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Home My WebLink AboutWorkers Comp Info 84/0B/Z9 04:Z1:38 1-855-893-4357 -> 588768347 The Hartford Page 001 ttftRTFORLD The Hartford Fax Cover Page RE: YANKEE CRAFTERS INC Fax Number: 508-760-3472 From: The Hartford Business Service Center Date: 4/8/2020 4:21'05 AM Subject: Total Pages: 4 PRIVILEDGED AND CONFIDENTIAL: This electronic communication, including attachments, is for the exclusive use of addressee and may contain proprietary,confidential and/or privileged information, If you are not the intended recipient, any use, copy,disclosure, dissemination or distribution is strictly prohibited. If you are not the intended recipient, please notify sender Immediately by phone,destroy this communication and all copies. 84/88/a 84:Z1:40 1-055-093-4357 -> 588768347 The Hartford Page 003 h;, THE HARTFORD =' -:"'• BUSINESS SERVICE CENTER THE��' " 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 April 8, 2020 Town Or Yarmouth Health Department Attn:Bruce Murphy 1146 ROUTE 26 SOUTH YARMOUTH MA 02664-4463 Account Information: Contact Us Policy Holder Details : YANKEE CRAFTERS INC Business Service Center t..,.,.,. ..,. ....._......... ....... _._.�_ ,_._... �... _., _ .m w _,.� _ Business Hours: Monday- Friday (7AM-7PM Central Standard Time) Phone; (877)287-1312 Fax: (888)443-6112 Email: astency.servicesgtheharlford.corn Website: https:/business.thehartford.com Enclosed please find a for the above referenced Policyholder, Please contact us if you have any questions or concerns, Sincerely, Your Hartford Service Team WL TR005 04/88/Z8 @4:Z1:55 1-B55-B93-4357 -> 588768347 The Hartford Page H04 �[rv':C_J'�i+tl:+l DATE IMMIDDIYVYY) « CERTIFICATE OF LIABILITY INSURANCE_ _ 04/08/2020 THIS CERTIFICATE IS ISSUED AS Am MATTER OF INFORMATION ONLY AND ONFERS 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 INSURERIS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:! It the certificate !bolder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. II SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does _not c_an_fer rf pts to the certificate balder in lieu of su_ch_e_nd_orsementls). V PROMO ER�" cONTAci NAME: PAYCHEX INSURANCE:AGENC=Y INC, PHONE {BI"!)286-6$50 .� FAX (58S)_..a(SOS}359-7894- 7621070.5 (Glc,No.FA: (A/C,No): 150 SAWGRASS DRIVE .. ROCHESTER NY 14620 a OIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAICe INSURER Twin City lira Insurance Company 2445'4 v INSURED. _..._...,.....�_.,.,..","....,».��....",._w.M ...:a:.»�..�:,.::_:w INSURER rJ: :a. ..,._:_.,�w., ... .,,w::"..,.....,:.w..:.H:.,__,��w�................:..__.,.,.:.:..,:.. w:-_:....__....:.µ.»,:w:. YANKEE CRAFTERS INC INSURER C: PO BOX 296 SOUTH YARMOUTH MA 02B64-02DIN°URkR U: [ INSURER E: INSURER F C_OVERAG_E_S _ _ CERTIFICATE NUMBER: REVISION NUMBER; THIS-IS TO CERTIFY THAT THE POUCI ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWTHSTANDING 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. Trus°.._-:::.. TYPE 0-FWSURANC6...:..::., F. E: •U „„-Pot..ICY NumFIER —{OLICI�(= .°1'1CF.°S.- ..:'„ .,.......: LIMITS �,.�.,,. :—:... LIR !NSA WVD I.NIMIDDIYVYYI IMMTDENY YYVI COMMSRC:IAL G'EdEIC.f/L.LI AMILyn' rificH l%CC'IIRP0NcJE. ,^.••• (4 E.AIM'.MAW'.I_•.»IO,C.A.F:. F'NF u11H{ l pc ru cr c;ce+ l MED FM,IAny cAA�:c,Acn) �C:IRiTA.X AM IN.N TRY --- GEh.:.!}Gcr(EGAT0 LUIIIT AIPPUILj PER: - i;f rdFR A,.AO Cir r•A lrw____._�_.,^,__ .^Tl hr i.1(v'L...,.] 1•-ICr L:..�1.,./C.. riODDLIZ..-,,.:.-7010'CP P A(.;,..,�— -, T rI1I'3: AUTOMOBILE LIABILITY C1^MIIINETT SINOLri LIMIT ,,.,... -LTU.. "Icl'"U:..,, ".,,...r..,«.....,— ANY Al1O IiC(71LY IN,:lfrgY Ihy*'l'An4m) hUl'C.,^> AUTOS., Bouli V INJII?Y(Pe Orr ow) HIRED -- NON-GYrNr:r WI'Rnr>_?Z1 y CIAMAI C....,._-u,.,w:....:..___V...__...'_..,.....- AUrpa AVT!'iS )1'<,,,:Gnu)4nt) i I UMBRELLA HAD OCCLN G:hCI1r;1 crr<Nc ICE I ritCRSS LAB C:LAIM:C, ""'"'I' ''• Irl n,(lE_ A-CRL ,111 r OED NE1 EN;ION WORKERS COMPENSATION x ) F 1TE: of II _ AND Erd pf-(,VERS'LIABILITY I: Ahl'' YIN EAC lI Pr 1 x: r 5100,000 A IriOPnI1 r rd!l CR1Nr:R/exkC:Llr.,: ---- Hla 76 WEG NZ1661 05(06{x020 05/06 2021 __ ---.~.•--~~~~_-,. — _ QrFIC RIMEIABM EXCLLa?eD7 I..,. 1.:1,5 °E EA r fOLOYEE m$100,000 IMeneatety In NMI — —._.._..--_—___..—.`.-_ li yns,rinrrr!be urvfcr 1..7..CIS£:A.0 P.:4 IC:;UN'l 5500,000 I)OCCINPT I,}N OF 01,14/,..ICNr)M-I..... DE•FCRY'T/ON OF 0P/PAT7ONS•LOCA riOns'ven'CLEs(ACORD ICI.ActdItionat Remake Schedule,may be attached If more space In regmrncl; Those;!sUal to the Insured's Operations CERTIFICATE HOLDER CANCELLATION Town 01 Yarmouth Health Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED Attn.Bruce Murphy BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 114E ROUTE 213 IN ACCORDANCE WITH THE POLICY PROVISIONS, ..,_..,..,.._«...� ...,.,..,::.M ,.,,•,.,......»...•:._µ.,.ms .,...,_.....»._ .,:...,.,.,»,,."".... SOUTH YARMOUTH MA 02654-4453 AUTHOweb REPRE$FNIAT1vE 0 19811-2015 ACORD CORPORATION.All rights reserved. ACORO 25(2016103) The ACORD name and logo are registered marks of ACORO 04/89/Z0 04:ZZ:17 1-855-893-4357 -> 5897619347 The Hartford Page 885 AGENCY CUSTOMER ID: "ft ` ADDITIONAL REMARKS SCHEDULE Page ,x of 2_ AGENCY .,..�—..---.,..,M..,.a.»...,,,,,,..,,.,..�..�,.P ....�..,.�.,r,-,...,..,�,...-.........,,—,,.....,.._.,.- NAMEl71N5lJRF.D....,...,.,-. --,,,..»,......... ......................,,...,,.�,,,�.,,.,,w.,-.-,.--.—,.,-,...-„T...,-,.,....m-,..........,m PAYCHEX INSURANCE AGENCY INC YANKEE CRAFTERS INC POLICY NUMBER PO BOX 296 SEE ACORD 25 SOUTH YARMOUTH MA 02664-0296 CAPRIER NAIL CODE SEE ACORD 25 8EEE TIve DATE:SEE ACORD 25 ADDITIONAL,REMARKS_ THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Brian M, Heaslip Asst. Health Agent ACORD 101 (2014!61) 6 2014 ACORD CORPORATION.All rights reserved, The ACORD name and Togo are registered marks of ACORD 134/88/ZB 84:Z3:85 1-855-893-4357 -> 588768347 The Hartford Page 081 T#FE..✓. HARTFORD The Hartford Fax Cover Page RE: YANKEE CRAFTERS INC Fax Number: 508-760-3472 From: The Hartford Business Service Center Date: 4/8/2020 4:21:15 AM Subject: Total Pages: 4 PRIVILEDGED AND CONFIDENTIAL: This electronic communication,including attachments, is for the exclusive use of addressee and may contain proprietary, confidential and/or privileged information, If you are not the intended recipient, any use, copy,disclosure, dissemination or distribution is strictly prohibited. If you are not the intended recipient, please notify sender Immediately by phone,destroy this communication and all copies, �� _ _ 84/88/ZH H4:Z3:14 1-855-893-4357 -> 588768347 The Hartford Page 883 ),; THE HARTFORD BUSINESS SERVICE CENTER THE";' " 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 713251 April 8,2020 Town Of Yarmouth Health Department Attn.Brtu;K Murphy 1145 ROUTE 26 SOUTH YARMOUTH MA 02664-44073 Account Information: Contact Us Policy Holder Details : YANKEE CRAFTERS INC Business Service Center Business Hours: Monday- Friday (7AM-7PM Central Standard Time) Phone: (877)287-1312 Fax: (888) 4466112 Email: ageency.servicesgtheharlford.corn Website: https://husiness.ihehartford.com Enclosed please find a for the above referenced Policyholder, Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 H4/1313/Z13 H4:Z3:Z1 1-855-893-4357 -> 58/3768347 The Hartford Page 1384 1 .4 w Workers' Lroa e Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE le Legal Name and address of Insured(use street address only) lb.Business Telephone Number of Insured YANKEE CRAFTER INC 1c. NYS Unemployment Insurance Employer PO BOX 296 Registration Number of Insured 'SOUTH YARMOUTH MA 02664 1d. Feder&Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State.i.e. a Wrap-Up Policy) 04-2500571 2. Name and Address of the Entity Requesting Proof of 3a, Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) 3b. Policy Number of Entity Listed in Box'la": Toe/n Of Yarmouth Health Department 76 WELL NZ1661 AttnBruce Murphy 3c Policy effective period: 1 146 rt0i.11 E 213 SOUTH YAR MOUTH MA 02664-4463 05/06/2020 to 05/06/2021 3d. The Proprietor, Partners or Executive Officers are Included. (Only check box if all partnereiofflcers included) I:1 all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box "la" for workers'compensation under the New York State Workers'Compensation Law. (To use this form, New York (NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy Is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate, (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box "3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Danielle Clausen (print name of authorized representative or licensed agent of Insurance carrier) Approved by: .r (.:(6,0.,„4.);;Z") 04/08/2020 (Signature) (Date)' - -_.,.m.._._.._ ... :_._._._:_...:.. Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier (877) 287-1312 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) Form WC 88 31 21 F Printed in U.S.A. www.wcb,ny.t)ov Page 1 of 2 84/88/Z8 84:Z3:4B 1-B55-893-4357 -> 588768347 The Hartford Page 885 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the Issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal deportment, board, commission or office to pay any compensation to any such employee it so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding arty general or special statute requiring or authorizing arty such contract, shall not enter into arty such contract unless proof duly subscribed by an insurance carrier Is produced in a form satisfactory to the chair, That compensation for all employees has been secured as provided by this chapter. C-105.2(9,171 REVERSE www.wcb,ny.gov Form WC 88 31 21 F Printed in U.S.A. Page 2 of 2