HomeMy WebLinkAboutGourmet Pizza & Grill 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishmenj
Type: FOOD ESTABLISHMENT
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
HILAL AIT OUAKKA
Whose place of business is:
GOURMET PIZZA & GRILL
221 NORTH MAIN STREET
PERSON(S) IN CHARGE:
YOUNES CHEIKH, OWNER
Permit Expires: December 31, 2016
License Number: FS -25
Food Fee: $62.50
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Date received:
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By:
I
Permit # Issued
i.
FS -25
FOOD ESTABLISHMENT PERMIT APPLICATION
pp kation musstbe submitted affeast-36days before -the planned opening dateT
1) Establishment Name GOURMET PIZZA & GRILL
2) Establishment Address 221 NORTH MAIN STREET
3) Establishment Mailing Address (if different) 221 NORTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-5800
5) Applicant Name & Title: HILAL AIT OUAKKA
6) Applicant Address 42 FISHER STREET, #11, NORTH ATTLEBORO, MA
7) Applicant Telephone No.: (508) 212-3410
24 Hour Emergency No.: (508) 212-3410
8) Owners Name & Title HILAL AIT OUAKKA
-
9) Owner Address (If different from applicant) 42 FISHER STREET, #11, NORTH ATTLEBORO, MA j
Owner's telephone number (508) 212-3410
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
❑ A Corporation Na e Title Address
0 An Individual-
❑ APartnership C _---- -- - 4-
D Other Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc )
Name & Title: YOUNES CHEIKH, OWNER j
[Address: 117 ERICK ROAD #27, MANSFIELD, MA 02048
Telephone No: (5081212-341 24 Hour Emergency No: -.- `" V L)
FAX:
E-mail: CASAYC(&-GMAIL.COM
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title 'HILAL AIT OUAKKA✓
Address:
Telephone No cA9,9��d'S .� �f.� .�� (� 24 Hour Emergency No: (508) 212-3410
FAX: E-mail: 6,
� t L 1 l D(,�� f� �� NA L
- - - - --
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: MON-SAT 10 AM -11 PM
j 15) SEWAGE DISPOSAL:
16) No of Food Employees
VLSI, Ak'
18) Name of Person In Charge Certified in Food Protection Management: JAMAL CHERAA
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0
F— __ ---
20) Location: Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
0 Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
!(Check all that apply):
22) Establishment Type
❑ Retail ( 1000 Sq. Ft)
[i Food Service up to 100 or
up to 10' PHF display $62.50
❑ Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
5
❑ Caterer $12.50
❑ Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts:
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non -PRFs
r Sale of Commercially Pre -Packaged PRFs
❑ Delivery of Packaged PHFs
❑�/ Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
n PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Perishable Foods Only - ❑❑ Ice Manufactured and Packaged for ccontact ontrol) alternative, time as a public health
❑ Preparation of Non-PHFs Retail Sale - - -----
_ - - _ -- -- _-_- --__ red a - - lural Origin-----
-i--n
ri in
Other Food Operations Juice Manufactured and Packaged for ; ❑ Offers Raw Or Undercooked Food Of i
Retail Sale An g
- -- - " �❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities
'_ Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date - - - -- -
or Reconditioned Food To be completed by the Board of Health
-- --. -
Total Permit Fee: $62.50
Payment is due with application ❑ waived
I, the undersigned, attest to the ay of the information provided in this papplication and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all otherp' licable law. I have been instructed by the
board of health on how to obtain coglof 1y CMR 590.000 s nd the f� I FoocpG�de.
24) Signature of Applicant: J I f fr rrvv�
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 014-90-796 <- •�
26) Signature of Individual or Corporate Name:
I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
* ature o41ndiv�idudl or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the certification clause is signed by
the applicant.
** Your Social Security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or tax
payment obligations. Licensees who fail to correct their non -filing or delinquency
will be subject to license suspension or revocation. This request is made under
the authority of Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
N
Address: 22 tQ(1ky 4\ K)
City/State/Zip: Phone #: 32) j
Are you an employer? Check theappropriate box:
1.�4 1 am a employer with employees (fu!l and/
or part-time).*
2. ❑ 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers'.comp. insurance req.]
Business Type (required):
5. ❑ Retail
6. Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
1 l , ❑ Health Care
12.❑ Other
*Any applicant that checks box # t must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box dll.
I am an employer that is providing workers' compensate n insurance for my employes Below is the policy information.
Insurance Company Name: C i`jt< LU `I J-82 S u�
Insurer's Address:
M
�q
City/State/Zip: �1v 1 yy ► y�—c--� �_�
Policy # or Self -ins. Lic. # '1 `� - Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
www, mass, gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such -employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number, In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial veniiu•e (i,e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05
*000072*
P.O. BOX 8090
1ViLitllaL WAUSAU WI 54402-8090
INSURANCE
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
Y H ENTERPRISES INC DBA GOURMET PIZZA & GRILLE
221 N MAIN ST
MANSFIELD, MA 02048
March 18, 2016
In conjunction with the upcoming renewal of your Workers Compensation policy,
we have reviewed your loss history. This history indicates that, as of
March 18, 2016, no losses have been reported to Liberty Mutual for the
policy WC2-31S-365459-035 during the years 2011 to 2015.
We hope this information will assist you and your insurance agent in managing your
Workers Compensation exposure.
Involuntary Market Operations
CC: KARL A BRIGHT INSURANCE AGENCY INC
'0�Libel°ty rRoxY
ML1tUc11® LIBERTY MUTUAL HOLDING COMPANY INC.
INSURANCE Annual Meeting of Members to be Held on April 13, 2016
The undersigned, a member of LIBERTY MUTUAL HOLDING COMPANY INC. (the "Company"), hereby constitutes and appoints
James F. Kelleher, Richard P. Quinlan, Michael B. Garvey, and Tara A. Colby, or any of them individually, my true and lawful
proxies, each with full power of substitution (which substitution may be full or partial with respect to proxies received) to vote and
act in my name at the 2016 Annual Meeting of the Company (the "Annual Meeting") and at any adjournment thereof, as indicated
on this proxy on the matters specified, and as said proxies may determine in the exercise of their discretion on any other matters
which may properly come before the meeting or any adjournment thereof. This proxy will revoke (or will be used by the proxies
to revoke) any prior proxy delivered in connection with the Annual Meeting.
IF PROPERLY EXECUTED AND RETURNED, THIS PROXY WILL BE VOTED AS SPECIFIED OR, IF NOT SPECIFIED, WILL BE VOTED: FOR
ELECTING ALL DIRECTOR NOMINEES; AND FOR THE EMPLOYMENT OF ERNST & YOUNG LLP TO AUDIT THE BOOKS AND
ACCOUNTS OF THE COMPANY FOR THE CALENDAR YEAR OF 2016.
0001-020011315 151267915
Y H ENTERPRISES INC DBA GOURMET PIZZA &
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD, MA 02048
♦ FOLD HERE
YOUR SIGNATURE IS REQUIRED FOR YOUR VOTE TO BE
COUNTED. Please sign exactly as your name appears. If
acting as a representative of a legal entity, sign name
and title. If the policy is a joint policy, only one
member's signature is required.
Signature
Title if required
, 2016
Date
YOUR VOTE IS IMPORTANT SO WE URGE YOU TO ACT PROMPTLY. THE MATTERS WE ARE SUBMITTING FOR YOUR CONSIDERATION
ARE SIGNIFICANT TO THE COMPANY AND TO YOU AS A MEMBER. PLEASE READ THE PROXY STATEMENT, VOTE BY SIGNING AND
DATING ABOVE, MARK ONE CIRCLE PER PROPOSAL AS DETAILED BELOW, AND RETURN THIS ENTIRE PROXY IN THE POSTAGE -PAID
ENVELOPE PROVIDED. THIS PROXY CARD MUST BE RECEIVED BY APRIL 6, 2016 IN ORDER TO BE COUNTED AT THE MEETING.
THE BOARD OF DIRECTORS RECOMMENDS A VOTE FOR ALL NOMINEES AND FOR PROPOSAL 2.
To vote, fill in one circle per proposal in blue or black ink. Example
1. Election of Directors. Nominees: Francis A. Doyle, III, John P. Manning, Thomas J. May
and Ellen A. Rudnick, each for a three-year term.
FOR ALL WITHHOLD ALL ABSTAIN
O O O
O For all, except vote withheld from this nominee (these nominees):
FOR AGAINST ABSTAIN
2. To vote that the firm of Ernst & Young LLP be employed to audit the
books and accounts of the Company for the calendar year of 2016.
THANK YOU FOR YOUR CONSIDERATION AND YOUR VOTE.
TAG ID: 151267915
rightJensen
T6 Agency I Sheehan
INSURANCE
6 Congress St., Milford, MA 01757
508-473-0556 800-287-9191
March 25, 2016
Y H Enterprises, Inc.
221 N. Main St.
Mansfield MA 02048
RE: WC2-31 S-365459=03
Effective 6/4/201 to 6/4/2016
Dear Insured,
This note is to remind you the workers' compensation insurance policy referenced above
will expire on 6/4/2016. Liberty Mutual must receive your payment of $1,139.00 prior
to 05/15/16 in order to continue the policy. To avoid a lapse in coverage please send this
payment as soon as possible.
If you wish to finance the policy please sign the enclosed finance agreement and return
along with your down payment of $398.65.
The renewal premium has been based on payroll information on file with the company.
If there has been a change in operation or payroll please contact our office for further
information.
If payment has been sent, please disregard this friendly reminder.
Sincerely,
JLc'� jQu�
Commercial Lines Coordinator
Bright Agency, Inc.
4'
Servicer Address PREMIUM FINANCE AGREEMENT LLOYDS CREDIT OF 6
P.O. BOX 15089 CONGRESS STREET
6 CONGRESS STREET
WORCESTER,MA 01615-0089
(800)922-8195 FAX: (508)862-1245
CUSTOMER SERVICE: (866)412-2431
A
CASH PRICE
PREMIUM
(TOTAL PREMIUMS)
B
CASH DOWN
PAYMENT
C
PRINCIPAL BALANCE
0.000% 12
(A MINUS B)
Account #:
NUAL PERCENTAGE RATE
cost of your credit as a yearly rate.
15.00
$1,139.00
$398.65'
$740.35'
AGENT
(Name & Place of business)
BRIGHT AGENCY, INC.
6 CONGRESS ST
MILFORD,MA 01757
(508)473-0556 FAX: (508)478-6709
INSURED
(Name & Residence or business)
Y H ENTERPRISES INC.
DBA GOURMET PIZZA & GRILLE
221 N Main St
MILFORD,MA 01757-4130 MANSFIELD, MA 02048-2214
(508)473-0556 FAX: (508)478-6709 (508)212-3410
LOAN DISCLOSURE
FINANCE CHARGE
The dollar amount the credit will
cost you.
$37.49
Commercial
Quote Number: 4805016
MOUNT FINANCED TOTAL OF PAYMENTS
ie amount of credit provided to The amount you will have paid after you
,u or on your behalf. have made all payments as scheduled
$740.35 $777.84
1 IL
YOUR PAYMENT SCHEDULE WILL BE
YOU HAVE THE RIGHT TO RECEIVE AN ITEMIZATION
Number Of Payments Amount Of Payments When Payments OF THE AMOUNT FINANCED:
Are Due MONTHLY' II I WANT AN ITEMIZATION (DO NOT CHECK IF YOU DO
7 $111.12]Beginning: 07/04/2016NOT WANT AN ITEMIZATION)
Security: Refer to paragraph 1 below for a description of the collateral assigned to Lender to secure this loan.
Late Charges: A late charge will be imposed on any installment in default 10 days or more. This late charge will be 5.00% of the installment due.
Prepayment: If you pay your account off early, you may be entitled to a refund of a portion of the finance charge computed by the actuarial method
on a 360 day basis or as otherwise allowed by law. The finance charge includes a predetermined interest rate plus a non-refundable
service/origination fee of $16.00. See the terms below and on the next page for additional information about nonpayment, default and penalties.
POLICY PREFIX EFFECTIVE DATE SCHEDULE OF POLICIES
AND NUMBER OF POLICY INSURANCE COMPANY AND GENERAL AGI
PENDING 06/04/2016 LIBERTY MUTUAL FIRE INSURANCE CO
COVERAGE
MINIMUM POL
PREMIUM
r
EARNED TERM
PERCENT
WORKERS
0.000% 12
1,092.00
COMP-
Tax: 47.00
ASSIGNED
RISK
Broker Fee:
$0.00
TOTAL:
$1,139.00
The undersigned insured directs LLOYDS CREDIT OF 6 CONGRESS STREET (herein, "Lender") to pay the premiums on the policies described on the Schedule
of Policies. In consideration of such premium payments, subject to the provisions set forth herein, the insured agrees to pay Lender at the branch office address
shown above, or as otherwise directed by Lender, the amount stated as Total of Payments in accordance with the Payment Schedule, in each case as shown in
the above Loan Disclosure. The named insured(s), on a joint and several basis if more than one, hereby agree to the following provisions set forth on pages 1
and 2 of this Agreement: 1. SECURITY: To secure payment of all amounts due under this Agreement, insured assigns Lender a security interest in all right, title
and interest to the scheduled policies, including (but only to the extent permitted by applicable law): (a) all money that is or may be due insured because of a loss
under any such policy that reduces the unearned premiums (subject to the interest of any applicable mortgagee or loss payee), (b) any unearned premium under
each such policy, (c) dividends which may become due insured in connection with any such policy and (d) interests arising under a state guarantee fund. 2.
POWER OF ATTORNEY: Insured irrevocably appoints its Lender attorney-in-fact with full power of substitution and full authority upon default to cancel all
policies above identified, receive all sums assigned to its Lender or in which it has granted Lender a security interest and to execute and deliver on behalf of the
insured documents, instruments, forms and notices relating to the listed insurance policies in furtherance of this Agreement.
NOTICE: A. Do not sign this agreement before you read it or if it
contains any blank space. B. You are entitled to a completely filled in The undersigned hereby warrants and agrees to Agent's
copy of this agreement. C. Under the law, you have the right to pay in Representations set forth herein.
advance the full amount due and under certain conditions to obtain a
partial refund of the finance charge. D. Keep your copy of this
agreement to protect your legal rights.
Signature of Insured or Authorized Agent DATE Signature of Agent
Page 1 of 2
DATE
3/25/2016 Web - MACPUR
Insured and Lender further agree that:3. POLICY EFFECTIVE DATES: The finance charge begins to accrue as'of the earliest policy effective date.
4. AGREEMENT EFFECTIVE DATE: This Agreement shall be effective when written acceptance is mailed to the insured by Lender. 5. DEFAULT AND
DELINQUENT PAYMENTS: If any of the following happens insured will be in default: (a) a payment is not made when it is due, (b) a proceeding in bankruptcy,
receivership, insolvency or similar proceeding is instituted by or against insured, or (c) insured fails to keep any promise the insured makes in this Agreement;
provided, however, that, to the extent required by applicable law, insured may be held to be in default only upon the occurrence of an event described in clause
(a) above. The acceptance by Lender of one or more late payments from the insured shall not estop Lender or be a waiver of the rights of Lender to exercise all
of its rights hereunder or under applicable law in the event of any subsequent late payment. 6. CANCELLATION: Lender may cancel the scheduled policies
after providing at least 10 days notice of its intent to cancel or any other required statutory notice if the insured does not pay any installment according to the
terms of this Agreement or transfers any of the scheduled policies to a third party and the unpaid balance due to Lender shall be immediately due and payable
by the insured. Lender at its option may enforce payment of this debt without recourse to the security given to Lender. 7. CANCELLATION CHARGES: If
cancellation occurs, the insured agrees to pay a finance charge on the outstanding indebtedness at the maximum rate authorized by applicable state law in
effect on the date of cancellation until the outstanding indebtedness is paid in full or until such other date as required by law. 8. INSUFFICIENT FUNDS (NSF)
CHARGES: If insured's check or electronic funding is dishonored for any reason, the insured will pay to Lender a fee of $10.00 or the maximum amount
permitted by law. 9. MONEY RECEIVED AFTER CANCELLATION: Any payments made to Lender after Lender's Notice of Cancellation of the insurance policy
(ies) has been mailed may be credited to the insured's account without any obligation on the part of Lender to request reinstatement of any policy. Any money
Lender receives from an insurance company shall be credited to the balance due Lender with any surplus refunded to whomever is entitled to the money. In the
event that Lender does request a reinstatement of the policy(ies) on behalf of the insured, such a request does not guarantee that coverage under the policy
(ies) will be reinstated or continued. Only the insurance company has authority to reinstate the policy(ies). The insured agrees that Lender has no liability to the
insured if the policy(ies) is not reinstated and Lender may charge a reinstatement fee where permitted up to the maximum amount allowed by law. 10.
