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HomeMy WebLinkAboutClassic Signs Liability Documents - Miscellaneous - 3/6/2025 it -matid Martin 1, Noi Of Delta MB 1"..J.-E propel y Owner's 11ame � (business name,1whiell applicable) Y .''- located , MA 0 1876 --..__..._._......- fAmherst, New Hampshire hereby authorize Class'c Signs Inc. o } to act as t agent . # inn require signpermits - 3 k to be completed at: -iance fior woi vat 3 Market BasketCif 350 Winthrop Ave, N Andover (Sign location Street address) 1&4 3 Am)t*oved } (phone number) Agenl o Claysic Sigms.- 4 1 Date., 1,,3 14� 11115 x :�r MIDO ►C R CERTIFICATE OF LIABILITY INSURANCEDATi~{hi4120 4: THIS CERTIFICATE IS ISSUED AS A MATTER F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEN.THIS F TIFI CATE DOE S NOT AFFIRMATWELY OR NEGATIVELY AM ENi ,E [TEND 0 R ALTER THE COVERAGE A F FO RDED BY TH E PO LIDJB BELOW. THIS DEF TiFIDATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN UI EI ( ),AUTHORIZED REPRESENTATIVE OFF PRODUCER,AND THE CERTIFICATE HOLDEN. IMPORTANT: If the certificate holder is an ADDITIONAL AL INSURED,the policy(le )must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Stacie LaVall e NAME: HPM Insurance pka The Dolt Agency PHONE (5 ) 7 -1201 FAX 0 )673-4825 AfC o fix#: (Al,No 101 Ponemah Roam,Suite I Ar�oR�E : Stacie a@hpmin ura�nce.com €NSURER{ �AFFORDING COVERAGE NAM# Amherst NH 0 031 I UR Acadia Insurance Company31325 INSURED INSURER S CLASSIC SIGNS INCli"# i.JREFt 13 COLUMBIA DRIVE INSURER o BAY#16 IN$VRER E AMHERST NH 03031 INSURER F Pqw COVERAGES CERTIFICATE NUMBER: CL2410440773 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEN BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OFF OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, INSR ADULSUBR. POLICY EFE POLICY EP LTR TYPE OF INSURANCE INSD WVD POLIO'NUMBER M1DE)P Y Y) JIMIMMY) LIMIT OiV#M ERM L.GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED I CLAIMS-MADE F-10CCUR PREMISES Ea 000L I rencC LIED EXP(Any one person) P E RSONAL&ADV INJURY GEN'L AGGREGATE UNIIT APPLIES PER: GENERALAGGREGATE POLICY El PRO- Loc PRODUCTS-C , PIOPA JE7 F-1 OTHER- AUTOMOBILE LiAMLITY COMBINED SINGLE LIPAIT A accident ANY AUTO BODILY INJURY(Per person) OWNED SCHEDULED BODILY INJURY(Per accIdent) AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONL Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION X PER STA ORH 'AND EMPL YER LIABILITY ANY PROPRIETORWAF��'NER/EXECUTI VE {N E.L_EACH ACCIDENT 1P000,000 OFFICE RiTAEMBER EXCLUDED? NIA 1 A 2�1 Y17 1Q10I1 0 � 11�1�112� (Mandatory in ) E-L.DISEASE-E EMPLOYEE $ } It yes.describe Crider 1, 00, 00 DESCRIPTION OF OPERATION bebw E.L_DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE (ACORD 101,Additional Remarks Schedule,may be attached if more space is tequired) Paul Tripp is are included officer for WC benefits. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED IBED POLICIES BE CANCELLED BEFORE Town of North AndoverTHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE ITH THE POLICY PROVISIONS. 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 1 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/0 The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref# Description Coverage Code form No. Edition Date WC&Employer's liability W EL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1 ,7 O.00 Ref# Description Coverage Code Form No. Edition Gate Adj t.to reconcile-e cp mod,premium AF E 1 Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$1,912.00 Ref Description Coverage Code Form No. Editlon Date Domestic Terrorism,Earthquake&Catastrophe ATE Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $150.00 Ref# Description Coverage Code Form No. Edition Date Premium discount PDI Limit I Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$ 0 .0 Ref## Description Coverage Code Form No. Edition Date Increased employer's liability I JEL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $173.00 Fief# Description Coverage Code Form No. Edition Date Expense on tant EX i T Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $1 0.00 Ref# Description Coverage Code Form No, Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref## Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Corte Form No. Edition Date Limit 1 Limit 2 Clair 3 Deductible Amount Deductible Type Premium Ref## Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Fief Description Coverage Code Fora No. Edition Date Limit 1 Unift 2 Limit 3 Deductible Amount Deductible Type Premium FADTL V Copyright 2001,AIDS Services,Inc. t a WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. 11'I!e will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone net named in the Schedule. Schedule Any Person or Organization for Whom You are Performing Operations This endorsement charges the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorser ent is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. 1 '1 2 24 WCA 5320149 1 Insured Premium Classic Signs Inc Insurance Company: Countersigned by Acadia Insurance Company WC 00 03 13 04 84 @ 1983 National Council on Compensation Insurance Page 1 of I The Coninionivealth of Massachitsetts ----- --nwn._ epa rtin en of Ire istria A eer'. en is .............. Office of Investigations Lafayette City Cenei# = x. 2 A venit e de Lafayette, Boston, MA 02111-1750 - Y r io v w,in ass.go vl(fia Workers' Compensation Insurance Affidavit: tiiid r C ii ractor#s l trici n Yti ib i-s AP cant Information Please Print Legibly Nam Busine ss/0 rgani zati on/Indi v idu al); Classic Signs Inc. L.L C Address: 13 Columbia Drive City/State/Zip:Amherst} NH, 03031 Photi #: 603-883-0384 Are you an eniployer7 Clieckthe appropriate box: Type of project (required): I.Al I any a employer With 16 4. ❑ I am a general contractor and I 6. New construction employees full and/or part-time).* have hires the sub-contractors 2.❑ I any a sole proprietor or partner- listed on theattached sleet, 7'. ❑ Remodeling � I slip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 0 9. B��ilcli�� addition� [No workers" eo���p �. ins ��•ane . comp. insurance required.] . ❑ We are a corporation and its 10.0 Electrical repairs or additions .❑ I am a homeowner doing all work officers have exercised their ME] 11umbing repairs or additions myself. [No workers-' comp. right of exemption per M L 12. Roof repairs is e •ecl r e. 152, §1(4), and we haveno employees. o� or er ' 13.0Other �Ig comp. insurance required.] 'Any applicant that checks box#l MLISt also fi I I out the section below Mtming their workers'compensation policy information Homeowners who SUbmit this affidavit indicafing they are doing all work and then hire outside contractors must submit a tiew affidavit indicating such. i ontractors that check this box must attached an additioul shee(showing the name of the sub-contra (ors acid state whether or not those entities have employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. rtrrr are erirp o,y r•firth ispr,,oi�id`tig it7ot-firer-s'coirip resat orr iiisiti•rirc}ejif r•iyi l eiri ,t?catos. Below is thepolicy andjob site information. Insurance Company ny Name, HPM Insurance Policy or Self-ins. Lie. :WC 01 -1 xpiration Date: 1 1 2 25 Job Site Address: 3 0Winthrop Ave, North Andover, MA 01845City/State/Zip; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration iratfo (late). Failure to secure coverage as required under Section 2 A of MGL c, 152 can lead to the imposition of criminal penalties of a fine sip to $1,500.00 and/or one-year imprisonment,ent, as well l as civil penalties in the form of a STOP WORK ORDERand a fille of up to $2 0.00 a day against the violator. Be advised that a copy of this statement ent may be forwarded to the Office of Investigations of the ILIA for insurance coverage verification. o her ef5j,c rtijj� rrjrdc r the pains tind p nuffles of 1mi jui-v th at the r`rrfin-inat on pro vided above is true an d correct. Si mature: DAate: 'lone M - - 4668 6//" .. .ffftcial use only. Do not iwife in this area, to be completed 1P eitj' or town o,f icr`a. City or Town: Permit License 1s uhig Authority (check cane): 10 Board of Health 20 Building Department 0 it /Town Clerk 4.0 Electrical Inspector 51alumbling Inspector .❑other Contact Person: P11011e ii fInformati*on and Instruc Massachusetts General Lays chapter 152 requires all employers to provide workers* compensation for their employees. Pursuant to this statute, an einplojwe 'is defined "...every person in the service of another under any contract of hire., express or implied, oral or Nvr•itten." An errr to per-is defined as "an individual, partnership, association, corporation or other legal entity, or any tNvo 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 o�N ier•of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling horse of another who employs persons to do maintenance,nance, construction or repair work on such dwelling house on oil the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, 2. C 6 also states that i�every state or local licensing agency sliall withhold the issuance or renewal of a license or per snit to operate a business or to construct uct buildings in the coninionwealth for ally applicant who has not produced acceptable evidence of compliance with the insurance coverage required."' Additionally, MGL chapter 152, § states "Neither the commonwealth nor any of its political subdivisions shall enter; into any contract for the performance of public wort 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 sub-contractor names , address(es) and phone numbers s along with their;certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnership LLP with no employees other than the members or partners, are not required to carry workers'ers' compensation insurance. if are LLC or LLP does have employees, a policy is required. Be advised Iliat this affidavit may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sureto sign and date the affidavit. The affidavit should be returned to the city or;town that the application for the perinit 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. elf-insured companies should enter their self-insurance license number on the appropriate lire. 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, all applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information if necessary) and under;"Job Site Address" the applicant should write "all locations in city or- town)." 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 hol e owner or citizen is obtaining a license or permit not related to any business or commercial venture i.e. a dog license or pernnit to burn leaves etc, said person is NOT required to complete this affidavit. The Office of investigations would life to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. i1A I I I I I I I I II Ii1lilYlY PPPPPPPIIIYYIIqI1tl11111YII11Y11'IYYYYY PPPPPPPPPPPPIiPPIiI1PIIpYIhIY '^� �RFlII I I I I IIIIIIIIIIIIIYi PIIPPIIIIIIIIIIIIYYIIYIIIYIYI'IWI'IW IPIPPPPPPIiPlililililililililYililYYiIN ^'�^ The 1 epar(nient's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center;, 2 Avenue de Lafayette Boston, MA 02 l r 1-17 Tel. 617 727-4900 or 1-877-MASSA Fax 17 727-77 9 Devised 7- 019 ww.i a s.gov di