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CERTIFICATE OF LIABILITY INSURANCE (622)�Al�s�ate� You're in good hands. � �. �,��:�a BU114R3 CUSTOMER NUMBER: 565911 DAVID RICARDO TAPIA 133 N GARDEN AVE CLEARWATER, FL 33755-4119 CITY O�' CE,EARWATER 100 S MYRTLE AVE CLEARWATER, FL 33756-5520 109001501146481497880104000010001005 RUN DATE: 01-14-15 �Allstates You're in good hands. L'r 'r d: t� BU114R•3 DM CW 14 01 10 Alistate Insurance Company �AllstateW You're in good hands. � ��, ... ��: Policy Number 648149788 COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS Allstate Insurance Company Named Insured GALA' S GELATERIA Effective Date: 03 -12 - 2 015 12:01 A.M., Standard Time Agent Name DAVID RICARDO TAPIA Item 1. Business Description: ICE CREAM STORE Item 2. Limits of Insurance Coverage Limit of Liability Aggregate Limits of Liabitity Products/Completed $ 1, 000, 000 Operations Aggregate General Aggregate (other than $ 1, 000, 000 Products/Completed Operations) Coverage A- Bodily Injury and any one occurrence subject to Property Damage Liability $ 1, 000, 000 the Products/Completed Operations and General Aggregate Limits of Liability any one premises subject to the Damage To Premises Coverage A occurrence and the Rented To You $ 10 0, 0 0 0 General Aggregate Limits of Liability Coverage B- Personal and any one person or organization Advertising Injury $ 1, 000, 000 subject to the General Aggregate Liability Limits of Liability Coverage C- Medical Payments any one person subject to the Coverage A occurrence and the $ 5, 000 General Aggregate Limits of Liability Ifiem 3. Retroactive Date (Not Applicable in New York) Coverage A of this Insurance does not apply to "bodily injury" or "property damage" which occurs before the Retroactive Date, if any, shown here: (Enter Date or "None" if no Retroactive Date applies) Item 4. Form of Business and Location of Premises Forms of Business: LIMITED LIABILITY COMPANY Location of All Premises You Own, Rent or Occupy: See Schedule of Locations Item 5. Forms and Endorsements Form(s) and Endorsement(s) made a part of this policy at time of issue: See Schedule of Fams and Endorsements Item 6. Premiums Covera e Part Premium: $ 484 . 00 Other Premium: Total Premium: $ 484 . 00 THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. DL CW 22 01 10 Allstate Insurance Company BU114R-3 �AIls�atea You ie in good hands. � ��' Policy Number 648149788 COMMERCIAL GENERAL LIABILITY COVERAGE SCHEDULE Ailstate Insurance Com�pany Named Insured GALA' S GELATERIA Effective Date: 03 -12 -15 12:01 A.M., Standard Time Agent Name DAVID RICARDO TAPIA I�em 5. Location of Premises Location of All Premises You Own, Rent or Occupy: See Schedule of Locations Code No. Premium Basis Premises/Operations 49950 Flat Charge Location ALL Exposure Rate Premium lassification: $ 2 5. 0 0 dditional Insured — Products/Completed Operations Rate Premium Code No. Premium Basis Premises/Operations 14401 ross Sales Location 0 01 / 0 O 1 Exposure $10 0, 0 0 0 Rate Premium lassification: 4. 14 0 $ 414 . 0 0 ICE CREAM STORES Products/Completed Operations Rate Premium .452 $ 45.00 Code No. Premium Basis Premises/Operations Location Exposure Rate Premium lassification: Products/Completed Operations Rate Premium Code No. Premium Basis Premises/Operations Location Exposure Rate Premium lassification: Products/Completed Operations Rate Premium BU114R-3 DL CW 12 01 10 Allstate Insurance Company �Allstatem You're in good hands. POLICY NUMBER: 64 814 978 8 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLJCY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section 11 — Who Is M Insured is amended to include as an additional insured the person(s) or organiza- tion(s) shown in the Schedule, but only with respect to liabiliry for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. '��Y lt� �T F,• Z �Y.ii�.� BU114R-3 CG ZO 26 07 04 O ISO Properties, Inc., 2004 Page 1 of 1 ❑ �.,`�J� �c� �, �5� � �