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HomeMy WebLinkAbout2022 App-License-Certifications ."""► TOWN OF YARMOUTH BOARD OF HEALTH L tt I i 2022 >#0 APPLICATION FOR LICENSE/PERMIT -2022 * Please complete form and attach all necessary documents by Dec •• • s- j: _, s PT. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: �,u,I� [Atli l� al� %TAX ID: - LOCATION ADDRESS: 1.-14 1 O U.� g x `l1k TEL.#: 5b AI- 153q MAILING ADDRESS: 55 1Z ) eoA'Q Q , ni5 Mk- C (p? E-MAIL ADDRESS: Sl _OW VIJ41L ,I D OWNER NAME: rft1�I?t t\--_ SIVYk0 CORPORATION NAME (IF APPLIC BLE): \ 5 , I1+' _' MANAGER'S NAME: A A Jest • TEL.#: MAILING ADDRESS: ,b OAK_o ;L_ Win..15 mit- C24 1 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ope : a s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two em. a •--_ rrently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certifie. e -- on premises at all times. Please list the employees below and attach copies of their certifications to this form.The : 1 Department will not use past years' records. You must provide new copies and maintain a file at your place . : iness. 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 andel maintain a file at your establishment. 1. J t \� \OW7 2. PERSON IN CHARGE: Each food establishmet must have at least one Person In Charge (PIC)on site during hours of operation. 1. \k, (\ 1 ni,©Y1f2— 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 a d maintain a file at your establishment. 1. RON\ Pt _ i► 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# -49-...-- 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 <25,000 sq.ft. $150 FROZEN DESSERT $40 TOBACCO $111 ' NAME CHANGE: $15 AMOUNT DUE = $ 4. I(e5 *****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 preyious_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 18, 2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A S)T LAN. �1 DATE: g' Gr ."P-- SIGNATURENOVI SIGNATURE/ a PRINT NAME&TITLE: CLI/ J 4. ltSiy'loLJl')-1,4D- Rev t. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $165.00 Food Establishment License Number: BOHF-18-2902-04 Issue Date: 1/1/2022 Mailing Address: Location Address: MARY'S LIL CABOOSE INC. 1279 ROUTE 28 MARY'S LIL CABOOSE SOUTH YARMOUTH. MA 02664 8 RED CEDAR CIRCLE DENNIS, MA 02638 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Frozen Dessert Manfucturer; 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. Conditions Seating: 0 *RESTRICTIONS: Disposable service only. Ice cream and steamed hot dogs. *FROZEN DESSERT- Regulation 105 CMR 561.009 requires monthly plate count and coliform tests. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . Bruce G. Murphy, MP , R.S., CHO/James G. Gardiner Health Directo"/Assistant Health Director L J d Yf E left r> m w o c `' ib /left tn. o- Zc may n ;; o � � MINN U') R 0 W c (j ❑ yal ' o T c p ArtivizI < - c tKi Z svgs- p m j 1.1 5- w el tit -- 2 -1 5 T n SI-, ,,. .!;e- 17. 2 > M AK ->,_ cz e I.: N" O T (P .;<-r-- sic, N;o ...2a z e Fr c ZIto 4 _ m Ii ocv1 73 o a_ v.,,_ - C 0 N cf,y O . N T 0smog 0 o p _ 7 , O 1 E- NN o 0 o' D �.p W m t f9 �® a o CD C., B m CO D '_'41. - Z Cr) ® N 3 i m O N � - o g- . m GJ 0 O <p am g- >< D 3 n Z Q O Q T W Olrn - fD o Z —r o 0. 5 1C., 5d m Q N� rn o5' 0 N Q j�f.-_.e' ki y.�..e M tit ..-3,....e. 4 $ Z. it Y ..e it y �.ni.' _ ,4�" R 11. ° tl. .1 e ,e ii 4(i e,4 r a t Z n e .4.s,4a41: = t -f�.; i ,i r 4LIA s 4 't �I . - S- 'e./-±t.. .9;Q - SG\-9;reZ/J`�G\3;e-e/� Q C s9•C'_�l`JG `;e.-- C ,`Cl. - a,,.=-x_�, 7rxIST.rill T'I'm titeni•in, In .3.3-1.1.{ flfl a' -'i ilU2 aa.=E2 1/4‘.").1. j _ 1 4.2a3 _ CERTIFICATE OF • ,', TRAININGALLERGEN AWARENESS ,v.. ;A ;.7 , • MARY DESIMONE 4•IP' �C,.. Name of Recipient. � � L j,cy�� Certificate Number: 3333383 - YE3•w�v: 4132079 "C.c n i Date of Completion: . Vel ; Date of Expiration: 4/312°23tCsy ii.i..„ .1 4-f?.1111111. .4;41,^ r=1 .•**. y r?\ Issued By: : 'Cc.: The above-named person is hereby issued this certcate 1 NATIONAL : 1� �v#� .fin-completing an allergen awareness training program -_-1 RESTAURANTa �a recognized by the Massachusetts Department of Pubfte Health """"' t , in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 f3 333 Turnpike Road,Suite 102 www.testaurantotgRti'Ci} Southborough.MA 01772 • r z 7h.is certificate will be valid or ve(5) ears(*ram date o com letion. iz f f .. f� i f P sos-3o3-mos -31, www matestaurantassoc.otg _ cr:rc. - �� a .-rn uiia In z- =n n.v-r •'.rr= n. -.r f "41'--,- �G�,7 C G�.7 C/'�7c t6-----,..1.,C/7e . mc..” ) C7 G19,.,C 4 S G�..��C GQ.a,.1 T. ?"' V. Tr. Rf?n R - R en', ' V ly • U 4 , TCI , r V. t nom 'e 1 A , 4 �r'., .0 c U i > U. 5. e r. , i;., I 1. ,, t ± ;IL, ±.� -& j ',I;fl 'N t . viB 02, (11 22 HATH°EPT. The Commonwealth of Massachusetts _ Department of Industrial Accidents . it-,474,,,,_ Office of Investigations ;; n "�"" ' 1 Congress Street,Suite 100 *4.=' :t� Boston, MA 02114-2017 3 0 022 I: r w y w www.mass.gov/dia HEALTH DPT. Workers' Compensation Insurance Affidavit: General ; usinesse Applicant Information ��AA�,q,t Please Print Legibly Business/Organization Name: MRJ�1Ar' U l,t�lY Address: 19-r7C) tam tS City/State/Zip: S, �tiI a* cum- Phone #: 5° gal ' l 39 . Arey u an employer? Check the appropriate box: Business Type(required): 1.E I am a employer with V.) 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. 0 Office and/or Sales(incl. real estate, auto,etc.) employees wcrking 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 10.0 Manufacturing no employees, [No workers' comp. insurance required)** 4.❑ We are a non-profit organization,staffed by volunteers, I 1•❑p . ealth Car with no employees. [No workers' comp. insurance req.] 12.it Other la 0,vtarlS Rce *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corpdrate 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 insura ce for my employees. Below is the policy information. Insurance Company Name: • (; Mk i c 'A Insurer's Address: q r15 y�`�� Y l ILtA City/State/Zip: P-41\ 0%0) 'NO/ 0 t, 2 49, I:2,1 f , ki.11 ir,0 al Policy#or Self-ins. Lic. # 1 Expiration Date: �a'ai(k) oj1t),in Mae- Attach a copyof the workers' compensation p nsation 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 lo$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 certify,under theitin and penalties of perjury that the information provided ab ve is true and correct. Si 6L nature: p►C.CJ)It nLQ. Date: lq Gl Mq Phone#: 0 i-/6y) 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 t Contact Person: Phone#: www.mass.gov/dia CO Is DATE(MM/DD/YYYY) A CCERTIFICATE OF LIABILITY INSURANCE 02/02/2022 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 INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Tina Reeves PRODUCER NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX INC.No,Ext): (A/C,No): 973 lyannough Road E-MAIL treeves@doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S Hyannis MA 02601 INSURERA: Penn-America Insurance Company — INSURED INSURER B: Mary's Iii Caboose Inc VNSURER C: ,- 1279 Route 28 ,,NSURER D INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER _ (MMIDDIYYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED100,000 CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) S MED EXP(Any ale person) $ 5,000 A PAV0302842 03/3012021 03/30/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE UMIT APPLIES PEE GENERAL AGGREGATE $ 2,000,000 PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JECT — $ OTHER: --•-- ._, COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY COMBINED accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY _ AUTOS PROPERTY DAMAGE HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) _ S UMBRELLA DAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS,MADE AGGREGATE $ _ DED RETENTION$ —_._._ $ WORKERS COMPENSATION PER OTH- STATUTE ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE N f A EL.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ — BUSINESS PERSONAL PROPERTY A PAV0302842 03/3012021 03/30/2022 $10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate Of instxa V s all be deemed to have altered,waived,or extended thecoverage provided by the policy provisions. I`td 0 G ZOZZ HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 t --a..` .J ar ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ® DATE(MM/DDNYYY) ACORE, CERTIFICATE OF LIABILITY INSURANCE `..�/- _ !_ 02/02/2022 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _ PRODUCER CONTACT NAME_ Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY LNG, .exc). (508)775-1620 Ia,No): E-MAIL Do ESS: Isullivan@doins.com 973 IYANNOUGH RDINSURER(S)AFFORDING COVERAGE NAIL u __ HYANNIS MA 02601 INSURER A: HARTFORD UNDERWRITERS INS CO _ 30104 INSURED INSURER B: MARYS LIL CABOOSE INC INSURER C: INSURER D: 8 RED CEDAR CR INSURER E: DENNIS MA 02638 INSURERF: COVERAGES CERTIFICATE NUMBER: 741464 _ 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'EI=EN REDUCED BY PAID CLAIMS. INSR ADDL SUBR' 1 POLICY EFF I POLICY EXP LIMITS LTR I TYPE OF INSURANCE INSD WVD POUCY NUMBER _l(MM/DD/YYYY) (MM/DO/YYYY) II COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 '--i DAMAGE TO RENTED CLAIMS-MADE j I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ ` J N/A PERSONAL 8 ADV INJURY $ I GEN'L AGGREGATE LIMIT APPLIES PER: ('py - GENERAL AGGREGATE $ `1 POLICY I I ECT I LOC v�� �� D PRODUCTS-COMP/OP AGG '$ OTHER: f ) �j n�yfry/ $ AUTOMOBILE LIABILITY Fie IJ f, LUQ` i COMBINED SINGLE LIMIT $ (Ea accident) I ANY AUTO BODILY INJURY(Per person) $ ALL OS OWNED I AUTOS U�D N/A ►-IEALTI' DEPT. BODILY INJURY(Per accident) $ 1 NON-OWNED PROPERTY DAMAGE I$ HIRED AUTOS AUTOS I(Per accident) $ IUMBRELLA UAB _ OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB 1 CLAIMS-MADE N/A AGGREGATE $ I DED I RE I LNTION$ I $ I WORKERS COMPENSATION X(STATUTE I ERH AND EMPLOYERS'UABILITY ANYPROPRIETOR/PARTNERJEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A ,OFFICER/M En BENHEXCLUDED? N/A NIA NIA 6S60UB1 K28070121 03/31/2021 03/31/2022 E.L.DISEASE EA EMPLOYEE $ 500.000 I It yes,describe under DESCRIPTION OF OPERATIONS below 1 EL.DISEASE-POLICY LIMIT $ 500,000 I N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwdfworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE CL--Ci South Yarmouth MA 02644 Daniel M.Cr lv ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD