HomeMy WebLinkAboutApplication and WC . _ ��N�1ND�28�f�.� :
� � TOWN OF YARMOUTH BOARD OF HEALTH ; �
' � � � APPLICATION FOR LICENSE/P�L V µIT - 0 c,Y` ., � � ��:,�'1 "; � ��j�� � `
•..• * cem�r S 1 S. _
Please com lete form and attach all necess ����� ��.��s. �'Y: ` �
�� P . � � �.- , �; : z ,
Failure to do so will result in the retu .Q�'yo ����1i�a�o��.,p�Eket.�______w __ '_��_ ...
E�TABLISHMENT NAME: �'il�a<2` "��2 ��fl�- TAX ID• ��� ��
LOCATION ADDRESS: c.3 .t TEL.#: �� s^2�9 2
1VIAILINGADDRESS: .��5-'t �v�'�r�t1"�� �'� ��'
E-MAIL ADDRESS:
OWNER NAME: �AiG� 5 ��+j�"'2- -
CORPORATION NAME (IF APPLICABLE): ��.'9,��r���-� ���
MANAGER'S NAME: "7�R'� �,a rr�L. TEL.#:
MAILING ADDRESS: � � c ��� ��"
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Ppol Operator(s) and attach a copy of the certification to this form.
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Pool operators must list a minimum of two employees currently certified in standard First Aid and Community j
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. 4. �
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FUOD PROTECTION MANAGERS - CERTIFICATIONS: '
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.
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PERSON IN CHARGE: '
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ,
__ _1. _ _ _ __ �• _ _
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as d`efined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please aitach ,
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.
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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' records.
You must provide new copies and maintain a file at your place of business.
L 2.
3. 4.
RESTAURANT SEATING: TOTAL#
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__ -- _
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_ �IL�'-- __
LODGING:
i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LI ENSE REQUIRED FEE P RMIT#
iB&B $55 _CABIN $55 �MOTEL $110 j(o-Ol��
� I� $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $1 l0ea.
� FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# L[CENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 �CONTINENTAL $35 �� NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
— — —RESID.KITCHEN $80
�ItETAIL SERVICE:
LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIR�D FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $I50 _FROZEN DESSERT $40 TOBACCO $110
NAMECHANGE: $15 U��,,.I� ZS5•O�
; �u:_--�.�' ,,���
� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION � �-- t
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
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE '
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR j
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CERT. OF INSURANCEATTACHED '
OR '
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ',
APPROPRIATELY IF PAID: � / ,
YES V NO I
MOTELS AND OTHER LODGING ESTABLISHMENTS '
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall 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
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
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. '
. FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contac�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
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
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
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 COOKING:
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 MAY REQU�/A�,S�,TF�PLAN—.
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DATE: � %� /�� �� SIGNATURE: ��
PRINT NAME&TITLE: T vq��9 /,%Z
Rev. 10/O 1/I S
� The Commonwealfh of Massachusetts
i , _ Department of Industrial Accidents
Office of Investigations
' I Congress Streei, Suite 100
Boston, MA 02I14-2017.
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: �r��1�� )�� ��.�
Address: � �� ������} �?$'
City/State/Zip: ���� �,i J1,u oj y •�!� Phone#: 52��� ���'-s' �z�9Z
Are you an employer? Check the appropriate boz: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
-
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
--- ---
_ ---
2. I am a sole proprietor or partnership and have no -- - � --- - - ----
7. ❑ Office and/or Sa1es (incl.real estate,auto,etc.)
employees working for me in any capacity.
i [No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Enterta.inment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organiza.tion,staffed by volunteers, 11.� Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**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 providing workers'compensation insurance for my employees Below is the policy infor»zation.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Fa.ilure 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.
I do hereby certafy,under the pains and penalties ofperjury that the information provided above is true and correct.
Si�nature: G7 �� Date• //' l� , lS'
Phone#: ��y.- ��o�- �6 2!�
Official use only. Do not write in this area,to be completed by city or town offacia�
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• Phone#• ;
�
www.mass.gov/dia i
Massachusetts Work�ars' Gompensation Insurance Plan
g V rk�V Acadia insurance Canpany FtCG Carrier Code 33391
� � Administered by BerEcley Assigned Risk Services
ASSiGNED RISK S�Rt�ICES P.O.Box 59143,Minneapalis,Minnesota 55459-0143
' Phane(605)945-2144 Fax(8fi6)215-8118 Toll Free(Sd0)fi34-4589
www_berkleyassignedrisk.com policyservicesQberkleyrisk.wm '
INFORMATION PAGE
Renewal Of No. New •
�. Tne insured: Normat AIR � Poiicy Number:wc-2o-zo-oosss�-oo
Swami Shree LLC Risk ID:0811208 ,
dba: Thunderbird Motal _ �
Tax 1D#.
216 Main Street Route 28
West Yannouth,MA 02673 Date of Mailing: 5l26l2015
�Individual � Partnership
Other workplaces not shown above: . �Corporation X�Other
S88 Schedule Limited Liability Company(LLC)
2.The policy period is from 12:01 a.m.5/20/2015 to 12:01 a.m.5I20/2016 at the insured's mailing address.
3.A.Workers'Compensation Insurance:Part One of the policy applies to the Worlcers'CompensaUon Law of the states listed here:
MA .
B.Employers Liability Insurance:Part Two of the policy applies Eo work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodity Injury By Accident $SOO,Q00 each accident. •
Bodily Injury By Disease $500,000 policy limit.
Bodily Injury By Disease $500,000 each employee.
C.Other States Insurance:Part Three of the poliCy 8pplies to the states,if any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20-03-06 (B) •
• D.This policy includes these endorsements and schedules:
WC000308 WC0004U3 WC000404 WC000414 WCOOd421D WCd00422B WC200301 WC200302A WC200303D WC2003066 WC200307
WC200401 WC200405 WC200fi01A WC200604 WC990001A WC990601
4.The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
All ioformation required below is subject to ver�cation and change by audit.
PREMIUM BASIS RATES ENTRIES IN THIS ITEM,EXCEPTAS SPECIFiCALLY PROVIDED ESTlMATED
ESTIMATED TOTAL PER$10U OF CODE ELSEWHERE IN THIS CONTRACT;DO NOT MODIFYANY OF APENUAL
ANNUAL FtEMUNERATION REMUNERATION NO. THE OTHER PROVISIONS OF 7HIS POLICY. PREMIUM
anual Premium . ;790.00
SE@ SCh@dUle ncreased�imits , 1.01 $8.00
ncreased Limits Minimum , $42.00
Minimum Premium : $284.00 • ubject Premium � ;840.00
od[fied Premium $840.00
tandard Premium 5840.00
Expense Constant ' ;250.00
errorism 0.83 $15.00
otal Estimated Annual Premlum - �1,105.00
DIA Assessment • 1.058 $46.00
Aqency Name and Address Total Feas 8 Premium y1,151.00
. Miller MCCdrtin InC Net Deposit Premlum Required ' S1,151.00
Dowling 8 Oneil Ins Premium Paid to Date ($1,151.00)
973 Lyannough RD Total Premium Due $0.00
Hyan�is,MA 02601
DATE: 5/26/2015 •,;l,,;rr - �����.
Signature� .������ _
Indudes Copynght ma[erlal of the Natiofl�Coundl on Compenaation Ir�surance used witli its permission
�79831�-D 1991 National Council Canpensation Insurance WC 99-00-01
a
Masaaci�setts Workers' Compensation lnsurance Plan .
� Berkle �cadia lnsurance Cor�any NCCI Carrier Code 33391
y Adminisfered by BerkleyAssigned Risk Seroices
ASSIGyED RISK SERVICES PO.Box 59143,Minneapofis,Minnesota 55459-0143
Phone(605)945-2144 Fax(866)215-8118 Toll Free{800)634�589 .
www.berkieyassignedrisk.com poiicyservioes@bedcleyrisk.cam
;
� tNFORMATION SCHEDULE
{
Renewal Of No. New
� 1. The Insured: No�mel A1R Policy Number: WC-20-20-005661-00
� Risk ID: 08'E1208
' Swami Shree LLC
dba: Thunderbird Motal Tax�D#: -
� 296 Main Street Route 28 Policy Period: From: 5l2d/20'{5
West Yarmoufh,MA 02673 To:5/20120'[6
. Endorsement Eff. Date:5/20/2015
Date of Mailing: 5/26/2015
� Changes as set forth below are hereby made,with respect to the estimated remuneration,premium and/or rates.
PREMIUM BASIS RATES 5/20/2015 -512D/2016 ES71MA7ED
ESTIMATED TOTAL pER$100 OF CLASS ANNUAL
ANNUAL REMUNERATION REMUNERATIO CODE PREMIUM
CLASSIFICATION
State: MA
Swami Shree LLC •
216 Main Street Routs 28
West Yarmouth MA, 02673 ' .
$50,000 1.58 9052 HOTEL-ALL OTHER EMPLOYEES&S E�D . $790
If A�y 1.58 9058 HOTEL-ALL RESTAURANT EMPLOYEES $0 � .
