Loading...
HomeMy WebLinkAboutBCOI-23-1752 2026 4� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYVY) D8/29/2025 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 Tina Reeves NAME: The Hilb Group New England,LLC PHONE (800)640-1620 I No): Mir'. ADDRESS: treeves@hilbgruup.com 973 lyannough Road INSURER(S)AFFORDWG COVERAGE NAICa Hyannis MA 02601 INSURER A: Tri-State Insurance Co of Minnesota 31003 INSURED INSURER B: Safety Indemnity Insurance Co 33616 A.B.PIZZA.II,INC.,APANDIDA LLC INSURER c: Hartford Accident&Indemnity Co 22357 715 ROUTE 6A INSURER D: INSURER E: YARMOUTHPORT MA 02675 INSURER F. COVERAGES CERTIFICATE NUMBER: CL2582983134 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. 'NVTYPE OF INSURANCE IWUL�UBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MMIDEINYYY) (MWDD/YYYY) LOAM X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED 300,000 CLAIMS-MADE Ell OCCUR PREMISES(Ea occurrence) $ MEDEXP(Any one person) $ 10.000 A ADV5502722-12 12/20/2023 12/20/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑ LOUJECaT PRODUCTS-COMP/OPAGG $2.000.000 OTHER: ADVANTAGE GENERAL $ AUTOMOBILE LIABIUTY SOMBBINEOSINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED 5901241 02/15/2025 02/15/2026 BODILY INJURY(Perawgent) $ AIRED ONLY AUTOS HIRED X NON-OWNLY PROPERTY DAMAGE $ X AUTOS ONLY !�AUTOS ONLY (Per PIP-Basicaccident) S 8,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION (STATUTE I IER AND EMPLOYERS'LIABILITY YIN 500,000 C ANYPROPRIETOR/PARTNER/EXECUTIVE El N/A OSWECBCSJPJ 03/18/2025 03/18/2028 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED'! 500.000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE-$ DE DESCRIPTION under OFO E.L.DISEASE-POLICY LIMIT $500'000 DESCRIPTION OF OPERATIONS babvi EACH OCCURRENCE $1,000,000 LIQUOR LIABILITY A ADV5502722-12 12/20/2023 12/20/2024 AGGREGATE $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) "'Workers Compensation"" A.Bolanos,President,is excluded from coverage. Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions 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 -------- I ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 4. NOT10ETO EMPLOYEES%‘ THE COMMONWEALTH OF MASSACHUSETTS Jess ` ��b DEPAF' k WENT OF INDUSTRIAL ACCIDENTS IF Y J ARE INJURED ON THE JOB : o Immediately notify your emp ver that you have been injured. Employer HR/Workers' Compensai Contact Phone Number o Tell the medical provider that 'ou have been injured at work and give the information below: Insurance Carrier Address Phone Number Hartford Accident and Indemnity One Park Place, 300 South State St, 7th Floor, Company Syracuse. NY, 13202 (800) 327-3636 Employer Address A.B. Pizza II Inc. 6 A # .715 MA YARMOUTH PORT MA 02675 o If the employer fails to repo, the injury to the insurer, the employee may file an Employee's Claim (Form 110). o Additional information regardi ig your rights and eligibility for benefits pursuant the Workers' Compensation law may be obtained by cor tacting the Department of Industrial Accidents at 617.727.4900 or visiting www.mass.govldia. �' IFMEDICAL TREATMENT IS NEEDED: Injured workers may select their c Am medical provider. Medical treatment costs that are reasonable, necessary, and related to the injury , workt ry will a paid by the above-named insurer. If medical facility information is rovided below, the above-named insurer has a preferred provider arrangement it d the insurer has arranged for your initial treatment at: Medical Facility: Address: o plti..110:42:•;•• . a.:•• •._a Li. • . . .. . • ... . .; . .. ,• •. Phone Number: : .::••• :iW..* • .• • 41 • ••` •.. •.. *• •ce.•W"• • ••••`N •. �•.•• .•1 ••.i..•=, •=2.,.7",�I.._' .. !i •••. • • •f .•. •• • .. :• •• 1 • N • M • EMPLOYER: THIS NOTICE MUST BE FI .. .f.::D OUT AND POSTED WHERE EMPLOYEES CAN •. „ 4# . • = j• _• READ IT PURSUANT M.G.L.C. 152, SECTIONS 21, 22, 30, AND 75B (2). EMPLOYERS MAY NOT • ••:..••• •i =•••S : .` ": RETALIATE, DISCRIMINATE (IN ACCORDANCE WITH ANY APPLICABLE STATE OR FEDERAL / ."" .•! •" ,".; .:• LAWS WHICH INCLUDES IMMIGRATION , "1�TUS), OR PROVIDE FALSE INFORMATION ABOUT a •• L•••3 �, ,�*; .•o.S•` '•`. THE WORKERS' COMPENSATION PROCE33 TO THEIR EMPLOYEES. THIS NOTICE MUST BE ` ` '•' " • « « .«•x UPDATED, POSTED AND REDISTRIB'. TED WHEN THERE ARE CHANGES TO THE INFORMATION. REVISED JUNE 2024 C....... A If' 00 es n9 IN n_: _•_ :_ I I (Policy Provisions: WC000000C INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident and Indemnity Company ` ONE HARTFORD PLAZA 1ARTFORD CT 06155 < THE ' HARTFORD NCCI Company Number: 10448 Company Code: 5 • Suffix LARS RENEWAL POLICY NUMBER: 08 WEC BC8JPJ 2 Previous Policy Number: 08 WEC BC8JPJ 1. Named Insured and Mailing Address: A.B. PIZZA II INC. (No., Street, Town, State, Zip Code) 6 A# 715 MA YARMOUTH PORT MA 02675 FEIN Number: 46-1580269 State Identification Number(s): — The Named Insured is: Corporation ▪ Business of Named Insured: Full-Service Restaurants Other workplaces not shown above: 6A# 715 MA YARMOUTH PORT MA 02675 2. Policy Period: From 03/'. t/25 To 03/18/26 ANNUAL 12:01 a.m. `,tandard time at the insured's mailing address. Producer's Name: THE HILB (RP OF NEW ENGLANDLLC/PHS PO BOX 1990 HYANNIS M\ 02601 Producer's Code: 08088233 Issuing Office: THE HARTECRD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8 7 30 Total Estimated Annual Premium: $2,982 Deposit Premium: Policy Minimum Premium: $251 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Twelve Pay (8.33%Down+11 @8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by Cj anon 02/06/25 Authorized Representative Date Form WC 00 00 01 A (1) Printer i U.S.A. Page 1 (Continued on next page) Process Date: 02/06/25 Policy Expiration Date: 03/18/26