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Home My WebLink AboutCasey O'Conors - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE 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:. ROBERT BURNS, PRESIDENT Whose place of business is: ARB ENTERPRISES, INC. dba CASEY O'CONOR'S 219 NORTH MAIN STREET PERSON(S) IN CHARGE ROBERT BURNS & ANDREA BURNS Permit Expires: ,June 01, 2010 License Number: FS-2 Food Fee: $100.00 Milk & Cream W BOARD OF HEALTH Dr. Raymond Martin, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: ROBERT BURNS, PRESIDENT having a place of business at: ARB ENTERPRISES, INC. dba CASEY O'CONOR'S 219 NORTH MAIN STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 License No.: FS-2 Leite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-2 FOOD ESTABLISHMENT PERMIT APPLICATION (Anolication must be submitted at least 30 days before the planned openina date) 1) Establishment Name: ARB ENTERPRISES, INC. dba CASEY O'CONOR'S 2) Establishment Address 219 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 31 PILGRIM ROAD MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-6203 5) Applicant Name & Title: ROBERT BURNS, PRESIDENT 6) Applicant Address 31 PILGRIM ROAD, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-6203 (506) 736-3225 24 Hour Emergency No.: CELL (509) 736-3225 8) Owners Name & Title ROBERT BURNS, PRESIDENT 9) Owner Address (If different from applicant): 31 PILGRIM ROAD, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association E/A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address — -- - - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 24 Hour Emergency No: ------ ---- FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 30 17) DAYS/HOURS: TUES-WED 4 PM-1 AM/THURS-SUN 11 AM-1 AM 18) Name of Person In Charge Certified in Food Protection Management: FREDE TEBEAU If more than 3 individuals are certified, complete list is on file. ROBERT BURNS Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate _ I 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0 20) Location: W Permanent Location ❑ Mobile Mobile Start Date: Moblie End Date: Mobile Comments 21) Length of Permit: ❑d Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $75 ❑d Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ( Meals/Day) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 ❑J Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 If of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23 Food O Operations F (Check all that apply): Definitions:PHF - Potentially hazardous food (timelfemperature controls required) Non-PHF's - non -potentially hazardous tood(no time/temperature controls required) RTE- ready -to -eat foods (Ex, sandwiches, salads, muffins which needno furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PFHs PHFCoc ked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food EPay,ent mpleted by the Board of Health rmit Fee: $100.00 is due with application ❑waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 59 00 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 9000 and - \ I Food Code. 24) Signature of Applicant c �� """ 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 slate tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 20-3835431 n 26) Signature of Individual or Corporate Name: /" 94F'61Z-,5 Town of Mansfield Town of Mansfield -Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1 st of each year. NAME OF BUSINESS: ARB ENTERPRISES, INC. dba CASEY O'CONOR'S ADDRESS: 219 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6203 FAX NUMBER: OWNER OF BUSINESS: ROBERT BURNS, PRESIDENT TELEPHONE OF OWNER: (508) 339-8434 FEDERAL ID/SS NUMBER: 20-3835431 FEE: $2.00 PERMIT NUMBER: FS-2 SIGNATURE: DATE: 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 (Mandatory) By: Corporate O icer (Mandatory, if applicable) p-O 3 ,9'3 ** 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. Ln M z E LL g Q X W M A 0 N M .i H SO} It V H O O Z Z W c � s Q a' V O H LL LL Q � K W W Vwaft p 0 zau - Oy_O J y 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: r I o�Y7�/2 t�✓Zi�SE�? Dhl�//n�FX Address:_ t:2 101 1,, .-&A' 5-r— C';r.,tcrafPt7;,,• :M,4-Af :-..i;z Ze ✓l ►M9�U Phone #: 7 d 3 0.;-el 3 c Are you an employer? Check the appropriate box: Business Type (required): I. I am a employer with fZ_ employees (full and/ 5. ❑ Retail or part-time).* 6. [ a testaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. g. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the cotpomte officers have exempted themselves, but the cotporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. A r Insurance Company Insurer's Address: N o Q e1 X 11y 1-" City/State/Zip: VAW,_W_%10 Policy # or Self -ins. Lic. # 0 7& 19 ti ,5_0 4 Expiration 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. I do hereby certify, it/��yper thne pains and penalties ofperjury that the information provided above is true and correct. 3 I r X DQ _ r,... 7 A/fJ J 4 official use only. Do not write in this area, to be couipleted by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: www.tuass.gov/dia Phone 341[jll l.l'aA 1\!.-L r�r LYl/V40 L, JV [.l .t'I'I VMR" J/VVJ I,&,% I:CJSYCI. --1-"_--_ COT 75PR Ok ]N3LRANCE �— iocc quhlBER I'OL]('Y YU1,ICt' LIA77T5 CFR CFTECRYE DATE LZPIILATION DATE L IMhVDD!YYI LMh1(DArI'T1 LRLRnt GE,9ERAi. L1 MI-ITY fhODL'IC.ISCOMWOP AGO $ n MNERAI. LIALALOY ------------- 1, AM T JURY --------1 S WwNIEROAL. CLAIMS MADE L! OCCUR. [nwloatlRRC:NCL 1_—__� I iDOVn ER3h CONI'RA2TOR'S PROT. _—.._._.—_. TIRE Dn_n1n!iE Lll!'9w l"t,;' Y C MED. i3YFFFCU)LI. Ir V_^_� - —1 � 'SLI 51?LIWT n fNDILY IM(IRl' 1 1 IJD Amo , lL ALLOWFIR'ALIT05 IPn IT.x. n) J O SCHRIV)EDAMUS - O:TILYIIJIURY ) :1 }HREU AUTOS LP<, .\aldaA j ! 1l YROPERTI'OAIJAOE $ C, vAR.A617 II&MIFFY _F E\CEJT.r i,IAB1LlTt--- --- -� - r,ro:n occuaarncl s__ _ rAl1i1,Lt 1.AlO11M _ —._._ . —t .SOGRtA:iSU S � OTIIFR IBAN CAIERFLLA FORM I'I SfAlUTORY MIFFS J' A itORFER•SCO:NPEn5AT[ON EACH ACCIMI- --__ 3100.000 DISEAVEKAXYLIMIT 3500,000 { AND 0768N50A 05130/'2009 0-8012010 nr.,cAs[-cEurf>,IVLOYLe 100,000 RMPI.OYER'S 1.1 ARILETY .j ` + `v I THE S(ILE YROPREETUR;I'AR'I\ERISIARE_---- I 1NCL1:DE0 S PHIS IS TO CLRi 1PC'THAT'CHP.POL[C:13S 021NSURANCE LISTE:U RELOW HnVEB'cOJ ISSL'ED TD I'HI INSURED iJAIAL'D ARGVli FOR'�HE VOLLEY PlR[CD WDICA'i'PD. NOTW'ITHSTANDINOMY Rn(RIIRP.MFNT, TRAM OR COIN DITIM IF ANY CONTRAC'I'(ROFFER DDCl1A1PNT WITH RPBFEC I'T01NHICH'ITIIS CF:RTIFICATIi MAY BE, iSSUM OR MAY FERTAIN, THE INSURANCE. AFFORDED BY THEYOUCIES DESCRIBED HEREIN IS SUBIRCTTYI ALL. "HE TERMS, EXCLUSIONS 1 AND COMDI R'0.S OF SLCH POLf711:44HMITS SIOWN MAY HAVE WIN RFDI CPU BY PAID Ci AIMS TOWN OF Si ANMELU HOCLD ANY 07111E AROIEDELRIDED fVL0.f@ n.l r 5 PARK ROW F.CPIIUFION DAR3 TNour P', T1161SYUND COM1IfANY M I EAIMM 1 R IO YI F L IU II A IIATF. 11T.V 11, St C TOIN 1'iA 119CA 11SY N 1r PI JCAT Iq OR IF,fT. 11ANSI'IELD, MA010A�i nlT euLl uv lo.LAusrrxnonrl alnn. 1o11+xl s-I onu .nTfwcu 06/01/2009 13:43 15083394811 C%S INSURANCE AGENCY PAGE 01 ..rr••I-Uull uiatuS aearch .Page 1 of 1 WCRIBMA r: MWCARPApplication Status Search Data Last Updated 6/r/2oo9 1:00:t2 PM MWCARP Overview Producer Con m Wity Horne NOTICE: By accessing this section of the Bureau's web site, you accept and agree to the terms and conditions for use that are set forth throughout this web site. STATUS key reference - CARRIER NUMBER key reference t?mployer Name/Address Client I lame Cove a ID t aS Received Date Tentative Erfective Date Status Status Date ❑ Canner Ivtun6cr L-�J ARE ENERPRISES INC DBA CASEYOCONNORS 31 PILGRIM RD 0779130 05/�9/09 90 3 5- ASSIGNED o6 01/09 ia456 MANSFIELD , MA 02048 --1- https://www.wcribtna.org/mass/1 roducer/ApplicationStatusSearebIStatusSearchPage.aspx 6/t/2009 0G/01/2009 09:42 15083394811 C*S INSURANCE AGENCY PAGE 01 lwm�) TO. Scott I_eide Fax: 508-261-7425 Phone: C & S insurance Agency, Inc. P.O. Box 406 Mansfield, MA 02048 Tel. (508) 339-2951 Fax (508) 339-4811 Debble0candsins.com From: Debra Gerraughty Date: 6/1/09 Pages: 5 Re: ARB Enterprises Inc - cc: Application for Workers Compensation Scott, Please find a copy of ARB Enterprises Application for Workers Compensation that was submitted last week. The finance company received the paperwork and was going to walk the application over to the MWCARP Friday and we should receive an asslgment soon. If you need anything further, please feel free to contact me, Thank yowl Debbie 0G/01/2009 09:42 15083394811 CwS INSURANCE AGENCY PAGE 02 MAS APPLICAT ON FOR WORKERS' CASSIGNED POOL OMPENSAT ONINSURANCE MAIL TO: r The Workers' Compensation Rating & Inspection Bureau of Massachusetts P.O. Box 55005 Boston, MA 02205 (617) 439-9030 IMPORTANT: Forassisfance completing 0115 application, refertotne Pool Proceduresfor New Applications under Realdmil Market on the SUMOe'e wabstie, Nww-wc -on1 A separate application mutt be filed for Bach tagal entity. This application must be typed or printed In Ink and submitted in duplicate to Vie 6ureeu, Under no circumstance will ooverege be assigned If: payment or raqulred deposit does not accompany the application; the deGinadon requirements Bre not met; there tea record of audit udit or Inspection Iowato� a priorr workers'comlipensationn* applicant is In policy the remenssIncolt of premIUM for prior mplete due to the applicant's failurelpensation coverage; of, to cooperate wida the prior Insurer, the applicant has an auditor Inspectorthe The undiesi possible date coverage can bb to hound Is at compensation A.M. the day Baer the application and In the edeposit are receivedanh in by ppl s for such In urance inu. nthe MassachusettslAmigned Risk Poolln mrKef4- nd expressly represetnts that such inaurencelity insurance n sought In good faith voluntary market and hereby applies Requested I. GENERAL INFORMATION Effective Date: /W/0 - 1. AR8 Ente rises Iqc ribs Case O'Connors NAME OF EMPLOYER lName the Bala prpdelor, general pedneas) or Watee(s) along with the trade name of me business.) ❑PENDING 2. 20.3835431 FEDERAL EMPLOYERS IDENTIFICATION NUMBER (It pending, attach acopY of the lRS application.) 3. 4. 5, TOTAL NUMBER OF MA LOCATIONS 6. non Stela Zip Phone 1 ADDITIONAL MA LOCATION Number Street City (If there is mor than one additional MA location, attach a list of street addresses and phone numbers. Fully complete Secton VI for each location.) Mansfield MA 02048 08-339.5203 7. 31 Pil rim Road _ raw State Zip Phone 6, LEGAL STATUS ❑ Sole proprietor ❑ Partnership ® Corporation ❑ LLC 0 LLP ❑ Other (explain) II. ELIGIBILITY REQUIREMENTS 0 Trust ❑ Limited Partnership To be e1191bie to obtain assigned risk coverage: • The employers application for voluntary Massachusetts workers' compensation coverage must have been rejected by two (2) carrierslicensed to write workers compensation in Mai aechusetts; • The employer must not be in dafaua of premium for Massachusetts workers' compensation insurance; • The employer must have complied with all laws, ordees, rules and regulations in force and effect relatng to the welfare, Mardi and safety of employees; and, • The employer must not have an audit or inspection on a pdorworkers' eompansatlon policy that remains Incomplete due to the employers failure to cooparate with the Insurer. 1. List the names, representatives, data(s) of discussion, and phone numbers of two Insurance companies licensed to write workers' compensation In Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must bean employee who has authority to bind coverage for the insurance company. A failure to reach such a representative cannot be construed as a refusal to write coverage. %AV119 all!03/19l09 800-258-3574 Merchants Insurance Group John Miles Guard Insurance Group Janet Albany 03/19/09 570-820,7088 NOTE: If coverage was recently terminated or expired in either the voluntary or assigned risk market, you must attach a copy of the cancellation or nonronewal notice. e reason l mutt be indicated. If the coverage was in the days, the cancel ation or nonr nsocancellation a wal will as one of the two required declinations. Generally, voluntary coverage must bereplaced In the voluntary market if voluntary Coverage was canvelied or non -renewed at the employer's request. El VES NO 2. Have you received any offers of voluntary coverage? ® If YES, attach the offer for coverage, including ell multi -line, deductible, or retrospective rating terms. 3. Is there any unpaid workerscompensation premium due from you or any other commonly owned enterprise? ❑ YES ® NO If YES, provide the entity name, balance and policy numbads). If the premium is being disputed, attach an explanation for Bureau consideration. If an arrangement for payment has been made, attach a copy of the signed agreement. 4. Does the employer' Have any outstanding audits or inspections on a prior worker' compensation policy.? ITS �NO If YES, provide the name of the carrier and the policy number. If the employer has scheduled en audit, provide the net-- Rnd telephone number of a contact at the carrier, 9MECTAM JANUARY 20, 406. (EDmON Of) 06/01/2009 09:42 15083394811 CxS INSURANCE AGENCY Ill. CORPORATE OFFICERS, SOLE PROPRIETORS, PARTNERS & MEMBERS If there are more than four Officers, Partners or Members, attach a I191 including the required Information for each additional individual. PAGE 03 For Sole Proprietors, PartnersLLC Members and LLP Psriners; List the Names, titles, Ownership and Duties of all Proprietors. Partners or Members, and indicate whether each Is slatting coverage. Sole Proprietors, Partners and Members are not covered unless they elect coverage. To elect coverage, a letter must be submitted on company letterhead In accordance with MA Regulation 452 GMR 8.07. Refer to the MA WC & EL Insurance Manuel, to the Rates Page with Miscellaneous Values, for Sole Proprietors', Partners' and Mambas Basis of Premium. In Section A, Include the Basis of Premium for as Sole Proprietors, Partners and Members elading coverage. For Coroomft w List the Name, Title, Ownership, Duties and actual Salary of all officers listed In the Corporate Articles of Organization, and indicate whether each has chosen to exempt himself from coverage In accordance with MA Regulation 452 CMR 8.06. Corporate officers will be included unless a Form 153 has been submlaed to and approved by the MA Department of Industrial Accidents. The stamped and approved Form 153 must be attached. Corporals orfioer salaries may be subject to payroll limitation; refer to the MA WC & Et, Insurance Manual, Part One , Rule IX. In Section VI, Include the salary, subject to 0Ye minimums and maximums, of all nonexempt corporate officers. 6WGlY�Te.LI� �) ♦ ,;1.ul ,�a 'l ili�lPNlt ilFlf ..:.�. £.fll4t yi,..,I4mq.-'j.trite.F..d4:r- 11 F'f5 V" J: «iI1.N,ltN1L 1•rl IV. INSURANCE RECORD t. Has the applicant previously had Massachusetts workers' compensation Insurance from a licensed insurance company? ® YES ❑ NO 2. If YES, complete the following for the most recent three years: .r 1iu.' t:i ,d�r.....:.a , r .., c.i. .a..y�..., a.1l�...n.. `ya I/��_7 'wr�J �u✓vn.4 r n Y,'��.ISr rl..�,..A,..R ri.`r�'Cu F{fr,..S1 x! Q..j. :3't17h t r r: r r t• 1 03 If NO, complete: ❑ New Business © Uninsured ❑ Self Insurance Group ❑ Self Insured ❑ Other (explain): Was the applicant self -Insured within the last twelve months, or was the applicant's expiring policy subject to the ❑ YES NO Premium Determination Endorsement — Former Self Insurers —1? If YES, an audit must be completed before coverage can be bound. Refer to the Pool Procedures for New Applicadons for details. Former members of Self insurance Groups are not subject to this endorsement. If self Insured within the last twelve months, provide the termination date: _ ® Is the employer in bankruptcy? If YES, attach a copy of the approved bankruptcy filing, ,,..// d YES N +9 Does this entity or any other commonly owned entity have operations in states other then MA? EM ❑ YES NO If YES, attach a list of employer names, slates, carriers and Interstate or intrastate ID numbers. / QHas there been a name change within the last five years? ❑ YES t� Has there been a merger or consolidation within the last five years? ❑ YES V Has there been a sale, transfer or conveyance of ownership interest within the last five years? ❑ YES D Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last five years? ❑ YFS t t Have the owners or officers ever had ownership Interest in any other entity, either currently or previously existing? Vic) ❑ YF,S (J NO If the answer to 7, S, 9, 10 or 11 is YES, complete an ERM Form and attach It to this application. V. BUSINESS OF EMPLOYER Does the employer provide temporary or leased employees to other businesses? ❑ YFS NO - If YES, refer to the Pool Procedures for New Applications for Instructions. r2 Does the employer lease employees or regularly have temporary employees supplied to them from another business? ,,..,// ❑ YES LLG NO If YES, refer to the Pool Procedures for New Applications for instructions, 1/3] MA Law provides that the employer is liable for Injury of employees of uninsured subcontractors. V Premium will be charged In the absence of a certificate of Insurance from subcontractors. Is it antldpated that subcontracted labor will be utilized during the policy term? ❑ YES NO if YES, estimate payrolls made to subcontractors without certificates of insurance. S ©Transfer this amount to Section VI and identify by classification of work performed. Does the employer use independent contractors? [j YES Pf NO If YES, documentation must be maintained which supports that they are, in fact, independent contractors. If such documentation is not available, or If the designated carder finds evidence of an employment relationship, then premium may be charged as if the individuals were employees. E"ECTIVE JAWw Y em, me- Mmfiaa or) 36/01/2009 09:42 15083394811 CWS INSURANCE AGENCY PAGE 04 V. BUSINESS OF EMPLOYER (continued) 6: Completely describe all operations of the employer. If there are multiple locations, provide a description for each, VI. MASSACHUSETTS CLASSIFICATIONS, ESTIMATED EXPOSURE AND PREMIUM CALCULATIONS Attach the four most recently filed Form 941s or DET Form Is. Provide an Inforrnaann Mr nnnh r.,.,os..., r.., ei 1 1 1 1 Restaurant NOC 9079 Il.'�GdlS 1 89,0oo 1 1,10 979 MANUAL PREMIUM Employers Liability Limit Options (check one): _ " Waiver of Our Right To Recover From Others Charge ❑^ 100l100/500 no charge " Employers Liability Increased Limits Charge ( ) _ 100/10011,000 .50% _ $75 minimum_ " Deductible Credit ( ) _❑ 500/500/600 F 1.00% $50 minimum " Experience Rating ( ) or Merit Rating ( ] ❑ 500/500/1,000 1.25% $75 minimum " MCCPAP Adjustment ( ) ❑�1,00011,00011,000 2,00% $75 minimum STANDARD PREMIUM 970 " ARAP ( ) QLMP Adjustment( ) Balance to Admiretty/FELA Minimum Premium " Loss Constant VII. DEPOSIT REQUIRED __ _ Expense Constant 250 ,1. Installment Options (check one): * Terrorism Premium ( Total Payroll / 100)(0,03) 27 Installment Requked Total Deposft Additional Basi4_.0 Fit. Premium Factor _ Payments 'Balance to Total Policy Minimum Premium 218 ❑ —Annually > so 100% none " Former Self Insurers Insurance Charge Seml-Annually : $5,000 75"% one TOTAL ESTIMATED PREMIUM 1260 _ Quarterly 2 $10,000 50% three " I]IA Assessment( 6,30 %) 62 ❑ Monthly �> $25,000 _ 25% nine _ TOTAL EST. PREMIUM AND DIA ASSESSMENT 1318 REQUIRED DEPOSIT 1318 2. Enclosed Is check number in the amount of $ Make the check payable to the Massachusetts Workers' Compensation Assigned Risk Pool (or "MWCARP"). 3. Any binding of coverage is conditional until the check has cleared. If the Check is found to be non•negotlable, the check will be returned to the employer who will be given ten (10) days to provide the carrier with a bank check or money order fOr the full amount of the required deposit. Only if sufficient funds are received by the carder on a timely basis, will coverage be effective as of the tentative binding date on the Notice of Assignment issued by the Bureau. 4. Is the premium being financed? ® YES ❑ NO If YES, then 100°% of the Total Est. Premium and DIA Assessment must be sent with the application along with a sighed copy of the finance agreement. If appllcable. Referto the Pod Procedures for New Applications and to the Residual Market Premium Algorithm —Appendix F In the MA Manual for details. « Applies only to Former Sett Insurers. Refer to the Pool Procedures for New Applications for details. �» Calculation of Required Deposit: (((Talal Est. Premium + DIA) — (Expense Constant+ Insurance Charge)) x Deposit Factor) + (Expense Constant+ Insurance Charge) EMOT VE JANUMY M. 9 . (EM(ON 01)