Preview
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE
X
WORKERS' :
COMPENSATION BOARD OF THE STATE OF NEW YORK,
Plaintiff, :
-against- :
AMERICAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF :
AFFIRMATION
LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC
OF
Defendant(s)
NON-PAYMENT
:
:
X
Workers'
The undersigned, an attorney in theoffice of the Compensation Board of the State of New
York, Plaintiffherein, hereby affirmsthat the following is trueunder the penalty of perjury,upon
information and belief:
This affirmationisbased upon a review of the file
which ismaintained by the L kem'
Compensation
Board inits regularcourse of business.
I am familiarwith the status of payment in thismatter. The award/penalty/assessment/demand for
deposit of securitymade against the defendant(s) in theamount of $35,000.00 isin default,as more
than thirtydays have elapsed since the demand upon the defendant(s) herein forpayment. No paymêñt
has been received nor has the aforesaid security been clarmited in comp;;äñco with said demand to
date, except the sum of $0.00, leaving due and payble the sum of $35,000.00.
Dated: 12th day of April , 2021 .
S/
James R. McGinn, Esq.
Judgment Unit
C-45.45E 1/2009
Filedin Orange County 09iO2/202 i 12:49:47 PM $0.00 Bk: 1 of
5146 7 Pg: 1085 Index: # EF006221-2021 Clerk:DK
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
2 of 7
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE
X
WORKERS' :
COMPENSATION BOARD OF THE STATE OF NEW YORK,
Plaintiff, :
-against- :
AMERICAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF :
AFFIRMATION
LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC
OF
Defendant(s)
REGULARITY
X
Workers'
The undersigñéd, an attorney in theoffice of the Corñpéñsation Board of the Stateof New
York, Plaintiffherein, hereby affirms that thefollowing is trueunder the penalty of perjury,upon
information and belief:
Werkers'
This affirinationisbased upon a review of the which
file ismaintained by the Compensation
Board initsregular course of business.
Workers'
The Compensation Board of the State of New York, inacccidance with the provisions of the
Workers'
Compensation Law, has made an assessment/award inthe sum of $35,000.00, against the
defendant(s). Attached hereto and made a part hereof are certifiedcopies of the Notice of Decision and
Award, and/or a certifiedcopy ofthe derüand for deposit of security,and/or a certifiedcopy ofthe chair's
order imposing, and the demand for payment of, assessments imposed by the chairpursuant to
Werkers'
subdivision five ofsection fifty-twoand/or one hundred thirtyone of the Compensation Law, as
Workers'
required for of
filing judgment per Compensation Law, Section 26 and/or 219. Appeals before
the Board have been exhausted.
No payment of award has been made except $0.00, leaving $35,000.00 due and payable.
WHEREFORE, it isrespectfullyrequested that judgment be entered against the Defendant(s) herein in
the sum stated as remaining due and payable.
Dated: 12th day of April , 2021 .
S/
James R. McGinn, Esq.
Judgment Unit
C-45.1E 6/2007
3 of 7
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
4 of 7
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
STATE OF NEW YORK
WORKERS'
NEW Workers' COMPENSATION BOARD THISAGENCYEMPLOYSAND SERVES
JUDGMENT UNIT PEOPLEWTH DISABILITES WTHOUT
ÏŸZE Compensat1ort
328 STATE STREET DISCRIMINATION.
Board
SCHENECTADY, NY 12305-2318
866-298-7830
THOMAS ANDRYSHAK, iviEiviBER OF LLC WCB EMPLOYER #: 2C¤Q20R
THOMAS AiýüRY8HAK JR, MEMBER OF LLC UlER #: 53-29879
AMERICAS LIFE SAVERS LLc
FEIN/SS # *****3859
1 COMMERCIAL DR STE 5
FLORIDA NY 10921-1055
It is
hereby certified
thatthis is a true
and correct copy ofthe originalas filed
Workers'
with the Compensation Board
S/
James R. McGinn, Esq.
FINAL NOTICE e;=±unit
DATE: 04/12/2021
prtified
nn nanom
Non-Compliance
Item DescilpUGñ Dates Accident Date Be!ance Due
I
2018W0012203 Failure to Workers' Ins 02/09/2018-01/09/2020 $35, 000. 00
Carry Comp
Total Balance Due $35,000.00
*
Ifpaymêñt isnot received immediate!y, judgmêñt willbe filedand the employer is subjectto seizure
of assets, both business and personal, without further noticefrom the Board.
In orderto insureprompt creditof yourpayment, emplete thefe!!ewingwiththe
Date, Nurnber and Amount of yourcheck and return with
it, along your payment to:
WORKERS'
COMPENSATION BOARD
FINANCE OFFICE
328 STATE STREET, SCHENECTADY, NY 12305-2318
Please detach and retum bottom portion with your payment.
MAKE CHECKS PAYABLE TO "UNINSURED EMPLOYERS FUND".
PLEASE !NCLUDE YOUR WCB EMPLOYER NUMBER ON YOUR CHECK.
Employer AMERICAS LIFE SAVERS LLC WCB Employer # 2999298
Customer ID #
Check
Check Date Check #
Amount
C-45.37 5/2004 Page 1 Of 2
5 of 7
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
Non-Compliance
Item Description Dates Accident Date Balance Due
MAKE CHECKS PAYABLE TO "UNINSURED EMPLOYERS FUND".
__________________________________________________
Mail payment along with this form to:
WORKERS'
COMPENSATION BOARD
FINANCE OFFICE
328 STATE STREET
SCHENECTADY, NY 12305-2318
C-45.37 5/2004 Page 2 of 2
6 of 7
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021
SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE
X
WORKERS' :
COMPENSATION BOARD OF THE STATE OF NEW YORK, JUDGMENT
Plaintiff, :
-against- : EMP# : 2999298
: JUD# : 2116549
AMER[CAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF :
LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC : INDEX # :
Defendant(s)
FILING DT:
X
Workers'
By order of the Chair of the Corñpeñsation Board of the State of New York, demand for the
payment of the sum of$35,000.00, representing Awards and Penalties having been made against the
above captioned Defendant(s), afterdue notice, having defaulted in payment thereof,except the sum of
$0.00 leaving $35,000.00 due and payable.
NOW, upon the certifiedcopies of notices attached hereto, and upon motion ofthe General Counsel of
Workers'
the Compensation Board of the State of New York, attorney for pursuant
Plaintiff, toSection
Workers'
26 of the Compensation Law of the State of New York providing forentry of judgment by the
Workers'
County Clerk in event of such default, itis ADJUDGED, that the Plaintiff, Compensation Board
of the Stateof New York, 328 State Street,Schenectady, NY 12305 does recover from the
above-captioned Defendant(s), whose lastknown address(es) are; 1 COMMERCIAL DR STE 5,
FLORIDA, NY 10921-1055; 1 COMMERCIAL DR STE 5, FLORIDA, NY 10921-1055 ;and 1
COMMERCIAL DR STE 5,FLORIDA, NY 10921 , respectively; the sum of$35,000.00, and the Plaintiff
have execution therefore.
Judgment signed this: day of .
Clerk
James R. McGinn, Esq.
Attorney forPlaintiff
Workers'
Compensation Board
328 State St.
Schenectady, NY 12305
C-45 6/2007
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Preview
FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE X WORKERS' : COMPENSATION BOARD OF THE STATE OF NEW YORK, Plaintiff, : -against- : AMERICAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF : AFFIRMATION LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC OF Defendant(s) NON-PAYMENT : : X Workers' The undersigned, an attorney in theoffice of the Compensation Board of the State of New York, Plaintiffherein, hereby affirmsthat the following is trueunder the penalty of perjury,upon information and belief: This affirmationisbased upon a review of the file which ismaintained by the L kem' Compensation Board inits regularcourse of business. I am familiarwith the status of payment in thismatter. The award/penalty/assessment/demand for deposit of securitymade against the defendant(s) in theamount of $35,000.00 isin default,as more than thirtydays have elapsed since the demand upon the defendant(s) herein forpayment. No paymêñt has been received nor has the aforesaid security been clarmited in comp;;äñco with said demand to date, except the sum of $0.00, leaving due and payble the sum of $35,000.00. Dated: 12th day of April , 2021 . S/ James R. McGinn, Esq. Judgment Unit C-45.45E 1/2009 Filedin Orange County 09iO2/202 i 12:49:47 PM $0.00 Bk: 1 of 5146 7 Pg: 1085 Index: # EF006221-2021 Clerk:DK FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 2 of 7 FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE X WORKERS' : COMPENSATION BOARD OF THE STATE OF NEW YORK, Plaintiff, : -against- : AMERICAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF : AFFIRMATION LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC OF Defendant(s) REGULARITY X Workers' The undersigñéd, an attorney in theoffice of the Corñpéñsation Board of the Stateof New York, Plaintiffherein, hereby affirms that thefollowing is trueunder the penalty of perjury,upon information and belief: Werkers' This affirinationisbased upon a review of the which file ismaintained by the Compensation Board initsregular course of business. Workers' The Compensation Board of the State of New York, inacccidance with the provisions of the Workers' Compensation Law, has made an assessment/award inthe sum of $35,000.00, against the defendant(s). Attached hereto and made a part hereof are certifiedcopies of the Notice of Decision and Award, and/or a certifiedcopy ofthe derüand for deposit of security,and/or a certifiedcopy ofthe chair's order imposing, and the demand for payment of, assessments imposed by the chairpursuant to Werkers' subdivision five ofsection fifty-twoand/or one hundred thirtyone of the Compensation Law, as Workers' required for of filing judgment per Compensation Law, Section 26 and/or 219. Appeals before the Board have been exhausted. No payment of award has been made except $0.00, leaving $35,000.00 due and payable. WHEREFORE, it isrespectfullyrequested that judgment be entered against the Defendant(s) herein in the sum stated as remaining due and payable. Dated: 12th day of April , 2021 . S/ James R. McGinn, Esq. Judgment Unit C-45.1E 6/2007 3 of 7 FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 4 of 7 FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 STATE OF NEW YORK WORKERS' NEW Workers' COMPENSATION BOARD THISAGENCYEMPLOYSAND SERVES JUDGMENT UNIT PEOPLEWTH DISABILITES WTHOUT ÏŸZE Compensat1ort 328 STATE STREET DISCRIMINATION. Board SCHENECTADY, NY 12305-2318 866-298-7830 THOMAS ANDRYSHAK, iviEiviBER OF LLC WCB EMPLOYER #: 2C¤Q20R THOMAS AiýüRY8HAK JR, MEMBER OF LLC UlER #: 53-29879 AMERICAS LIFE SAVERS LLc FEIN/SS # *****3859 1 COMMERCIAL DR STE 5 FLORIDA NY 10921-1055 It is hereby certified thatthis is a true and correct copy ofthe originalas filed Workers' with the Compensation Board S/ James R. McGinn, Esq. FINAL NOTICE e;=±unit DATE: 04/12/2021 prtified nn nanom Non-Compliance Item DescilpUGñ Dates Accident Date Be!ance Due I 2018W0012203 Failure to Workers' Ins 02/09/2018-01/09/2020 $35, 000. 00 Carry Comp Total Balance Due $35,000.00 * Ifpaymêñt isnot received immediate!y, judgmêñt willbe filedand the employer is subjectto seizure of assets, both business and personal, without further noticefrom the Board. In orderto insureprompt creditof yourpayment, emplete thefe!!ewingwiththe Date, Nurnber and Amount of yourcheck and return with it, along your payment to: WORKERS' COMPENSATION BOARD FINANCE OFFICE 328 STATE STREET, SCHENECTADY, NY 12305-2318 Please detach and retum bottom portion with your payment. MAKE CHECKS PAYABLE TO "UNINSURED EMPLOYERS FUND". PLEASE !NCLUDE YOUR WCB EMPLOYER NUMBER ON YOUR CHECK. Employer AMERICAS LIFE SAVERS LLC WCB Employer # 2999298 Customer ID # Check Check Date Check # Amount C-45.37 5/2004 Page 1 Of 2 5 of 7 FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 Non-Compliance Item Description Dates Accident Date Balance Due MAKE CHECKS PAYABLE TO "UNINSURED EMPLOYERS FUND". __________________________________________________ Mail payment along with this form to: WORKERS' COMPENSATION BOARD FINANCE OFFICE 328 STATE STREET SCHENECTADY, NY 12305-2318 C-45.37 5/2004 Page 2 of 2 6 of 7 FILED: ORANGE COUNTY CLERK 09/02/2021 12:49 PM INDEX NO. EF006221-2021 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/02/2021 SUPREME COURT OF THE STATE OF NEW YORK, COUNTY OF ORANGE X WORKERS' : COMPENSATION BOARD OF THE STATE OF NEW YORK, JUDGMENT Plaintiff, : -against- : EMP# : 2999298 : JUD# : 2116549 AMER[CAS LIFE SAVERS LLC; THOMAS ANDRYSHAK, MEMBER OF : LLC ; and THOMAS ANDRYSHAK JR, MEMBER OF LLC : INDEX # : Defendant(s) FILING DT: X Workers' By order of the Chair of the Corñpeñsation Board of the State of New York, demand for the payment of the sum of$35,000.00, representing Awards and Penalties having been made against the above captioned Defendant(s), afterdue notice, having defaulted in payment thereof,except the sum of $0.00 leaving $35,000.00 due and payable. NOW, upon the certifiedcopies of notices attached hereto, and upon motion ofthe General Counsel of Workers' the Compensation Board of the State of New York, attorney for pursuant Plaintiff, toSection Workers' 26 of the Compensation Law of the State of New York providing forentry of judgment by the Workers' County Clerk in event of such default, itis ADJUDGED, that the Plaintiff, Compensation Board of the Stateof New York, 328 State Street,Schenectady, NY 12305 does recover from the above-captioned Defendant(s), whose lastknown address(es) are; 1 COMMERCIAL DR STE 5, FLORIDA, NY 10921-1055; 1 COMMERCIAL DR STE 5, FLORIDA, NY 10921-1055 ;and 1 COMMERCIAL DR STE 5,FLORIDA, NY 10921 , respectively; the sum of$35,000.00, and the Plaintiff have execution therefore. Judgment signed this: day of . Clerk James R. McGinn, Esq. Attorney forPlaintiff Workers' Compensation Board 328 State St. Schenectady, NY 12305 C-45 6/2007 7 of 7