HomeMy WebLinkAboutApplication and WC a� D -
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TOWN OF YARMOUTH BOARD OF HEALTH �
� � � � APPLICATION FOR LICENSElP �'�� - ° � �,� D�C �'�;��' 2��5
""'°� * Please com lete form and attach all necess ��� ` '� e�� be S 201 S.
p ar� o .0
, Failure to do so will result in the return of�ot�-:a�c��o�` EPT.
ESTABLISHMENT NAME: C Ts a r� � a TAX ID: �
LOCATIONADDRESS: ��� �uCk 15/a✓1C� c� /,tl� d/�/�ou�i v1613TEL.#: 50�• Zd�aZ f
MAILING ADDRESS:� � %'S t o an �e. � D�f6 Main St�'// erV�/P M Zd..�-
E-MAIL ADDRESS: nd �' r�c e co�(. Corh
OWNER NAME:
CORPORATION NAME IF APPLICABLE):
MANAGER'S NAME: /'¢� �Cl�� P,� TEL.#:,�'08� L-v `4 z 99
MAILING ADDRESS:C 4 �i'r � � d Prr,e•^� �c d✓e d cld�'�s5
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.
_—,___�:_���. r a _�Ja�� ���► 2. ��__-��� �(en Sdh _
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 att�.ch copies of tlieir certifications to this form. The Health Department will not use past
• ' ���must provide new copies and maintain a file at your place of business.
� 2. �a✓� ,S�✓�n So�
1. .S�e�q i o L�a h le�
3. 4.
FOOD 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.
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. !
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ALLERGEN CERTIFICATIONS:
All fQod 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 ',
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. ;
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#
_--— - --��+'acE TTCL' n�ri v . '
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LODGING:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110
_INN $55 CAMP $55 �SWIMMING POOL$110ea.�-�lo�OS� '
LODGE $55 _TRAILER PARK $105 WHIRLPOOL $I l0ea.
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 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. $I50 _FROZEN DESSERT $40 TOBACCO $110 '
NAME CHANGE: $is AMOUNT DUE _ $ ZZo•oa
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION '
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Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ;
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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 r
AFFIIIAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
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OR i
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 9C- I
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Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID: ,
YES � NO '
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 mai�tairr--�'pri��al place of residence ;
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30}�aqs;-�d __�
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 j
inspected and opened. '
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POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count i
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly �
thereafter.
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POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
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FOOD SERVICE �
SEASONAL FOOD SERVICE OPENING:
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: I
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 A \ APPROVE , BY T BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY UT A SIT PL .
DATE: /2 � �� SIGNATURE: � �
PRINT NAME& TITLE: r'a e� �I a nd � �� w �, �
Rev. ]0/O1/15
� The Commonwealth of Massachusetts
' Department of Industrial Accidents
� Office of Investigations
' ' I Congress Street, Suite I00
` ' Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/Organization Name: �u e r�. 15��nol� �� d C' Cd n c�0�vr���vw� /r u S�
Address: �g� �u c� 1 s/a hd /��
City/State/Zip: � d/'Nt0 u 7� /�{�QZ6 73 Phone#: SD�` `�z a ' d,Z Q�'
Are you an employer? Check the appropriate boz: Business T�pe(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
� or part-time).* 6. ❑ RestaurantlBar/Eating Esta.blishment
. am a`s`oIe propn'e�or r�p ers p , ave �, Office and/or Sa1es(incl.real esta.te,auto,etc.)
employees working for me in any capacrty. ,
[No workers' comp.insurance required] g• ❑Non-profit
3.❑ We are a corporation ar�d its ofFicers have exercised 9. ❑Entertainment
the�'r-r�ght of exemption per c. 152, §1(4),and we have 10.�Manufacturing
�no employees. [No workers' comp. insurance required]* 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers, / ,
with no employees. [No workers' comp. insurance req.] 12.�,Other /2es i a�ef?�7 a� �O vJGi�O
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation poticy 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#L
I am an employer that is providing wor ers'compensation insurance for my em loyees Below is the policy information. '.
