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� The Commonwealth ofMassachusetts ���� � ��.� ���`�����
Department of Industrial Accidents
;
O�ce of Investigations
1 Congress Street,Suite l00
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
; Apnlicant Information Please Print Lesiblv
Business/Organization Name:�t`�����_�����'� ��J���—!�
Address: ��/� / �/;- ��'; ��
City/State/Zip: � T �O�'b��iOne#: ���9.�,�� f"'���
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. estaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estate,auto,etc.)
' employees working for me in any capacity.
; (No workers' comp.insurance required] g• ❑Non-profit
; 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
; no employees. [No workers'comp.insurance required]* 1 L� Health Care
i 4.❑ We aze a non-profit organization,staffed by volunteers,
; with no employees. [No workers'comp.insurance req.] 12.❑ Other
i *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
a organization should check box#1.
;
I am an employer that is provi ing workers'compensation insurance for my einployees Below is the policy information.
Insurance Company Name: " `$ (� �
� Insurer's Address: � ��
City/State/Zip: �d" � �
Policy#or Self-ins.Lic.# 0(N C ����,�� Expiration Date: 0 �' �
Attach a copy of the workers'compensation policy declaration page(showing the po6cy number and ez ration date).
Failure to secure coverage as required under Section 25A of MGL a 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce fy, der the ains and penalties of perjury that the information provided abo e is true and correc�
Si ature: Date:
Phone#: �� �
, _.._ _._
_ .
Offtcial use only. Do not write in this area,to be completed by city or town officiaL
/
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#•
www.mass.gov/dia
AC�� ROURTOP-01 MV H
DATE(MMIDD/YYYY)
`.,.�- ERTIFICATE OF LIABILITY INSURANCE 11/08/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONtRACT BETWEEN THE ISSUING INSURER(S),AUTNORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
; this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
iPRODUCER �ITACT
Ro ers�Gray Insurance Agency,Inc. allorEie " - - - - -^ --- F�
43�Rte 134 �M,�L,Extl: �ac,No:(877)816-2156
South Dennls,MA o2660 ,,,�,�_mail a�rogers9ray.com_ �_�,_
INSURERIS)AFFOROING COVERAGE NAIC#
I - - �-
------ __--___._ iNsuRERn Capitol Speciait_y Insurance Cor ration 10328
—__------- ---____.______
�Nsu�o iNsu�Rs:_NorGUARD Insurance Com an 31470
� Rourke's Top of the Cove LLC �rosur�R c:
--_�_—_._�.-- ------ —
i 183 Mdlll$� INSURER D:_
' South Yarmouth,NIA 02673 ----------------------__. -._�__
INSURER E:
INSURER F: �
COVE S CERTIFIC TE MBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE 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 ADDL SUBR--- -- -------
TYPE OF INSURANCE POUCY NUMBER �uCY EFF POUCY EXP � V�I,�
A X COMMERCIALGENERALLIABIUTY EACHOCCURRENCE ���O�OOO
CLAIMS-MADE �OCCUR DAMAGE TO RENTED
CS1600038401 04/07/2017 04/07I2018 pg�MisEs��a oc�xr g 100,000
' - ----- - - MED EXP(Any one aerson) $ S,OOO
i
PERSONAI.&ADV INJURY $ �eOOO�OOO
� GEN'L ACaGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2�000�000
i X POLICY P
_ ❑�E�r ❑LOC 2,000,000
PRODUCTS-COMP/OP AGG $
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO
1 -- $
OWNED SCHEDULED BODILY INJURY(Per person) $
_ AUTOS ONLY A�7'OS BORDILY INJURY(Per aatident $
— AUTOS ONLY _. AUT�O�Y PPer�a��eMZ MAC�E $
UMBRELLA W►8 OCCUR EACH OCCURRENCE $
EXCE83 LIAB CLAIMSMADE --- -
— - AGGREGATE _ $
DED RETENTION$
B WORKERS COMPENSATIpN P,ErR OTH-
� ANDEMPLOYERS'W4BILITy Y/N - -$-_
., ANYPROPRIEfOR/pARTNER/EXECUTIVE ROWC853372 ���7/2��7 ��7�2��8 E.L.EACHACCIDENT $ ����000
�����F�n��EXCLUDED9 � N/A
� if yes describe under
E.L.DISEASE-EA EMPlOYE $ �OO�OOO
DESG�RIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ �O,OOO
A Liquor Liabiiity CS1600038401
04/07/2077 04/07/2018 Each Common Cause 500,000
A Liquor Liability CS1600038401 04/07/2017 04/07/2018 Aggregate Limit 1,000,000
DESCRIpTION OF OPERATION8/LOCAT1pNS/VEHICLES(ACORD 101,AddtHonal Remarks SchedWe,may ba attachetl H more space Is requlred)
Restaurant
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
1146 Route 28 ACCORDANCE WITH THE POLICY PROVISION3.
South Yarmouth,MA 02664
AUTHORIZED REPRESENTATIVE
AC �� ���'�D�
ORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD