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The Commonwealth of Massachusetts Fee /1' Town of Yarmouth $150.00 Food Establishment License Number: BOHF-21-4103-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NAOUM ENTERPRISES 16 EAST MAIN ST GULF EXPRESS _ WEST YARMOUTH. MA 02673 14 EAST MAIN STREET WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE _ TO OPERATE: Retail This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston . A / Bruce G. Murphy,MPH,R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-21-4105-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NAOUM ENTERPRISES 16 EAST MAIN ST GULF EXPRESS WEST YARMOUTH. MA 02673 16 EAST MAIN STREET WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, M'H, R CHO Health Director > TOWN OF YARMOUTH BOARD OF HEALTH E_ APPLICATION FOR LICENSE/PERMIT-2022 * Please complete form and attach all necessary documents by December 18 1, 02b E.AL.TH D F.PT. Failure to do so will result in the return of your application packet. — Lk C 110 Cec- ESTABLISHMENT NAME: i- i r TAX ID: LOCATION ADDRESS: lb e ' 'fin.i n f 1 yc,, i J4EL.4: Sob-36.7-24'4 MAILING ADDRESS: 4 5 60✓�c� E-MAIL ADDRESS: /14%cti ILL G � c,l L o r`i OWNER NAME: s rd. '/r..0 L' CORPORATION NAME(IF APPLICABLE): ;,J.'' VXC.,M L ti/e plj CP . MANAGER'S NAME: Q,�.A ,rcI /li?.•r?v✓1� TEL.#: MAILING ADDRESS: Sc.-,ttn_ POOL CERTIFICATIONS: 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. 1. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community 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. 2. 3. 4. 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. 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: 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# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $110 INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. 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 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 T<25,000 sq ft $150 _FROZEN DESSERT $40 TTOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ to,t7-49 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 615I/0l'nag 1.4-1"'"(747? f-Y°y v :3 IJ I L'3W VN INRId f1.LVNDIS —Z >lZ — f :3IVO NV Id 3i f1O321 AVIAI SNOIIVAON321 1N3LAIlDN11N IMOD 01 2IO111d HIIV3H dO O2IVOH 3H1 AH 13AO'IddV MId 01031110d3113!SIMI'013`1N31A1diflOg /MN `DNIINIVd "0.0 'IOOd 110 'I3.LOVI `1N31VHSI1EIVIS3 00W ANN/ O.I. 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Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. hello sorry the name is gulf express please. thank you for reaching out On Wed, Apr 27, 2022 at 3:22 PM Slack, Christine<CSlack@yarmouth.ma.us>wrote: Afternoon, I am reaching out to confirm the business name at 16 E. Main St,W.Yarmouth, MA. I have one application that says Racing Mart and another with Gulf Express. Both have the same tax id#. Could you please confirm the name for me please? Thank you, Christine Slack Principal Office Assistant Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 ext 1241 1 AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE AcCPR UMBRELLA / EXCESS SECTION HE, I-1 H DATE(MM/DD/YYYY) 06/25/2021 IMPORTANT-If CLAIMS MADE is checked in the POLICY INFORMATION section below,this is an application for a claims-made policy. AGENCY CARRIER NAIC CODE Oxford Insurance Agency,Inc. Evanston Insurance Company N/A POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S) TBD/QUOTE 06/25/2021 Naoum Enterprises Inc POLICY INFORMATION TRANSACTION TYPE LIMIT OF LIABILITY RETAINED LIMIT X NEW X UMBRELLA X OCCURRENCE RETROACTIVE DATE $ 2,000,000 EA OCC $ RENEWAL EXCESS CLAIMS MADE PROPOSED CURRENT $ 2,000,000 Aggregate EXPIRING POL#: $ FIRST DOLLAR DEFENSE(Y/N) Y EMPLOYEE BENEFITS LIABILITY LIMIT OF INSURANCE(Ea Employee) AGGREGATE LIMIT FOR EBL RETAINED LIMIT FOR EBL RETROACTIVE DATE FOR EBL $ $ $ NAME OF BENEFIT PROGRAM PRIMARY LOCATION&SUBSIDIARIES(ACORD 125) NAME AND LOCATION OF PRIMARY AND ALL SUBSIDIARY COMPANIES(Describe Operations) ANNUAL PAYROLL ANN GROSS SALES FOREIGN GROSS SALES #EMPL NAME: Naoum Enterprises Inc 1 LOCATION: 16 East Main St West Yarmouth,MA 02673 $110,000.00 $1,875,000.00 $0.00 3 DESCRIPTION:Gas Station with Convenience Store NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: UNDERLYING INSURANCE LIST ALL LIABILITY/COMPENSATION POLICIES IN FORCE TO APPLY AS UNDERLYING INSURANCE --j RATING TYPE CARRIER I POLICY NUMBER POLICY EFF DATE POLICY EXP DATE LIMITS ANNUAL RENEWAL MOD PREMIUM CSL EA ACC $ $ AUTOMOBILE BI EA ACC $ $ LIABILITY SI EA PER PD EA ACC $ $ TBD EACH OCCURRENCE $ 1,000,000 PREM/OPS GENERAL LIABILITY GENERAL AGGR $ 2,000,000 $ POLICY TYPE PROD 8 COMP OPS AGGREGATE $ 2,000,000 PRODUCTS X OCCUR 06/21/2021 06/21/2022 uuuRY B`ADV $ 1,000,000 $ CLAIMMADES PREMISES DAMAGE TO RENTED $ 50,000 OTHER TBD MEDICAL EXPENSE $ 10,000 $ TBD EACH ACCIDENT $ 500,000 EMPLOYERS 06/21/2021 06/15/2022 DISEASE 1.0000 LIABILITY EACH EMPLOYEE $ 500,000 $ TBD DISEASELCLIMIT $ 500,000 $ $ ACORD 131(2009/10) Page 1 of 5 ©1991-2009 ACORD CORPORATION. All rights reserved. ATTACH TO ACORD 125 AND ACORD 126 The ACORD name and logo are registered marks of ACORD UNDERLYING INSURANCE(continued) AGENC:Y CUSTOMER ID:NAOUENT-01 LLAVIGNE UNDERLYING GENERAL LIABILITY INFORMATION(Explain all"YES'responses) 1. ARE DEFENSE COSTS: WITHIN AGGREGATE LIMITS? I A SEPARATE LIMIT? UNLIMITED? 2. INDICATE THE EDITION DATE OF THE ISO FORM OR SIMILAR FILING FOR THE UNDERLYING COVERAGE: 3. HAS ANY PRODUCT,WORK,ACCIDENT,OR LOCATION BEEN EXCLUDED,UNINSURED OR SELF INSURED FROM ANY PREVIOUS COVERAGE?(Y/N) Pollution 4. FOR CLAIMS MADE,INDICATE RETROACTIVE DATE OF CURRENT UNDERLYING POLICY: H EALTH DEPT, 5. FOR CLAIMS MADE,INDICATE ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 6. FOR CLAIMS MADE,WAS"TAIL'COVERAGE PURCHASED FOR ANY PREVIOUS PRIMARY OR EXCESS POLICY? (Y/N) [ j EFF.DATE: CHECK ALL COVERAGES IN UNDERLYING POLICIES.ALSO CHECK IF ANY EXPOSURES ARE PRESENT FOR EACH COVERAGE.PROVIDE AN EXPLANATION.EXPLAIN IF DIFFERENT LIMITS,EXTENSIONS,OR EXCLUSIONS.EXPLAIN ANY SPECIAL COVERAGES BEYOND STANDARD FORMS.EXPLAIN ALL EXPOSURES. CHECK IF APPROPRIATE COVERAGE EXPOSURE COVERAGE EXPOSURE ANY AUTO(SYMBOL 1) CARE,CUSTODY,CONTROL PROFESSIONAL LIABILITY(E&O) _ CGL-CLAIMS MADE EMPLOYEE BENEFIT LIABILITY VENDORS LIABILITY X CGL-OCCURRENCE FOREIGN LIABILITY/TRAVEL WATERCRAFT LIABILITY COVERAGE EXPOSURE^ GARAGEKEEPERS LIABILITY AIRCRAFT LIABILITY INCIDENTAL MEDICAL MALPRACTICE AIRCRAFT PASSENGER LIABILITY LIQUOR LIABILITY X ADDITIONAL INTERESTS POLLUTION LIABILITY UNDERLYING INSURANCE COVERAGE INFORMATION(INCLUDE ALL RESTRICTIONS:e.g.LASER ENDORSEMENTS,DISCRIMINATION,SUBROGATION WAIVERS,OR EXTENSIONS OF COVERAGE)Attach ACORD 101,Additional Remarks Schedule,if more space is required. PREVIOUS EXPERIENCE:(GIVE DETAILS OF ALL LIABILITY CLAIMS EXCEEDING$10,000 OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS,DURING THE PAST FIVE(5)YEARS, WHETHER INSURED OR NOT. SPECIFY DATE,COVERAGE,DESCRIPTION,AMOUNT PAID,AMOUNT OUTSTANDING)Attach ACORD 101,Additional Remarks Schedule,if more space is required. X NO SUCH CLAIMS CARE,CUSTODY,CONTROL LOC PROPERTY TYPE VALUE A* W C• D" SQ FT OF BLDG OCC REAL PERSONAL OCCUPANCY/DESCRIPTION OF PERSONAL PROPERTY *APPLICANT:[A]IS HELD HARMLESS IN THE LEASE,[B]HAS A WAIVER OF SUBROGATION,[C]IS A NAMED INSURED IN THE FIRE POLICY,[D]OTHER(specify) VEHICLES #NON- RADIUS(MILES) TYPE A OWNED #LEASED PROPERTY HAULED INTER- LONG OWNED LOCAL MEDIATE DISTANCE PRIVATE PASSENGER LIGHT MEDIUM TRUCKS HEAVY EX.HEAVY -- — — — -- TRUCKS/ HEAVY TRACTORS EX.HEAVY BUSES ACORD 131(2009/10) Page 2 of 5 ADDITIONAL EXPOSURES AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE EXPLAIN ALL"YES"RESPONSES,PROVIDE OTHER INFORMATION REQUIRED Y I N --- ADVERTISERS LIABILITY 1. MEDIA USED: �_.. ANNUAL COST:$ 2. ARE SERVICES OF AN ADVERTISING AGENCY USED? N 3. ANY COVERAGE PROVIDED UNDER AGENCY'S POLICY? LTH -,- AIRCRAFT LIABILITY 4. DOES APPLICANT OWN/LEASE/OPERATE AIRCRAFT? N AUTO LIABILITY 5. ARE EXPLOSIVES,CAUSTICS,FLAMMABLES OR OTHER DANGEROUS CARGO HAULED? N 6. ARE PASSENGERS CARRIED FOR A FEE? N 7. ANY UNITS NOT INSURED BY UNDERLYING POLICIES? N 8. ARE ANY VEHICLES LEASED OR RENTED TO OTHERS? N 9. ARE HIRED AND NON-OWNED COVERAGES PROVIDED? N CONTRACTORS LIABILITY 10. IS BRIDGE,DAM,OR MARINE WORK PERFORMED? N 11. DESCRIBE TYPICAL JOBS PERFORMED (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 12. DESCRIBE AGREEMENT (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 13. DOES APPLICANT OWN,RENT,OR OTHERWISE USE CRANES? N 14. DO SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN APPLICANT? N EMPLOYERS LIABILITY 15. IS APPLICANT SELF-INSURED IN ANY STATE? N 16. SUBJECT TO: JONES ACT FELA STOP GAP OTHER: INCIDENTAL MALPRACTICE LIABILITY 17. IS A HOSPITAL OR FIRST AID FACILITY MAINTAINED? N 18. ARE COVERAGES PROVIDED FOR DOCTORS/NURSES? N 19. INDICATE#OF DOCTORS: NURSES: BEDS: ACORD 131 (2009/10) Page 3 of 5 ADDITIONAL EXPOSURES(continued) AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE EXPLAIN ALL"YES"RESPONSES,PROVIDE OTHER INFORMATION REQUIRED Y I N EPA It: POLLUTION LIABILITY 20. DO CURRENT OR PAST PRODUCTS,OR THEIR COMPONENTS,CONTAIN HAZARDOUS MATERIALS THAT MAY REQUIRE SPECIAL N DISPOSAL METHODS? — --..___- 21. INDICATE THE COVERAGES CARRIED: GL WITH STANDARD ISO POLLUTION EXCLUSION _ GL WITH POLLUTION COVERAGE ENDORSEMENT GL WITH STANDARD SUDDEN&ACCIDENTAL ONLY SEPARATE POLLUTION COVERAGE PRODUCT LIABILITY 22. ARE MISSILES,ENGINES,GUIDANCE SYSTEMS,FRAMES OR ANY OTHER PRODUCT USED/INSTALLED IN AIRCRAFT? N 23. ANY FOREIGN OPERATIONS,FOREIGN PRODUCTS DISTRIBUTED IN THE USA OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? N (If"YES",Attach ACORD 815) 24. PRODUCT LIABILITY LOSS IN PAST THREE(3)YEARS?(SPECIFY) N 25. GROSS SALES FROM EACH OF LAST THREE(3)YEARS: $ $ $ PROTECTIVE LIABILITY 26. DESCRIBE INDEPENDENT CONTRACTORS (Attach ACORD 101,Additional Remarks Schedule,if more space is required) WATERCRAFT LIABILITY 27. DOES APPLICANT OWN OR LEASE WATERCRAFT? N LOC# #OWNED LENGTH HORSEPOWER LOC# #OWNED LENGTH HORSEPOWER APARTMENTS I CONDOMINIUMS I HOTELS I MOTELS 28. LOC# #STORIES #UNITS #SWIMMING POOLS #DIVING BOARDS LOC# #STORIES #UNITS #SWIMMING POOLS #DIVING BOARDS REMARKS(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ACORD 131 (2009/10) Page 4 of 5 AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE REMARKS(Attach ACORD 101,Additional Remarks Schedule,if more space is required) HEALTH DF'T. SIGNATURE ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO,COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND[NY:SUBSTANTIAL]CIVIL PENALTIES.(Not applicable in CO,DC,FL,HI,MA,NE,OH,OK,OR,VT or WA;in LA,ME,TN and VA,insurance benefits may also be denied) IN THE DISTRICT OF COLUMBIA,WARNING: IT ISA CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE,INCOMPLETE,OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO,MAY BE COMMITTING A FRAUDULENT INSURANCE ACT,WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IN WASHINGTON,IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,INCOMPLETE,OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT,FINES,AND DENIAL OF INSURANCE BENEFITS. IF THE COMPANY TO WHICH I AM APPLYING OFFERS UNINSURED MOTORISTS(UM)AND/OR UNDERINSURED MOTORISTS(UIM)COVERAGE IN MY STATE: UNINSURED MOTORISTS(UM)COVERAGE:$ UNDERINSURED MOTORISTS(UIM)COVERAGE:$ * *IF APPLICABLE IN YOUR STATE APPLICABLE ONLY IN LOUISIANA,NEW HAMPSHIRE,VERMONT AND WISCONSIN APPLICABLE ONLY IN LOUISIANA: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME,AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS,UM LIMITS LOWER THAN MY LIABILITY LIMITS,OR TO REJECT UM COVERAGE ENTIRELY. 1. I SELECT UM LIMITS INDICATED IN THIS APPLICATION. OR 2. I REJECT UM COVERAGE IN ITS ENTIRETY. (INITIALS) (INITIALS) APPLICABLE ONLY IN NEW HAMPSHIRE: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME,AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS OR TO REJECT UM COVERAGE ENTIRELY. 1. I SELECT UM LIMITS INDICATED IN THIS APPLICATION. OR 2. I REJECT UM COVERAGE IN ITS ENTIRETY. (INITIALS) (INmALS) APPLICABLE ONLY IN VERMONT: I ACKNOWLEDGE THAT I HAVE BEEN OFFERED UM COVERAGE EQUAL TO MY LIABILITY LIMITS. I HAVE SELECTED THE LIMITS INDICATED IN THIS APPLICATION. APPLICABLE ONLY IN WISCONSIN: I ACKNOWLEDGE THAT I HAVE BEEN OFFERED UNINSURED MOTORIST(UM)COVERAGE AND UNDERINSURED MOTORIST(UIM)COVERAGE. 1. I SELECT UM LIMITS INDICATED IN THIS APPLICATION. OR 2. I REJECT UM COVERAGE IN ITS ENTIRETY. (INITIALS) (INITIALS) 3. I SELECT UIM LIMITS INDICATED IN THIS APPLICATION. OR 4. I REJECT UIM COVERAGE IN ITS ENTIRETY. (INITIALS) (INITIALS) IMPORTANT - THE STATEMENTS (ANSWERS)GIVEN ABOVE ARE TRUE AND ACCURATE.THE APPLICANT HAS NOT WILLFULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCE CONCERNING THIS APPLICATION.THIS APPLICATION DOES NOT CONSTITUTE A BINDER. PRODUCER'S SIGNATURE PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Required in Florida) I House Account APPLICANTS SIGNATURE DATE NATIONAL PRODUCER NUMBER ACORD 131 (2009/10) Page 5 of 5 ____.........IN LLAVIGNE ACORLL COMMERCIAL INSURANCE APPLICATION DATE(MM/DD/YYYY) `.../ APPLICANT INFORMATION SECTION 06/25/2021 AGENCY CARRIER 1 NAIC CODE Oxford Insurance Agency, Inc. Evanston Insurance Company NIA PO Box 370 COMPANY POLICY OR PROGRAM NAM PROD Oxford, MA 01 540 GRAM CODE Umbrella POLICY NUMBER TBD/QUOTE CONTACT House Account UNDERWRITER UNDERWRITER I.AW: PHONE (508)987-0333 (A/C.No.Ext); FAX C Nol; (508)987-5517 _ _ _ QUOTE ISSUE POLICY RENEW ADDRESS:Info@oxfordlnsuranCe.com _-- STATUS OF ACTION BOUND(Give Date and/or Attach Copy): TRANS _ CODE: SUBCODE: CHANGE DATE TIME AM AGENCY CUSTOMER ID:NAOUENT-01 CANCEL PM SECTIONS ATTACHED INDICATE SECTIONS ATTACHED PREMIUM PREMIUM PREMIUM ACCOUNTS RECEIVABLE/ $ ELECTRONIC DATA PROC t TRANSPORTATION/ ; VALUABLE PAPERS MOTOR TRUCK CARGO BOILER&MACHINERY $ EQUIPMENT FLOATER $ TRUCKERS/MOTOR CARRIER $ BUSINESS AUTO $ GARAGE AND DEALERS $ X UMBRELLA $ _ BUSINESS OWNERS $ ^_ GLASS AND SIGN t YACHT $ COMMERCIAL GENERAL LIABILITY $ INSTALLATION/BUILDERS RISK $ 8 CRIME 8 OPEN CARGO $ t DEALERS $ PROPERTY $ $ AITACHMENTS ADDITIONAL INTEREST PREMIUM PAYMENT SUPPLEMENT ADDITIONAL PREMISES PROFESSIONAL LIABILITY SUPPLEMENT APARTMENT BUILDING SUPPLEMENT RESTAURANT/TAVERN SUPPLEMENT CONDO ASSN BYLAWS(for D&O Coverage only) STATEMENT/SCHEDULE OF VALUES CONTRACTORS SUPPLEMENT STATE SUPPLEMENT(If applicable) COVERAGES SCHEDULE VACANT BUILDING SUPPLEMENT DRIVER INFORMATION SCHEDULE VEHICLE SCHEDULE INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT LOSS SUMMARY POLICY INFORMATION PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMMUM IUM POLICY PREMIUM PRE 06/25/2021 06/25/2022 $ $ $ DIRECT Pil AGENCY APPLICANT INFORMATION NAME(First Named Insured)AND MAILING ADDRESS(including ZP+4) GL CODE SIC NAICS FEIN OR SOC SEC# Naoum Enterprises Inc 47 Chandler Gray Road West Yarmouth,MA 02673 BUSINESS PHONE#: WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER'S'CORPORATION INDIVIDUAL LLC NO OF MEMBERS AND MANAGERS: PARTNERSHIP TRUST NAME(Other Named Insured)AND MAILING ADDRESS(including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC# BUSINESS PHONE it: WEBSITE ADDRESS CORPORATION L JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS AND MANAGERS: PARTNERSHIP TRUST NAME(Other Named Insured)AND MAILING ADDRESS(including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC S BUSINESS PHONE ak WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS PARTNERSHIP TRUST AND MANAGERS: ACORD 125(2013/09) Page 1 of 4 ©1993-2013 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONTACT INFORMATION AGENCY CUSTOMER ID: NAOUENT LLAMC1NE CONTACT TYPE:Inspection Contact CONTACT TYPE: CONTACT NAME:Richard Naoum CONTACT NAME: PHONE# ❑ HOME❑ BUS ❑CELL SHONE#ARY ❑ HOME®BUS ❑CELL PHON I ❑HOME❑BUS ❑CELL PH ONDARY 0 HOME❑BUS ❑CiLL (508)737-9140 `' PRIMARY E-MAIL ADDRESS: PRIMARY EMAIL ADDRESS: SECONDARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: PREMISES INFORMATION (Attach ACORD 823 for Additional Premises) LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ 1,875,000 16 East Main St 1 INSIDE OWNER 2 OCCUPIED AREA: 1,838 SQ FT t-— BLD# Cf'Y:West Yarmouth STATE:MA OUTSIDE X TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT 1 COUNTY: ZIP:02673 1 TOTAL BUILDING AREA: SQ FT DESCRIPTION OF oPERATKNNs:Gas Station with Convenience Store ANY AREA LEASED TO OTHERS?Y/N LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ INSIDE OWNER OCCUPIED AREA: SO FT BLD# CITY: STATE OUTSIDE TENANT I PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: ZIP: TOTAL BUILDING AREA: SO FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y/N LOC# STREET CITY LIMITS INTEREST *FULL TIME EMPL ANNUAL REVENUES:$ _ INSIDE OWNER OCCUPIED AREA: SO FT BLD# CITY: STATE: , OUTSIDE. TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT y COUNTY: ZIP: � TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?V/N LOC# STREET CITY LIMITS 1 INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ INSIDE OWNER OCCUPIED AREA: SOFT BLD# CITY: STATE: OUTSIDE TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: LP: TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N NATURE OF BUSINESS APARTMENTS CONTRACTOR MANUFACTURING - RESTAURANT SERVICE X i Gas Station with DATE BUSINESS Convenience Store STARTED(21/2021 06 CONDOMINIUMS INSTITUTIONAL OFFICE RETAIL WHOLESALE DESCRIPTION OF PRIMARY OPERATIONS Gas Station with Convenience Store INSTALLATION,SERVICE OR REPAIR WORK OFF PREMISES INSTALLATION,SERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS'A OF TOTAL SALES: % '/, DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS ADDITIONAL INTEREST(Not all fields apply to all scenarios-provide only the necessary data) Attach ACORD 45 for more Additional Interests INTEREST NAME AND ADDRESS RANK: EVIDENCE: -LCERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO.OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT ITEM ITEM: AS LESSOR CLASS: LEASEBACK TRUSTEE ITEM DESCRIPTION OWNER LIENHOLDER REFERENCE/LOAN#: INTEREST END DATE: LIEN AMOUNT: PHONE(NC,No,Ext): FAX(A/C,No): REASON FOR INTEREST: EMAIL ADDRESS: ACORD 125(2013/09) Page 2 of 4 AGENCY CUSTOMER ID: NAOUENT-01 LLAVIGNE GENERAL INFORMATION EXPLAIN ALL"YES"RESPONSES Y I N la. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? N PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1 b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? N SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? N SAFETY MANUAL MONTHLY MEETINGS SAFETY POSSON OSHA 3. ANY EXPOSURE TO FLAMMABLES,EXPLOSIVES,CHEMICALS? Y That usual to gasoline service station operation 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) N LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER -- 5. ANY POLICY OR COVERAGE DECLINED,CANCELLED OR NON-RENEWED DURING THE PRIOR THREE(3)YEARS FOR ANY PREMISES OR N OPERATIONS? (Missouri Applicants-Do not answer this question) NON-PAYMENT AGENT NO LONGER REPRESENTS CARRIER NON-RENEWAL UNDERWRITING CONDITION CORRECTED(Describe): 6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS,DISCRIMINATION OR NEGLIGENT HIRING? N 7. DURING THE LAST FIVE YEARS(TEN IN RI),HAS ANY APPLICANT BEEN INDICTED FOR.OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, N BRIBERY,ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI,this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? N OCCURRENCE RESOLUTION DATE EXPLANATION RESOLUTION DATE 9. HAS APPLICANT HAD A FORECLOSURE,REPOSSESSION,BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE(5)YEARS? N OCCURRENCE RESOLUTION DATE EXPLANATION RESOLUTION DATE 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE(5)YEARS? N OCCURRENCE RESOLUTION DATE EXPLANATION RESOLUTION DATE 11. HAS BUSINESS BEEN PLACED IN A TRUST? N NAME OF TRUST 12. ANY FOREIGN OPERATIONS,FOREIGN PRODUCTS DISTRIBUTED IN USA,OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? N (If"YES",attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? N REMARKS/PROCESSING INSTRUCTIONS(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) PRIOR CARRIER INFORMATION YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM 8 S S $ EFFECTIVE DATE EXPIRATION DATE ACORD 125(2013/09) Page 3 of 4 AGENCY CUSTOMER ID: NAOUENT-01 LLAVIGNE PRIOR CARRIER INFORMATION(continued) YEAR CATEGORY GENERAL UABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information) ENTER ALL CLAIMS OR LOSSES(REGARDLESS OF FAULT AND WHETHER OR NOT INSURED)OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS TOTAL LOSSES: $ SUBRO- CLAIM DATE OF UNE DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED GATION OPEN OCCURRENCE TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM Y/N Y I N SIGNATURE Copy of the Notice of Information Practices(Privacy)has been given to the applicant.(Not required in all states,contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT,MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES.YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.THESE RIGHTS MAY BE LIMITED IN SOME STATES.PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,or WV. Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials): Applicable in AL,AR,DC,LA,MD,NM,RI and WV: Any person who knowingly (or willfully)*presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)*presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.*Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,incomplete,or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: Any person who knowingly and with intent to injure,defraud,or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony(of the third degree)*.*Applies in FL Only. Applicable in KS: Any person who,knowingly and with intent to defraud,presents,causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer,purported insurer,broker or any agent thereof,any written statement as part of,or in support of,an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto;or conceals,for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY,NY,OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,information conceming any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties(not to exceed five thousand dollars and the stated value of the claim for each such violation)*.*Applies in NY Only. Applicable in ME,TN,VA and WA: It is a crime to knowingly provide false,incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties(may)*include imprisonment,fines and denial of insurance benefits.*Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application,or presents,helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit,or presents more than one claim for the same damage or loss, shall incur a felony and,upon conviction,shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than ten thousand dollars ($10,000),or a fixed term of imprisonment for three(3)years,or both penalties. Should aggravating circumstances[be]present,the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present,it may be reduced to a minimum of two(2) ,_years. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE,CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Required in Florida) House Account APPLICANTS SIGNATURE DATE NATIONAL PRODUCER NUMBER ACORD 125(2013/09) Page 4 of 4 ��+1 LLAVIGNE ACORO WORKERS COMPENSATION APPLICATION DATE(MM/DYYYY) �-� D/06/25/2021 AGENCY NAME AND ADDRESS COMPANY: Utica Mutual Insurance Company Oxford Insurance Agency,Inc. — PO Box 370 UNDERWRITER: Oxford,MA 01540 APPUCPJIT NAME:Naoum Enterprises Inc OFFICE PHONE: MOBILE PHON : MAIUNG ADDRESS(Including ZIP +4 or Canadian Postal Code) YRS IN US: 47 Chandler Gray Road - West Yarmouth,lMA 02673 sic: PRODUCER NAME:House Account NAICS: CS REPRESENTATIVE WEBSITE NAME: ADDRESS: OFFICE PHON 508 987-0333 (A/C,No.Ext): E-MAIL ADDRESS: MOBILE SOLE PROPRIETOR PHONE: X CORPORATION LLC TRUST UNINCORPORATED FAX (508)987-5517 PARTNERSHIP — SUBCHAPTER JOINT VENTURE OTHER: _ ASSOCIATION (A/C,No): S-CORP ADOREs3:info@oxfordinsurance.com CREDIT REDAU NAME: ID NUMBER: CODE: SUB CODE: FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER OTHER RATING BUREAU ID OR STATE EMPLOYER REGISTRATION NUMBER AGENCY CUSTOMER ID:NAOUENT-01 86-2686396 STATUS OF SUBMISSION BILLING I AUDIT INFORMATION QUOTE ISSUE POLICY BLLING PLAN PAYMENT PLAN AUDIT _ BOUND(Give date and/or attach copy) AGENCY BILL ANNUAL AT EXPIRATION MONTHLY — ASSIGNED RISK(Attach ACORD 133) X DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL QUARTERLY %DOWN: QUARTERLY LOCATIONS LOC# INV STREET,CITY,COUNTY,STATE,ZIP CODE — 1 16 East Main Street West Yarmouth,MA 02673 POLICY INFORMATION PROPOSED EFF DATE PROPOSED EXP DATE NORMAL ANNIVERSARY RATING DATE PARTICIPATING RETRO PLAN 06/25/2021 06/25/2022 NON-PARTICIPATING PART 1-WORKERS PART 2-EMPLOYER'S LIABILITY PART 3-OTHER DEDUCTIBLES AMOUNT/% OTHER COVERAGES COMPENSATION(States) STATES INS (N/A In WI)_ MEDICAL (N!Ain WI) — — U.S.L.&H. MANAGED $ 500,000 EACH ACCIDENTCARE OPTION _ _ $ 500,000DISEASE-POLICY LIMIT _ INDEMNITY VVOOLMUP ARY $ 500,000 DISEASE-EACH EMPLOYEE FOREIGN COV DIVIDEND PLAN/SAFETY GROUP ADDITIONAL COMPANY INFORMATION SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTS(Attach ACORD 101,Additional Remarks S:hedule,if more space is required) TOTAL ESTIMATED ANNUAL PREMIUM-ALL STATES TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES TOTAL MINIMUM PREMIUM ALL STATES I TOTAL DEPOSIT PREMIUM ALL STATES $ $ j $ CONTACT INFORMATION TYPE NAME OFFICE PHONE MOBILE PHONE E-MAIL INSPECTION Richard Naoum ACCTNG Richard Naoum RECORD CLAIMS Richard Naoum - INFO INDIVIDUALS INCLUDED/EXCLUDED PARTNERS,OFFICERS,RELATIVES(Must be employed by business operations)TO BE INCLUDED OR EXCLUDED(Remuneration/Payroll to be included must be part of rating information section.) Exclusions In Missouri must meet the requirements of Section 287.090 RSMo. STATE LOC S NAME DATE OF BIRTHTITL/ OWNER- RELATIONSHIP SHIP% DUTIES INCIEXC CLASS CODE REMUNERATIOWPAYROLL MA 1 Richard Naoum Owner/President Store clerk/gas attend/admin 100.0 I 8006 30,000 ACORD 130(2013/09)) Page 1 of 4 ©1980-2013 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE RATING SHEET# 1 OF 1 SHEETS AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE STATE RATING WORKSHEET FOR MULTIPLE STATES,ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM RATING INFORMATION-STATE: MA DESCR #EMPLOYEES ESTIMATED ANNUAL ESTIMATED LOC# CLASS CODE CODE CATEGORIES,DUTIES,CLASSIFICATIONS FULL PART SIC NAICS REMUNERATION/ RATE ANNUAL MANUAL TIME TIME PAYROLL PREMIUM 1 8006 Convenience Store with Gas Sales 2 1 $90,000.001.08000 $972.00 PREMIUM STATE: MA FACTOR FACTORED PREMIUM FACTOR FACTORED PREMIUM TOTAL N/A $ 972.00 $ INCREASED LIMITS $ 50.00 _SCHEDULE RATING' $ DEDUCTIBLE' $ CCPAP $ terrorism $ 27.00 STANDARD PREMIUM $ EXPERIENCE OR MERIT MODIFICATION $ PREMIUM DISCOUNT $ $ EXPENSE CONSTANT N/A $ 338.00 ASSIGNED RISK SURCHARGE• $ _ TAXES/ASSESSMENTS' N/A $ ARAp. $ MA Assessment $ 34.00 `N/A in Wisconsin TOTAL ESTIMATED ANNUAL PREMIUM I MINIMUM PREMIUM iii DEPOSIT PREMIUM $ 1,421.00 $ $ REMARKS(ACORD 101,Additional Remarks Schedule,may be attached f more space is required) ACORD 130(2013/09) Page 2 of 4 PRIOR CARRIER INFORMATION/LOSS HISTORY AGENCY CUSTOMER ID-NAOUENT-01 LLAVIGNE PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER&POLICY NUMBER ANNUAL PREMIUM MOD #CLAIMS AMOUNT PAID RESERVE CO: POL#: CO: POL#: CO: I POL#: CO: POL#: CO: L POL#: NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS,OPERATIONS AND PRODUCTS:MANUFACTURING-RAW MATERIALS,PROCESSES,PRODUCT,EQUIPMENT;CONTRACTOR-TYPE OF WORK,SUB-CONTRACTS;MERCANTILE-MERCHANDISE,CUSTOMERS,DELIVERIES;SER'✓ICE•TYPE,LOCATION;FARM-ACREAGE,ANIMALS,MACHINERY,SUB-CONTRACTS. ---- --._.—_. __..----- --- ___-..--------..___----------- Convenience store with gas stations Convenience store with gas stations GENERAL INFORMATION EXPLAIN ALL"YES"RESPONSES Y I N 1. DOES APPLICANT OWN,OPERATE OR LEASE AIRCRAFT/WATERCRAFT? N 2. DO/HAVE PAST,PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING,TREATING,DISCHARGING,APPLYING,DISPOSING,OR N TRANSPORTING OF HAZARDOUS MATERIAL?(e.g.landfills,wastes,fuel tanks,etc) 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? N 4. ANY WORK PERFORMED ON BARGES,VESSELS,DOCKS,BRIDGE OVER WATER? N 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? N 6. ARE SUB-CONTRACTORS USED?(If"YES",give%of work subcontracted) N 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If"YES",payroll for this work must be included in the State Rating Worksheet on Page 2) N 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION? N 9. ANY GROUP TRANSPORTATION PROVIDED? N 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? N 11. ANY SEASONAL EMPLOYEES? N 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If"YES",please specify) N 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? N 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and frequency) N -- ---- — --- 15. ARE ATHLETIC TEAMS SPONSORED? N 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? N ACORD 130(2013/09) Page 3 of 4 GENERAL INFORMATION(continued) AGENCY CUSTOMER ID:NAOUENT-01 LLAVIGNE EXPLAIN ALL"YES"RESPONSES Y I N 17. ANY OTHER INSURANCE WITH THIS INSURER? N 18. ANY PRIOR COVERAGE DECLINED/CANCELLED I NON-RENEWED IN THE LAST THREE(3)YEARS?(Missouri Applicants-Do not answer this question) N 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? N 20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES? N 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If"YES",#of Employees: N 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE(5)YEARS? (If"YES",please specify) N 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? N IF YES,EXPLAIN INCLUDING ENTITY NAME(S)AND POLICY NUMBER(S). SIGNATURE Copy of the Notice of Information Practices(Privacy)has been given to the applicant(Not required in all states,contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT,MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES.YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.THESE RIGHTS MAY BE LIMITED IN SOME STATES.PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,or WV. Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials): Applicable in AL,AR,DC,LA,MD,NM,RI and WV: Any person who knowingly (or willfully)*presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)*presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.*Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,incomplete,or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: Any person who knowingly and with intent to injure,defraud,or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony(of the third degree)*.*Applies in FL Only. Applicable in KS: Any person who,knowingly and with intent to defraud,presents,causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer,purported insurer,broker or any agent thereof,any written statement as part of,or in support of,an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto;or conceals,for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY,NY,OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties(not to exceed five thousand dollars and the stated value of the claim for each such violation)*.*Applies in NY Only. Applicable in ME,TN,VA and WA: It is a crime to knowingly provide false,incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties(may)*include imprisonment,fines and denial of insurance benefits.*Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application,or presents,helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit,or presents more than one claim for the same damage or loss, shall incur a felony and,upon conviction,shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than ten thousand dollars ($10,000),or a fixed term of imprisonment for three(3)years,or both penalties. Should aggravating circumstances[be]present,the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present,it may be reduced to a minimum of two(2) years. Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information,files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE,CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. APPLICANTS SIGNATURE(Must be Officer,Owner or Partner) DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 130(2013/09) Page 4 of 4