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NAMU OI; BIJSINESS ()cean i\{ist Seach llotel & Suitcs
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. PLEAS[.) (]0}IPI,E E I'HIS }\I'PI,I(]A'IION AND RETTJRN I'T WITH TIIE I,ICT]NSE rEE
.ltJ'\-8.10,2025
PLhASh (:O1\{PLtlTI: ALt- Qt.lUSTIONS
Ilt.lSINIiSs 1'l:l. ;sos-:s85#trHoepr
BUSINESS ADllltESS lN YARN{Ot.lTll 97 South Strolc DriYc. South Yamrouth. N4A.026fr4
l\'lAlLlNG ADt)I{l:SS 28 Jaconrc Wav !l iddlctorvn Ii l. {)ll-11
EM.{lL ADDRESS Lm:rrvnvch(rlnurvool.ll!orll
RlrQUt RUI) MANAGETL( ONTAa]- pERSO\Jctl [j.r'arrs
TELEPHoNE r 508-243-90lti
RllQ{ ll{t.l) OWNER NAME J<ut Cohen Tr,L.# 401-8.15-0900
llO\4E ADDRI:SS 2l .laeonrc \\'ar . \l irldictou n. Itl. 0l8ll
CORPT)IL{l lON Ni\\JI: {ll'APPLI( .\ltl-l:) Occan \'n11. F 401 -E,15 -090i)list l. L('
( onponaltcll ADI)RESS 2li .laconrc wrqv, MiddlctoB t'l Iil 02ii42
MAlLl NG A t)D Rt'- SS I t larolrrJYay-_Nfuk11c&run. Rl. I ) 2 lt{l
TAx rD(FErNoR ssN) RllQl;Iltr.l).l{.-i .- 1) I :(tfl
LICENSES RUN ANNUALLY I]ROM JIiI-\' I 'TO JUNE 30. IT IS 1'OT-]R RESPoNSIIIIL I]'Y TO RETURN
'IIIE tlOI{Pl-E lED ,{PPLI('ATIO: '-tS ) .\ND REQUIRED FIjE(S) tsY JUNI ]0. t:AILURE TO t)O S() \\'tLL
RESI-]LT IN CLOSURE OI. \'OUR ES'|AIJLISI IM E,.VT UNI'II- III[ REQIIIREI) AI'PLICATIONS(S) ANI)
FEE(S) ARE RLCt:lvLI). A HEARIN(i tsEFORE'l-HE UOARD OF HIIAL'I-H N'IAY BE R!.QLIlRl-;D PRIOII,I'O REOPENING,
T.rvn ol-Yarurouth tarcs and lisrrs must bc paid prior (o ranru'itl or issuancc of vour pcnnits. Plr:asc chccl
appropriately if paid: y'es_ no __ rla-
Under Chaptcr 152. Sec. 2-iC. subsecti{)n (). lhc To\vn ol'Yarmouth is rcquircd to hold issuance or renerval of any
Iicense or pennit to opcrlte a businc'ss if l pcrsru or compan-v does noI hlvc a ('enitlcation of Wurkers Conrpt'nratiorr
insurance. As part oftencs al or issuarcc ol lrrur penrrits. vi!u urust complct€ thc cnclosed Workcrr Conrpcnsatiru
Affidavit. Il'not applicublc. plcusc cxplain:
Rf;GISTRATI0N F'ORM SIGNF.D ANI) CON{PLETEI)
( llll(lK AND WORKERS COMP r\l;FlDAVll hNCLOSEI,
Al.l- SAFIIl\'I)A'lr\ Slllrl:TS Ol\ lrll.l:
YN
ANY NI]W CHE}IIC,\LS I\I TIST ItF: PRE-APPRO\/ED BY THE HEAI,'T'II DEPAITT),IT,N'I-.
,/RENE\\ AL API'LI('ATIoN "/ NI.:W .,{I'PL I('ATI( )}'
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D.,\',t !_eolrr lxs
{billqd.4AI'PLIC]ANT'S SI(iNA UIIE
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Thc Comnronwculth ttf :l[assach u sett.s
Dcpartn ent oJ I nd u st rial A ccidants
O f/i ce of I nvestigation s
I-o-frr.ynt t" City 6ouru,
2 Ayanuc dc l.afayette , Boston, tll,4 021 I I -1750
tytt rr,.lz-rass.goty'dia
\Yorkcrs' Conrpensation Insurancc ;\flidat,it: General Businesses
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Annlicant Infilrnration I'leasc l'rint Le iht
Businessi0rgarr ization Namc:Ocean Mist Beach Hotel & Suites
Address: 97 South Shore Drive
Are you an employer? Check the appropriate box:
l. [f I am a cnrpk)yer \vith + enrplolccs (full anrt,'
or part-time).'
2. E I am a sole proprictor or partncrship and havc no
employccs urrrking for nrc in any capircrt..
[No rvorkers' conrp. insurancc rctluirctll
3. E Wc are a corporation and its oUie crs har c cx,.'rcts,.'tl
thcir right ofexcrnption pcr c. l5l..sl(.1). arrd qc havc
no enrployees. [No rvorkcrs' conrp. insurance rcquircrll*
a. I We are a nol-prolit organiz-ation. slatfcd b1 \'oluntecrs.
with no cnrployccs. [No rvorkcrs' conrp. insurancc rcq.]
Phonc #.508-398-2633
Business Type (required):
5. f] Rcrail
(,. fl Rcstarrralt,13arr'Erting Establ!stln'clt
7. fi Ot1ice and./or Sales (incl. real estate. auto, clc.)
8. I Nor-profit
Intcrtainrrcnt
i\lanulhctrrring
Hcalth Carc
t0E
iAny applicanl lhat cherl,i bor *l nlrrst also fill orl lhc scrlion below showing thcir rtorkcm' conpensation policy inl'omtation.
organization should check bor ;i l.
(),1',., Hotel
lnsurunce Contpalv Nantc Genatt V LLC
Ciqvrs6l. 71,',New Hyde Park, NY 1 1042
Iblicy + or Srlt'-ins. 1ig. pWCO14008010 11t15125
Attnch a cop) of the rvorkers' compensl(ion policl' declarati<rn prgc (short'ing the policy number and erpiration datc).
Failurc to sccurc covcragc ls rcc;uirctl under I 25,\ of\4(iL c. 151 can Ic'ad lo thc ir'Ilpositi{rn ofct'inrinal pr-'ttirltics.tfa fittc u1r
to S I .500.00 and/or one-year imprisonnrent- as rvc'll as civil penalties in thc lonn ot a STOP \\"ORK ORDI:R and a tifle ol-up i(,
$250.00aday against thc violator. Be adviscrl tlrat a copy olthis statenrcnt rrray be fbnvarded to the Office of lnvcstigatjons or'
the DIA for insurarlcc covcragc vcrification.
F.xoiration Drlc
I).r 1.Iu les
I)lrure l; 4Ot.L(5- Oq,oo ext . r2f
OJlicial usa only. Do iot ,"''ritr" i,t lltis ur'<,u, to bt complatt'd h.t'citr or towt ollicinl
lsruillg .,tuthorit!, (check one):
I flBoard of Health 2*! Buikling f)epartnrenr 3{] Citt,/To]vn Clcrk 4. ! l,ice nsing Board5[ Selectmcn's Office 6. f]Othcr
Contact Person;
Pr.nuia/[,irtnsc 4
I)hone #:
('i(v or Ton n:
$ w\!"rniiss.!o\,,dril
Citylstate/Zip: South Yarmouth' MA, 02664
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lnsurcr,s A6dress:3333 New Hyde Park Rd, Suite 400
Sig..rrurc 1,*rll-m,o
Information and Instructions
Massachusetts Gcneral Laws chaptcr l5?rcqrrircsa)l cnrploycrs k) prr)r idc workcrs conrpersalion for thcir crlployces.
Purs[ant to this statulc. an enployec is detinr"d {s -.. crery persol in thc service o1'anuthcr undi}r any conlract ofhire.
cxpress or irnplicd. rrral or rlritten."
An ca?/a.rer is dqtlncd as "un individual. panncrship. associirtion, corporatiorr or other lcgal entity- or any r\vo or nlore
of the loregoing englgctl in a joinr enterprisc. lnd includirrg the leeal representalives ol'a dcceased enrployer. or t6e
tcccivcr or trustcc of an individual. partncrship. asst',ciaticrrr or olhcr lcgal cntitl, cmploving emplo-v-ees. Ilovvcvcr, the
orvner tlf a du'elling hottse having nol nlorc lhan rbree apannrcrrts aod u'ho resides thercin. or the occupant ofthc
dwellirtg housc ol anothcr who employs perserrs lo do mainlenancc, colst[uclion or rcpair l ork on such drvelling h,;usc
or on thc grounds or building appurtenart thcrcto shall not lrccar,rsc ofsrrch cmploymcnt bc dcerncd to bc arr crrploycr."
i\'lcL chapter 152, $25C(6) also states that "cr.erv stato or local llccnsing agcnc.r- shall withhold the issrance or
ren$val of a liccnsc or pe rmil to opcrrlr a busincss or to construct buildilgs in thc commonweallh forunv
applicant rrho has noa produced acccptablc evidcnce ofcompliance with the insurancc covcrage required."
Addilionallv. MGI- chrpter I 52, $lsc(7) s(irtcs "Ncither the conlnl()rlw(:alth nor anr.- ol'its political subdivisions shall
rcquirements of this chapler have been prcsentcd to (he contracting authority."
r\pplictl nts
Please lill out the rvorkcrs con'rpcnrllion .rflitllvit conrpletcly. hy- checking thc boxc's that lpplv to your sinurtion and. il
r')cccssary. supply 1'our insurrnce cornpan.y-'s uamc, address lnd plrone nuntber along u,ith a cenificate ol'i[suranc!'.
Limited Liability Conrpauies (LLC) or Liruitcd l-iabilily Partncrships (LLP) \f ilh no cnrylo;'ccs othcr than thc u)umbcrs
or panners. are not rcquircd to carr) \\'orkcrs' conrpcnsation insulancc, lf an LLC or l.l,l' does have cmployccs. a policy
is rcquired. Bc adviscrl that (his atldavit nray be sulxnitted to the f)cpanDrent of lndustriul Accidentir i'or contirmation ol
insurarce colcragc. Also be sure to sign and datc thc affidavit. 'l'hc affidarit shr.ruld be retumed to thc cil] or tor\r]
that the application lbrthc permitorlicense is bcing requestcd. rlot the Department ol'lndustrial Accidents. Should vou
luvc ;:nv questions rcgartling the larv or il l,oLr alc rcquircd to obtain a rorkers' cortrpensrtion policy. please call thr'
Dcparlnlent at tltc nunrbcr Iistcrl belou. Scll'-insurcd cr)mlanlcs should cntcr thcir sclf-itrsurancc liccnsc numhcr on lhc
appropriatc line.
City or'forrn Officials
Pleasc tre surc thal thc allidavit is cornplctc and printcd lcgibly. Thc Dcpantrcnl has providcd t spacc at the bottonr
of tlrc affidavit tbr you to lill out in thc cvcrlt lhc Otlicc of Invcstigations has to contacl you regarding thc applicant.
Please be sure ro till in the perrnit'license nunrbcr rvhich rvill be used as a r!'ferencc numbcr. In addition, an applicant that
rnust submir uruhiplc pcrmit.:liccnse applications in any giren 1,ear, nced only subnrit onc aflidavit indicating currcnt
policy infomration (ifncccssary). A copy of thc al'fidavit that has bccn ollciall.v stan:pcd or Dnrkcd by thc'city or t()\ur
must be filled out each year. Wherc a honre orvrer or citizen is ohtairring a license or pcrtnit not telat€d to any busincss
or comlcrcial vcnturc (i.c. a dog licensc or purmit to bun: lclvcs clc.) said pcrson is N0'[ rcquired to conrplctc t[is
atlldavit.
The Officc of Invcstigations \ould likc ro rhank you il advancc for ]'our coopcralion and shorrld you lravc any qucstions.
plerse do not hcsitate to give us a call.
1-he Dcplrlment's adtllcss lelephone lnd lirx Durbsr:
'1'he Conrmonwealth ol lvlassachuselts
Dcpartrnent of Indr.rstrial Accidents
Offi ce of Investigations
Lal'ayctte City Center
2 Avenue de Lafayette.
Boston" MA 02 I I l- 17,-s0
Tel. (tt57) 321-7406 or l-877-MASSAI;E
Fax (6t7) 727-7749
wr!,ltr.nrass. go\r/d iaFom) R..!is!'d 7 l(,19
COVERAGES CERTIFICATE NUMBER:'1 500876221 REVISION NUMBER
5t2012025
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 OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endo.sed.
It SUBROGATION lS WAIVED, subject to the terms and condltions of the policy, certain policies may require an endorsement. A statement on
this cerlilicate does not confer rights to the certificate holder in lieu of such endorsement(s).
i?illf ' p"rL to ctrrxr :n
lf35E", ero, s Lo-saa,:oo!
-iffilr.,lg,lq'@gnattspecralty-com
rN!!lREBlq) aFlgEDlllc cqyERAqE
rNslEER 4t zu!!!h Ame.ican lnsurance cimp?D/
l!suEER B illcE-American]nsurance ComLany
INSURfR C,
-G,r.tll9gr1zrz
4E1
I6!45
22667
Genatt V lnsurance Services
3333 New Hyde Park Road
Suite 400
New Hyde Park NY 1'1042
INSURED
Newport Hotel Group LLC, Etal
28 Jacome Way
Don Mccall
l\.4iddletown Rl 02842
NET IPHOT.Ol
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED AELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOP THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERI\.,I OR CONDI]'ION OF ANY CONTRACT OR OTHER DOCUI\.,IENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LII\,4ITS SHOWN I\,IAY HAVE AEEN REDUCED BY PAID CLAII\,{S.
POLICY EFF POLICY EXP
[ ] coxr:ncrucsxeul uerrv
] I l".o,r..roo. ]x lo..r*LI_1pqq.qs0
1q90.q9q
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1,00q000
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1,000,000
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f DAMAcridREi,TED- i _
PREMISES (Ea ecuren@l $[t.tqrao.rr*;;I
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frE!E!4!3rr +
PRODUCTS, COMP/OP AGG S1..r"".^""r* l;
4t1212425Y Y G1O011456110 4112t2026
GEN'L AGGREGATE LIMIT APPLIES PERI "o.,", f- 59"o; fx-.ocX otrrp LtouoR LtlBtLrv
A AUTOMOBILEfhAILfTY
X ANY AUTO
OWNEDArrrosoNl Y i
C-oMBTNEO STNGLE LMrt s 1 o0o o0o
[ibo,.i-,r-"'r"".**;-fs -
EOplLY TNJURY (P./ accdenr)i $
] AUTos oNLYx
8AP011657510
8AP012619008
411212025
411212025
4112t2026
411212026
SCHEOULEO
NON.OWNEDIlll,i{",."PROPERW DAMACE
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! 50,000,000
NLt24AGl4aa2321
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AGGREGATE
[ ] o""r"411212025 4/1212026 EACHoccURRENcE $ 50,000.000
ANYPROPRIETORPARTNERT€XECIJTIVFOFFICER/MEMBERFXCI IJI]FD'
DESCRIPTION OF OPERATIONS h.l.s
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pa-
.000
,000
wco14oo801o 11115/2024 X
El",^] I +-lEAC c l 000
s ASE EEA aa 000
SEASE c M T 000
ANO E'II PLOYERS' IIABI!ITY
] OTH.Llatttstzozs t. $F
DESCRTPTION OF OPERAIK)NS / LOCATIOT'iS /VEHICLES (ACORD lol.Addatlonal R.frarb sch.dote. fr.y b..rt ch.d It mor. sp.c. ii r.qutr.d)LOCATIONS:
2. 213 Ocean Skeel, Hyannrs. [.1A 02601 Btdg#1 & #2
3. 178-180 Thames SIr;et, Newport, Rt028454. '15-13 Kitburn Ct. Newport, Ri02840
5. 82 Ml. Hope Street, N. Atfleboro. NrA 026706.72 Common Courl, Settlers Green, Rt. .16, North Conway, NH 039607. 40 l,lain Street, Fatmouth. MA 025408. 28 Jacome Way, [4iddletown, Rt 02842See Attached...
CERTIFICATE HOLOER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO AEFORETHE.EXPIRATION OATE THEREOF, NOTICE WLL gr OCLIVCNCO IIIACCORDANCE WITH THE POLICY PROVISIONS.
EVIDENCE OF INSURANCE
AUTI]ORIZEDCK 6./<r'/
o 1988.2015 ACORO CORPOThe ACORD name and logo are registered marks ofACORDACORO 2s (2016/03)RATION. All riqhts reserved.
CERTIFICATE OF LIABILITY INSURANCE
Llf rs
B x I UMBRELLALAaL]
EXCESS LIAB
AGENCY CUSTOMER lD: NEWPHOT-01
Page 1 ol l
Genatt V lnsurance Services Newporl Hotel Group LLC, Etal
28 Jacome Way
Don [,,lccall
[,,liddletown Rl 02842
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORO FORM,
FORM NUMBER: 25 TONM TTLE.CERTIFICATE OF LIABILIry INSURANCE
10. 97 South Shore Road, South Yarmouth, MA 02664 Bldgs. #1,2,3
12. 73 South Shore Road. South Yarmoulh, MA 02664 Bldgs.#1,2,3,4
13. 38 Purgatory Road, Middletown, Rl 02842 Bldgs#1,2
14. 368 Old Post Road, North Attleboro, MA 02760
'15. 390 N. Glenwood, Jackson, WY 8300'1
16
17
18
19
20
21
22
23
251,259,267 Thames Streel, Bristoi, Rl 02809 Bldgs#1,2,3,4,5
1 State Streel, Bristol, Rl 02809 Bldg#6'157 Holly Ridge Road, Conway, NH 03818
235 Ocean Street, Hyan6is, MA 02601
120 Palmer Avenue, Falmouth, MA 01930'107-108 Atlantic Road, Gloucester, MA 01930 Bldgs#1,2,3
43 & 45 Hull Shore Drive, Hul!, MA 02045
131 Ocean Street, Hyannis, MA 02601
24. 149 Ocean Street, Hyannis, MA 02601
25. 42 Wylie Ct. #14, North Conway, NH 03860
26. 70 Wylie Ct. #26, North Conway, NH 03860
27.70 Wylie CL #28, North Conway, NH 03860
ADDITIONAL REMARKS
O 2008 ACORO CORPORATTON. A rights reserved
The ACORD name and logo are registered marks o, ACORD
ACORD 101 (2008/01)
LOC #:
ADDITIONAL REMARKS SCHEDULE