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HomeMy WebLinkAbout2023 Licensing - Inspection Report �� ® DATE(MM/DD/YYYY) A a CERTIFICATE OF LIABILITY INSURANCE 10/02/2029 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 iii 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). E PRODUCER CONTACT CB Aon Risk Services Southwest, Inc. NAME:PHONE — Dal 1 as TX Office (A C.No.Ext): (866) 283-7122 FAX No): (800) 363-0105 N 5005 Lyndon B Johnson Freeway E-MAIL c Suite 1500 ADDRESS: Dallas TX 75244 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: AIU Insurance Company 19399 5EI Speedway Holdings, LLC INSURER B: 3200 Hackberry Road Irving TX 75063 USA INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570102045590 REVISION NUMBER: Vg 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. Limits shown are as requested WSW ADDL TYPE OF INSURANCE INSD SUBR WVD POLICY NUMBER POLICY EFF POLICY LIMITS (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGEI O REN FED CLAIMS-MADE I I OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL a ADV INJURY o rn GEN'L AGGREGATE LIMIT APPLIES PER: -- J I GENERAL AGGREGATE v POLICY PRO ILOC oitPRODUCTS-COMP/OPAGG JECT nn��r/� OTHER: AUTOMOBILE LIABILITY 13UT j 1 �O23 L COMBINED SINGLE LIMIT n U) (Ea accident) , ANY AUTO BODILY INJURY(Per person) 0 OWNED —SCHEDULED AUTOS _ HEALTH DEPT. I z BODILY INJURY(Per accident) d AUTOS ONLY NON OWNED PROPERTY DAMAGE U HIRED AUTOS .—ONLY _AUTOS ONLY (Per accident) F t= 0) UMBRELLA LIAB OCCUR EACH OCCURRENCE C.) EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION A WORKERS COMPENSATION AND WC049154450 10/01/2023 10/01/2024 X PER STATUTE OTH- EMPLOYERS'LIABILITY Y/N AOS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT Si,000,000 A OFFICER/MEMBER EXCLUDED? N N/A wC049154451 10/01/2023 10/01/2024 (Mandatory in NH) CA E.L.DISEASE-EA EMPLOYEE Si,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000— III ell- DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Speedway Store #2438 at 441 Main Street, West Yarmouth, MA, Speedway Store #2440 at 14 East Main Street, West Yarmouth, MA and Speedway Store #2445 at 1353 Route 28, South Yarmouth, MA. rr- -y 0 CERTIFICATE HOLDER CANCELLATION m SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE r , EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. sr—E. 8 ;• Town of Yarmouth AUTHORIZED REPRESENTATIVE o 1146 Rt. 28 0 South Yarmouth MA 02664-4451 u5A t'7,, OY Y�� far M o �TCIr 8 0 III ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10039991 LOC#: A� ADDITIONAL REMARKS SCHEDULE Page _ of AGENCY NAMED INSURED Aon Risk Services Southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER See Certificate Number: 570102045590 CARRIER NAIC CODE See Certificate Number: 570102045590 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY INSR :1DDL St.BR POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR TYPE OF INSURANCE INSD WVD DATE DATE (1IAI/DD/VYYY) (MM/DD/YYYII WORKERS COMPENSATION A N/A wc049154452 10/01/2023 10/01/2024 WI CU. 11 2023 HEALTH DEPT. J ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10039991 LOC#: A ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER See Certificate Number: 570102045590 CARRIER NAIC CODE See Certificate Number: 570102045590 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Named Insured Schedule 2Go Tesoro Company; 7-Eleven, Inc. ; Giant Four Corners, LLC; Giant Stop-N-Go of New Mexico LLC; Northern Tier Bakery LLC; Northern Tier Retail LLC PF7 Southeast LLC; SEI Speedway Holdings, LLC; Speedway LLC; Speedway of Massachusetts LLCM _ Speedway Prepaid Card LLC; ' speedway western Holdings LLC; * * speedway.com LLC SWTO LLC; Tesoro Northstore Company; Tesoro Sierra Properties, LLC; Tesoro South Coast Company, LLC; Tesoro West Coast Company LLC; TRMC Retail LLC western Refining Retail TRS I, LLC; western Refining Retail IRS II, LLC Western Refining Retail, LLC Western Refining Texas Retail Services, LLC WIP LLC OCT 11 ' ®Z3 HEALTH DE . a m m 0 C- p O O O O ACORD 101(2008/01) CO 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD