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HomeMy WebLinkAboutBCOI-24-30 2025 The Commonwealth of Massachusetts Town of g"YA. ./..4..14.74.448\ U 1 YARMOUTH o i-'~C,.RPOR AiE° " 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:Thacher Hall Trade Name: Thacher Hall BCOI-24-30 Identify property address including street number, name, city or town, and county Certificate Expiration Located at 266 ROUTE 6A YARMOUTH PORT, MA 02675 April 10, 2025 Floor Occupancy_ Use Group Other 01 st Floor 175 A-3 Lecture halls,dance halls, Chairs Only-175 Persons churches and places of religious Tables/Chairs-96 Persons Use Group Classification(s) worship,recreational centers, terminals,etc. Allowable Occupant Load 02nd Floor 133 A-3 Lecture halls,dance halls, 133 Persons churches and places of religious worship,recreational centers, 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 ' i Name of Municipal Chief Commissioner Mark Gry ate of Inspection a ANC/ Signature of Municipal Fire Signature of Municipal Building //�� Chief Commissioner Date of Issuance `� l/2-/ 2- p.A.„ TOWN OF YARMOUTH o . BUILDING DEPARTMENT cc, 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 R E C E I v- APPLICATION FOR CERTIFICATE OF INSPECTION MAR p 6 2024 7\ March 1, 2024 PAYABLE RECEIIETARTMLNT (X) Fee Req iretl$13668_____---- ( ) No Fee R e. In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a 9i� 6 Certificate of Inspection for the below-named premises located at the following address: �/ Street and Number: 21,1, ' 1 4e- 6 A A Name of Premises: /4 J R.d ie-1 Ha Tel: vi08'' I Purpose for which permit is used: 413 0_1417 £k -tL"License(s)or Permit(s)required for the premises y other governm ntal agencies: License or Permit Agency Certificate to be issue��jjt ,h .4L N ,xrvati FT el: 3 2)d -tcy l3 Address: 214 xfr,. Owner of Re ord of Building setae, Address .C- Present Holder of Certific e • • —1;:ljtdel re-e- Signature of person to who Title � � � 1 Certificate is issued or his agent do / P Date Email Address: Of petvile n-►iti f, Copp" 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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# 04/10/2024-04/10/202 5 l ® DATE(hiM/DD/YYYY) ACCOA"r CERTIFICATE OF LIABILITY INSURANCE 03/06/2024 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 CONTACT Trevor Hart NAME: ROGER KEITH&SONS INSURANCE AGENCY INC PHONE(A/c.No.Exq (5 583 1106 FAX ) (NC,No): E-MAIL ADDRESS: THart(gr erkeith.com � 1575 Main St MSURER(S)AFFORDING COVERAGE NAIC! BROCKTON MA 02301 MSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: YARMOUTH NEW CHURCH PRESERVATION FOUNDATION INC INSURERC: INSURER D: 266 ROUTE 6A INSURER E: YARMOUTH PORT MA 026751719 INSURER F: COVERAGES CERTIFICATE NUMBER: 984285 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 L1R INSD,p(VD POLICY NUMBER (MNYDOYYYY) (MWDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECf 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 -_. AUTOS ONLY AUTOS accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _._... AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DES RETENTION$ $ WORKERS COMPENSATION %( PER OTH- AND EMPLOYERS'LIABILITY X STATUTE- -- __ER - Y/N O EL EACH ACCIDENT $ 100,000 A OFFICER/MEMBERP XECUTIVE EXCLUDED? NIA WA VVVC10060237812023A O4/01/2023 04/01/2024 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 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/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 Yarmouth New Church Preservation Foundation ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 237 AUTHORIZED REPRESENTATIVE Yarmouth Port MA 02675 1 Daniel M.Cr y,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 The Commonwealth of Massachusetts 9) Town of ;: °g j'� o,, YARMOUTH o '�. _ "'a1 •\ ~coRPORAi02, 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:Thacher Hall BCOI-24-30 Trade Name:Thacher Hall Identify property address including street number, name, city or town, and county Certificate Expiration Located at 266 ROUTE 6A April 10, 2025 YARMOUTH PORT, MA 02675 Floor Occupancy_ Use Group Other 01 st Floor 175 A-3 Lecture halls,dance halls, Chairs Only-175 Persons churches and places of religious Tables/Chairs-96 Persons Use Group Classification(s) worship,recreational centers, terminals,etc. Allowable Occupant Load 02nd Floor 133 A-3 Lecture halls,dance halls, 133 Persons churches and places of religious worship,recreational centers, 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 Chief Name of Municipal Building Mark Gry ate of Inspection (/a Commissioner ` Signature of Municipal Fire Signature of Municipal Building Date of Issuance �j Z I 1-y Chief Commissioner !� gRg171 oo TOWN OF YARMOUTH 1761 y BUILDING DEPARTMENT Trot '�d 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECEIV ® APPLICATION FOR CERTIFICATE OF INSPECTION MAR 06 2024 March 1, 2024 PAYABLE RECE I.TARTMENT (X) Fee Req iredigtio�b0___.----- ( ) No Fee R 3.• In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a �f) Certificate of Inspection for the below-named premises located at the following address: 7\ Street and Number: Z41c, e fot,t 6A A Name of Premises: /? a die-1 /lta Tel: v68! /11 f 731S U �� Purpose for which permit is used: 445 6 f,14.t i .ft i/-t 6./.4411 License(s)or Permit(s) required for the premises other govemmtintal agencies: License or Permit Agency Certificate to be issue YaMI 4I N a ? ivJ;,' rail tl: Address: 261, Aff, fI Owner of Re ord of Building Sa_ Address 3p .L- Present Holder of Certific e �1�y►�� • • -1;;;..cact re-e" Signature of person to who Title / Certificate is issued or his agent �,rd� lf 2„;is/ Date Email Address: •fAil.pe.fivie , C'or►i 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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection # eCo/-r-W-3v 04/10/2024-04/10/2025 / 1 ® DATE(MMIDD!YYYY) A ��' CERTIFICATE OF LIABILITY INSURANCE 03/06/2024 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 CONTACT NAME: Trevor Hart ROGER KEITH&SONS INSURANCE AGENCY INC NCNNEo (508)583-1106 FAX(NC.r -' ADDRESS: THart@rogerkeith.com 1575 Main St INSURER(S)AFFORDING COVERAGE NAIC# - BROCKTON MA 02301 Ramat A: AIM MUTUAL INS CO 33758 INSURED INSURER B YARMOUTH NEW CHURCH PRESERVATION FOUNDATION INC INSURERC: USURER D: 266 ROUTE 6A INSURER E YARMOUTH PORT MA 026751719 INSURER F: COVERAGES CERTIFICATE NUMBER: 984285 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. IMSR TYPE OF INSURANCE AWL SUER POLICY ERR POLICY EXP LTR INSD WVD POLICY NUMBER 04110DO/YYYY1 oetwoo(YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 'CLAIMS MADE 1 OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ NED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPR $ POLICY -,, LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY AUTOS ONLY AUTOS (Per accident) 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 PERAND EMPLOYERS'LIABILITY Y/N _STATUTE___ ER H A OFFICER/MEMBERANOEXCLUD EXCLUDED? N/A NIA NIA WVC10060237812023A 04/01/2023 04/01/2024 EL EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached rf 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/Iwdlworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yarmouth New Church Preservation Foundation ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 237 AUTHORIZED REPRESENTATIVE Yarmouth Port I MA 02675 �—',�--i. Daniel M.Crol y,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 The Commonwealth of Massachusetts Town of zog YAo YARMOUTH '. .0 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:Thacher Hall BCOI-24-30 Trade Name:Thacher Hall Identify property address including street number, name, city or town, and county Certificate Expiration Located at 266 ROUTE 6A April 10, 2025 YARMOUTH PORT, MA 02675 Floor Occupancy_ Use Group Other 01 st Floor 175 A-3 Lecture halls,dance halls, Chairs Only-175 Persons churches and places of religious Tables/Chairs-96 Persons Use Group Classification(s) worship,recreational centers, terminals,etc. Allowable Occupant Load 02nd Floor 133 A-3 Lecture halls,dance halls, 133 Persons churches and places of religious worship,recreational centers, 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 Name of Municipal Chief Commissioner Mark Gry ate of Inspection is Signature of Municipal Fire Signature of Municipal Building //2 g P Date of Issuance Chief Commissioner k:°1..YaRto TOWN OF YARMOUTH a y BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION MAR p 6 2024 March 1, 2024 PAYABLE " RECEI1 ARTMENT (X) Fee Req � ( ) No Fee R B.• In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply f6or a Certificate of Inspection for the below-named premises located at the following address: 7\ Street and Number: 2 L,1, o f ea-le- 6 A Name of Premises: /1`7!z( � HQ /I Tel: S— liq--73 I 0 I Purpose for which permit is used: 446 License(s) or Permit(s)required for the premises y other governor ntal agencies: License or Permit Agency Certificate to be issue4itp ,r7 N ( ? v ;,' 1r' l: 32 '110-120 Address: 714. Att. Owner of Re ord of Building Sd/1"Ne-- Address .-- Present Holder of Certific e • .(fact rem Signature of person to who Title / Certificate is issued or his agent , cd� Date Email Address: 0/ ,pt e ,, t'f, C.Oyn 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 CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# (3CQi-ay 3(� 04/10/2024-04/10/202 5 DATE(MMlDD/YYYY) `0ROO CERTIFICATE OF LIABILITY INSURANCE 03/06/2024 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 CONTACT Trevor Hart NAME: ROGER KEITH&SONS INSURANCE AGENCY INC PHONE (508)583 1106 FAX (A/G.No.Ext) '(NC,NOR ADDRESS: THart@rogerkeith.com 1575 Main St INSURER(S)AFFORDING COVERAGE NAIC# BROCKTON MA 02301 MSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER 13: YARMOUTH NEW CHURCH PRESERVATION FOUNDATION INC INSURERC: INSURER D: _ 266 ROUTE 6A INSURER E: YARMOUTH PORT MA 026751719 INSURER F: COVERAGES CERTIFICATE NUMBER: 984285 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. SUBR ICY EFF POLICY EXP LIR TYPE OF INSURANCE ADDL INSD WVD POLICY NUMBER /MMIDD YYYY) IMM(DDIYYYY► LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ WA PERSONAL&ADV INJURY $ GEM AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1 POLICY JPERo `- 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 AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION XPER OTH- AND EMPLOYERS'LIABILITY Y J NANYPROPRIETO -._STATUTE__ _-.__.Er3-_-` -. _ --- A OF CER/M MBEEXCLUDED?ECUTIVE N/A N/A NIA VWC10060237812023A 04/01/2023 04/01/2024 EL EACH ACCIDENT $ 100,000 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A I DESCRIPTION OF OPERATIONS I 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 ic¢rie 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/Iwdlworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Yarmouth New Church Preservation Foundation P.O. Box 237 AUTHORIZED REPRESENTATIVE Yarmouth Port MA 02675 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