ASSIGNMENT: The insured agrees not to assign this Agreement or any policy listed hereon or any interest therein (except for the interest of mortgagees or
loss payees), without the written consent of Lender, and that Lender may sell, transfer and assign its rights hereunder or under any policy without the consent
of the insured, and that all agreements made by the insured hereunder and all rights and benefits conferred upon Lender shall inure to the benefit of Lender's
successors and assigns (and any assignees thereof). 11. INSURANCE AGENT OR BROKER: The insured agrees that the insurance agent or broker soliciting
the policies or through whom the policies were issued is not the agent of Lender; and the agent or broker named on the front of this Agreement is neither
authorized by Lender to receive installment payments under this Agreement nor to make representations, orally or in writing, to the insured on Lender's behalf
(except to the extent expressly required by applicable law). This Agreement may be purchased or assigned for consideration directly from your agent/broker or
from another originator of premium finance loans. Your agent/broker may have a financial interest in the premium finance company that you have contracted
with and, as a result, may receive a financial benefit from arranging the financing of your insurance premiums. If you have any questions about this financial
interest, you should contact your agent/broker. 12. FINANCING NOT A CONDITION: The law does not require a person to enter into a premium finance
agreement as a condition of the purchase of insurance. 13. COLLECTION COSTS: Insured agrees to pay attorney fees and other collection costs to Lender to
the extent permitted by law if this Agreement is referred to an attorney or collection agency who is not a salaried employee of Lender, to collect any money
insured owes under this Agreement. (Not applicable in KY) 14. LIMITATION OF LIABILITY: The insured agrees that Lender's liability to the insured, any other
person or entity for breach of any of the terms of this Agreement for the wrongful or improper exercise of any of its powers under this Agreement shall be limited
to the amount of the principal balance outstanding, except in the event of Lender' gross negligence or willful misconduct (not applicable in KY). Insured
recognizes and agrees that Lender is a lender only and not an insurance company and that in no event does Lender assume any liability as an insurer
hereunder or otherwise. 15. CLASSIFICATION AND FORMATION OF AGREEMENT: This Agreement is and will be a general intangible and not an instrument
(as those terms are used in the Uniform Commercial Code) for all purposes. Any electronic signature or electronic record may be used in the formation of this
Agreement, and the signatures of the insured and agent and the record of this Agreement may be in electronic form (as those terms are used in the Uniform
Electronic Transactions Act). A photocopy, a facsimile or other paper or electronic record of this Agreement shall have the same legal effect as a manually
signed copy. 16. REPRESENTATIONS AND WARRANTIES: The insured represents that (a) the insured is not insolvent or presently the subject of any
insolvency proceeding (or if the insured is a debtor of bankruptcy, the bankruptcy court has authorized this transaction), (b) if the insured is not an individual,
that the signatory is authorized to sign this Agreement on behalf of the insured, (c) all parties responsible for payment of the premium are named and have
signed this Agreement, and (d) there is no term or provision in any of the scheduled policies that would require Lender to notify or get the consent of any third
party to effect cancellation of any such policy. 17. PRIVACY: Our privacy policy may be found at https://www.ipfs.com/Privacy.aspx. 18. ENTIRE DOCUMENT/
GOVERNING LAW: This document is the entire Agreement between Lender and the insured and can only be changed in writing and signed by both parties
except that the insured authorizes Lender to insert or correct on this Agreement, if omitted or incorrect, the insurer's name and the policy number(s). Lender is
also authorized to correct patent errors and omissions in this Agreement. In the event that any provision of this Agreement is found to be illegal or
unenforceable, it shall be deemed severed from the remaining provisions, which shall remain in full force and effect. The laws of the State of Massachusetts will
govern this Agreement. 19. AUTHORIZATION: The insurance company(ies) and their agents, any intermediaries and the agent / broker named in this
Agreement and their successors and assigns are hereby authorized and directed by insured to provide Lender with full and complete information regarding all
financed insurance policy(ies), including without limitation the status and calculation of unearned premiums, and Lender is authorized and directed to provide
such parties with full and complete information and documentation regarding the financing of such insurance policy(ies), including a copy of this Agreement and
any related notices. 20. WAIVER OF SOVERIGN IMMUNITY: The insured expressly waives any sovereign immunity available to the insured, and agrees to be
subject to the laws as set forth in this Agreement (and the jurisdiction of federal and/or state courts) for all matters relating to the collection and enforcement of
amounts owed under this Agreement and the security interest in the scheduled policies granted hereby.
AGENT/BROKER REPRESENTATIONS
The agent/broker executing this agreement represents, warrants and agrees: (1) installment payments totaling $0.00 and the down payment indicated in Box
"B" on Page 1 has been received from the insured in immediately available funds, (2) the insured has received a copy of this Agreement; if the agent/broker has
signed this Agreement on the insured's behalf, the insured has expressly authorized the agent/broker to sign this Agreement on its behalf or, if the insured has
signed, to the best of the undersigned's knowledge and belief such signature is genuine, (3) the policies are in full force and effect and the information in the
Schedule of Policies including the premium amounts is correct, (4) no direct company bill, audit, or reporting form policies or policies subject to retrospective
rating or to minimum earned premium are included, except as indicated, and the deposit of provisional premiums is not less than anticipated premiums to be
earned for the full term of the policies, (5) the policies can be cancelled by the insured or Lender (or its successors and assigns) on 10 days notice and the
unearned premiums will be computed on the standard short rate or pro rata table except as indicated, (6) there are no bankruptcy, receivership, or insolvency
proceedings affecting the insured, (7) to hold Lender, its successors and assigns harmless against any loss or expense (including attorney fees) resulting from
these representations or from errors, omissions or inaccuracies of agent/broker in preparing this Agreement, (8) to pay the down payment and any funding
amounts received from Lender under this Agreement to the insurance company or general agent (less any commissions where applicable), (9) to hold in trust
for Lender or its assigns any payments made or credited to the insured through or to agent/broker directly or indirectly, actually or constructively by the
insurance companies and to pay the monies, as well as the unearned commissions to Lender or its assigns upon demand to satisfy the outstanding indebtness
of the insured, (10) all material information concerning the insured and the financed policies necessary for Lender to cancel such policies and receive the
unearned premium has been disclosed to Lender, (11) no term or provision of any financed policy requires Lender to notify or get the consent of any third party
to effect cancellation of such policy, and (12) to promptly notify Lender in writing if any information on this Agreement becomes inaccurate.
Page 2 of 2 3/25/2016 Web - MACPUR
AR
Ube= Mutual.
.,
March 25, 2016
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
RE: Workers Compensation Renewal Quote
Quote Number: 949774-01
Dear Insured:
LIBERTY MUTUAL FIRE INSURANCE
COMPANY
P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
We value your business and would like to continue your coverage. That's why we are writing to inform you
that your current workers compensation policy is about to expire. We are required by law to notify the
applicable bureau in your state that your coverage will terminate on June 4, 2016.
Your policy WC2-31S-365459-035 is set to expire on June 4, 2016 at 12:01 a.m. Your quote of $1,139 is based
on the latest available rates, classifications, payrolls and any applicable modifiers, and may be subject to change.
You can renew your policy now by sending a deposit of $1,139 along with the bottom portion of this letter in
the enclosed envelope. A renewal policy will not be issued and all coverage will cease on the expiration date
noted above if the deposit premium is not electronically submitted or received by Liberty Mutual Insurance at
the address below before May 15, 2016. Payment of the deposit premium will constitute your acceptance
and agreement to the terms and conditions of this policy.
If your premium is financed, please send a signed copy of the finance agreement and power of attorney to us by
email at IMS@LibertyMutual.com or by fax at (603) 334-8162.
To Allow For Timely Processing of Your Payment, Carefully Detach and Return Original with Payment in the Enclosed Envelope
Minimum Deposit: $1,139.00
Premium and Surcharges: $1,139
Payment Amount: $
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
❑ Make any changes to Insured or Agent address,
fax and email on the back of this remittance slip
and check this box.*
Account Number: 1365459-0000
Payment Due Date: 05/15/2016
Please Forward Remittance Only To:
**See reverse for overnight mailing address
�I�11111'�III11�11��1111���111 "�I1111�1'IIII�IIII1�
LIBERTY MUTUAL INSURANCE
PO BOX 2027
KEENE NH 03431-7027
iiiliiiiiiiliiiiilIR1miiiilillil1
If you previously submitted an approved Form 153 OFFICERS OR DIRECTORS AFFIDAVIT OF
EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS, in accordance with M.G.L. c. 152,
§1(4) and 452 CMR c. 8.00 et. seq. a copy of this form should be submitted to the insurance carrier on an annual
basis, prior to the renewal of any existing policy, as affirmation that the statements previously indicated remain
in effect. If there has been ANY change in status of a corporate officer or director, a new Form 153 must be
filed with the DIA and provided to the insurance carrier.
Additionally, if you previously submitted a written request as a sole proprietor, partner or member of an LLC to
elect coverage as an employee under a workers' compensation insurance policy, the sole proprietor, partner or
member must reaffirm in writing their right of inclusion as an employee on their workers' compensation policy
to the insurance carrier annually and prior to the renewal date of the policy.
If you need to overnight your payment, please use the overnight address below. Please include your policy
number on your check.
Overnight Mailing Address:
For the states of - AL, CT, DC, DE, FL, GA, IA, IL, IN, KY, MA, MD, ME, MI, MN, MS, NC, ND, NE, NH, NJ, NY,
OH, PA, RI, SC, SD, TN, VA, VT, WI, WV, send to:
Liberty Mutual Insurance
Attn: Payment Processing
62 Maple Avenue
Keene, NH 03431-7027
Telephone: (800) 320-7582
For the states of - AK, AR, AZ, CA, CO, HI, ID, KS, LA, MO, MT, NM, NV, OK, OR, TX, UT, WA, WY, send to :
Liberty Mutual Insurance
Attn: Payment Processing
1615 Murray Canyon Road Suite 300
San Diego, CA 92108-4314
Telephone: (800) 320-7582
Questions? We're here to help. Please call (800) 653-7893 or email us at IMS@LibertyMutual.com.
Thank you for your business. We hope to continue to provide you coverage in the years to come.
Sincerely,
Jeff Eldridge
Manager, Commercial Service Operations
Enclosures
cc: KARL A BRIGHT INSURANCE AGENCY INC
Make any changes to Insured or Agent address, fax and email here:
Insured:
Address
City State Zip
Phone Number
Fax Number
Email Address*
Agent:
Address
City
Phone Number -
Fax Number—
Email Address*
State Zip
* By providing your email address you are authorizing Liberty Mutual to transact business electronically.
12.Mutual.
r, ,
Quote Number: 949774-01
Quote Period: 06/04/2016 - 06/04/2017
Issue Date: 03/25/2016
Legal Status: CORPORATION
Principal
YOUNESS CHEIKH
HILAL AITOUKKA
LIBERTY MUTUAL FIRE INSURANCE
COMPANY
P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
Insured: Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
FEIN: 261830872
Title
TREASURER
PRSIDENT
Workers compensation insurance offered by this quote applies to the following states:
MA
Employer's Liability
Limits of Coverage: Bodily Injury by Accident: 100,000 Each Accident
Bodily Injury by Disease: 500,000 Policy
Bodily Injury by Disease: 100,000 Each Employee
Location Number and Address (Notify us promptly of any location changes to avoid issues regarding coverage.)
001 221 N MAIN ST, MANSFIELD, MA 02048-0000
Loc. Class
867
Estimated
Ratel
MA STANDARD TOTAL
State # Code
Description
Exposure
$100
Premium
MA 001 7380
DRIVERS, CHAUFFEURS AND THEIRHELPERS NOC
3,784
6.17
233
$1,139
- COMMER
9079
RESTAURANT NOC
55,091
1.15
634
Location Total
867
[PREMITJM SUMMARY
Charge Description Factor Status Premium
MA TOTAL CLASS PREMIUM
867
MA MERIT RATING PLAN
.950 -43
MA STANDARD TOTAL
824
EXPENSE CONSTANT
250
MACHWC (SURCHARGE)
1.058 47
TERRORISM RISK INS ACT 2002
1.030 18
MA FINAL TOTAL
1,139
Total Premium and Surcharges
$1,139
IM 0090 0311 Account Number: 1365459-0000 Page 3 of 4
The above rates are subject to state mandated changes. The factors used in rating this quote are also subject
to change pending promulgation of final experience modification and classifications/exposures from final audit
of your current workers compensation policy. If your operations, payroll exposures or any other pertinent
information has changed or differs, notify us immediately so a revised quote can be issued.
To notify us of location, payroll or any other changes, please use the above contact information.
IM 0090 0311 Account Number: 1365459-0000 Page 4 of 4
r
Lib Mutua]7.INSURANCE
LIBERTY MUTUAL FIRE INSURANCE
COMPANY
P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
Massachusetts
Workers Compensation Small Deductible Election Form
Account Number: 1365459-0000
Effective/Expiration Dates: June 4, 2016 — June 4, 2017
Insured: Y H ENTERPRISES INC DBA GOURMET PIZZA & GRILLE
Massachusetts law permits the election of two small deductible programs, for those employers who satisfy
credit eligibility standards, by selecting one of the deductible options indicated below.
Option I — Massachusetts Benefits Deductible Program: If this program is selected, the coverage Part 1 of
the workers compensation applies only for each claim in excess of the deductible amount selected. The
deductible is a benefits deductible. This means the deductible applies to indemnity and medical combined.
Option II — Massachusetts Benefits Claim and Aggregate Deductible Program: If this program is selected,
a medical and indemnity claim deductible of $2,500 and aggregate deductible amount of $10,000 is offered as
long as your estimated annual standard premium is not in excess of $200,000. The aggregate deductible amount
of $10,000 is the most that we will seek reimbursement from you for each policy period.
We will pay the claim and bill you for the deductible portion. Under each program, you are required to
reimburse us within thirty (30) days of receipt of the deductible invoice. Failure to reimburse us may result in
non-payment cancellation. Any unearned premium we hold may be applied to the unpaid deductible.
(If no deductible is desired, please disregard this form.)
A premium reduction credit is applied to the premium on your workers compensation policy according to the
deductible selected. Your agent should be able to assist you with determining if a deductible program is
beneficial to you. If you select a deductible, please indicate your choice below.
Note: If you wish to elect a deductible option, you must make your election before the effective date of your
policy.
CHOOSE ONE OPTION:
Option I
Medical & Indemnity Combined
Deductible Choice:
$500 $1,000 $2,000 $2,500 $5,000
Option II
Claim & Aggregate Deductible
Sign Here:
Signature & Title: Date:
Return the signed form to Liberty Mutual CSO Underwriting via the above listed contact information.
GPO 4678 (10/2010) Account Number: 1365459-0000 Page 1 of 1
TERRORISM INSURANCE PREMIUM NOTICE
This notice contains important information about the Terrorism Risk Insurance Act and its effect on your policy. Please read it
carefully.
THE TERRORISM RISK INSURANCE ACT
The Terrorism Risk Insurance Act, including all amendments ("TRIA" or the "Act'), establishes a program to spread
the risk of catastrophic losses from certain acts of terrorism between insurers and the federal government. If an
individual insurer's losses from certified acts of terrorism exceed a specified deductible amount, the government will
reimburse the insurer for a percentage of losses (the "Federal Share") paid in excess of the deductible, but only if
aggregate industry losses from such acts exceed the "Program Trigger". An insurer that has met its insurer
deductible is not liable for any portion of losses in excess of $100 billion per year. Similarly, the federal government
is not liable for any losses covered by the Act that exceed this amount. If aggregate insured losses exceed $100
billion, losses up to that amount may be pro -rated, as determined by the Secretary of the Treasury.
The Federal Share and Program Trigger by calendar year are:
Calendar Year
Federal Share
Program Trigger
2015
85%
$100,000,000
2016
84%
$120,000,000
2017
83%
$140,000,000
2018
82%
$160,000,000
2019
81%
$180,000,000
2020
80%
$200,000,000
MANDATORY AVAILABILITY OF COVERAGE FOR "CERTIFIED ACTS OF TERRORISM"
TRIA requires insurers to make coverage available for any loss that occurs within the United States (or outside of
the U.S. in the case of U.S. missions and certain air carriers and vessels), results from a "certified act of terrorism"
AND that is otherwise covered under your policy.
A "certified act of terrorism" means:
[A]ny act that is certified by the Secretary [of the Treasury], in consultation with the Secretary of Homeland
Security, and the Attorney General of the United States
(i) to be an act of terrorism;
(ii) to be a violent act or an act that is dangerous to —
(1) human life;
(II) property, or
(III) infrastructure;
(ii) to have resulted in damage within the United States, or outside of the United States in the case of —
CNW 90 09 01 15 Page 1 of 2
(1) an air carrier (as defined in section 40102 of title 49, United States Code) or United States flag
vessel (or a vessel based principally in the United States, on which United States income tax is
paid and whose insurance coverage is subject to regulation in the United States); or
(II) the premises of a United States mission; and
(iv) to have been committed by an individual or individuals as part of an effort to coerce the civilian population of
the United States or to influence the policy or affect the conduct of the United States Government by
coercion.
PREMIUM DISCLOSURE STATEMENT
Your policy does not contain an exclusion for losses resulting from "certified acts of terrorism." Coverage for such
losses is still subject to, and may be limited by, all other terms, conditions and exclusions in your policy.
THE PREMIUM CHARGE FOR THIS COVERAGE FOR THE POLICY PERIOD APPEARS ON THE ATTACHED
QUOTE AS "CERTIFIED ACTS OF TERRORISM COVERAGE".
YOU NEED NOT DO ANYTHING FURTHER AT THIS TIME.
The summary of the Act and the coverage under your policy contained in this notice is necessarily general in nature.
Your policy contains specific terms, definitions, exclusions and conditions. In case of any conflict, your policy
language will control the resolution of all coverage questions. Please read your policy.
If you have any questions regarding this notice please contact your agent.
CNW 90 09 0115 Page 2 of 2
10� l' LIBERTY MUTUAL FIRE INSURANCE
Liberty Mutual. COMPANY
INSURANCE P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
MASSACHUSETTS
PAYMENT PLAN OPTIONS
Account Number: 1365459-0000
Effective/Expiration Dates: June 4, 2016 - June 4, 2017
Insured: Y H ENTERPRISES INC DBA GOURMET PIZZA & GRILLE
Payment Plan Options:
Payment Plan
Frequency
Estimated
Annual Premium
Minimum
Number of
Installments
Deposit
Percentage
Annual
$0
0
100%
Semi -Annual
$5,000
1
75%
Quarterly
$10,000
3
50%
Monthly
$25,000
9
25%
*The specific due date for each installment will be indicated on your invoice.
• Qualification for a payment plan is based on estimated annual premium less any surcharges, taxes,
assessments and contingency deposit on LSRP policies, if required in your state. Payment options listed
above are the only payment options available based on your state's rules and your estimated annual
policy premium.
• Your quote was issued using the payment plan you selected on the expiring policy.
• Pursuant to Plan rules, a carrier has the right to discontinue or change a policyholder's payment plan, if
any, under certain circumstances. For example, a history of noncompliance with audit requests or the
issuance of multiple cancellation notices to the same policyholder may result in all premiums becoming
immediately due and payable.
• For questions or concerns, contact us using the above email, phone or fax information.
GPO 4915 (10/2012) Account Number: 1365459-0000 Page 1 of 1
THE WORKERS' COMPENSATION
RATING AND INSPECTION BUREAU
July 3, 2012
CIRCULAR LETTER NO. 2199
To All Members and Subscribers of the WCRIBMA:
UPDATED AUDIT GUIDELINES FOR SOLE PROPRIETOR AND PARTNERSHIP
CERTIFICATES OF INSURANCE
In response to inquiries from the Division of Insurance, we have updated the Audit
Guidelines that were issued on October 24, 2007 (Circular Letter No. 2071). These
updated Audit Guidelines do not change the way in which Sole Proprietor and Partnership
Certificates of Insurance will be treated at audit. The updated Audit Guidelines have a
new format that is easier to follow, incorporate the instructions for issuing Certificates of
Insurance that were originally announced on February 14, 2007 (Circular Letter No.
2045) and contain some clarifying language.
As indicated in previous Circular Letter Nos. 2045, 2057, and 2071 (Circular Letter No.
2057), the purpose of the Audit Guidelines is to provide consistent application of the
Independent Contractor Law, consistent treatment of Certificates of Insurance, and
consistent collection of premium at audit. The Massachusetts Commissioner of Insurance
has approved the standard Workers' Compensation and Employers Liability Insurance
Policy ("Policy") and the Massachusetts Workers' Compensation and Employers Liability
Insurance Manual ("MA Manual"). In accordance with the terms of the Policy and the
provisions of the MA Manual, insurers are entitled to collect premium for all persons
engaged in work for the policyholder that could make the insurer liable under the
Massachusetts workers' compensation law. As set forth in the Audit Guidelines,
policyholders need to provide their insurers with proof that the persons they have hired
are independent contractors or that the employers of any persons performing work for
the policyholder have lawfully secured their workers' compensation coverage obligations.
If such proof is not provided, premium will be collected for any such persons performing
work for the policyholder.
Since the first issuance of the Audit Guidelines in 2007, a proof of coverage application
has become available for policyholders and insurers to verify whether persons hired by
the policyholder have met their workers' compensation obligations. The Proof of
Coverage Application may be accessed on the Massachusetts Department of Industrial
Accidents web site.
WCRIB Account Number: 1365459-0000 Page 1 of 4
These Guidelines are mandatory for all policies issued through the Residual Market and are
strongly recommended for all policies issued through the Voluntary Market.
Any questions regarding the Audit Guidelines may be addressed to Daniel Crowley, Vice
President — Customer Services at 617-646-7594; dcrowlev@wcribma.org or Ellen Keefe,
Vice President/General Counsel at 617-646-7553; elceefe@wcribma.org.
Daniel M. Crowley, CPCU,
Vice President -Customer Services
WCRIB Account Number: 1365459-0000 Page 2 of 4
WCRIBMA CIRCULAR LETTER NO. 2199
AUDIT GUIDELINES FOR
SOLE PROPRIETOR AND PARTNERSHIP CERTIFICATES OF INSURANCE
The following audit guidelines shall be followed by carriers when a policyholder
provides a Certificate of Insurance for a sole proprietor or partnership to determine
whether payments by the policyholder to the sole proprietor or partnership should be
included in the policyholder's workers' compensation insurance premium basis in
accordance with Parts One and Five of the standard Workers' Compensation and
Employers Liability Insurance Policy ("Policy") and Rule V-A or Rule IX of the
Massachusetts Workers' Compensation and Employers Liability Insurance Manual.
In Massachusetts, the workers' compensation insurance Policy does not provide
coverage for a sole proprietor or partner(s) unless those individuals elect coverage for
themselves in accordance with G.L. Chapter 152, section 1(4) and 482 CMR 8.07.
As announced in Circular Letter No. 2045, before issuing a Certificate of Insurance,
carriers must determine whether any coverage elections are reflected on a Policy issued
to a sole proprietor or partnership. Based on the carrier's findings, one of the following
comments must be shown in the Description of Operations section of the Certificate of
Insurance. See Exhibit A as an example.
COVERAGE ELECTIONS
LEGAL ELECTION
STATUS REFLECTED ON POLICY
Sole Sole Proprietor ("SP") has elected
Proprietor coverage
Sole Proprietor ("SP") has not
elected coverage
Partnership All partners have elected coverage
Some but not all partners have
not elected coverage
COMMENT FOR
CERTIFICATE OF INSURANCE
"<SP NAME> is covered by the
workers' compensation policy."
"The workers' compensation
policy does not provide coverage
for <SP NAME>."
"All partners are covered by the
workers' compensation policy."
" < P NAMES > are covered by the
workers' compensation policy."
AND" < P NAMES > are not covered
by workers' compensation policy."
No partners ("P") have elected coverage "No partners are covered by the
workers' compensation policy."
'The ACORD Certificate of Insurance is used countrywide and contains the following question:
"Any Proprietor/Partner/Executive Office/Member Excluded?" It should be noted that
In Massachusetts, sole proprietors, partners (and members of LI -Cs per the Department
of Industrial Accidents) are excluded from coverage unless they specifically elect to be
deemed employees in accordance with G.L. Chapter 152, section 1 (4) and 452 CMR, sec.
8.07. Corporate/Executive officers are covered as employees unless they qualify for an
exemption in accordance with G.L. Chapter 152, section 1(4) and 452 CMR sec. 8.06.
Therefore, it is important to include a comment on the Certificate of Insurance that specifically
states the coverage election of any sole proprietor or partner, rather than just checking the Y/N
box on the ACORD form.
WCRIB Account Number: 1365459-0000 Page 3 of 4
If during an audit, the carrier determines from review of the Certificate of Insurance,
that their policyholder has hired a sole proprietor that has selected coverage for himself
or a partnership of which one or more of the partners have elected coverage for
themselves, (< NAME(s) > is covered by the workers 'compensation policy is shown on
the Certificate of Insurance), then no additional payroll should be picked up on the
policyholder's policy.
If during an audit, the carrier determines from review of the Certificate of Insurance,
that their policyholder has hired a sole proprietor who has not elected coverage for
himself or a partnership of which none of the partners have elected coverage for
themselves, then all payments made to the sole proprietor or partnership shall be
picked up on the policyholder's policy in accordance with the Policy and Massachusetts
Workers' Compensation and Employers Liability Insurance Manual, Rule IX. The only
possible exceptions are:
A. The policyholder can present satisfactory evidence to the auditor that the sole
proprietor or partnership is a bona fide employer whose employees are covered
by the policy identified on the Certificate of Insurance.
B. The sole proprietor or partnership cannot prove they have employees, but the
policyholder can prove that the sole proprietor or partnership meets the following
three-part test set forth in G.L. c. 149, section 148B that distinguishes
independent contractors from employees:
1. The individual is free from control and direction in connection with the
performance of the service, both under his contract for the performance of
service and in fact; and
2. The service is performed outside the usual course of the business of the
employer; and
3. The individual is customarily engaged in an independently established trade,
occupation, profession or business of the same nature as that involved in the
service performed.
NOTE: In those situations where the Certificate of Insurance is silent on coverage
elections for the sole proprietor or partnership (or when no Certificate of Insurance has
been presented), the auditor shall ask additional questions and obtain additional
documentation from the policyholder to determine:
Whether the sole proprietor or partnership is a bona fide employer as
describe in footnote 2, or
Whether the sole proprietor or partnership is an independent contractor or
an employee of the policyholder in accordance with the three-part test
referenced above.
2Evidence to establish whether a sole proprietor or partnership is a bona fide employer could
include, but is not limited to, the following types of documents that show the existence of
employees: contracts providing size and scope of work between the policyholder and the sole
proprietor or partnership; invoices itemizing work and materials from a sub -contractor to the general
contractor; Employer Identification Numbers (EINs); state and federal tax forms listing employee and
wage information, such as: W2 Forms: Wage and Tax Statements; 940 Forms: Employer's Annual
Federal Unemployment (FUTA) Tax Returns; and/or 941 Forms: Employer's Quarterly Federal Tax
Return
WCRIB Account Number: 1365459-0000 Page 4 of 4
VantagePort®
Did you know that you can manage your Liberty Mutual Workers Compensation policy online?
With VantagePort®, our free, dedicated, secure portal for Liberty Mutual Insurance customers,
you'll have instant access to the account -specific information you need to manage your insurance
program. VantagePort® currently offers:
• View Your Policy - Copies of all policy documents (new/renewal policies,
endorsements, audit adjustments) are available electronically, with the ability to view,
save, and print.
• Online Claims Reporting - Report workers compensation claims online with EXPRSTM
and receive immediate confirmation that the claim has been received by our office.
• Online Claims Management - Stay on top of claims from beginning to end with
RISKTRAC0 CSP Reports Only feature. You can create detailed and summary level loss
reports to monitor claims activity. Reports are available on demand or can be scheduled
to run automatically.
• Loss Control Resources - Liberty Mutual SefetyNetTM provides you the ability to access
a variety of safety resources including training materials, OSHA compliance information,
self-assessment tools, model programs, e -newsletters and more.
• Online Billing Services - Access billing inquiry, payment information and premium
refund check information as well as the ability to view and print electronic copies of
invoices.
To enroll in VantagePort®, call us at 800-653-7893 or email IMS@libertymutual.com. A
member of our team will walk you through the simple registration process.
LTW 90 01 11 15 Account Number: 1365459-0000
March 25, 2016
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
RE: Other States Coverage Notification
LIBERTY MUTUAL FIRE INSURANCE
COMPANY
P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
Insured: Y H ENTERPRISES INC DBA GOURMET PIZZA & GRILLE
Policy Number: WC2-31S-365459-036
Dear Insured:
Your workers compensation policy covers only states listed in Part 3.A. of your policy. If you are working in
states other than those covered by this policy and listed in Part 3.A. of this policy, please ensure you have the
coverage needed.
• If you are working in other states and have obtained workers compensation coverage,
please forward us a copy of your Policy Information Page(s).
• If you are working in other states and have not obtained workers compensation
coverage, please notify us in writing.
As a business owner, it is imperative that you comply with each state's requirement for workers compensation
coverage. It is our intent to cover the known exposures, only for states listed in Part 3.A of this policy. Failure
to notify us may result in claims not being covered.
For questions or concerns, contact us using the above email, phone or fax information.
Note: Liberty Mutual cannot combine the states of Indiana, Massachusetts, Mississippi, North Carolina,
Tennessee and Wisconsin with other states on an assigned risk policy. Contact your agent for additional
information.
Sincerely,
Jeff Eldridge
Commercial Service Operations
cc: KARL A BRIGHT INSURANCE AGENCY INC
I 40068 0314 WC2-31S-365459-036 Page 1 of 1
Liberty Mutual
INSURANCE
March 25, 2016
Y H ENTERPRISES INC DBA GOURMET PIZZA &
GRILLE
221 N MAIN ST
MANSFIELD MA 02048
RE: Subcontractors - Important Information
LIBERTY MUTUAL FIRE INSURANCE
COMPANY
P.O. Box 8090
Wausau WI 54402-8090
Telephone: (800) 653-7893
Fax: (603) 334-8162
Email: IMS@LibertyMutual.com
Insured: Y H ENTERPRISES INC DBA GOURMET PIZZA & GRILLE
Policy Number: WC2-31S-365459-036
Effective Date: June 4, 2016
Dear Insured:
The following information applies to all insureds using subcontractors.
Individual state workers compensation rules provide direction in determining employer/employee relationships.
Contractors may be held liable for injuries to the employees of subcontractors if those subcontractors do not
carry their own workers compensation coverage. As your workers compensation insurance carrier, we are
required to collect premium for payments you make to uninsured subcontractors. The premium basis used to
calculate this charge will be the actual payroll for the employees of the uninsured subcontractors, if those records
are available. If complete payroll records for the subcontractor's employees are not available, we will use the
subcontract price as the premium basis, subject to the following:
• If the subcontract price does not reflect a definite payroll amount, we will use the full price for the work
performed during the policy period as payroll.
• If the subcontract price does reflect a definite payroll amount, we will use the amount indicated subject
to the following:
If the job involves:
o Mobile equipment with operators - we will use not less than 1/3 of the contract price
o Labor only - we will use not less than 90% of the contract price
o Labor and materials - we will use not less than 50% of the contract price
o Piecework - we will use 100% of the contract price
Note; This paragraph is applicable in the state of Massachusetts.
Additionally, Massachusetts Bureau circular 2057, released June 25, 2007, discusses subcontractors who are sole
proprietors or partners who do not elect to be covered on their own policy, and how these elections may affect
your premium. You may wish to contact your broker to determine how this circular may affect you.
IM0065 1010 WC2-31S-365459-036 Page 1 of 2
Note: This paragraph is not applicable in the state of Illinois.
For individuals with no additional employees, premium will be charged if we determine there to be an
employer-employee relationship. General liability insurance certificates and/or written agreements are not
sufficient as evidence of independent contractor status. In making our determination, we will consider the
frequency of work, method of pay, type of work performed, extent of control, who supplied the tools and other
factors.
To avoid billing issues, workers compensation certificates of insurance or the information outlined above should
be obtained annually from all of your subcontractors and provided to us upon audit. It is recommended you
consider a retention policy concerning these records.
Failure to pay premium for uninsured subcontractors may result in cancellation of your policy.
For questions or concerns, contact us using the above email, phone or fax information.
Sincerely,
Commercial Service Operations
cc: KARL A BRIGHT INSURANCE AGENCY INC
IM0065 1010 WC2-31S-365459-036 Page 2 of 2
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