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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH it APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15,2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15th. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME:�-ii'is Lrh//e n AE-71t4 (1,0W 00 /.JJOc- TAX ID: LOCATION ADDRESS: 6O 41(01) l)WtQy W Vi1R TEL.#:(6/7) 7 71-16 6‘ MAILING ADDRESS: E-MAIL ADDRESS: (otic Kril EA.00IP 1p (,m4/i-,(00m OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME:/10 even 0 r tuts, TEL.#: MAILING ADDRESS: (4 a Qleo A‘,/1 - POOL CERTIFICATIONS: � ::1*--:': The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - 1 Pool Operator(s)and attach a copy of the certification to this form. .1 _ 0) 1. eooL7E'f TidA/ 2. ; 1 , c , Pool operators must list a minimum of two employees currently certified in standard First Aid and Community L, 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. L 1. DOf?FLi/ YW'Odi( 2. S/ 'L OEE/)f 3. Y1 N1) 12/4_ 04A.0 bF,.-' 4. J /t et E vl;,,vJ FOOD PROTECTION MANAGERS-CERTIFICATIONS: 1 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: x m Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 4,.? A' 1. 2. Z. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, Ui 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. 1. 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'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 130 P t�--(9`l3'0 Li OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 _A SWIMMING POOL$I 10ea. f—/ BADGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.T� 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 RETAIL SERVICE: —RESID.KITCHEN $80 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. $150 -FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ //O. 0 c *****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 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 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.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 CAFÉS: 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(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 APP'OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY '4'0 l/ 'A SITE PLAN. DATE: /— // 0' SIGNATURE: 1/ A PRINT NAME&TITLE: T' Rev.10/23/18 The Commonwealth of Massachusetts -��... Department of Industrial Accidents Office of Investigations -=-.7,01=7-.7 1 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: EA/(i ci.j gp-Aehc (&..ti u ,4iJU(,f�Ti Address: 60 tjj�v,q,�,,tigr City/State/Zip: �(l yf�,ery�,,Ty/im G261? Phone #: ((/2) ??/-/66 e Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. El 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. ❑ 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.❑ Manufacturing no employees. [No workers' comp. insurance required]*'' 4.0 We are a non-profit organization,staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.►/ Other ('OAf 00/14 'f't *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 information. Insurance Company Name: Al /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. I do hereby c, ,1 er the pains and penalties of perjury that the information provided above is true and correct. Si.nature: Date: /—/r- / �4 /r Phone#: I 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 i-0,-(s) TOWN OF YARMOUTH BOARD OF HEALTH ( APPLICATION FOR LICENSE/PERMIT-2019 _-% *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER I5'". Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME:fw4-LE-we:a e14Ki* C®N.00 /4Jd®c- TAX ID: (-73'— 3 So 05'7-C- LOCATION ADDRESS: lO /U( 4LI,,' )- Ut/: VI1(Z TEL.#:(a/7) 7 71-/6 6e MAILING ADDRESS: E-MAIL ADDRESS: e�'4i‘k'lYl6A.c),,,,P jp C 4.0./L,(°OIY! OWNER NAME: CORPORATION NAME(IF APPLICABLE): Scri ►Delt) MANAGER'S NAME:/la elks) Or rh6'1', TEL.#: ( Qom"R• MAILING ADDRESS: f,0 Qea A 44.✓/4!- cJ 2 1N&Ew POOL CERTIFICATIONS: 69.00‘c._ -)(4JE 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. (A)„664 L-S TO S, 1. Poo L7EtlJ.r/ 2. MR oi583— Pool operators must list a minimum of two employees currently certified in standard First Aid and Community i9 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. OneE3-:✓ rhrianci,( 2. Sff.,2d 8QE/)/A 3. Y1=n/012 y/yt/1_v j F.`' 4. *I i2 e I E z✓lt v.. .T_ � F-. .. FOOD PROTECTION MANAGERS-CERTIFICATIONS: '2> (' All food service establishments are required to have at least one full-time employee who is certified as a Food H L Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. II: 0) r 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. G.' 1. 2. � �� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food 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. 1. 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'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN S55 MOTEL 5110 --INN S55 —TRRAILILER PARK $105 — SWIMMINGO POOL Sl10e. WHIRLPOOL SIIOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL S35 NON-PROFIT S30 _>I00 SEATS S200 COMMON VIC. S60WHOLESALE 580 RETAIL SERVICE: —REM.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _ sq S50 >25,000 sq R. S285 VENDING-FOOD S25 <25,000 sq.ft. S150 =FROZEN DESSERT S40 TOBACCO S110 NAME CHANGE: S15 AMOUNT DUE = S //0. o,) 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 r/ 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 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 swinuning,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 contact the Health Department to schedule the inspection three(3)days prior to opening. CATERLNG 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.varmouth.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(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 APPOVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY • i; ' A SITE PLAN. DATE: /— 1l— 2 p/9 SIGNATURE: �� (t,1,�'7 {?*SQvex PRINT NAME&TITLE: T- . : - e-/e/. Rev.10/23/18 The Commonwealth of Massachusetts Print Form I Department of Industrial Accidents _ -- Office of Investigations -119—= 1 Congress Street,Suite 100 Boston,MA 02114-2017 'r••:1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E��i (16,4.00 kw pr.A7/4,✓ Address: 60 ® D City/State/Zip:VV. YA,e0v,m, m/ 0260? Phone#: �/2) 72/--f66 Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with 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] S. El 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]*" 4. We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp.insurance req.] 12.2 Other 00,J OaM/N;�• (���,� Ardmi&d..d *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 information. Insurance Company Name: /V//�nsurer'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. I do hereby c , I er the pains and penalties of perjury that the information provided above is true and correct. i•nature: i Date: /'/" ?o/y Phone#: 7/—/(6 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 AC o'. CERTIFICATE OF PROPERTY INSURANCEDATE(MMIDD/YYYY) 01/11/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CODERS 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 PRODUCER Ccnr to Rescigno Tarpey Insurance Group,Inc. PHONE 781-246-2677 FAX 442 Water Street INCNo.EM): (NC,No): Waledeld,MA 01880 ADDRESS: connneatarpey(nsurance corn PRODUCER CUSTOMER ID:163 INSURER(S)AFFORDING COVERAGE NAIC• INSURED Englt ood Beach Condominium Association INSURER A:Llo)ds Of London A0233 do Craig Meador INSURER B:Trawlers Casualty&Surety Co A0470 6 Gtmmood Lane Wakefield,MA 01880 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LOCATION OF PREMISES I DESCRIPTION OF PROPERTY (mach ACORD 101,Additional Remarks Schedule,if more space is required) Lac#1-7 unit condo building 60 Broadway, West Yarmouth,MA 02673 TMS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TI-E INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOLAREMENT,TERM OR CONDITION OF ANY CONTRACT CR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,11-E INSURANCE AFFORDED BY TI-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS CF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POUCY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTRDATE(MM/DD/YY COVERED PROPERTY LIMITS A PROPERTY Yh DATE(MM/DDNYW) ✓� QSRMA11061 01/05+2018 01/05/2019 V BULDNJG $ 1225,500 CAUSES OF LOSS DEDUCTIBLES \ PERSO AL PROPERTY $ 18,000 BAS BULDING BUSNESSINCOME5,000 $ BROAD CONTENTS EXTRA ETENSE SPECIAL 5,000 RENTAL VALUE $ EARTHQUAKE BLANKET BL.&DING WIND BLANKET PERS PROP $ FLOOD BLANKET BLDG&PP $ $ INLAND MARINE TYPE OF POLICY CAUSES OF LOSS NAMED PERILS POLICY MIMER $ CRIME TYPE OF POLICY BOILER&MACHINERY I EQUIPMENT BREAKDOWN $ B General Liability 106042281 12/31/2017 12/31/2018 V Aggregate $ 2,000,000 V Pe iOccirence $ 1,000,000 SPECIAL CONDITIONS/OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED ED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /J rii/J'� 16414dr, ;'° ©1995-2015 ACORD CORPORATION. All rights reserved. ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD • ACo CERTIFICATE OF PROPERTY INSURANCE DATE(MMIDDIYYYY) `..../ 01/11/2019 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 POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU RER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER PRODUCER CONTACT TarpeyInsurance Group,Inc. PHO : PHONE FAX 442 Water Street INC.No.Ext): (NC,No): Wetid ald,MA01880 AAD -MAIL PRODUCER CUSTOMER ID:16083 INSURER(S)AFFORDING COVERAGE MSC* INSURED Englewood Beach COndoniniun Association INSURER A:UO)dS Of Landon A0233 c/o Craig Meador INSURERS: 6 Gunwood Lane Wakefield,MA 01880 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LOCATION OF PREMISES/DESCRIPTION OF PROPERTY (Mach ACORD 101,Adddional Remarks Schedule,if more space is required) Loc#1-7 unit condo building 60 Broadway, West Yarmouth,MA 02673 TI-ItS IS TO CERTIFY THAT THE POLICIES CF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOME INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECLNREMENT,TERM CR CONDITION OF ANY CONTRACTOR 011-ER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED CR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TFE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POCKY NUMBER POLICY EFFECTIVE POiICY EXPIRATION COVERED PROPERTY LIMITS LTR DATE(MM/DD/YYYY) DATE(MM/DO/YYYY) A VI PROPERTY QSRMA19283 01/05/2019 01/05/2020 V BUILDING $ 1,225,500 CAUSES OF LOSS DEDUCTIBLES J PERSONAL PROPERTY $ 18,000 BASIC BLa.OING 5000 BUSINESS INCOME $ — BROAD CONTENTS EXTRA B1 $ V CItCIAL 5,000 ' RENTAL VALUE $ EARTHQUAKE - BLANKET BULDIN3 + )HAND - BLANKET PERS PROP FLOOD BLANKET BLDG&PP $ $ _ INLAND MARINE TYPE OF POLICY $ CAUSES OF LOSS NAMED PERILS POLICY NUMBER $ CRIME TYPE OF POLICY u $ BOILER 8 MACHINERY/ $ EQUIPMENT BREAKDOWN A General Liability QSRMA19283 01/05/2019 01/05/2019 J Aggregate ggreg $ Z000,000 V Per/Occurence $ 1,000,000 SPECIAL CONDITIONS I OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached N more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1995-2015 ACORD CORPORATION. All rights reserved. ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:11111111111111111111111111111.11.1.1.1111. ---^40LOC#: ACCORD ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Tarpeylnsurance Group,Inc. Englewood Beach Condorrinium Association POUCY NUMBER c/oCraig Meador 6 GurrvAood Lane Waletreld,MA 01880 CARRIER NAIL CODE A0233 EFFECTVE DME: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ACORD 101(2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD