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Home My WebLink AboutApplication and WC 1 TOWN OF YARMOUTH BOARD OF HEALTH !' E. , r APPLICATION FOR LICENSE/PERMIT-2019 - *Please complete form and attach all n documents by ez b r IS 2171 . NOTE:ALL BUSINESSES WITH LIQUOR LICENSES ST RETURN ER 154, Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: irk/. :Awl VCtCs Lyn (..e1), -4 TAX ID: LOCATION ADDRESS:'APIA ` c,;;� Zb 1 s+:est- TEL.#:C5($Z .7 7 S-c 4 t y MAILING ADDRESS: 1N_yC.�.rmo L.Z41 0`Lb 13 = Ej E-MAIL ADDRESS:YYiti z A.c 1,e 1; :may vCLc . Cur r> 1.11 < GO OWNER NAME: CORPORATION NAME(IF APPLICABLE): = corja MANAGER'S NAME: LkaflCj �0\0.r,s,.j TEL.#: "17S—GLI 1 q p N 6• MAILING ADDRESS: { t 1e Z 13 y Mo- i•--'t 0 7 3 rn o IR io 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. qh )�1'_).113 �) 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.Ma--\dt 101::),nThc,.-? 2.vCts\Gttr30- Se--toetca—Celna.1a-,4.1. 3. kkiAel i rf'tPX 4. 1l ncie.,_ ' A1 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. 1. 2. PERSON IN CHARGE: k55o Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. CA N C 'O 1. 2 \ -4' 1 '�V 1 E6 -us , NN ALLERGEN CERTIFICATIONS: ` 1 1 1 All food service establishments are required to have at least one full-time employee who has Allergen certification, .J j J .G as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3)(a). Please attach .t,....E i' copies of certification to this application. The Health Department will not use past years'records. You must O ,.,Q C.13 -1 1 provide new copies and maintain a file at your establishment. ( 1 O 1 oat 1. 2. U � � -L HEIMLICH CERTIFICATIONS: n r% All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich �J Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and V 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY LICENSEE REQUIRED FFEE PERMIT# LICENSE REQUIRED FEE PERMIT# CENSE REQUIRED FEE ' ,„i _.CABIN $55 MOTEL S110 • ' ►r —INN $55CAMP _LODGE $55 _TRAILER PARK $105 WHIRLPOO5 SWIMMINGL POOL$11 i 3L .. 012 WHIRLPOOL S110ea. '�; _..6, FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# ! NF ENSE REQFEE ,.., LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 � RO$60 —WHOLESALE SSO RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE X50 ..1t. $50 sq REQUIRED FEE PERMIT# =<25,14 I sq•&• $150 —FROZEN DESSERT$40TOBAINGCCO-FOODS 110 i to ='TOBA NAME CHANGE: $15 AMOUNT DUE _ $ 47540 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ADMINISTRATION 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 CERT.OF INSURANCE ATTACHED 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 NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe 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 Healthpp ent to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People are NOT allowed to sit Department 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 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 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.yannouth.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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION($)AND REQUIRED FEE(S)BY DECEMBER 15,2018. 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 REQUIRE A SI PLAN. DATE: 1 C t`� SIGNATURE: - t, � PRINT NAME& 1TILE:` ,a ? 7cy ,,r-}ii Rev.10/23/18 1 The Commonwealth of Massachusetts Department of Industrial Accidents ,� F-2.-7-.=_lila= f Office of Investigations —_"�'= " 1 Congress Street,Suite 100 • : l.l� 4 1. ='=_ Boston,MA 02114-2017. '- www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: `#-10\k dal VC tc C: rr\ctYl r i v oYl Address: '48B Pok SES L&it1 S{-c'-. ,:t- City/State/Zip: Lmat- yarniO u-14), 6Z6/3Phone#: �5b -)-1 Sc- lf((j Are you an employer?Check the appropriate box: Business Type(required): 1.alma a employer with IC) employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 12 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance required)** 11'D Health Care 4.0 We are a non-profit organization,staffed by volunteers, r with no employees.[No workers'comp..insurance req.] 12.�th ,er J i m6s Lit, *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. s.. I am an employer that is providing workers'compensation insurance for my employees, Below is the policy information. 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 expiration date). Failure 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. Ido hereby certify,under the pains and penalties of perjury that the Information provided above is true and correct. Signature: Date: Phone#: 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 aerk 4.Licensing Board 5.Selectmen's Office 6.Other 0 Contact Person: Phone#: www.mass.gov/dia VDAC C H U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) RENEWAL OF (6S62UB-4494P90-0-17) INSURER: ACE AMERICAN INSURANCE COMPANY NCCI CO CODE: 12165 INSURED: PRODUCER: HOLIDAY VACATION CONDOMINIUMS AMITY INS AGENCY INC PO BOX 940 500 VICTORY RD SOUTH YARMOUTH MA 02664 MARINA BAY NORTH QUINCY MA 02171 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s)attached. 2. The policy period is from 03-02-18 to 03-02-19 12:01 A.M.at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s)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 our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 01-31-18 WC ST ASSIGN: MA OFFICE: RPM CHUBB 24M PRODUCER: AMITY INS AGENCY INC 77W2C VDAC C H U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) RENEWAL OF (6S62UB-4494P90-0-17) INSURER: ACE AMERICAN INSURANCE COMPANY 1 NCCI CO CODE: 12165 INSURED: PRODUCER: HOLIDAY VACATION CONDOMINIUMS AMITY INS AGENCY INC PO BOX 940 500 VICTORY RD SOUTH YARMOUTH MA 02664 MARINA BAY NORTH QUINCY MA 02171 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s)attached. 2. The policy period is from 03-02-18 to 03-02-19 12:01 A.M.at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s)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 our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 01-31-18 WC ST ASSIGN; MA OFFICE: RMD CHUBB 24M PRODUCER: AMITY INS AGENCY INC 77W2C VDAC C H U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 7 011 NAICS: 721199 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 2805 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 44 TOTAL ESTIMATED PREMIUM 3187 TAXES AND SURCHARGES 126 DEPOSIT AMOUNT DUE 3313MP A/R (WCIP) # Minimum Premium: $ 500 EMPLOYERS LIABILITY MINIMUM: $ 50 ST ASSIGN: MA DATE OF ISSUE: 01-31-18 WC OFFICE: RMD CHUBB 24M PRODUCER: AMITY INS AGENCY INC 77W2C VDAC C H U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 7011 NAICS: 721199 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 2805 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 44 TOTAL ESTIMATED PREMIUM 3187 TAXES AND SURCHARGES 126 DEPOSIT AMOUNT DUE 3313MP AIR (WCIP) # Minimum Premium: $ 500 EMPLOYERS LIABILITY MINIMUM: $ 50 ST ASSIGN: MA DATE OF ISSUE: 01-31-18 WC OFFICE: RID CHUBB 24M PRODUCER: AMITY INS AGENCY INC 77W2C C HUB B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6S620B-4494P90-0-18) INSURER: ACE AMERICAN INSURANCE COMPANY 12165-MA INSURED'S NAME: HOLIDAY VACATION CONDOMINIUMS RATE BUREAU ID: 000364081 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN ENTITY CD 001 HOLIDAY VACATION CONDOMINIUMS 488 MAIN ST, RTE 28 WEST YARMOUTH, MA 02673 SIC CODE: 7011 NAICS: 721199 CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS NOT EXCEEDING THREE STORIES IN HEIGHT 5645 1710 8.11 139 CLERICAL OFFICE EMPLOYEES NOC 8810 IF ANY .07 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9052 