� MA
Manual Premium $790.U0
Supplementary Disease $o.oa
Waiver of Subrogation Facfor ' 50.00 ,
Number of Waivers 50.00 .
Increased Limits 1.01 $8.00
Increased Limits Minimum 342.U0
Deductible Factor $0.00
Subject Premium � $840.00
Experience Modification $0.00
Merit Rating ;0.00 •
Modified Premium � $840.00
Contracting Class Prem Adj Pgm , SO.QO
Standard Premiurn $840.00
Supplemenial Disease Exposure $0.00
ARAP $0.00 '
Quality Loss Management Prg $0.00
Loss Constant $0.00
Expense Constant $250.00
Terrorism � 0.03 $15.00
Short Rate $0.00
Minimum PremiumAdjustment $O.QO
Former Self Insured Charge $0.00
Total EsGmated Annual Premium $7,105.00
� Page 1 of 2 WC990001A
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B/� Massachusetts Workers' Compensation Insurance Plan
C 1 ��V ' Acadia insurance Company NCCI Carrier Code 33391
v� Administered by BerlcleyAssigned Risk Services
ASSIG�lED RISK SEt�'VICES P.O.8ox 59143,Minneapolis,Minnesota 55459-0143
� Phone(605)945-2144 Fax(866)215-8118 Toll Free(800)634-4589
� www.berkleyassignedrisk.com policyservices@berkleyrisk.cam
� INFORMATION SCHEDULE
�� Renewal Of No. New
1. The Insured: Normal A!R Policy Number: WC-20-20-005661-00
Risk ID: 08712p8
Swami Shree LLC
dba: Thunderbird Motal Taz ID#:
! 218 Main Street Route 28 Policy Period: From: 5/20l2015
� West Yarmouth,MA 02673 To:5120l2016
Endorsement Eff.Date:5/20t2015
• Date of Mailing: 5/26/2015
Changes as set forth below are hereby made,with respect to the estimated remuneration,premium and/or rates.
� DIAAssessment 1.058 $46_00
�
' Policy Sumrnary 5/20/2075-5120120'[6
pAanuai Premium 5790.00 �
Increased Limits . 1.01 S8.OQ
Increased Limits Minimum • $42.00 '
Subject Premium 5840.OQ
� Modified Premium 5$40.00
SWndard Premium $840.OQ
Expense Constant $250.00
Terrorism 0.03 $15.00 �
Total Estimated Annual Premium ;1,105.00 �
DIAAssessment 1�.058 �t6.d0 .
Total Fees&Premlum $1.751.00
Net Deposit Premium Required �1,151.�0
Premium Paid to Date {51,161.04} .
Refund SO.dO _ '
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All other terms and conditions of this policy remain unchanged. -
Agency Name and Address
Miller McCartin Inc �
Dowling 8��Oneit tns ,
973 Lyannough RD
Hyannis,MA 02601 .
Page 2 of 2 WC990001A
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Massachusetts Workers' Compensation lnsurance Plan
� ������ Acadia lnsurance Company NCCI Carrier Code 33391
i y Administered by BerkleyAssigned Risk Services
� RSSIGNE�RISK SERIIICES P•0,Box 59143,Minneapolis,Minnesota 55459-0143
, Phone(fi05)945-2144 Fax(866)21�8118 Toll Free(800)634-4589
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� www.berkleyassignedrisk.com policyservices@berkleyrisk.com
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ENTITY AND LOCATION SCHEDULE
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1.The lnsured: Policy Number: WC-20-20-005667-00
; Normal A!R Risk ID: 0811208
i Swami Shree LLC
� dba: Thunderbird Motal Tax ID#:
216 Main Street Route 28
; • Policy Period: From: 5/2a)2015
a West Yarmouth,MA 02673 To:5/20/2016
. Endorsement Eif.Date: 5/20120i5
{ Date of Mailing: 5/26/2015
d! . �
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Entity Information:
Insured Name: Swami Shree LLG �Individual �Partnership
Federal ID Number: F 75-32b3953 ❑Corporation X�Other
UIC Number: •
dba:Thunderbird Motaf �
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; 2'16 Main Street Route 28 .
West Yarmouth,MA 02673 . �
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Aqency Name and Address
Miller McCartin t�c
Dowling&Oneil Ins
973 Lyannough RD �
Hyannis,MA Q2601
WC990601
MassacF�usetts Workers'Compensation insurance Plan
Berkle Acadia lnsurance Company NCCI Carrier Code 33391
y Administered by BerkleyAssigned Risk Services .
� ASSIGN�RISK SER��CES P O.Box 59143,Minneapolis,Minnesota 55459-0143
Pho�e(605)945-2144 Fax(866}215-8118 Toll�ree(800)634-4589
www.berkleyassignedrisk.com policyservices(a�berkleyrisk.com -
� MASSACHUSETTS CANCELLATION ENDORSEMENT•
i
1.The Insured: Normal A!R Policy Number: WC-20-20-005661-00
i Risk ID: 0811Z08
j ' Swami Shree LLC �
dha: Thunderbird Motal Tax ID#:
� 216 Main Street Roufe 28 Poli Period: From: 5/2QI2015
�Y
West Yarmouth,MA 02673 To: 5/2b12016
� Endorsement Eff. Date: 5l20/2015
{
• Date of Mailing: 5/26l2075
This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A. of
the Information Page.
The Cancellation Condition of the policy is replaced by the following:
Cance[lation
1. You may cancel this policy by mailing or delivering to us advance written notice requesting cancellation. Such cancellation
shall not be effective until ten days after written notice is given by us to The Workers'Compensation Rating and Inspection
Bureau of Massachusetts(Bureau), or until notice has been received by the Sureau that you have secured insurance
� from another insurance company,whichever occurs first. Our natice to the Bureau may be given by electronic transmission.
� 2. We may cancsl this policy only if based on one or more of the following reasons: (i) nonpayment of premium; (ii)fraud o�
material misrepresentation affecting your policy;or(iii)a substantial increase in the hazard insured against. Such
' cancellation shall not be effective until ten days after written notice is given by us to you and The Workers' Compensation
� Rating and Inspection Bureau of Massachusetts(Bureau},or until notice has been received by the Bureau that you have
secured insurance from another insurance company,whichever occurs first. Our notice to the Bureau may be given by
� efectronic transmission. �
3. We will maif or deliver the notice of cancellation to you at your last address,which shall be the mailing address shown in " �
; Item 1 of the Information Page or the change of mailing address shown in an Endorsement to the Policy. Pursuant to
� M. G.L. Chapter 175,Section 187C, a written notice of cancellation shal(be deemed effective when mailed by us if we
obtain a certificate of mailing receipt from the United States Postal Service showing your name and address as stated
in the policy.
4. Any of these provisions that conflict with the law that controls the cancellation of this insurance policy is changed by this
statement to comply with the law
All other terms and conditians of this policy remain unchanged.
Agencv Name and Address
Miller McCa�tin!nc
Dowling&Oneil Ins '
873 Lyannough RD .
Hyannis,MA 02601 WC 20 06 01 A
{Ed.7-2008)
8122*
�1992 National Council on Compensalion Insurance.
�
Berkle Massachusetts Workers' Compensation Insurance Ptan
' � Acadia lnsurance Company NCCI Carrier Code 33391
j Admm�stered by BerkleyAssigned R�sk Sernces
� I����EQ��SK��j}(��ES PO.Box 59143,Minneapolis,Minnesota 55459-0143
= Phone(605)945-2144 Fax(866)215-8118 Toll Free(800)634-4589
3
www.berkleyassignedrisk.com policysetvicesQbericleyrisk.com
� � MASSACHUSETTS PENDING PREMIUM CHANGE ENDORSEMENT
� 1. The Insured: NO�IT1aI AJR Policy Number: WC-20-20-005661-00
� . Risk ID: 0811208
Swami Shree LLC .
dba: Thunderbird Motal Tax ID#:
216 Main Street Route 28 � Policy Period: From: 5/20/2015
West Yarmouth,MA 02673 To: 5/20/2076
Endorsement Eff. Date: 5/20I2015
Date of Mailing: 5/26/2015
A filing is being considered by the Massachusetts Division of Insurance which may resuft in premiums different from those
shown on the policy. If it does,we will issue an endorsement to show the new premiums and their effective date.
All other terms and conditions of this policy remain unchanged.
Apency Name and Address �
Mille�McCartin tnc
Dowling 8�Oneil Ins
973 Lyannough RD �
Hyannis,MA 02601
wc 2o ac o�
(Ed. 11-90)
�1992 National Council on Compensation Insurance.
