FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`(46)14345509-1
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`
`SUPREME
`
`COURT OF THE STATE
`
`OF NEW YORK,
`
`COUNTY
`
`OF KINGS
`
`WORKERS'
`
`COMPENSATION
`
`BOARD OF THE STATE
`
`-against-
`
`MEILECH
`
`FASTAG
`
`& HAY
`
`FASTAG
`
`OF NEW YORK,:
`Plaintiff,
`
`Defendant(s)
`
`X
`
`:
`:
`:
`:
`
`:
`
`JUDGMENT
`
`EMP#
`JUD#
`
`: 3159043
`: 2113317
`
`INDEX
`
`#
`
`:
`
`FILING
`
`DT:
`
`-X
`
`.
`
`By order
`payment
`above
`$0.00
`
`the
`of
`the Chair
`of
`the sum of $9,000.00,
`of
`captioned
`Defêñdañt(s),
`$9,000.00
`due
`leaving
`
`of New York,
`the State
`Compeñsation
`the
`for
`demand
`of
`Board
`and Penalties
`the
`against
`been made
`Awards
`having
`defaulted
`in payment
`except
`the sum of
`thereof,
`having
`
`Workers'
`
`representing
`after
`due
`notice,
`and payable.
`
`upon motion
`of
`and
`attached
`of ñõtices
`copies
`the certified
`upon
`hereto,
`NOW,
`the Workers'
`for Plaintiff,
`of New York,
`Board
`of
`the State
`Compensation
`attorney
`Workers'
`26 of
`Compensation
`Law of
`the State
`of New York
`for entry
`the
`providing
`Workers'
`of such
`in event
`it
`is ADJUDGED,
`that
`the Plaintiff,
`Clerk
`default,
`County
`NY 12305
`recover
`of
`the State
`of New York,
`328 State
`does
`Scheñectady,
`Street,
`2610 AVENUE
`whose
`last
`known
`above-captioned
`Defeñdañt(s),
`are;
`address(es)
`have
`the sum of $9,000.00,
`and the Plaintiff
`execution
`11210-4633,
`respectively;
`
`the General
`Counsel
`to Section
`pursuant
`judgment
`by the
`of
`Compensation
`Board
`from the
`L, BROOKLYN,
`therefore.
`
`of
`
`NY
`
`Judgment
`
`signed
`
`this:
`
`day of
`
`,
`
`.
`
`Clerk
`
`James
`Attorney
`Workers'
`
`328 State
`Schenectady,
`
`Esq.
`
`R. McGinn,
`for Plaintiff
`Compensation
`St.
`
`NY
`
`12305
`
`Board
`
`6/2007
`C-45
`(46)14346609-1
`
`1 of 6
`
`

`

`FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`(47)14345511-1
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`
`SUPREME
`
`COURT OF THE STATE
`
`OF NEW YORK,
`
`COUNTY
`
`OF KINGS
`
`WORKERS'
`
`COMPENSATION
`
`BOARD OF THE STATE
`
`-against-
`
`MElLECH
`
`FASTAG
`
`& HAY
`
`FASTAG
`
`OF NEW YORK,:
`Plaintiff,
`
`Defendant(s)
`
`X
`
`:
`:
`
`X
`
`The
`undersigñéd,
`Plaintiff
`York,
`information
`
`an attorney
`herein,
`hereby
`belief:
`and
`
`in the office
`affirms
`that
`
`Workers'
`
`the
`of
`the fóllsvv|ñg
`
`Board
`Compensation
`under
`is true
`the penalty
`
`AFFIRMATION
`OF
`REGULARITY
`
`of New
`of
`the State
`of perjury,
`upon
`
`This
`Board
`
`is based
`affirmation
`in its regular
`course
`
`a review
`upon
`of business.
`
`of
`
`the file which
`
`is maintained
`
`by the
`
`Workers'
`
`Compensation
`
`Workers'
`The
`Workers'
`
`defendant(s).
`and/or
`Award,
`order
`imposing,
`subdivision
`five
`required
`for
`filing
`the Board
`have
`
`Compensation
`Compensation
`Law,
`hereto
`Attached
`a certified
`copy
`and the demand
`of section
`fifty-two
`judgment
`per
`of
`been
`exhausted.
`
`the
`of
`the provisions
`of New York,
`of
`Board
`with
`in acccidance
`the State
`the
`against
`in the sum of $9,000.00,
`an assessment/award
`has made
`and
`of Decision
`hereof
`are certified
`a part
`copies
`of
`the Notice
`and made
`the chair's
`the demand
`a certified
`of
`of
`for deposit
`of security,
`and/or
`copy
`by the chair
`pursuant
`to
`for payment
`of, assessments
`imposed
`the Workers'
`and/or
`one of
`Compensâtion
`one
`hundred
`thirty
`Workers'
`Compensaticñ
`Law, Section
`219. Appea!s
`26 and/or
`
`as
`
`Law,
`before
`
`No payment
`
`of award
`
`has been made
`
`except
`
`$0.00,
`
`leaving
`
`$9,000.00
`
`due and
`
`payab|e.
`
`WHEREFORE,
`the sum stated
`
`is respectfully
`it
`as remaining
`
`requested
`that
`payable.
`due and
`
`judgment
`
`be entered
`
`against
`
`the Defendant(s)
`
`herein
`
`in
`
`Dated:
`
`day of
`
`__ ,
`
`APR
`
`2 7
`
`2021
`
`Yvonne
`
`M. Ward,
`
`Esq.
`
`4/2007
`C-45.1
`(47)14345511-1
`
`2 of 6
`
`

`

`FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`(48)14345513-1
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`
`SUPREME
`
`COURT OF THE STATE
`
`OF NEW YORK,
`
`COUNTY
`
`OF KINGS
`
`AFFIRMATION
`OF
`NON-PAYMENT
`
`áf New
`the State
`of
`upon
`of perjury,
`
`X
`
`:
`
`: :
`
`:
`:
`
`: : X
`
`WORKERS'
`
`COMPENSATION
`
`BOARD OF THE STATE
`
`-against-
`
`MEILECH
`
`FASTAG
`
`& HAY FASTAG
`
`OF NEW YORK,:
`Plaintiff,
`
`Defendant(s)
`
`The
`undersigñêd,
`Plaintiff
`York,
`information
`
`an attorney
`herein,
`hereby
`and
`belief:
`
`in the office
`that
`affirms
`
`Workers'
`
`of
`the
`the fcilcWing
`
`Board
`Compensatica
`under
`is true
`the penalty
`
`This
`Board
`
`is based
`affirmation
`in its regular
`course
`
`a review
`upon
`of business.
`
`of
`
`the file which
`
`is maintaiñed
`
`by the
`
`Workers'
`
`Compensation
`
`for
`in this matter.
`award/penalty/assessment/demand
`of payment
`The
`the status
`with
`I am familiar
`of $9,000.00
`is in default,
`as more
`in the amount
`against
`deposit
`of security
`made
`the defendant(s)
`for payment.
`the demand
`herein
`since
`upon
`the defendant(s)
`days
`No payment
`elapsed
`have
`thirty
`in compliance
`with
`the aforesaid
`said
`demand
`to date,
`nor has
`been
`deposited
`been
`received
`security
`and
`the sum of $9,000.00.
`the sum of $0.00,
`except
`payble
`leaving
`
`due
`
`than
`has
`
`Dated:
`
`day of
`
`,
`
`.
`
`APR
`
`2 7
`
`2021
`
`Yv
`
`nne M. Ward,
`
`Esq.
`
`C-45.45
`(48)14345513-1
`
`1/2009
`
`.
`
`3 of 6
`
`

`

`FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`(49)14345515-1
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`
`NEW Workers'
`YORK
`----..
`STATE CG
`
`casaatiOll
`
`MElLECH FASTAG & HAY FASTAG
`2610 AVENUE L
`BROOKLYN NY 11210-4633
`
`STATE
`WORKERS'
`
`OF NEW YORK
`COMPENSATION
`JUDGMENT
`UNIT
`328 STATE
`STREET
`NY 12305-2318
`SCHENECTADY,
`866-298-7830
`
`BOARD
`
`THIS AGENCY EMPLOYS AND SERVES
`PEOPLE WITH DISABILITIES WITHOUT
`DISCRIMINATION.
`
`WCB EMPLOYER
`UlER #:
`FEIN/SS
`
`#:
`
`#:
`
`3159043
`-
`*****
`
`certified
`is hereby
`It
`and correct
`copy
`the Workers'
`with
`
`that
`th
`of
`Com
`
`this
`
`is a true
`al as filed
`oard
`
`__.............................
`
`DATE:
`
`03/28/2021
`
`Item
`
`Descriptiüii
`
`G2716391
`Total
`Balance
`
`Workers
`Due
`
`EINAL
`
`NOTICE
`
`*
`
`tÎf
`
`n
`
`Compensation
`
`Claims-26A
`
`Non-Comp|iañce
`Dates
`
`Accident
`
`Date
`
`Balance
`
`Due
`
`07/31/2019
`
`$9,000.00
`$9,000.00
`
`*
`
`If payrñéñt
`of assets,
`
`is not
`received
`both
`'üüsliless
`and
`
`imu-"-y,
`personal,
`
`judgment
`without
`further
`
`will
`
`and the employer
`be filed
`notice
`from the Board.
`
`is subject
`
`to seizure
`
`to insure
`with the
`the following
`complete
`credit of your paymêñt,
`prompt
`In order
`to:
`of your check and return it, along with your paymêñt
`and Amount
`Date, Number
`WORKERS'
`COMPENSATION
`BOARD
`FINANCE
`OFFICE
`328 STATE STREET,
`SCHENECTADY,
`detach
`and
`return
`bottom
`portion
`
`NY 12305-2318
`with
`your
`payment.
`
`Please
`
`MAKE CHECKS
`PLEASE
`INCLUDE
`
`FUND".
`EMPLOYERS
`TO "UNINSURED
`PAYABLE
`YOUR WCB EMPLOYER
`NUMBER
`ON YOUR CHECK.
`
`Employer
`
`MEILECH FASTAG & HAY FASTAG
`
`Check
`
`Date
`
`Check
`
`#
`
`WCB Empicyer
`
`#
`
`3159043
`
`Customer
`
`ID #
`
`Check
`Amount
`
`C-45.37
`
`5/2004
`
`(49)4345515-1
`
`4 of 6
`
`Page
`
`1 of 2
`
`

`

`FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`
`STATE OF NEW YORK
`WORKERS'
`COMPENSATION
`PO BOX 5205
`13902-5205
`
`BINGHAM
`
`BOARD
`
`Clarissa M. Rodriguez
`Chair
`
`(800) 877-4461
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`coeo
`this
`that
`cenified
`is hereby
`It
`of
`and correct
`is a true
`copy
`as filed with
`the original
`W0therS'
`Com
`
`b
`
`;
`
`Board.
`
`.
`
`.....
`
`..
`
`-
`
`.
`
`-
`
`- - -
`
`Certified
`
`on....
`
`....
`
`......
`
`State
`
`of New York
`
`- Workers'
`
`Compensation
`
`Board
`
`In
`
`regard
`
`to Maricela
`
`Dominguez,
`
`WCB Case
`
`#G271
`
`6391
`
`OF DECISION
`NOTICE
`NO INSURANCE
`CASE
`keepfor your acords
`
`.
`
`the Workers'
`At
`Brooklyn
`hearing
`
`held on 09/08/2020
`Compensation
`involving
`hearing
`Judge Elisabeth
`Sawyer made the following
`location,
`
`the claim of Maricela Dominguez
`and directions:
`findings
`decision,
`
`at the
`
`DECISION:
`claimant's
`$720.00
`Meilech
`
`The
`shoulder.
`the right
`related injury
`had a work
`The claimant Maricela Dominguez
`involving
`disease is
`related injury
`or occupational
`before this work
`the year worked
`average weekly wage for
`is established. Claimant was the employeo
`prejudice.
`per C-3 without
`Employer/Employee
`relationship
`Fastag & Haya Fastag.
`
`of
`
`treatment
`to one of
`
`Medical
`rendered
`Guidelines.
`
`for established
`and care, as necessary,
`the body parts covered by the Medical
`
`Treatment
`is authorized.
`and/or
`sites of
`conditions,
`injury
`Treatment Guidelines must be consistent with those
`
`Claimant
`
`is to produce medical
`
`evidence
`
`for all periods
`
`of causally
`
`related lost
`
`time.
`
`of WCL Section 50 and liable for penalties
`in violation
`Employer
`non-compliance
`is 4/30/2019
`to 7/31/2019.
`
`under WCL Section 26(a).
`
`The period
`
`of
`
`. No further
`
`action is planned by the Board at this time.
`
`.
`
`Payment
`Liability
`in the record,
`the evidence
`Fastag & Hay Fastag. Upon review of all
`of Meilech
`Claimant was the employee
`Fastag & Hay Fastag, employer
`or date of
`on the date of accident
`3159043 was uninsured
`number
`Meilech
`of WCL § 50.If
`disablement
`for
`seeks to file a request
`the uninsured
`employer
`and therefore,
`is in violation
`it must
`a rebuttal
`to a request
`for administrative
`administrative
`it must use Form RB-89.
`If
`review,
`review,
`filing
`. Failure
`to utilize
`Those forms are available
`on the Board's website,
`at http://www.web.ny.gov
`use Form RB-89.1
`the application
`or
`be considered
`to be a defective
`subject
`to denial of review of
`the prescribed
`forms will
`filing,
`Fastag & Hay Fastag is liable for 100.00% of
`rebuttal
`under 12 NYCRR
`or 300.13(c).
`Meilech
`300.13(b)(4)
`to WCL § 26-a.If
`for administrative
`seeks to file a request
`awards and assessments pursuant
`the uninsured
`employer
`*** Continued on next page ***
`
`I find
`
`-
`Claimant
`Social Security No.
`-
`WCB Case No.
`Date of Accident
`District Office
`
`-
`
`-
`
`Maricela Dominguez
`
`-
`
`G271 6391
`07/31/2019
`NYC
`
`-
`
`Employer
`-
`Carrier
`-
`ID No.
`Carrier
`Carrier Case No.
`of
`Date of Filing
`
`Meilech
`Uninsured
`W990004
`
`-
`this Decision-
`
`Fastag & Hay Fastag
`Employers
`Fund TPA
`
`09/16/2020
`
`ATENCION:
`Puede 11amar a la oficina de la Junta de Compensacion Obrera, en su area caric3psñdiente,
`acerca de su reclamacion(caso).
`principio
`de la pagina y pida.informacion
`
`cuyo numero de telefono aparece al
`
`EC-23 (4/98)
`FILE COPY
`
`Page 1 of 2
`
`5 of 6
`
`

`

`FILED: KINGS COUNTY CLERK 05/06/2021 10:34 AM
`NYSCEF DOC. NO. 1
`
`INDEX NO. 091155/2021
`
`RECEIVED NYSCEF: 05/04/2021
`2500§066
`
`If
`
`it must use Form RB-89.
`it must use Form
`for administrative
`to a request
`a rebuttal
`review,
`review,
`filing
`Those forms are available
`. Failure
`to utilize
`the
`at http://www.wcb.ny.gov
`on the Board's website,
`RB-89.1
`the application
`to be a defective
`to denial of review of
`or rebuttal
`forms will
`be considered
`prescribed
`subject
`filing,
`Fastag & Hay Fastag was without
`under 12 NYCRR
`or 300.13(c).
`I find that Meilech
`coverage
`for
`300.13(b)(4)
`is assessed per WCL § 26-a a sum of
`the following
`4/30/2019
`period(s):
`to 7/31/2019.
`the employer
`Accordingly,
`for such non-compliance.If
`for administrative
`it
`$9,000.00
`the.uninsured
`employer
`seeks to file a reqúest
`review,
`must use Form RB-89.
`it must use Form RB-89.1
`Those
`a rebuttal
`to a request
`for administrative
`If
`review,
`filing
`forms are available
`on the Board's website,
`at http://www.wcb.ny.gov
`. Failure
`to.utilize
`the prescribed
`forms will
`be considered
`to be a defective
`subject
`to denial of review of
`the application
`or rebuttal
`under 12 NYCRR
`filing,
`Fastag & Hay Fastag to the IJninsured
`or 300.13(c).
`Awards
`and assessments are payable
`by Meilech
`300.13(b)(4)
`Fund. Payment
`is due within
`Employers
`10 days of
`date of
`the filing
`this decision.
`Failure
`to pay awards and
`due will
`constitute
`a default which will
`against
`the employer.
`result
`in an entry of judgment
`assessments
`Causally
`related medical
`bills
`are payable per
`fee schedule.
`
`-
`Claimant
`Social Security No.
`-
`WCB Case No.
`Date of Accident
`District Office
`
`-
`
`-
`
`Maricela Dominguez
`
`-
`
`G271 6391
`07/31/2019
`NYC
`
`-
`
`Employer
`-
`Carrier
`-
`ID No.
`Carrier
`Carrier Case No.
`of
`Date of Filing
`
`Meilech
`Uninsured
`W990004
`
`-
`this Decision-
`
`Fastag & Hay Fastag
`Employers
`Fund TPA
`
`09/16/2020
`
`ATENCION:
`Puede llamar a la oficina de la Junta de Compensacion Obrera, en su area correcpondiente,
`acerca de su reclamacion(caso).
`principio de la pagina y pida informacion
`
`cuyo numero de telefono aparece al
`
`EC-23 (4/98)
`FILE COPY
`
`Page 2 of 2
`
`6 of 6
`
`