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HomeMy WebLinkAboutCape Cod Potato Chip Co. - 6/7/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP 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: THE CAPE COD POTATO CHIP COMPANY Whose Place of Business is: THE CAPE COD POTATO CHIP COMPANY @ TWEETER CENTER Permit good June 7-October 1, 2008 License Number. MF-202 Food Fee: $100.00 Milk & Cream: NO 5-TOTTIRTIMONIUMMU Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: THE CAPE COD POTATO CHIP COMPANY AT THE TWEETER CENTER FOR THE PERFORMING ARTS 2) Establishment Address: 885 MAIN STREET, MANSFIELD, MA 02048 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 508-339-3333 5) Applicant Name & Title: CATHERINE O'DONNELL, SALES MARKETING MGR. 6) Applicant Address: GREATER MEDIA, INC., 55 MORRISSEY BLVD., BOSTON, MA 02125 7) Applicant Telephone No.: 617-822-6260 24 Hour Emergency No.: 973-476-7076 8) Owner Name & Title (if different from applicant): THE CAPE COD POTATO CHIP COMPANY 9) Owner Address (if different from applicant): 100 BREED'S HILL ROAD, HYANNIS, MA 02601 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. CORPORATION ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal entity 12) Person Directly Responsible For Daily Operations (Owner. Derson in charge. Sunervisor. Mananer. etc.) Name & Title: HEIDI DALY FORD, DIRECTOR OF MARKETING Address: 100 BREED'S HILL ROAD, HYANNIS, MA 02601 Telephone No: 508-771-3999 Fax: 508-771-4334 Emergency Telephone No: 13 District Or Regional Supervisor(if applicable) Name & Title: Address: Telephone No: Fax: Food Establishment Information 14.) Water Source: TOWN DEP Public Water Supply No: (if applicable): 15) Sewage Disposal TOWN 16) Days and Hours of Operation: 6f7/2008—10/112008 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003 A Please attach copV of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): NO 20) Location: 22) Establishment Type: PROPOSED DATES: PERMANENT 6n/08 ❑ Retail ( Sq. Ft) ❑ Food Service - ( ) Seats ❑ Caterer ❑ Food Delivery ❑ Permanent 7130/08 ❑ Food Service - Institution ❑ Residential Kitchen for Retail Sale ® Mobile (Dates 8/2108 ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Home 8/6/08 Other (Describe) ❑ Residential Kitchen for Bed & Breakfast 8/17/08 SAMPLING AT THE TWEETER Establishment CENTER FOR THE PERFORMING ARTS AT VARIOUS CONCERTS ❑ Frozen Dessert Manufacturer 21) Length Of Permit: SEASONAL — MAY - OCT 23) Food Operations: Definitions: PHF— Potentially hazardous food (time/temperature controls required) Non-PHF's — non -potentially hazardous food (no time/temperature controls required) (check all that apply): RTE— ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no further processing) ❑ Sale of commercially Pre- PHFCooked To Order ooked and Cooled or Hot Held Packs ed Non-PHFs han a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And TE Foods Prepared For Highly Packaged PHFs cold HoldingFor Single Meal le Population Facility ffPHF Service ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intendedackaging/Cook Chill to be Pre ared b Consumer❑ Reheating of commercially ❑ Customer Self -Service cess Requiring A Variance Processed Foods For and/or HACCP Plan (including bare hand Service Within 4 Hours. contact alternative, time as a public health control Customer Self -Service of ❑ Ice Manufactured and Packaged for El Offers Raw Or undercooked Food Of Non PHF and Non- Retail Sale Animal Origin Perishable Foods Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or institutional Food Service U Offers RITE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health El Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Total Permit Fee: $100.00 Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 59"00.and the federal Food Code. 24) Signature of Applicant: 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 returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3311412 26) Signature of Individual or Corporate Name: THE CAPE COD POTATO CHIP COMPANY TAX CERTIFICATION FORM 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) DLY --3311141 z *"Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. RdHm thVane's Documents\TAX CERTIFICATION FORM.doe The Commonwealth ofMassachuseus Department ofludmirialAccidems Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: L �J.CE aNC. dbo, C.AP,,!� �t (Ota�O Ct+ws) Address: B&C)o SOOTN RJ_Vt> City/State/ZiP: l .t1Al2t_n-rTr_. -PLC aea6P, Phone #: LAMCE Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail 2. ❑ or pert -time),' I 6. ❑ Restaurant/Bar/Eating Establishment am a sole proprietor or partnership and have no employees working for me in any capacity. 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) [No workers' comp. insurance required) S• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10,© Manufacturing 4. ❑ no employees. [No workers' comp. insurance required)" We are a non-profit organization, staffed by volunteers, 11.❑ Health Caro with no employees. [No workers' comp. insurance rw.l mEl Other "Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy infbrmation:- F•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 # 1. lam an employer that Is providing workers' compensation Insurance for my employees. Beloip is the policy information. Insurance Company Name: ZUR It N Insurer's Address: QC Vj3IRUICW --ppSe900' city/state/zip: _ (24PRL..6-11F MC 9ga10 Policy # or Self -ins. Lic. X3g6s(4 Expiration Date:. . vk_I_Q[�$_ 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 o£criminal penalties of a fine up to $1,500.00 and/or one-year hnprlsomneut, 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. do hereby cerito, under r� s an penalties of perjury that the Wormadon provided above is line and correct. ieriature: Date: CL-, 10 bone #: i O Official use only. Ao not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selecfinen's Office 6.Other Contact Person: Phone pl K-033112- OZURICH-AMERICAN INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY COMMERCIAL INSURANCE INSURANCE POLICY - INFORMATION PAGE Servicing Office: Insurance lot this onwrage part provided by: ATLANTA ZURICH AMERICAN INSURANCE COMPANY 3003 SUMMIT BLVD, SUITE 1800 ATLANTA, GA 1, Policy Number WC 2939036-04 Renewal of Number WC 2939036-03 Named Insured and Mailing Address Producer and Mailing Address LANCE, INC. WACHOVIA INS SERVICES INC (SEE ENDORSEMENT U-WC-321-A) 6100 FAIRVIEW ROAD 8600 SOUTH BOULEVARD SUITE 800 CHARLOTTE NC 28273 CHARLOTTE NC 282104261 Producer Code 80083-000 Other workplaces not shown above: FEIN: 56-0292920 NCCI Company No. 10863 ❑ New Q Renewal ❑ Rewrite of Prior Polley No. This information page, with policy provisions and endorsements, If any, completes this policy. Insured IS:CORPORATION 2. Polley Period: From 08-01-07 toO8-01-08 at 12:01 A.M. Standard Time at insured's mailing address. Insured's Identification number(s): 910370154/ NJTIN #560292920/000 IN TAX ID #025114 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: AL, AR, AZ , CA, CT, DC, DE, FL, GA, IA, IL, IN, KS , KY, LA, MA, MD , HI, MO, MS , NC, NE,NH,NJ,NM,NY,OX,OR,PA,SC,TN,TX,VA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed In Item S.A. The Limits of Liability under Part Two are: Bodily Injury by Accident 1,000,00o each Accident Bodily Injury by Disease 1,000,000 policy limit Bodily Injury by Disease 1,000,000 each employee C. Other States Insurance: Pan Three of the policy applies to the states, If any, listed here: ALL STATES NOT LISTED IN 3.A EXCEPT OH, No, WA, WV AND WY D. This pollcy Includes these endorsements and schedules: See Schedule of Forms and Endorsements 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required on the following Classification Schedule Is subject to verification and change by audit. See Classification Schedule TOTAL ESTIMATED STANDARD PREMIUM $ 1,370,325.00 If indicated below, adiustmenls PREMIUM DISCOUNT $ - 507,099.00 of premium shall be media: EXPENSE CONSTANT $ 284.00 PREMIUM FOR ENDORSEMENTS $ ® Annually ❑ Monthly TAXES AND SURCHARGES $ 23,789.00 ❑ semi -Annually ❑ Thlsisa Three ❑ Ouanerly, YPolicyear Fixed Asia TOTAL ESTIMATED ANNUAL PREMIUM $ 887,299.00 MINIMUM PREMIUM $ DEPOSIT PREMIUM $ Agent or Producer untersigned by esideM cenaed Agent Data WC 000001A U.WO.0314-A (07-94) ...,..,..a, Paoe 1 of 1 D79 2090`193 0 Workers Compensation and Employers Liability ZURICH Endorsement It: 5 (sfd) 10.26 07 Pollev No. Eff. Date of Pol, lExu, Date of Pod Eff. Date of End. I Producer I Addl. Poem I Return Prem. The Insured: LANCE, INC. Mailing Address (including Zip Code): $600 SOUTH BOULEVARD CHARLOTTE, INC 28273 This endorsement is issued by ZURICH AMERICAN INSURANCE COMPANY. it forms a part of the policy as of its effective date, at the hour stated on the Information Page. This endorsement changes such insurance as is afforded by pmvislons of the policy retuning to the following: It is agreed and understood that form WC 99 03 IS (09/04) Foreign Voluntary Compensation and Employers Liability Co, Endorsement has been attached to be included as part of the policy, the Named Insured schedule has been revised per the and the FEIN # has been revised for the following Insured: Landhold Investments, Inc.#51-0390126 Lance Mfg LLC #56-2097021 Caronnts Inc.#56-1721503 Fresno Ventures Inc. #20.3643868 Countersigned Authorized Representative IYWO478-0(8193) Page 1 of 1 0 ZURICH FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 99 03 15 This endorsement changes the policy to which it Is attached effective on the inception data of the policy unless a different date is indicated below. (Thefollowing "attaching clone"need be completed only when rho endorsement is Issuedsubsequent to preparation oJthe pellry.) This endorsement, effective on at 12:01 A.M. standard time, forms a part of (DATE) Policy No, Endorsement No of the issued to (NAME OF INSURANCE COMPANY) SCHEDULE Authorized it,m oletive 1. Name(s) of State or Country Designated Workers Employees of operations Compensation Law Refer to Page 2, Section 1 All locations outside the STATE OF HIRE Employees Covered United States, Its territories or possessions (excluding any country or jurisdiction which is subject to trade or other economic sanction or embargo by the United States). 2. Limits of Liability for Repatriation Expense S _ each employee $ 100,000 each accident 3. Limits of Liability for Part Two —Employers Liability Insurance $1,000,000 Bodily Injury by accident each accident $1,000,000 Bodily Injury by disease each employee WC 99 03 15 (0904) Includes copyrighted materiel blue Now York Compensation Insurance naling Board Page 1 of 4 used with its permission $1,000,000 Bodily Injury by disease policy limit This endorsement adds Foreign Voluntary Compensation Insurance to the policy. Section 1. Employees Covered A. This coverage applies only to employees you hire within the limits of the United States of America while they are traveling to, or temporarily residing outside the United States of America, its territories or possessions or Canada. B. This insurance does not apply to any employees you hire outside the limits of the United States of America. C. This insurance does not apply to any employees who are employed to work at locations within the following country or countries: Section 2, How This Insurance Applies This insurance applies only to bodily injury by accident or to bodily injury by disease as described below. Bodily injury includes resulting death. Bodily injury includes any endemic disease. Endemic diseases are those which are peculiar to a locality or region. A. An employee included in the group of employees described in Item 1. of the Schedule of this endorsement must sustain the bodily injury; and B. The bodily injury must miss out of and occur in the course of employment necessary or incidental to work in a state, country or subdivision of a country listed in Item 1, of the Schedule of this endorsement; and C. Bodily injury by accident most occur during the policy period; and D. Bodily injury by disease must be caused or aggravated by the conditions of yaw employment. The employee's last day of last exposure to those conditions causing or aggravating such bodily injury must occur during the policy period. Section 3. Exclusions This insurance does not cover: A. Bodily injury arising from any direct or indirect consequence of war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, rebellion, revolution, insurrection or military or usurped power. No current or subsequent endorsement to this policy will override or waive this limitation; B. Compensation or benefits imposed by any non occupational, disability benefits law, plan or any similar low or plan; and C. Bodily injury intentionally caused or aggravated by you. Section 4. Voluntary Workers Compensation This endorsement amends Section A. of PART ONE— WORKERS' COMPENSATION INSURANCE of the policy by adding the following coverage: On your behalf, we will voluntarily pay an amount equal to the benefits you would be required to pay if you and the employees described in Item 1. of the Schedule were subject to the workers compensation law designated in Item I, of the Schedule of this endorsement. We will pay those amounts to the persons who would be entitled to them under the workers compensation law designated in Item I. of the Schedule of this endorsement. If this is not possible, we will reimburse you for amounts you would be required WC 99 03 15 (09 04) Ineludes copyrighkd materiel ofthe New Yosk Compemmtim Insurance kiting Board Page 2 of 4 used with its permission to pay under that law. The following provisions apply to this insurance: A. In no event will our liability under this section exceed the amount we or you would have been obligated to pay if the employment and bodily injury had been subject to the workers compensation law designated in Item 1. of the Schedule of this endorsement. The only exception to this is as provided for in Section 6. of this endorsement. B. We have the option of requesting you to pay sums due directly in persons entitled to them on our behalf, We will reimburse you for these payments when you provide us with satisfactory proof of payment. C. Before we are required to make any payment or reimburse you, the persons entitled must: (1) Release you and us in writing from all responsibility for the bodily injury or death; (2) Transfer to us their right to recover from others who may be responsible for the bodily injury or death to the extent of our payment or reimbursement; and (3) Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If a person entitled to payment under this section refuses to accept voluntary payments offered, we may, at our discretion, withdraw the offer to pay compensation benefits. If this happens, we will notify you and the employee that we will no longer be bound by the provisions of this section. D. Under this or any other policy we have issued to you, it is possible that the provisions of a workers compensation law, plan or any similar law or plan may hold you or us legally liable for any bodily injury or resulting death where payments have been made or would otherwise be made under Section 4. of this endorsement. If this happens, we agree that we will make no further payments under Section 4. if Section 5. of this endorsement applies. Section S. Legal Liability Under Workers Compensation Low A. If benefits are payable under a workers compensation or occupational disease law of any state, country or subdivision of a country other than the United States of America, its territories or possessions or Canada, we will reimburse you up to but not in excess of the cost of benefits which would have been payable under the workers compensation law of the state designated in Item 1. of the Schedule of this endorsement. B. We will not be liable for any loss for which you have other valid and collectible insurance. C. We assume no obligation to defend any suit or proceeding against you outside of the United States of America, its territories or possessions or Canada. D. The coverage Section 5. affords does not cover fines or penalties imposed on you for failure to comply with the requirements of any workers compensation or occupational disease law of any state, country or subdivision of a country. Section 6. Repatriation Expense This section only applies to coverage provided for in Sections 4. and 5. of this endorsement. Medical expenses payable under Sections 4. and 5. of this endorsement include additional expenses of repatriation to the United States of America incurred as a result of bodily injury to employees. In the event an employee is injured, our liability is limited to the amount by which these expenses exceed the normal cost of returning the employee. In the event of an employee's death, our liability is limited to the amount by which the expenses ofretuming the body exceed the normal cost of returning an employee who is alive and in good health. Oar liability will never exceed the amount indicated in Item 2, of the Schedule of this endorsement for one covered employee or accident. The policy does not afford coverage for repatriation expenses unless a specific limit of liability for each covered employee and accident appears in Item 2. of the Schedule of this endorsement, WC 99 03 15 (09 04) Includes copinkhtW metttiel ofthe New Yode Compcnsatian lnmrence Acting Board Section 7. Employers Liability This endorsement amends Section B. of PART TWO — EMPLOYERS LIABILITY INSURANCE of the policy with respect to the coverage this endorsement provides as follows: A. We Will Pay We will pay, on your behalf, all more which you become legally obligated to pay as damages because of bodily injury by accident or bodily injury by disease, including resulting death, sustained in any state or country or subdivision of a country other than the United States of America, its territories or possessions or Canada by any of your employees arising out of and in the course of employment by you. We will reimburse you for all reasonable expenses you incur, including attorneys' fees in defending any suit against you alleging injury and seeking damages on account of any insurance this section of this endorsement affords. We assume no obligation to defend any suitor any proceeding suit brought against you outside the United States of America, its territories or possessions or Canada. B. The limit of our liability under PART TWO— EMPLOYERS LIABILITY INSURANCE will be in accordance with the following provisions: The words "damages because of bodily Injury by accident or disease, including resulting death" in PART TWO — EMPLOYERS LIABILITY INSURANCE include damages for care and loss of services. These words also include damages for which you are liable because of suits or claims others bring against you to recover the damages obtained from such others because of bodily injury your employees sustain arising out of and in the course of their employment. The limit ofliability, in Item 3. of the Schedule of this endorsement which applies to bodily injury by accident is the total limit of our liability for all damages because of bodily injury by accident including resulting death that one or more employees sustain. The limit of liability in Item 3, of the Schedule of this endorsement which applies to bodily injury by disease is the total limit of our liability for all damages because of bodily injury by disease including resulting death that one or more employees sustain in any one state, country or subdivision of a country outside the United States of America, it territories or possessions or Canada listed in Item 1. of the Schedule of this endorsement. The limits of liability designated in this endorsement for PART TWO — EMPLOYERS LIABILITY INSURANCE supersede and are not cumulative with any limit(s) of liability elsewhere in the policy. Section 8. Other Insurance The fallowing provision replaces Section E. of PART ONE — WORKERS' COMPENSATION INSURANCE and Section F. of PART TWO — EMPLOYERS LIABILITY INSURANCE of the policy with respect to the coverage this endorsement provides. The insurance for a loss covered by this endorsement will be excess insurance over and above any other insurance except with respect to insurance provided under Section 5 of this endorsement.. The limits of liability for this insurance will be reduced by an amount equal to the limits of liability other insurance affords. WC 99 03 15 (09 04) Include, copyrighted malarial ofthe Now York Compensation Insurance Ruling snood Named Insured Schedule 0 ZURICH Policy No. H. Date of Pol.1 Exp. Date of Pol. Eff. Date of End. Producer I Addy. Prom Return Premm WC2939036-04 M01-07 M-01-08 M-0t-07 80-083400 S S NAICS—311821: SIC 2052 LANCE. INC. —FEIN 56-0292920 8600 SOUTH BOULEVARD 700 TOWS DRIVE 900 8TM STREET CHARLOTTE, NC 28273 PERRY, FL 32347 COLUMBUS, GA 31902 2648 BYINGTON SOLWAY ROAD 3001 EAST HIGHWAY 31 KNOXVILLE, IN 37931 CORSICANA, TX 75110 (10 EMPLOYEES) OUTSIDE SALESMEN/DRIVERS ONLY IN THE FOLLOWING STATES. NO PHYSICAL LOCATIONS: AL, AZ, AR, CA, CT, DE, DC, IL, IN, IA, KS, KY, LA, MD, MA, MI, MS, NO, NE, NH, NJ, NM, NY,OK, OR, PA, SC & VA NO.OFEMPLOYEES: KY-10;MS—S;NM-5 CAPE COD POTATO CHIPS. INC. — FEIN 04-3311412 100 BREED'S HILL ROAD HYANNIS, MA 02601 OUTSIDE SALESMEN/DRIVERS ONLY IN THE FOLLOWING STATES. NO PHYSICAL LOCATIONS: AZ, CA, CT, GA, IG MA, ML NC, NJ, NY, OR & PA VISTA BAKERY, INC.—FEIN 56-1761640 3000 MT. PLEASANT STREET BURLINGTON, IA 56201-0888 OUTSIDE SALESMEN/DRIVERS ONLY IN THE FOLLOWING STATES. NO PHYSICAL LOCATIONS: AR, IL, NO, NC, PA & SC TOM'S FOODS INC.—FEIN 958-1516963 900 EIGHTH STREET 3001 STATE HIGHWAY 31 E 2839 SOUTH CHERRY AVE. COLUMBUS, GA. 31901 CORSICANA, TX, 75110 FRESNO, CA. 93650 DUVALL STREET 7361 INDUSTRY DRIVE 2648 BYINGTONSALWAY INDUSTRIAL PARK PERRY, FL. 32347 N. CHARLESTON, SC 29405 KNOXVILLE, TN 37901 OUTSIDE SALESMEN/DRIVERS ONLY IN THE FOLLOWING STATES - NO PHYSICAL LOCATIONS: AL, AR, AZ, CT, DC, DE, IA, IL, IN, KS, KY, LA, MA; MD, MI, NO, MS, NC, NE, NH, NJ, NM, NY, OK, OR, PA & VA I NO. OF EMPLOYEES — KY— 5; MS —1; NM-1; IN - 55 U-WC-321-A (V94) Page 1 e12 0 Workers Compensation and Employers Liability ZURICH Endoraemenl e: 4 (srd) f 0.23g7 Policv No. Eff, Date of Pol. lExo. Dale of Pol. Eff. Date of End. I Producer I Addl. Prom I Return Prom. The Insured: LANCE, INC. Mailing Address (including Zip Code): 6600 SOUTH BOULEVARD CHARLOTTE, NC 28273 This endorsement is issued by ZURICH AMERICAN INSURANCE COMPANY. It forms a pan of the policy as of Its effective date, at the hour staled on the Information Page. This endorsement changes such Insurance as is afforded by provisions of the policy relating to the following: It is agreed and understood that the Pa. experience mod, has been revised to 2.482 in lieu of 2.494 and the following changes has been made: DELETE: CLASSIFIATION STATE CODE RATE EXPOSURE PRETZEL MFG. PA 104 6.04 $71,071 CRACKER MFG. PA 105 7.36 $56,540 ADD: WHOLESALE STORES PA 924 SA1 $127,611 SUBJECT TO AUDIT Countersigned Authorized Representative U-WC-170-C(8193) Pagel of 1 SOUTH STREET BAKERY 8600 SOUTH BOULEVARD CHARLOTTE, NC 28273 FEIN 056-0292920 LANHOLD INVESTMENTS, INC. 8600 SOUTH BOULEVARD CHARLOTTE, NC 28273 FEIN #51.0390126 FRESNO VENTURES, INC. 8600 SOUTH BOULEVARD CHARLOTTE, NC 28273 FEIN #20-3643868 COLUMBUS CAPITAL ACOUISITIONS INC — FEIN #58-1516963 8600 SOUTH BOULEVARD CHARLOTTE, NC 28273 LANCE MFG. LLC CARONUTS, INC. 8600 SOUTH BOULEVARD 8600 SOUTH BOULEVARD CHARLOTTE, NC 28273 CHARLOTTE, NC. 28273 FEIN 856-2091021 FEIN 856-1721503 U.WC-321-A(7194) Page 2 of2