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HomeMy WebLinkAboutBCOI-24-6 2025 The Commonwealth of Massachusetts Town of lk." YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:IFAW BCOI-24-6 Trade Name:IFAW Identify property address including street number,name,city or town,and county Certificate Expiration Located at 290 SUMMER ST , January 31,2025 YARMOUTH PORT,MA 02675 Floor Occupancy_ Use Group Other Use Group ClassIfication(s) 01st Floor 468 A-3 Lecture halls,dance halls, 468 Person-Standing churches and places of religious 93 Persons Table/Chairs Allowable Occupant Load worship,recreational centers, 200 PErsons-Chairs Only terminals,etc. This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure,or portion thereof as herein specified has been inspected for general fire and line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Building 1 E?e of Inspection Name of Municipal Chief Commissioner (:),;,1ark /3b/ANY' Signature of Municipal Fire Signature of Municipal Building 4;r ate of Issuance . /L /711, Chief Commissioner _ °� YRR TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION December 1,2023 PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 2 c\l n P r 5C 5e Name of Premises: —f cloo-•.p Tel: SO VC--7V `(- 2 1 6,3 I/ Purpose for which permit is used: aSS �Mb\`( �2 G� License(s) or Permit(s) required for the premises by othek governmental agencies: i Pi-,0 10 License or Permit RECEIVED Agency J//'= / 7•!l� N 112024 BUILbIN tEpARTMENT By. Certificate to be issued to j F J Tel: - 7 ( Y-Z/ v.3 Address: 2-ex.., 'r Owner of Record of Building Address Present Holder of Certificate P►-4.D roc cloc.r-4,1•No Signature of person to whom Title Certificate is issued or his agent Date Email Address: 1k FC. k(\JC) C �` c \ f.) ,c Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten (10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOTISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# �cb 01/31/2024-01/31/2025 �....14, INTEFUN-02 NFOWLER DATE(MM/DDYYY) '`��R� /Y CERTIFICATE OF LIABILITY INSURANCE 1/2/2024 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). PRODUCER N E: License#1780862 CONTACT Sharon Doyle HUB International New England PHONE 781 792-3279 I FAX WC, 300 Ballardvale Street (NC,No,Ext): Wilmington,MA 01887 itaku:Sharon.Doyle@hubintemational.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B:Federal Insurance Company 20281 International Fund for Animal Welfare Inc. INSURERC: - 290 Summer Street INSURERD: Yarmouth Port,MA 02675-1734 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY1 OMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE L X OCCUR PHPK2570776 6/30/2023 6/30/2024 PRRGM SESo(EaEoNTccurrenceI $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY lita X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: 1 $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ __— X ANY AUTO PHPK2570772 6/30/2023 6/30/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _AUTOS BB�ODILY INJURYD (Per accident) $ HIRED NON-OWNED (PeaEden Ot)AMAGE $ AUTOS ONLY _ AUTOS ONLY B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 15,000,000 EXCESS LIAB CLAIMS-MADE 79889955 6/30/2023 6/30/2024 AGGREGATE $ DED X RETENTION$ 0 $ 15,000,000 B WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY 71834621 6/30/2023 6/30/2024 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YNN NIA E.L.EACH ACCIDENT $ FICER/MEMBER EXCLUDED? 1,000,000 andatory in NH) E.L.DISEASE-EA EMPLOYEE$ ff yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers Compensation policy above covers the following states:CA CO CT DC FL GA ME MI NH NY PA TX VT.Massachusetts WC Proof to follow from the carrier if requested. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1145 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C DATE(MM/DD/YYYY) A cc CERTIFICATE OF LIABILITY INSURANCE 12/08/2022 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). PRODUCER CONTNAME;ACT Cheryl Woodside HUB INTERNATIONAL NEW ENGLAND LLC ONE (A/C.No.Ext): (978)661-6678 FAX (A/C, E-MAIL ADDREss: cheryl.woodside@hubintemational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B INTERNATIONAL FUND FOR ANIMAL WELFARE INC INSURER C: INSURER D: 290 SUMMER ST INSURER E: YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 842398 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE j CLAIMS-MADE ram. OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ AWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTEPER ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6HUB5B47942622 06/30/2022 06/30/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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/Iwd/workers-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. Building Department 1145 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/08/2022 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 PRODUCER NAME: Cheryl Woodside HUB INTERNATIONAL NEW ENGLAND LLC (A/C.N PHO o.Ext): (978)661-6678 FAX,No): ADEDRESS: cheryl.woodside@hubintemational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: INTERNATIONAL FUND FOR ANIMAL WELFARE INC INSURERC: INSURER D: 290 SUMMER ST INSURERE: _ YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 842398 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOO S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH PEATUTE AND EMPLOYERS'LIABILITY Y/N - ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6HUB5B47942622 06/30/2022 06/30/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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/Iwd/workers-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. Building Department 1145 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 " k Daniel M.CroGvlky,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD /.....%) INTEFUN-02 NFOWLER ACCPRO DATE(MM/DDIYYYY) ki...------ CERTIFICATE OF LIABILITY INSURANCE 1/2/2024 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). PRODUCER NAME: License#1780862 coNTAcT Sharon Doyle - _ HUB International New England PHONE 792-3279 FAX ,No): 300 Ballardvale Street (A/c,No,Ext):(7$1) Wilmington,MA 01887 lDaksS:Sharon.Doyle@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC f INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B:Federal Insurance Company 20281 International Fund for Animal Welfare Inc. INSURERC: - 290 Summer Street INSURER D: Yarmouth Port,MA 02675-1734 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INBR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMBS LTR INSD WVD (MM/DD/YYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCUR PHPK2570776 6/30/2023 6/30/2024 p( gETO REoNNTErrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRa X LOG PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO PHPK2570772 6/30/2023 6/30/2024 BODILY INJURY(Per person) $ OWNED —�SCHEDULED AUTOSONLY AUTOS BBOODILY INJURYp (Per accident) $ - AUTOS ONLY NLY (Per accident)ANVIGE $ $ B X UMBRELLA UAB X I OCCUR EACH OCCURRENCE $ 15,000,000 EXCESS LIAR I CLAIMS-MADE 79869955 6/30/2023 6/30/2024 AGGREGATE $ DED X i RETENTION$ 0 $ 15,000,000 B WORKERS COMPENSATION X 3E12-rUTE ETH- AND EMPLOYERS'LIABILITY Y 71834621 6/30/2023 6/30/2024 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ FFICER/MEMBEREXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE,$ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation policy above covers the following states:CA CO CT DC FL GA ME MI NH NY PA TX VT.Massachusetts WC Proof to follow from the carrier if requested. 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. Building Department 1145 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD