Ellenton Premium Outlets Cordova Mall Treasure Coast Square Tampa Premium Outlets Orlando Vineland Prem Outlets Florida Mall Coconut Point St. Johns Town Center 1 The Avenues Miami International Mall Phipps Plaza Sugarloaf Mills White Oaks Mall Chicago Premium Outlets Gurnee Mills Woodfield Mall Greenwood Park Mall Fashion Mall at Keystone The Mills at Jersey Gardens Newport Plaza Meadowood Mall Firewheel Town Center DocuSign Envelope ID: C20D701C-C731-40EF-A85A-D09218094706 Grand Prairie Premium Outlets Houston Premium Outlets North East Mall DocuSign Envelope ID: 8C189098-2FEF-45DD-8CB2-C81E981505CF South Las Vegeas Premium Outlets McCain Mall San Francisco Premium Outlets Tacoma Mall Orland Square Tippecanoe Mall College Mall Arundel Mills Beverly Center Briarwood Grapevine Mills Santa Rosa Plaza Gloucester Premium Outlets Livingston Mall North Las Vegas Premium Outlet Lehigh Valley Mall Philadelphia Mills Oxford Valley Mall Fashion Ctr at Pentagon City Potomac Mills Clinton Premium Outlets Crystal Mall City of Grapevine Agent Signature: Date: Title: DocuSign Envelope ID: 8C189098-2FEF-45DD-8CB2-C81E981505CF 1/25/2022 Agent at Inside Insurance LLC City of Grapevine P.O. Box 95104 Grapevine, TX 76099 (817) 410-3166 Voice (817) 410-3012 Fax TEMPORARY USE PERMIT Issue Date: January 27, 2022 PROJECT DESCRIPTION: Covid Testing Site - drive thru- 3000 Grapevine Mills Pkwy 1/28/22- 4/28/22 PROJECT # TUP-22-0334 (817) 410-3010 Inspections www.mygov.us Permits LOCATION TENANT LEGAL 3000 Grapevine Mills Pkwy. Suite # Temp Grapevine, TX 76051 Grapevine Mills Mall Temporary 1grapevine Mills Addition Blk 1 Lot 1r3 CONTRACTOR T/U Applicant 18800 Delaware Street #800 Huntington Beach, CA 92648-6019 (949) 691-5045 Phone kkruse@covidclinic.org OWNER Grapevine Mills Mall LP 225 W Washington St Indianapolis, IN 46204-6120 ph. (317) 636-1600 INFORMATION Approved NOTICES Any and all tents, canopies, signs, banners, balloons, fences require separate permits; please contact building inspections for information 817-410-3165. Fire Lanes - No tents/merchandise are allowed to cross fire lanes. Any fencing shall be such that it can be moved by one person in the event of an emergency.All City of Grapevine codes and ordinances shall apply. MYGOV.US City of Grapevine | TEMPORARY USE PERMIT | TUP-22-0334 | Printed 01/27/22 at 5:28 p.m. Page 1 of 1