HomeMy WebLinkAboutApplication and WC � ► TOWN OF YARMOUTH BOARD OF HEALTH �� �� � �'�'�'������
� � � APPLICATION FOR LICENSE/PERMIT - 2016
'_ ����8�� .,, , _ 9 . _ .�
�'°°� * Please comrlete form and attach all necessary d �, e ,�s y ecember�l S 201 S.
' Failure to do so will result in the return of y ur application packet" ���,�-r-� ����j ;
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ESTABLISHMENT NAME: US C 3.5 TAX ID: ��
LOCATION ADDRESS: r�.t���t-ti� TEL.#: � -
MAILING ADDRESS:C)11Q �U`� ��;✓P luC.�llQ) ��t�S�C�f!.Q.t (Z� c�2�'4 �
E-MAIL ADDRESS: �pnna L he��a l�e r (c� ��'S N Pal� � C�0/�-1
OWNER NAME: '�'�� `PI'x�;r YY��°�(��-j'� C
CORPORATION NAME (IF APPLICABLE): CV� Ph�r�rY`�e� ,�l
MANAGER'S NAME: Rpb��--� PQeX�p 2- TEL.#: ,`�fi��(ny-75� 9`
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2•
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
years' records. You must provide new copies and maintain a file at your place of business.
1. 2. '
3. 4•
P()�I��BQTE�TIC)NMADTAGEKS - CERTIEI�ATIQNS: -___ I
_ -
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application: The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment. ,
L 2.
PERSON 1N CHARGE: '
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. '
1. 2. �
ALLERGEN CERTIFICATIONS: '
All food service establishments are required to have at least one full-time employee who has Allergen certification, '
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach I
copies of certification to this application. The Health Department will not use past years' records. You must '
provide new copies and maintain a file at your establishment. '
1. 2.
HEIMLICH CERTIFICATIONS: '
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' reeords.
You must provide new copies and maintain a file at your place of business. ;
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
- —- -- _—. -----__ ---—�
L
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
L'�IN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-]00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 '
�<25,000 sq.ft. $150 � _FROZEN DESSERT $40 _TOBACCO $I 10
NAME CHANGE: $15 AMOUNT DUE _ $ !�d•Od ;
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION l �
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I
Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal [
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's j
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ,
�
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CERT. OF 1NSURANCE ATTACHED �
O ;
WORKER'S COMP. AFFIDAV T SIGNED AND ATTACHED ;
r
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Town of Yarmouth taxes and liens must be paid p or to renewal or issuance of your permits. PLEASE CHECK I
APPROPRIATELY IF PAID: i
YES NO
;
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be '
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. '
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence I
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter. �
�
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing.
i
FOOD SERVICE i
;
SEASONAL FOOD SERVICE OPENING: I
All food service establishments must be inspected by the Health Department prior to opening. Please contact the ;
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY: '
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the I
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be i
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, !,
Downloadable Forms. �,
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results I
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met. '
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. �
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
. ___,
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS Y QUIRE A SITE PLAN.
DATE: �Z-'�'�� SIGNATURE: G�I�`—
PRINT NAME & TITLE:
ier
Rev. 10/Oi/15 Licensing Coordinator
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� � The Commonwea/xh of 1Vlassachusetts
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� 13epartme�st r�f Industri.rxl Accidents
i �ce vj�nvestigatr�ns
6UD Washingtv��'tr�et
8os#on,M�1 �2ZIl
www�nass.g�rv/daa
Work�rs' Compensatirt�Insnrance Affid.avitt: General Businesses
�Iicant It�formation Please Frint LeQibiv
Business/Organization Name: CVS/Pharmacy # -7�Jc-
Addre�s:Q 7(� �v��+e � R'
Ma
City/StatelZip:�OL.�I--����,✓id� 0 1 a�� Phone#:�C�� S�� 2$'��
Are you an empioyet?Check#he�ppropriate box: Business Typc{rec�t�ired}:
1.� T am a�mployer with. ��- employees{full and! 5• �Retail
or part-time}.* 6. ❑Restauran#IFtar/Eating Esta�listunent
2.Q I am a sole proprietor ar partr�ership aud have no 7. ������or Sales{incl.reat estate,auto,etc.)
exnptoyees working for me in any eapacity.
[No workers' comp.insurance reguired� 8. ❑Non-profrt
3.Q 'ixire are a eorporafion and its officers have exercised 9. ❑Entertainmettt
�eir right of ex�mpii�n per c. 152,§1(4),and we have 10,�Manufaa,Ytut�ing
na emplay�es.[!�o workers'comp.insurazfce required]*
4.❑ �e are a non-profit organizarion,staffe�by vofunteers, Y 1:[]Kealth Care
with no employees.jNo workers'comp.insurance req-� 12.[]Other
"��Y gPPlican€that che.cks box#2 mvst sisa fiIl aut the s�t'scra botow showing their we�rtcers'cwmpensadon poticy infbrmatiou
*'�If the corporate offieers have exempteci themse3ves,but the corpoestiott lsas other ernplayees,a woskers'ccmtpensataon poticy is required and such an
atgani2atioa shoulsi chectc bax#t.
I am ar,ernrployer that as providirng�vor&ers y compensafion insurarnre for my enrpPnyecs. Betow is the policy information. !
Insurance Gompany Name: New Hamshire Insurance Company
175 Water Street
Insurer's Address. �
New York, NY 10 03 8 '
CitylStatel�ip:
�'alicy#or Self-irss.Lic.# WC 9 8 8 3 9 3 0
E�,iratit,n pate: 01/01/2 016
Attach a eepy of the w�rrkers'eompens�tien pali�cy decIaratket�page(s�awing the poliey a�mber aad eap�iira4.an date}.
Failure to secure Goverage.as r�quired under Section 2�A of IvIGL c_ 152 can Iead ro the iinposiiion of eriminal penalties of a
fine up to$I,�Qtt.00 andJar one-year impri�ntrent,as�re]?as civil pena.lfees in the ft>rm of a STOP WORK(3RDEI�and a fine
of up to�25f�.i?Q a day.xg�inst the wiolator. Be advised that a copy of this statement may be forwarded to ti�e(3ffice of
Investigatians of the DIA for insuxance eoverage vErificstion.
I dn hereb c�ra ,u�rlei-tlte p;arins aradpexa&ies a,f'perjury thut tJre tnformativn pravided above is trrae and correct
Si _ C:L�-� I3ate: � �1 c
Phane#: 40.I-770- C�d��'
lO,�ciat r�se anlj; I�o not w�ite in tlus area,trr be cvrrrpC�terl by�it3=or tv�vn o�ciaL
Cify Q�Town• PermitlL�icease#
Issuing Anthority(cirete o�ae):
1,Board ofHealth 2.Bailtting I�eparem�nt 3.City/Tu�vn C[erk 4.Licensing Board 5.Selec#nuem's[}f�ice '
€!.dt�i?BE'
1
Cor�taet Persna: Phflne#•
www:mass.govfdia
One CVS Drive
� � Woonsocket,RI 02895
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Dear Sir/IVlad�rr�: �—
E�a�fo�ed please firtd cor�pleted applicati�n(s) a�d/or iravoice(s) along with payt�enfi in
the appropriat� amount to cover the cost of the ren€vva6 for the Ci1S/pharrnacy store(s)
in your area. �lea�e note a�r��f�anrc�mar�te c�� #h�a�p)icatior�r�ar�l�n�ct traaF�^
n�me artd�r mailieaQ�ddre�, arrc!i�►cf�d�store�tsrrra�er�ort �r�wolces and�ernr�it�
as indicated on the applicati�n fo �r�sure c�r�►��t pa�r�nt#o the pro�er stare.
Pleas�sEnd the�errnit�sJ/t�c�nsefs) arrd a�r�r future rene�al app/fca#rons for ttrfs
sto�e yvith the s#ore�nurnt�er or�et i� at�errt�on at: ar►� Y��rfve L►censm
Depf, Maei Coafe 11G0, Woonsacke� ! tl2�9�. After receiving the licenses, 9 will
ma�ce the necessary copies for my files �rad f��nrard $he origin�ls to�he st�res for
posting.
If you have any questions, please contact r�e at 401-770-2278 or by fax 401-652-1280.
Sincereiy
Donrta Cheval�er
Lecensing Coordi►sator
One C10S DrivellYlai/Code ??SO
Woonsocket, R/02�95
�$ pk�armacy J �aremark / minute clinic / specialty
DATE(MM/DD/YYYY)
ACORCI� CERTIFICATE OF LIABILITY INSURANCE 1 213 0 7201 5
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 AFFORDEO 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 statemeM on this certficate does�ot confer rights to the
certificate hoider in lieu of such endorsement(s).
PRODUCER CONTACT �
MARSH USA,INC. NAME:
99 HIGH STREET PHONE ac No:
BOSTON,MA 02110 E-MAIL
Atln:CVSC�emadc.CertRequest@marsh.com Fax:212-948-5338 ao�rtEss:
INSURER S AFFORDING COVERAGE NAIC#
502406-ALL-GAW-16-17 �NSurteR a:New Hampshire Insurance 23841
INSURED INSURER B:N86(N121 Uf110I1 Flf@ IlIS CO urg 19445
CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180 INSURER C: ?"f '
WOONSOCKET,RI 02895 INSURER D:
INSURER E: �
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-00787580a22 REVISION NUMBER:1
THIS IS TO CERTIFY THAT THE POLICIES OF INSUR,4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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 7�ypE OF INSURANCE ADDL UBR POLiCY EFF POIICY EXP LIMITS
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY GL 2039188 01/01/2016 O1IO1IZO17 EACH OCCURRENCE $ 4,SOO,OOO
CLAIMS-MADE �OCCUR PR�EM SES EaEoxu ence S 1,000,000
X SIR: $500,000 MED EXP(My one person) $
X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY $ 4,500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 28�0���
POLICY❑PR� �LOC PRODUCTS-COMP/OP AGG S iNCLUDED
X JECT
OTHER: $
B nuTOMoei�e unsiuTv 9734291(AOS� 01/01/2016 01/01/2017 COMBINED SINGLE UMIT $ 1,000,000
Ea accident
B X ,4NY AUTO 9734292(VA) 01/Ol/2016 01/01/2017 BODILY INJURY(Per person) $
g ALL OWNED SCHEDULED g7342g3(MA) 01/01/2016 01/01/2017 BODILY INJURY(Per acciderrt) $
AUTOS AUTOS PROPERTY DAMAGE $
NON-OWNED Per accident
x HIRED AUTOS X AUTOS
SELF-INSURED PHY.DMG. $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A V1lORKERS COMPENSATION See Page Two fw Policy Numbers 01/01/2016 01/01/2017 X STATUTE ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $ 2,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS be�ow E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additlonal Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE
EXTENT REIXIIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIOUS LOCATIONS,STORE#161,
735&944.
CERTIFICATE HOLDER CANCELLATION
THE TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:BRUCE MURPHY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28
SOUTH YARMOUTH,MA 02664
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina �gvc�oa;��,. !?Zd.�u�rat�cc
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
�
AGENCY CUSTOMER ID: S02406
-�"""�', �
LOC#: Boston
ACORU ADDITIONAL REMARKS SCHEDULE Page 2 of s
AGENCY NAMEDINSURED �
MARSH USA,INC. CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180
�POLICY NUMBER . WOONSOCKET,RI 02895 � .
CARRIER NAIC CODE �
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 2� FORM TITLE: Certificate of Liability Insurance
i
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2016 TO JAN 1,2017
ins.Co. Policy# States Covered
i
A 066830239(MN) MN
A 066830241 ND,WA,WI,WY
A 066830236(FL) FL
A 066830235(CA) CA
A 066830237 IL,KY,NH,UT,VT
A 066830234(AZ) AZ
A 066830233(AOS)AL,AR,CO3 DE,GA,HI,IA,ID,IN,KS,LA,MD,MI,M0,MS,MT,NE,NM,NV,NY,OK,OR,SC,SD,TN,WV
A 066830240(PA) PA
A 0fi6830238(ME) ME
A 06S$30242(FX; TX r
EXCESS WORKERS COMPENSATION PROGRAM
POLICY DATES:JAN 1,2016 TO JAN i,2017
B 1103547 DC,MA,OH,RI
B 1103546 CT,NC,NJ,VA
Excess Workers Compensation Self-Insured Retentans:
DC,MA,OH,RI: $500,000
CT,NC,NJ,VA: $1,000,000
COVERAGE A:Workers Compensation:Statutory
COVERAGE B:Empbyers Liability Limits:$500,OOOl$500,OOOl$500,000
AUTO POL�CY NUMBERS FOR OMNICARE,INC.AND OMNICARE,INC.ENTITIES EFFECTIVE 1/112016:
POLICY:3434109(AOS)
CARRIER:NATIONAL UNION FIRE INSURANCE COMPANY
DATES: 111I2016-1I112017
POLICY:3434110(VA)
CARRIER:NATIONAL UNION FIRE INSURANCE COMPANY
DATES: 1/1/2016-1I1/2017
POLICY:3434111(MA)
CARRIER:NATIONAL UNION FIRE INSURANCE COMPANY
DATES: 1/1/2016-111/2017
ACORD 101 (2008/01) �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
f
AGENCY CUSTOMER ID: S02406
LOC#: Boston
ACO� ADDITIONAL REMARKS SCHEDULE Page s of s
AGENCY � NAMEDINSURED �
MARSH USA,INC. CVS HEALTH CORPORATION
ONE CVS DRNE,MC 2160
PouCY NUMBER WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
COMMON POLICY CONDITIONS
A.CanceNation
2.We[Carrier)may cancel this policy by mailing or delivery to the first Named Insured written notice of cancellation at least:
a.10 days before the effective date of cancellaGon if we cancel for non payment of premium
1)General Liability AddiGonal Insured-Where Required Under Conhact or Agreement language per endorsement 61712(12J06):
SECTION II-WHO IS AN INSURED,is amended to include as an additional insured:
Any person or organization to whom you becbrrie obligated to inGude as an additional insured under this policy,as a result of any conUact or agreement you enter into which
requires you to fumish insurance to that person or organizatan of the type provided by tl�is policy,but only with respect to liability arising out of your operaUons or premises owned
by or rented to you. However,the insurance provided will not exceed the lesser ot
�The coverage allor limits of this policy,or
•The coverage and/or limits required by said conUact or agreement.
2)General Liability Eadier Notice of Cancellation Provided By Us language per endorsement CG 02 2410 93:
_ _ _ _
NumDe�of�ays•'Notice 9� _ .
For any statutonly pertnitted reason other than nonpayment of premium,the number of days required for notice of cancellation,as provided in paragraph 2.of either the
CANCELLATION Common Policy Condition or as amended by an appiK:able state cancellatan endorsement,is increased to the number of days shown in the Schedule a�ove.
3)General Liabiiity Advance of Cancellation to Enti6es Other The Named Insured Limited to E-Mal No6ficatan per Cha�is Manuscript endorsemenL
In ihe event that the Insurer cancels this policy for any reason other than non payment of premium,and
t. The canceHation effective date is prior to ihis policy's expiratan date;
2. The First Nart�ed Insured is under an existing contractual obligation to no6ry a certificate holder when this policy is cancelled(hereinafter,the"certificate Hokier(s)');and has
provided ro the Insurer,either drcectly or through its broker of record,the email address of the contact at such enGty,
and the Insurer received ihis inforrnatbn a(ter tl�e First Named Insured received notice of cancellation of this policy and prior to this policys cancellatio�effecGve date,via an
electronic spre�lsheet that is�ceptable to ihe I�surer,
ihe Insurer will provide advice of cancella6on(the°Advice")via e-m�l to such CertiFicate Holders.
Proof of ihe Insurer emailing the Advice,using the information provided under this policy by ffie First Named insured,wiU serve as proof that lhe Insurer has fully sa6sfied its
obligations urder this endorsement
This endorsement dces not affect,in any way,coverage provided under this policy or the cancellation of this policy or the effective date thereof,nor shall this endorsement invest
any rights in any en8ty not insured urnier this policy.
The folbwing DefiniGons apply to this endorsement:
1.First Named Insured means the Named Insured shown on the Declaratbns Page of this policy.
2.Insurer me�s Uie insurance company shown in the header on the Declaratans Page of Nis policy.
NI other temu,conditbns and exclusrons sh�l remain the same.
ACORD 101 (2008/01 j �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD