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[No workers' comp.insurance required] 8. ❑Nor-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]** 11.0 Health Care 4.ED 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#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: MA -RETATL MERCHANTS WC GROUP TNC_ Insurer's Address: p n ROx 8cg772-4122 City/State/Zip: l«3&AINTREE, MA. 02185-0000 Policy#or Self-ins. Lic.# 014005034677119 Expiration Date: 01 /01 /2020 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under th p ' and penalties of perjury that the information provided above is true and correct Signature: _ /L, ' Date: 11/1.4 11J14/2019.. Phone#: (508)398-5592 Official use only. Do not write In this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia "'...uskip THUALOI.01 ASANZO A v$ CERTIFICATE OF LIABILITY INSURANCE °" ° °°" '" Y ' 9/9/2019 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 requke an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER License S 1780862 22NACT HUB International New England 'v1 E FAX 265 Orleans Rosi (MC,No.Exq:(508)945-0446 (A�, =(508)945-9136 North Chatham,MA 02650 Mass: INSURERS)AFFORDING COVERAGE__- NMC 0 INSURER A:Ohio Security Insurance Company 24082 INSURED INSURER s:Massachusetts Retail Merchants Workers•CaelPensallah Grm,p.In 34355 Thuan Loi Co.Inc.DBA Thuan Loi Restaurant INSURER C 1300 Route 28 INSURER D South Yarmouth,MA 02664 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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, MISRADpL' BR' .1107 TYPE OF INSURANCE illtySUNAND POLK:Y NUMBER Y EFF 1 Y YAP1 LaMTS A ; X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1°°C)0,°°0 CLAIMS-MADE X !OCCUR 'BLS58036396 ' 6/14/2019 6/14/2020 'KtMAGFt To RENTED 300.000 S(Ea ocaxrence) $ MED EXP(Any one Person) $ 15.000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 X POLICY J7 LOC PRODUCTS-COMP/OP AGG ;$ 2.000.000 pEC I OTHER: $ AUTOMOBB E MAMMY ((Ea acrid COMBINED SINGLE LIMIT S I ANY AUTO -OWNED SCHEpULED BODILY INJURY(Per Person) $ AUTOS ONLY AUTOS • 1RED NON OWNEp BODILY IITNJJUURY(Peracrid t);S AUTOS ONLY Al1TOS ONLY accident)_DAMAGE treat $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS•MADE AGGREGATE S # DED , RETENTION S ! _ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS LIABILITY ' STATUTE . . ER 74005034677119 1/112019 1/112020 ANY PROPRIETOR/PARTNER/EXECUTIVE ! 100.000 fICEWME ER EXCLUDED? NIA E.L.EACH ACCIDENT $ yyees5 SII E.L.DISEASE•EA EMPLOYEE $ 000 ; 1�� ( OFOFDESCRIPTIONOPERATIONS below A Liquor Liability BD058036396 E.L.DISEASE-POLICY LIMIT $ 500.000 6114/2019 6/14/2020 ' 500,000 DESCRIPTION/OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addlional Remelts Schedule,may be atter if more space is m4 'ed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Teem of Yarmouth ACCORD�E WITH N DATE POL POLICY THEREOF, NOTICENS. WILL BE DELNERED IN 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE VV ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD