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Home My WebLink AboutApplication and WC 4,::1; -' 14 s 1ys . F5 ti_,A-=-,':-,-_ __=',,.-,-„', + }rf a 1,00A-11420 AttiftelW 4. . • Vo WAIL-49N MAW "> .. ;yam^ ��.f, ekT... rommitari nto— owl— . e iRO SF Q ' i ,y, 4:15woltitot_fry-Stilitling. Fist< ed 1 Illi --I ra ASS_ '^ Fi ®§s : a s,ax 6,a.'ib n.G ` ;•4i. ligeoelkd0 ,_, itAin.sairicthetV .its F '.:1. ; •,i'•'-', �,e 9tl d �'*t f. 4 •!--'2.J...'4;-:P'1,, ., t Q. IJlli Yom' �. ' a�At� ,, � .,F. ,:- 1 ,.. - fro.4. _ 4 I 4 r. a• asp s 1 y -r ;; _. _. ., !II i - ^a' g maxxs 1,, co -'.•D' 1344 . ice, p '. - , + ,c- .r-1 oLs .,SEB - ` ; Attood az �. * - fl . joiatAlleteamithrookow E he ROO beggstakaittitedottigeptikytaitr::-z'''., r ''-1 You must - &AL t,, 9 . fn.a ai lg al iba s _ � rn at 4is§#4 -:,..77;;:.t.:.,f -, k 43. ., Y a`;.: ,� ... -f: !!. _ arc' • rJ1'l " RisgrAlmorisawnw � ' 2.0. z 1 . 0 . i !n l'4'..'..4.:` 'i. '44 '.u'c 314.0 - .A,4 g— aY. ,v �s ��. �. i �N 'A g fi ., _ a ,A z { wrw.. 9rxaFW, 9e x p$Rs .ate°�._ �;. ��ti,�`� ,�1s'.'^. $t; ��. _i� i $1$ = JOSOMPRAVVION Uniata01114.Sactics4MEtabatakiflAti,ditAltan latTired e_. t . _. . .,� n s Certificate. drwAtika's ti " _< r STAT''W .� INSURANCE Mkt OF . I•A'• APPROPIISATILYVINP 3, �� 87 '4 �'�- � ...: - _stabsi` y'glIMOMUY0*("Witin""Lati041640inat WAD � �. woo fir. * k o {: • s� w{ gs nt be considead,Wales OgglaWanff' thrietakadateRCIOill cleratOMOY arkIii0110d M.0L..4646 or 8O CMR(AG,as POOLS Y$ e • tis os ' obith.lopiiidakestaRtsad italtopomU#01-01MattrY P°°11aTM 111114111't "• 1**40414,114,404141044 • 4301110,3t!MOO � l ff.. FOOD RVE c. Y a - belga& 4 ,i;. , Nista opal*, Ptiouontstitte ,. y ,. ,. thO4 atjaltiragMAAMItKer1 f € .f &1.' FRi f :3' + inlox*pro* 40thelzwitnis yeses witattowda. `" c€. raj "0, :25IttOPSSPAL ` , ,- 0 3 ` �.3 VIP .a ,NOVATVSO MAY /1DATNik -� "/ f 71X _ +r,t c (a 1516/1 K j _ s Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company-A Stock Co. A•S LIARD Berkshire lire Hathaway Policy Number CAWC046643 Renewal of CAWC986704 � ComInsurancepanies NCCI No. [25844], Policy Information Page [1]Named Insured and Mailing Address Agency Cape Deli Foods Inc. THE FAIRWAY AGENCY DBA/TA Piccadilly Cafe&Deli 944 Washington St 1105 Main St. • Suite 2 South Yarmouth, MA 02664 South Easton, MA 02375 Agency Code: MAFAWA10 Federal Employer's ID Insured is Corporation Risk ID Number 39868 • Additional Names of Insured (N2) Piccadilly Cafe &Deli • • [2]` Policy Period From August 1, 2019 to August 1, 2020, 12:01 AM, standard time at the insured's mailing address. [3] Coverage • • A. Workers'Compensation Insurance - Part One of this policy applies to the Workers' Compensation ' Law of the following states: Massachusetts B. Employer's liability Insurance - Part Two of this policy applies to work in each of the states listed . in item [3]A. The limits of our liability under Part Two are: • Bodily Injury by Accident- each accident • $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance- Part Three of this policy applies to ail states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page- Schedule of Forms [4] Premium The Premium Basis and,therefore,the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. ,(Continued on another page) • • l• Total Estimated Policy Prem $ 4,897 • Total Surcharges/Assessments $ $167.00 Total Estimated Cost $ $5,064.00 INTERNAL USE XX Page- 1 - • Information Page MGA :CAWC046643 WC 000001A Date : 06/27/2019 MANOTE Issuing Office: P.O.Box A-H, 39 Public Square,Wilkes-Barre,PA 18703-0020•www.guard.com Arbella Protection Insurance Company, Inc. 1100 Crown Colony Drive,Quincy,MA 02269-9174 A R B E L L A Telephone Number: 1-800-272-3552 INSURANCE 0 R O U P COMMERCIAL UMBRELLA LIABILITY DECLARATIONS ty,^S�k ..'�� 7 „� 10/01/2019 Direct Bill 4620087186 01 RENEWAL p Y CAPE DELI FOODS INC PICCADILLY DELI • 1105 RTE 28 SOUTH YARMOUTH, MA 02664 ' 47 —f .cr4``^,s From: 10/01/2019 To: 10/01/2020 .-gam - �- „'' Corporation BREAKFAST/DELI RESTAURANT IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. Each Occurrence Limit $1,000,000 Personal&Advertising Injury Limit $1,000,000 Any One Person or Organization Aggregate Limit(except with respect to"covered autos") $1,000,000 Self-Insured Retention $10,000 $917 $50 $967 *Subject to policy minimum premium. OYes IEINo Forms and Endorsements made part of this policy at time of issue: SEE ATTACHED SCHEDULE OF POLICY FORMS AND ENDORSEMENTS • Countersigned by DATE 09/19/2019 Page 1 32AP1133 01 19 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. z r , '-__ v Rr". '�; F �•�s, k =z ,�,�, �a. �.-. 4620087186 01 RENEWAL 10/01/2019 SCHEDULE OF FORMS AND ENDORSEMENTS 28 AP 1274 01/2015 Policyholder Disclosure 2 Notice Of Terrorism Insurance Coverage 32 AP 1010 01/2019 Asbestos Exclusion 32 AP 1146 01/2019 Changes-Premium Audit 32 AP 1177 01/2019 Commercial Umbrella Policyholder Notice CU 00 01 04/2013 Commercial Liability Umbrella Coverage Form CU 01 02 01/2016 Massachusetts Residential Fuel Tank Exclusion CU 21 14 04/2013 Amendment Of Liquor Liability Exclusion-Exception For Scheduled Premises or Activities CU 21 23 02/2002 Nuclear Energy Liability Exclusion Endorsement(Broad Form) CU 21 26 04/2013 Exclusion-Cross Suits Liability CU 21 27 12/2004 Fungi Or Bacteria Exclusion CU 21 31 01/2015 Exclusion Of Other Acts Of Terrorism Committed Outside The United States;Cap On Losses From Certified Acts of Terrorism Endorsement CU 21 36 01/2015 Exclusion Of Punitive Damages Related To A Certified Act Of Terrorism CU 21 50 03/2005 Silica Or Silica-Related Dust Exclusion CU 21 55 06/2008 Amended Terrorism Coverage-Covered Autos CU 21 86 05/2014 Exclusion-Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability -With Limited Bodily Injury Exception CU 24 30 04/2013 Amendment Of Insured Contract Definition IL 00 17 11/1998 Common Policy Conditions Coverage Company Name Policy Number Policy Period Employer's Liability Berkshire Hathaway Guard Ins CAWC986704 08/01/2019-08/01/2020 Limit of Insurance $ 500,000 Each Accident/Bodily Injury by Accident $ 500,000 Each Employee/Bodily Injury by Disease $ 500,000 Policy Limits/Bodily Injury by Disease Coverage Company Name Policy Number Policy Period Commercial General Liability Arbella Protection 8500062959 10/01/2019-10/01/2020 Limit of Insurance $ 1,000,000 Each Occurrence Limit $ 1,000,000 Personal&Advertising Injury Limit(Any One Person or Organization) $ 2,000,000 General Aggregate Limit $ 2,000,000 Products/Completed Operations Aggregate Limit Coverage Company Name Policy Number Policy Period Commercial Auto Liability Main Street America Group M9K59865 10/02/2019-10/02/2020 Limit of Insurance $ 1,000,000 Each Accident/Combined Single Limit(CSL) 09/19/2019 Page 2 32AP1133 01 19 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. '. M"a*2 N -; t �:,.-sirlJ�"r,u r�" t} r �- },ati's , ," � � �� x� "'�� ,.��•�".. 4620087186 01 RENEWAL 10/01/2019 Coverage Comaany Name Policy Number Policy Period Liquor Liability Arbella Protection 8500062959 10/01/2019-10/01/2020 Limit of Insurance $ 1,000,000 Each Occurrence $ 2,000,000 Aggregate Limit 09/19/2019 Page 3 32AP1133 01 19 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. 2.wl A 1LG L.VLIi1/iU PVCIALL1L Vf iPAUJJKt.RKJGLLJ \ Department of Industrial Accidents Office of Investigations • _ I Congress Street,Suite 100 1 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Cet Q pp.( l C00( S 11y Address: t ( 0 c R o (,A �Q� Li City/State/Zip: So � lq r�6�" t^Z6 hone#: L _ G Are you an employer?Check the appropriate box: Business Type(required): 1.[a, I am a employer with 1 employees(full and/ 5. 0 Retail or part-time).* 6. ® Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ 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.El 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]** 11.0 Health Care 4.❑ 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: C L A,r clL S O rc t"‘C.. C ri Insurer's Address: r 0 A-I-1 City/State/Zip: w L I t Z. B Ot r _ ,, II F1 19`7 03 -0 g,c) Policy#or Self-ins.Lic.# (A i� 01 (p 6 y3 Expiration Date: a- I a oz 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. 1 do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct ignature;# Date: 1 1 - l _ f 9 Phone#: 5-0 O ^3 0 gq 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