Loading...
HomeMy WebLinkAboutApplication and WC DATE:12/11/2018 CK#:6399 TOTAL:$850.00***** BANK:Operating Account(mam000op) PAYEE:Town of Yarmouth(townofyarm) Property Address-Code Invoice- Date Description Amount Maplewood at Mayflower Place - ma CKRQ12112018B - 12/11/2018 850.00 850.00 1 i IIIIP cpo. ,, v1/404- . , s&...% n U-V /tJ^JNM' V, VoA im' a-k): 74 (.)r- , UO jc (2-° ) ..0j.. CI'9. / 91 b ./-. C'et-" ,2)%1 bw` k Rt crus'. .- ())(1.4k : 2./.6 , x22 c �s� Q 1 , ' PeektiktAs `jr5'(5 y1 a • I TOWN 01?YARMOUTH BOARD OF HEALTH S pii 6'---..iti,::),‘-' AI. APPLICATION FOR LICENSE/PERMIT-2019 D 3> . *Please complete form and attach all necessary documents by December I.S.2018. CI' >iALLBusINESSHSWnT8Liqu0•LICENS MUST RETURNFORbfSBI� 1OYBMBER1S`: y �11 Failure to do so will result m the return ofapplication acket Q yourP ESTABLISHMENT NAME:Maplewood at Mayflower Place TAX ID: LOCATION ADDRESS:579 Buck Island Road.West Yarmouth,MA 02673 TEL,#:(508)790-0200 MAILING ADDRESS: 579 Buck Island Road.West Yarmouth.MA 02673 E-MAIL ADDRESS:mavflowered( maplewoodslcom OWNERNAME: (See Below) • CORPORATION NAME(IF APPLICABLE):MaDlewood Mayflower Place ALF.LLC MANAGER'S NAME:Rachel Greenfield TEL.#:(508)790-0200 !f i Ti MAILING ADDRESS: 579 Buck Island Road.West Yarmouth,MA 02673 111 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law.Please list the designated Pool Operators)and attach a copy of the certification to this form. r:,. 1. Richard J.Pizzuto 2, Pool operators must list a minimum of two employees currently certified in standard First Aid and Community L. Cardiopulmonary Resuscitation(CPR),having one certified d •,•'oyez on premises at all times. Please list the ' t employees below and attach copies oftheir certifications to this .•.... The Health Department will not use past. F eWO years'records. You must provide new copies and maintain a file at your place of business. .440 } 1,Cryytai Moniz 2.Richard J.Pizzuto 3.Holly Foss 4.Linda A.Harding F.' 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. I r Please attach copies ofcertification to this application.The Health Department w 111 not use pastyears'records. You must provide new copies and maintain a file at your establishment. 1.Robert Patchel CSD 2. Keith Shuck • • PERSON IN CHARGE: g 1 r Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. . 1,Robert Patchet 2,Keith Schuck G ALLERGEN CERTIFICATIONS: • I All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined inthe State Sanitary Code forFood Service Establishments,105 CMR 590.009(G)(3Xa).Please attach copies of certification to this application. The Health Department will not use•pastyearsrecords.You must i I provide new copies and maintain a file at your establishment. 1. Robert Patchel 2• Maria Hollenberg W • • •HEIMLICH CERTIFICATIONS: 1 I g„. Ali 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-cholang procedures below and 1 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. t _I 14 1. Deborah Fleming_ • 1 2. Robert Patchel 3.Keith Schuck 4.Krista Mitsokostas RESTAURANT SEATING: TOTAL# 124 CSP.) t304'5(7-15-• l802.—Ot 0t t (so) GottSP-IS-030',—(:),f OFFICE USE ONLY goat?-1a3—(1305-04/ LICENSEREQU1RED FEE PERMIT UCENSEREQUIRED PEE PERMITS rICENSEREQUIRED FEE PERMITA g ._rite SSS CABIN 555 MOTEL 5710 , INN 555 —CAMP $55 ISiusvha JGPOOLSIlOea �()I9 .7 jp =LODOE S55 =1RAIIERPARK S105 WHIRLPOOL SllOea 11p FOOD SERVICE: F ..., LIQ PEE PERMITS LICENSEREQUILED PEE PERMITS LICENSE REQUIRED FEE PERMITS 0.100 SEATS 5125 CONTINEEN AL $35NON-PROFIT 530 • :125•100 SEATS 5200 -4 t:u _L•' Q OM MON VIC. 560 =OV? riot Esau s sso • RETAIL=VIM —RES1D,137 CFIEN S80 y LICENSE REQUMED FEE PERMIT I LICENSEREQUIRED PEE PERMITS LICENSE REQUIRED FEE PERMITS 1 <50 sq.*. 550 >25000 R 5285 VENDING-FOOD$25 =QS, sq , $150x`— ROBEST S40 _TOBACCO 5110 • 1 NAME CHANGE: SIS AMOUNT DUE= S-8550- -ea I 1- 111 PLEASE TURN OVER AND COMPLETE OTHER SIDE OFFORM‘"" t4 8O• .©0 1 -c . (SCJ g g 'g 4 i.3 • r�+ i 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 X I{ OR i 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 X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY:Forpurposes ofthe limitations ofMotel or Hotel use,Transient occupancyshall 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 i ry Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as I 1 amended,shall generally be considered Transient R 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�ppseudomonas,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 1(1 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,varn outh.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 wilt result in the suspension or revocation of your Frozen Dessert Permit until the • above terms have been met. OUTSIDE CAFLS: • Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. i r OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. I uTOBACCO 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 YOURRESPONSIBILITYTO RETURN THE COMPLETED RENEWAL APPLICATION(S)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 SITE PLAN. DATE:12/ /18 SIGNATURE: PRINT NAME&TITLE:Rachel Greenfield, Executive Director • Rev.10127118 t � • The Commonwealth of Massachusetts • p!, .47Department of Industrial Accidents Office oflnvestigations • I Congress Street,Suite 100 Boston,MA 02114-2017. ''-•=•���'+ www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Ma•lewood at Ma ower Pla - Address: 579 Buck Island Road City/State/Zip: W Yarmouth, MA 02673 Phone#: 508-790-0200 Are on an employer?Check o appropriate box: Business Type(required): 1. 1 am a employer with 70 employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 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. ❑Nou-profit 3.0 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./.i Health Care 4.0 We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp..insurance req.] 12.0 Other *Any applicant that checks box Cl 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 Cl. I am an employer that is providing workers'compensation insurance for my employees: Below is the policy information. Insurance Company Name: The Memic Group Insurer's Address: 180 Glastonbury Blvd#304 City/State/Zip: Glastonbury. CT 06033 Policy#or Self-ins.Lic.# 3102804908 Expiration Date: 6/1/2019 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required un er Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year int onment,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 vi91. o Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for. urA verage verification. I do hereby certify,under the p penalties of perjury that the information provided above is true and correct. � f Signature: 1 Date: PI/t/(Q f Phone#: 003 55—?- 777 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 moommWorkers Compensation and Employers Liability Insurance ��/ POLICY INFORMATION PAGE MEMIC Indemnity Company Policy Number Policy Period (A Stock Company) From TO 1750 Elm Street Suite 500 310 2804908 06/01/2018 06/01/2019 Manchester NH 03104-2920 12:01 A.M.Standard Time at the described location Renewal of Transaction Renewal of 310 2804908 RENEWAL DECLARATION 1. Named Insured and Address Agent MAPLEWOOD SENIOR LIVING LLC M&T INSURANCE AGENCY INC 3326374 ATTN: MELISSA ALGARIN 285 DELAWARE AVE ONE GORHAM ISLAND STE 100 BUFFALO NY 14202 t WESTPORT CT 06880-0000 Telephone: 716-853-7960 NCCI Carrier# 913933788 LTD LIAB CO Other Workplaces not shown above: SEE ATTACHED ADDITONAL WORKPLACES SCHEDULE 2. The Policy Period is from 06/01/2018 to 06/01/2019. 12:01 A.M.Standard time at the Insured's mailing address 3. A.Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here:CT, MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 Each accident Bodily Injury by Disease $ 1,000,000 Policy limit Bodily Injury by Disease $ 1,000,000 Each employee C. Other States Insurance: Part THREE of the policy applies'to the states, if any,listed here: AK, AL, AR, AZ, CA, CO, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, WV, D. This policy includes these endorsements and schedules:SEE ATTACHED ENDORSEMENT SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates,and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 750 Total Estimated AnnualPremium $ 1,220,027 Expense Constant $ 338 Premium Discount $ -161,696 Deposit Premium $ 1,220,027 Assessments and Taxes $ 55,164 0 This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; 0 Semiannual; ❑ Quarterly;0 Monthly Countersigned this Day of clifa.461-- Issued Date: 06/05/2018 Issuing Office:1750 Elm Street Suite 500 Au Ize Representative Manchester NH 03104-2920 WC 00 00 01 A(Ed.8-17) INSURED'S PDF COPY Page 1 of 8 Act CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY► `.e..• -- 11/21/2018 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 AFFORDED 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(les)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). PRODUCERT surance Agency, Inc. Ar eT Commercial Lines HONE _ _ FAX — __ry 285 Delaware Avenue, Ste 4000 (A,c- .Exn;718-853-7960 um,No):855-595-4605 Buffalo NY 14202 ADDRESS: CLServicIngamtb.com INSURES)AFFORDING COVERAGE _ NAIC# _ _ _ _ INSURER A Illinois Union Ins.Co 6 27960 INSURED MAPLE-5 INSURER B:MEMIC IndemnrCompany _ 11030_._.___ Maplewood Mayflower Place ALF, LLC do Maplewood Senior Living LLC INSURER ______ One Gorham Island INSURER D Westport CT 06880 INSURER E _ _____ —._. INSURER F COVERAGES CERTIFICATE NUMBER:1397909894 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. NOTWITHSTANDING 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.LIMITSSHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN$R I ._."__... ..__ __ Abeirgan-- . __ -�__ POLICY EFF- PCILICY EXP _.__� tIMnS LTR TYPE OF INSURANCE f INSD WYD POUCYNUMBER (MMIDD/YYYY) (MM/DD/YYYY)j A X COMMERCIAL GENERAL LIABILITY I Y Y (328122986 6/1/2018 6/1/2019 1 EACH OCCURRENCE $1, , 000000 I I CLAIMS-MADE L A 'OCCUR t i iSAMAGETO f1ENTEb __I 1 I PREMISES,LE•e occurrencel_ $50,000 -.___. ! LMED EXP(Any ons ersonl_ $___._ .__ _ I PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I i GENERAL AGGREGATE $3,000,000 I POLICY JECOT X_, LOC j PRODUCTS-COMP/OP AGG $1,000,000 X OTHER: Policy Aggregate 1' v- --. --_. Policy Aggregate $10,000,000 AUTOMOBILE LIABILITY COMBIND SINGLE LIMIT $ (Ea accident) —'ANY AUTO BODILY INJURY(Per person) $ ' OWNED SCHEDULED - --- �AUTOS ONLY ____/AUTOS BODILY INJURY(Per accident) $ 1 HIRED I NON-OWNED -- i PROPERTY DAMAGE $AUTOS ONLY ' AUTOS ONLY 1eaccident - -- $ 3 UMBRELLA UAB 1 I OCCUR r EXCESS LIAB EACH OCCURRENCE $ __i_,___ ! i CLAIMS-MADE 1 AGGREGATE $ I DED I (RETENTION$ {4 $ B WORKEAND EMPLOYERS LIA II IT Y/N I COMPENSATON3102804908 8/1/2018 8/1/2019 lX STATUTE - EPER RH_ ANYPROPRIETOR/PARTNERIEXECUTIVE !! OFFICER/MEMBER EXCLUDED? n N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) I I E LE.L.DISEASE-EA EMPLOYEE $1,000,000 II yyes��,describe under PEScnlf`Tlt'1N nr nprrtAT:rwe book., I -}-C.L.OffrCASC otiov LIMIT 51,000,000 A i Professional Liability 1 628122988 8/1/2018 8/1/2010I Each 3,000,000 I Each Profl Incident 1,000,000 Occurrence Form ! ( I Shared Policy Agg 10,000,000 I i 1 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is required) RECEIVED 1 NOV, 2 9 2018 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Board of Health 1146 Route 28 South Yarmouth MA 02684 AUTHORIZED EPRESENTATIVE '`‘,..Q -1 ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 2 o12 35 AcoREP CERTIFICATE OF LIABILITY INSURANCE DATE(14Mt/DD/YYYY) ‘rw.•/ 5/31/2019 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 AFFORDED BY THE POUCIES 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(les)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). PRODUCER CONTACT M&T Insurance Agency, Inc. Commercial Lines ____ Fax 285 Delaware Avenue, Ste 4000 c.Mo.EX :718-853-7960 ___ _ ._ Buffalo NY 14202 0 wC.Nol:855-595-4805 ADDRESS: CLServicing©mtb.com ,______________ INSIIRER(S AFFORDINOCOVERAGE ! NAIC# INSURER A:MEM IC Indemnity Co I 11030 INSURED MAPLE-5 INSURER B_ Hallmark SpeCi8 l Ins Co G 26808 Maplewood Mayflower Place ALF,LLC _ ___._ __..�_._.__�____ ,_ do Maplewood Senior Living LLC INSURER C__ ____ rt -f-- One -__ One Gorham Island INSURERDr Westport CT 06880 (NsurR E ___— ___ INSURER F: I COVERAGES CERTIFICATE NUMBER:1400906037 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. NOTWITHSTANDING 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. VL17G5DC (If3A —_ _ _>___ .._. - POLICY EFF Tu'p0 CY Exp I rR TYPE OF INSURANCE REIp WED POLICY NUMBER (IMIM/DQ/TYYYI (01.$41 4/YYYy)1 LIMITS B X T COMMERCIAL GENERAL LIABILITY Y Y 75LTP000739 8/1/2019 8/1/2020 ) i EACH OCCURRENCE $1,000,000 j CLAIMS-MADE ).(,:j OCCUR DAMAGE TO AMID- _ PREMISES(EA ogurrencel__ $50,900 _ ______ I__._.___—_ -----__,_.-____m MED EXP(Any one person)._ - �__ __ PERSONAL&ADV INJURY _ $1,000,000_- GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $3,000,000 I PRO- _ I POLICY _ JECT I LOCI PRODUCTS-COMP/oP AGG $1,000,000�� j X OTHER: Policy Aggregate Folic/Aggregate $10,000,000 AUTOMOBILE LIABILITYC8N BIKED SINGLE LIMIT $ (Ea acciden(l I ANY AUTO I BODILY INJURY(Per person) $ --I OWNED F-1 SCHEDULED i BODILY INJURY(Per accident) $ ---1 HIRED ONLY �_ AUTOS I II HIRED NON•OWNED f PROPERTY DAMAGE $ _ AUTOS ONLY �_ AUTOS ONLY _(pm accident) 1 UMBRELLA UAB L__ OCCUR I EACH OCCURRENCE $ EXCESS UAB I /CLAIMS-MADE AGGREGATE $ 1 I DED RETENTION$ $ A WORKERS COMPENSATION 3102804908 6/1/2019 6/1/2020 X I PER ' TOTH- AND EMPLOYERS'LIABILITY Y/N STATUTE �_ ER ANYPROPRIETOR/PARTNERJEXECUTIVEI FF(MandaERNE In H)EXCLUDED? N N/A j E.L..EACH ACCIDENT $1,000,000 E.L.DISEASE-EA EMPLOYEE $1,000,000 H ee describe under . _._...r._D.E. IPTIObL QF C]P RwTI S below _ j --- --_-___ - - --- _-. —E DIIEMMF.•POLICYUMII_$.1,000,000. - -___. B Professional Liability 75LTP000739 6/1/2019 8/1/2020 Each Profl Incident 1,000,000 Occurrence Form Prof!Aggregate 3,000,000 I I Shared Policy Agg 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addittonal Remarks Schedule,may be attached If more space is required) JUN 0 7 2019 HEALTH DPT. CERTIFICATE HOLDER CANCELLATION ---�- I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02684 AU NI •REPRESENTATIVE ®1988.2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 2"of 2 224 1 ACc,e CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDD/YYYY) ..---- 6112019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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), AUTHORIZED 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 suchheendorsement(s). PRODUCM&T Insurance Agency, Inc. CommercAcr ial Lines Service Team__,",_ 285 Delaware Avenue, te 4000 c.PHONE.Fyn: 716.853-7960 ( C.NO):855-595-4605 Buffalo NY 14202 ADP: CLServicingamtb.com { ----- INSURER(S)AFFORDING COVERAGE I NAIC# ��_____ ___ INSURER A:Great Northern Insurance Co. 20303 INSURED MAPLE-6 INSURER s .MEMIC Indemnity Co 11030 Maplewood Mill Pond LLC — -------_—.--...__ ' c/o One Gorham Island _INSURER National Fire A Marine Ins Co 20079 Westport, CT 06880 ��6 P INSURER D:Hallmark Specialty Co � ' 36808 INSURER E:TDC Specialty Ins Co 34487 INSURER F:StarStone Specialty Ins Co ! 44776 COVERAGES CERTIFICATE NUMBER:546590202 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. NOTWITHSTANDING 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. 1( p TYPE OF INSURANCE NS —ObiSUER r-01 LIC`!EFF'"-'POLICY EXP LIMnB INSD WVD POLICY NUMBER €(MM/DD/YYYY) (MM/DD/YYYYI D X I COMMERCIAL GENERAL LIABILITY 75LTP000739 6/1/2019 8/1/2020 EACH OCCURRENCE $1,OOO,D00 j CLAIMS-MADE C X OCCUR I DAMAGE TO RENTED I PREMISES(Ee occumcel__ $50,000 I MED EXP(Any Onepersott $ rvM " ___, -I - . ___�( I i PERSONAL&ADV INJURY $1,000,000 . GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY, 1 JECT L.. f LOC PRODUCTS-COMP/OP AGO $1,000,000 X I OTHER: Shared Aggregate Poll Aggregate $10,000,000 i A AUTOMOBILE LIABILITY 73594041 8/1/2019 6/1/2020 ( INGLE UMIT $1;000,000 • X ANY AUTO BODILY INJURY(Per person) $ OWNED i SCHEDULED BODILY INJURY(Per accident)$ AUTOS ONLY AUTOS " i HIRED ril NON-OWNED PROPERTY DANA E —" AUTOS ONLY AUTOS ONLY "_,_ rpcciden) _ , �." $ H _�_ _" I 1 I _ $ D I UMBRELLA UAB X OCCUR I 75LTX000740 6/1/2019 6/1/2020 $19,000,000 C " s FNSC100124 8/1/2019 6/1/2020 EACH OCCURRENCE FF X 1 EXCESS LIAB = CLAIMS-MADE N86678190AHL 6/1/2019 6/1/2020 AGGREGATE $W19,000,000 �"' LTX-00135-19-02 8/1/2019 ! 6/1/2020 �" "-'—�"' . DED I I RETENTION$ $ B WORKERS COMPENSATION 3102804908 6/1/2019 6/1/2020 X STATUTE - 0TTH. AND EMPLOYERS'LIABILITY Y/N - ANYPROPRIETOR/PARTNER/EXECUTIVE �� OFFICER/MEMBEREXCLUDED?' I I N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) I[fees,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 U br..HIPT:UN Or Ot'tHAI IONS oeiow -------------------_-___-- ----SI-DISEASE-P01.10y I 1 nno,ono D I Profession!Liability ! 75LTP000739 6/1/2019 6/1/2020 Perincident 1,000,000 Occurrence Form rgg I PAggregate ky Shared Aggr 3,000,000 0 000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02684 AU •R r REPRESENTATIVE r,tre,4, ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 2*of 2 133