,
Massachusetts Warkers' Compensa��surance Plan
Berkl� A�dia lnsurance Company NCC!Ca�rCoc#e 33391
� Administered by BerkleyAssigned Risk Services
� ASSIGNED RlSKSERVlCES P.O.Box 58143,Minneapolis,Minnesota 55459-0143
Phane(605)945-2144 Fa�c(866)275-8118 Toll Free(800)634-4589
www.berkleyassignedrisk.wm policyservices�berkleyrisk.com
;
; MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT
1. The Insured: No�lt'lal AIR Policy Number: WC-20-20-005661-04
� � Risk ID:•0871208
a
! Swami Shree LLC �
' dba: ThunderbErd Motal Tax ID#: F
; �
�
s 216 Main Street Route 28 Policy Period: From: 5/2012015
; West Yarmouth,MA 02673 To: 5/20l201fi
� Endorsement Eff. Date: 5/20/2075
j . Qate of Mailing: 5I2fi/2015
� Section D of Part Five of the Policy is replaced by this provision:
� .
PART FIVE
PREMIUM
D. Premium Payments is amended to read: •
You wi11 pay all premium when due. You will pay the premium even if part or afl of a workers compensation law is not valid.
The audit and retrospective premium shall be paid by the due date indicated on the billing statement.
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AI1 other terms and conditions of this policy remain unchanged.
Agency Name and Address
Miller McCartin Inc
Dowling&Oneil Ins
973 Lyannough RD
Hyanois,MA 02601 -
� wc Zo aa as
� (Ed.6-01)
�1992 NaHona!Council on Compensation InsuranCe.
�
. Massachuse�ts Workers' Compensation Insurance Plan
Berkle Acadia lnsurance Company NCCI Carrier Code 33391 .
j y Administered by BerkleyAssigned Risk Senrices
4SSIGNED RlSKSERVICES PO.Box 59143,Minneapolis,Minnesota 55459-0143
Phone(6Q5)945-2144 Fax{866)215-8118 Toll Free(800)634�589
jwww.berkleyassignedrisk.com policyservices(�berkleyrisk.com
� MASSACHUSETTS POLICY DEFINITION ENDORSEMENT
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� . �. Tne�nsured: Normal A!R Policy Number. WG20-20-005661-00
3 Risk ID:0817208
� Swami Shree LLC � '
� dba: '��underbird Motal Tax It}'#:
� 216 Main Street Route 28 Policy Period: From: 5I20/2015
; West Yarmouth,MA 02673 To: 512 0120 1 6
� Endorsement Eff. Date: 5/2012015
Date of Mailing: 5/26/2015
In the General Section, Part A. -The Policy, is replaced by the following: '
j This policy includes at its effective date the lnformation Page, all endorsements and schedufes Eisted there,and -
your application for the insurance. It is a contract of insurance between you (the ernployer named in Item 1 of the.
Information Page)and us{the insurer named on the Information Page). The only agreemenfs relating to this
insurance are stated in this policy. The ferms of this policy may not be changed or waived except by endorsement
issued by us to be part of this policy.
� . .
�
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All other terms and conditions of this policy remain unchanged.
Aqencv Name and Address
Miller McCartin Inc
Dowling 8�Onei{Ins
973 Lyannough RD
Hyannis, MA 02607 WC 20 Ofi 04
(Ed. 't'I-02j
8122•
�1992 National Council on Compensation Insure�ce.
� , _�..�-�
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Berkle Massachusetts Workers' Compensation Insurance Plan
i ,/ Acadia lnsurance Company NCCE Carrier Code 33391
rf Administered try BerkleyAssigned Risk Services
� ASSIGNED RISK SERVIGES P.O.Box 59143,Minneapolis,Minnesota 55459-0143
i Phone(605)945-2744 Fax(8fi6}215-8118 Toll Free{800)634-4589 '
� www.bericleyassignedrisk.com policyservices(�Dberkleyrisk.com
� .
PARTNERS. OFFICERS AND OTHERS EXCLUSION EN�ORSEMENT
�. The Insured: Normal A1R � Porcy N�meer:wc-Zo-Zo-oosss�-oo
Risk ID: 0811208
5wami Shree LLC .
i dba: Thunderbird Motal � Tax ID#: F
216 Main Street Route 28 Policy Period: From: 512a/2015
West Yarmouth,MA 02673 To: 5/20/2016
� Endorsement Eff.Date: 5l20/2015
� Date of Mailing: 5/26/2015
; This policy does not cover bodily injury to any person described in ti�e schedule.
The Premium basis for the policy does not include the remuneration of such persons.
You will reimburse us for any payment we must make because of bodily injury to such persons.
SCHEDULE
� Partners Officers Others
� Devang Patel �
i
Nikunj Patel
I
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� .
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�
� All other terms and conditions of this policy remain unchanged. �
Aqencv Name and Address
Miller McCartin Inc •
Dowling&Oneil Irss
973 Lyannough RD
Hyannis,MA 02601 •
wc oaoa-os
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