Insurance CompanyName: �0/'�O�l� ��ed hdl» Y'l u'1� a.� fiI('� ..�/I S t.�dYiC'E
Insurer's Address: o? o�oZ �Vl'►e5 ,��eP�
City/State/Zip:�7�e cf�a� i M�}- 6 z ���o
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Policy#or Self-ins.Lic.# �E� �S� 37� Expiration Date: �� g l '!
Attach a copy of the workers' compensation policy declaration page(showing the policy number nd ezpiration date). ;
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a '
-- me up o , . an or one-y i p ' th�farur af a � -- '
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
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I do hereby certi , nder the pain and e 1 ' of perjury that the information provided above is true and correct. �
Si ature: Date: � � � �S :
Phone#: 5 0$� y ZU � O 2,9 �
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: Phone#: �
www.mass.gov/dia
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WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
;. " INSURANCE POUCY----INFORMATION PAGE' t
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INSURER: POLICY NO: y,7E145637A �
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 1+,MES STREET RENEWAL i
DEDHAM, MA 02026 NCCI Company No: 21Q59 �
Account No:
FEIN:
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: '
BUCK ISLAND VILLAGE CONDOMINIUM MILLER MCCARTIN, INC. DBA
G/O FIRST PROPERTY MANAGEMENT DOWLING & O'NEIL INS. AGCY
�046 MAIN STREET SUITE 11 PO BOX 1990
OSTERVILLE MA 02655 HYANNIS, MA 02601
_AGENT NO.: 20962 , r
° -: :�,.� _ : .. , � . <.
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' = LEGAL ENTITY: gEp�I,TY TRUST
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OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
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ITEM 2. PQL.ICY.PERIOD: From: 11/08/2015 To� 11/08/2016
Effective 12:01 A.M. Standard Time at the Insured's mailing address. ;
�TEM 3. COVERAGE:
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A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the
". states listed here:
MA
. B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
�; of liability under Part Two are: . _
Bodily Injury by Accldent: $ 500,000 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 applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
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D. This Policy includes fhese Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 284 Annual Premium: $ 343
` Audit Period: �Up,t, : Additional/Return Premium:
Gomments:
¢ Issued At: � �� �--_..,,���
Date: p g�2 g�2 015 Countersigned by � �r/'�"'�� ��
WC 00 00 01 A Copyright 1987 Natlonal Council on Compensation Insurance
PRODUCER COPY
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 B
(Ed. 01-15)
INFORMATION PAGE NOTES ' �
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1 The sequence of Items 1 through 4 of the Information Page may not be changed except for Item 3.D. (See Note `
14.)The format of each item may be rearranged and these suggested headings may be used: 1.Jnsured; 2.
Policy Period; 3. Coverage; and 4. Premium.
" 2. The name and the five-digit NCCI carrier code number of the insuring company is to be shown prominently on the '
Information Page in the space above Item 1.
The address and type of insurer(stock, mutual, or other)are to be shown on the Information Page,the policy,or a
policy jacket.
3. The policy number must be appropriately labeled and shown in space reserved above Item 1 on the Information
Page.This number shall be unique to the company, shall not exceed 18 alphanumeric digits, and shali remain
constant during'the policy period. It shall be shown on all endorsements as weil as all other policy-related
correspondence after the policy is issued.
If the policy number displayed on the Information Page contains a policy symbol consisting of alphanumeric digits
that are not entered into the carrier's intemal statistical records as part of the actual policy number,,those symbols �
shall be shown as a separate prefix and/or suffix to the policy number and app�opriately labeled.
4. On the bureau copy of a renewal policy Information Page, use space reserved above Item 1 to show and
appropriately label the prior policy number.This number shall not exceed 18 alphanumeric digits. If the number
displayed on the Information Page contains a policy symbol consisting of alphanumeric digits that are not entered
into the carrier's internal statistical records as part of the actual policy number, those symbols shall be shown as a
separate prefix and/or suffix to the policy number and appropriately labeled. �
New business may be designated uNew."At its option,the company may show this on the insured's copy of the
Information Page.
5. On the bureau copy of the Information Page, show the letters"AR"next to the title"Information Page"if the
insured is an assigned risk.
6. Show in Item 1 the exact name of the employer insured and indicate whether the employer is an individual,
partnership,joint venture, corporation, association, or other legal entity. If separate Iegal entities are insured in a
single policy, consistent with the manual of rules, separately show the complete name of each insured employer
and indicate each employer's legal entity status.
7. The Interstate/Intrastate Risk Identification number must be shown and appropriately labeled on the Information
Page.
� 8. Reserve space in Item 1 of the bureau copy to show, if required,the insured's commonly required identification
numbers such as:Arkansas Workers Compensation File Number; Hawaii Unemployment Number; New Mexico ;
Unemployment Insurance Number; Oregon Contract Number, and State Employer Number.
The company may also show this on the Information Page at its option.
9. List in Item 1 or by schedule all usual workplaces of the insured that are to be covered by the policy. Also include �
the respective Federal Employer's Identification Number(FEIN), appropriately labeled,for each entity included on
the policy.
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10. The effective date and hour of the policy, and its expiration date and hour, must be shown in Item 2. The hour
� may be included as part of the printed form at the company's option. ',
11. List in Item 3.A. states where workers compensation insurance is provided. If none is provided,"none"or"not ,
covered"may be shown. See,for example,the notes to the Federal Mine Safety and Health Act Coverage '
Endorsement.
12. Show limits of liability separately for bodily injury by accident and by disease in Item 3.6.
I', 13. States may be shown in Item 3.C. by name or by designation, but do not name or designate a state listed in Item �
3.A.,a monopolistic state fund state, or a state where the insurer will not provide this coverage.
� The following entry may also be included:uAll states except North Dakota, Ohio,Washington,Wyoming,states
designated in Item 3.A.of the Information Page and "
; If the company learns that the insured is conducting operations in a 3.C. state, and if the company agrees to
, continue coverage, the company should add that state to Item 3.A.and remove it from Item 3.C. Normal company
procedures apply when the state is added to Item 3.A.
1 of 2
. m Copyrlght 2009 NaUonal Councll on Compensatlon Insurance,Inc.All Rlghts Reserved.
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WC 00 00 01 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
(Ed. 01-15)
14. Item 3.D. may be omitted so long as the list of the policy's schedules and endorsements appears somewhere on
the Information Page. Endorsements for which the companyhas not filed specimen copies with the rating bureau
or bureaus having jurisdiction must be attached to the Information Page filed with the bureau.
15. The content of Item 4 may be rearranged by the company. If the policy is issued for less than one year,the
� company may state whether the premium information is shown for the policy period or for an annual period.
16. In Item 4,the development of estimated annual premium shatl be displayed separately for each ciassification by
state.This same display of premium development must be shown on any classification schedules attached to the
policy. Total Estimated Standard Premium must be shown by state on the Information Page or on a schedule
attached to the policy.
The experience rating modification factor shall be shown in Item 4 for risks subject to the experience rating plan,
unless this factor is not available when the policy is issued.The company then may make an appropriate entry in
Item 4 to show that the factor is not available. See the Experience Rating Modification Factor Endorsement for
� more information.
' 17. In those states where a scheduJe rating plan has been filec�,and appr�ved, report the schedule rating 'tnformation
� in ltem 4,as required by the filed plan. '
18. Premium discount may be shown in Item 4,the Premium Discount Endorsement, or both.
19. Taxes, assessments, deposit premium, interim adjustments of premium,the rating plan, past experience,
cancellation of similar insurance, date and place of policy issuance, date and place of countersignature, and other
related information may be shown in Item 4.
20. Three-year fixed-rate policies must be so designated on the Information Page as required by Rule 3-B-1-b of �
NCCI's Basic Manual. In Item 4,the com an shall re ort the remium information ei
p Y ther as Standard Premi
P P um
or ota tandard Premium as defined in Rule 3-A-20 of NCCI's Bas/c Manual.
21. Other entries may be made on the Information Page as authorized by Notes to Endorsements, including:
Anniversary Rating Date, Defense Base Act Coverage; Nonappropriated Fund Instrumentalities Act Coverage;
Partners,Officers and Others Exclusion; Pending Rate Change; Sole Proprietors, Partners, Officers and Others
Coverage; and Voluntary Compensation Maritime Coverage Endorsements. '
22. The company may place the execution clause at the end of the Information Page, at the end of the standard .
policy, or on a policy jacket.
State Workers Compensation Rating Bureau Information Page Notes:
Refer to the Pennsylvania Basic Manual for Pennsylvania policy issuance instructions and specific requirements.
Refer to the sample Information Page in the Forms Section, Part Three, Section 2, of the New Jersey Workers
Compensation and Employers Liability Insurance Manual for a description of New Jersey requirements.
Refer to the New York Manual(Part Four)for complete instructions on policy issuance, including Information
Page Notes for preparing New York policies.
This endorsement changes the policy to which it is attached and is effecttve on the date issued unless othervvlse
stated.
(The information below is required only when thls endorsement is issued subsequent to preparatJon of the policy.) �
Endorsement Effective Policy No. Endorsement Na i
Insured Premium
Insurance Company Countersigned by
WG 00 00 01 B
(Ed. 01-15)
2of2
�Copyright 2009 NaUonal Councll on Compensatlon Insurance,lnc.All Rights Reaerved.
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Policy Number y�145637A
NORFOLK & DEDHAM MUTUAL EIRE INSURANCE COMPANY
WORKERS COMPENSATION CLASSIFICATION SCHEDULE
State of: Mp,SSACHUSETTS
Named Insured gUCK ISLAND VILLAGE CONDOMINIUM Effective Date: Zl/08/2015
12:01 A.M., Eastem Standard Time
Agent Name MILLER MCCARTIN, INC. DBA DOWLING & Agent No. 2 p�62
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Rates Deviation Estimated
Code Annual Per$100 of Annual
Classification of Operation No. Remuneration Remuneration Factor premium
LOC #1
BUCK ISLAND VILLAGE
CONDOMINIUM
FEIN #
481 BUCK ISLAND ROAD
WEST YARMOUTH MA 02673 _ �
BUILDINGS - OPERATION BY OWNER OR 9015 $ IF ANY 2.99 1.00 $ 0.00
LESSEE NOC (9015)
CLERICAL OFFICE EMPLOYEES NOC (8810) 8810 $ 25,000 .OS 1.00 $ 20.00
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WC 89 0415
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PRODUCER COPY II
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Policy Number y�145637A
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NORFOLK & DEDHAM MUTUAL FIRE INSIJRANCE COMPANY
WORKERS COMPENSATION CLASSIFICATION SCHEDULE
State of: Mp,SSACHUSETT5
Named Insured gUCK ISLAND VILLAGE CONDOMINItTM Effective Date: 11/08/2015
12:01 A.M., Eastem Standard Time
Agent Name MILLER MCCARTIN, INC. DBA DOWLING & Agent No. 20762
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' Rates Deviation Estimated
' Classification of Operation Code Annual Per$100 of Factor Annual
! No. Remuneration Remuneration Premium
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MA — STATE SUNAtARY
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TOTAL CLASS PREMIUM $ 20.00
E�QPL MTNIbii7M DIFFERENCE 9848 $ 50.00
TOTAL SUBJECT PREMIUM $ 70.00
MERIT RATING PLAN .9500 9885 $ — 4.00
TOTAL MODIFIED PREMIUM $ 66.00 '
LOSS CONSTANT 0032 $ 20.00
STANDARD TOTAL $ 66.00
EXPENSE CONSTANT 0900 $ 159.00
TERRQRISM RISK INSURANCE .0300 9740 $ 8.00
EXTENSION ACT
PREMIUM SUBTOTAL $ 342.00
POLICY MINIMUM DIFFERENCE 0990 $ 39.00
MA DIA ASSESSMENT .0575 9751 $ 1.00
FINAL TOTAL $ 343.00
POLICY TOTAL ESTIMATED COST $ 343.00
WC 89 04 15
PRODUCER COPY
Policy Number y�145637A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY �
SCHEDULE OFFORMS AND ENDORSEMENTS
Named Insured gUCK ISLAND VILLAGE CONDOMINIUM Effective Date: 11/08/2015
12:01 A.M., Eastern Standard Time
Agent Name MILLER MCCARTIN, INC. DBA DOWLING & Agent No. 20762
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WORKERS COMPENSATION FORMS AND ENDORSEMENTS
LOC SCHED SCHEDULE OF LOCATIONS '
WC 00 00 00 C INSURANCE POI,ICY
WC 00 00 O1 8 WC INF�RMATION PAGE
WC 00 04 14 NOTIFTCATION OF CHANGE IN OWNERSHIP END'� . �
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WC 00 04 22 B TERRORISM RISK INSURANCE PROGRAM
REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT
WC 20 03 01 MA LIMITS OF LIABILITY ENDT
WC 20 03 02 A MA ASSESSMENT CHARGE
WC 20 03 03 D MA NOTICE TO POLICYHOLDER ENDT
WC 20 03 06 B MA LIMITED OTHER STATES INSURANCE
WC 20 04 05 MA PREMIUM DUE DATE ENDT
WC 20 06 O1 A MA CANCELLATION ENDT '
WC 20 06 04 MA POLICY DEFINITION ENDT
WC 88 20 O1 C MA DEPARTMENT OF INDUSTRIAL ACCIDENTS
WC 89 04 15 WC CLASSIEICATION SCHEDULE
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WC 89 06 14 SCHEDULE OF FORMS AND ENDTS j
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WC 89 0614 PRODUCER COPY I�
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Policy Number WE145637A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
NAME AND LOCATION SCHEDULE
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Named insured BUCK ISLAND VILLAGE CONDOMINIUM Effective Date: 11/08/2015
12:01 A.M., Eastem Standard Time
i Agent Name MILLER MCCARTIN, INC. DSA DOWLING & Agent No. 20762
O'NEIL INS. AGCY
State: MASSACHUSETTS
BUCK ISLAND VILLAGE CONDOMINIUM
481 BUCK ISLAND ROAD
WEST YARMOUTH MA 02673
'' FEIN : : . . ,
� ` �` SIC t�ode : � 011I
# EMP : 1
PHONE # : 508-420-0299
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PRODUCER COPY
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MUTUALS-MEMBERSHIP AND VOTING NOTICE:The insured is notified by virtue of this policy,that he/she is a member of the
NORFOLK&DEDHAM MUTUAL FIRE INSURANCE COMPANY and is entitled to vote either in person or by proxy at any and all
meetings of said Company.The annual Meetings are held in its Home Office,on the second Wednesday or March,in each year,at 1:00 P.M.
MUTUALS-PARTICIPATION CLAUSE WITHOUT CONTINGENT LIABILITY: No Contingent Liability: This policy is
nonassessable.The policyholder is a member of the Company and shall participate,to the extent upon the conditions fixed and determined
by the Board of Directors in accordance with the provisions of law,in the distribution of dividends so fixed and determined.
In Witness Whereof,we have caused this policy to be executed and attested,and,if required by state law,this policy shall not be valid unless
countersigned by our authorized representative. :
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Secretary President ;
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