145356 1.80 2616 DATE OF ISSUE: 01-31-18 WC ST ASSIGN: MA SCHEDULE NO: 1 OF MORE C H U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6S62U8-4494P90-0-18) INSURER: ACE AMERICAN INSURANCE COMPANY 12165-MA INSURED'S NAME: HOLIDAY VACATION CONDOMINIUMS RATE BUREAU ID: 000364081 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN ENTITY CD 001 HOLIDAY VACATION CONDOMINIUMS 488 MAIN ST, RTE 28 WEST YARMOUTH, MA 02673 SIC CODE: 7011 NAICS: 721199 CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS NOT EXCEEDING THREE STORIES IN HEIGHT 5645 1710 8.11 139 CLERICAL OFFICE EMPLOYEES NOC 8810 IF ANY .07 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9052 145356 1.80 2616 DATE OF ISSUE: 01-31-18 WC ST ASSIGN: MA SCHEDULE NO: 1 OF MORE • C I-I U B la" WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 (CONT'D) HOTEL: RESTAURANT EMPLOYEES 9058 IF ANY 1.50 1.00% EMPL. LIAB. INCREASED LIMITS(9807) $ 28 ADD FOR INCREASED LIMITS MINIMUM (9848) 22 1.000 MERIT RATING MODIFICATION NONE TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2805 EXPENSE CONSTANT(0900) 338 0.0300 TERRORISM (9740) 44 4.56% MA WC SPECIAL FUND AND TRUST FUND 126 TOTAL ESTIMATED PREMIUM 3313 DEPOSIT AMOUNT DUE 3313 DATE OF ISSUE: 01-31-18 WC ST ASSIGN: MA SCHEDULE NO: 2 OF LAST C I -I U B B® WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4494P90-0-18) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 (CONT'D) HOTEL: RESTAURANT EMPLOYEES 9058 IF ANY 1.50 1.00% EMPL. LIAB. INCREASED LIMITS(9807) $ 28 ADD FOR INCREASED LIMITS MINIMUM (9848) 22 1.000 MERIT RATING MODIFICATION NONE TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2805 EXPENSE CONSTANT(0900) 338 0.0300 TERRORISM (9740) 44 4.56% MA WC SPECIAL FUND AND TRUST FUND 126 TOTAL ESTIMATED PREMIUM 3313 DEPOSIT AMOUNT DUE 3313 DATE OF ISSUE: 01-31-18 WC ST ASSIGN: MA SCHEDULE NO: 2 OF LAST CHUB EB. WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: (6S62UB-4494P90-0-18) LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 INFORMATION PAGE WC 00 00 01 A - 001 INFORMATION PAGE 2 WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE WC 00 00 01 A - 001 ENDORSEMENT LISTING WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 B - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT WC 20 03 01 00 - 001 MA LIMITS OF LIABILITY ENDORSEMENT WC 20 03 02 A - 001 MASSACHUSETTS - ASSESMENT CHARGE WC 20 03 03 D - 001 MA NOTICE TO POLICYHOLDER ENDORSEMENT WC 20 03 06 B - 001 MA LIMITED OTHER STATES BENEFIT ENDT WC 20 03 07 00 - 001 MA ASSIGNED RISK POOL ELIGIBILITY WC 20 04 03 00 - 001 MA. CONST. CLASS PREM. ADJ. PROGRAM WC 20 04 05 00 - 001 MASSACHUSETTS PREMIUM DUE DATE ENDT WC 20 06 01 A - 001 MA CANCELLATION ENDORSEMENT WC 20 06 04 00 - 001 MA POLICY DEFINITION ENDT DATE OF ISSUE: 01-31-18 ST ASSIGN: MA Page 1 of LAST I—I U B Be WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: (6S62UB-4494P90-0-18) LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 INFORMATION PAGE WC 00 00 01 A - 001 INFORMATION PAGE 2 WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE WC 00 00 01 A - 001 ENDORSEMENT LISTING WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 B - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT WC 20 03 01 00 - 001 MA LIMITS OF LIABILITY ENDORSEMENT WC 20 03 02 A - 001 MASSACHUSETTS - ASSESMENT CHARGE WC 20 03 03 D - 001 MA NOTICE TO POLICYHOLDER ENDORSEMENT WC 20 03 06 B - 001 MA LIMITED OTHER STATES BENEFIT ENDT WC 20 03 07 00 - 001 MA ASSIGNED RISK POOL ELIGIBILITY WC 20 04 03 00 - 001 MA. CONST. CLASS PREM. ADJ. PROGRAM WC 20 04 05 00 - 001 MASSACHUSETTS PREMIUM DUE DATE ENDT WC 20 06 01 A - 001 MA CANCELLATION ENDORSEMENT WC 20 06 04 00 - 001 MA POLICY DEFINITION ENDT DATE OF ISSUE: 01-31-18 ST ASSIGN: MA Page 1 of LAST