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HomeMy WebLinkAboutApplication and WC ` � , 1 ��:;� . �:� ! ' � � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE�R�MI ---•-2O0_• �,�,�� � �; °� �=A� F -ri ;�, � � ' `'°'� * Please complete form and attach all necessa��`.,�uments by ec ber 16 2016. -- � Failure to do so will result in the return of your app'Iication p ke ALTH ��PT. ESTABLISHMENT NAME: QC F.PttV M t ST i3FFtc.t1 HoT�L k�,� es T�ID: S�s�sas L�,o LOCATIONADDRESS: R7 3 . ��-IOQE �i2i� F TEL.#: SG� .��I� �lo.3� MAILING ADDRESS:_� �S ,p+eomE, CNq� 1 L��bL�TOt��N . �.l 02 FS�� E-MAIL ADDRESS:_��v�ZTC @n�Et�r�''��-r rla't��,'�Zcu'� _ Ccrr� OWNER NAME: bC�Arv fY��ST _ L�C ,' CORPORATION NAME (IF APPLICABLE): ! MANAGER'S NAME: gC�� A lern cn�r TEL.#: �0/�SFS�0�S�' MAILING ADDRESS:� �c,��,n�o_ [,�� m�dd��.-+�,..� .�� c�a�y� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a eopy of the certification to this form. ,� -�7��� #7- ---- -------- - �, _-- -- '� _- —__ Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. r1 � S S ( � 2.v��nnc, �rc.�C�s - (Y����e� 3. L� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food i Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification to this application. The Health Department will not use past years'records. ; You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL # �o►-t�L-tS-f937-oZ ���l�ot+SP-!5-1939-0 OFFICE USE ONLY � " r °r4� ��, �.: - ----- - ���P�o_i��P��S�C4�,1�OZ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FL;E PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 / MOTEL $110 ?�02� INN $55 CAMP $55 �_TSWIMMING POOL$110ea. 038 _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 ``�`" RETAIL SERVICE: .�' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 3 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 7 Y� �G r i � , ] ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED ANll SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pr' r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS _ s _-�. -�._.....---:., �.::_,� � ,��.w TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and ', an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dweiling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days priar to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16, 2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SI LAN. DATE: r'/l/7�/(�SIGNATURE: PRINT NAME & TITLE: �(�Q p?CC,a j� �(� Rev. 10/12/16 � , , � , � The Commonwealth of Massachusetts � ' Department of Industrial Accidents Office of Investigations ` ' I Congress Street, Suite 100 Boston,MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �C�C.Y� ��S� �eaG� �O-i�� -t Sv,�S Address: �7 `'j ��a��.—�r�u� 2 OZ4��{ City/State/Zip:�j. ���,��pU�'�n , (�� Phone #: 5a �S 3R� o2(p.33 Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with � o employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2•L I I am a sole proprietor or partriership and have no---- �, � Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Enterta.inment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other �0�� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy infarmation. Insurance Company Name:2(,��1 C,N �Me�+Ccn � ��G2 . Insurer's Address: ��7 UO �}(Y1e✓, �c� Lpn P % A_� � ��a✓ � City/State/Zip: �G (_ ' Policy#or Self-ins.Lic. #�,�)C �I y�0-OC) Expiration Date: // • /S•��P Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ___ -�ir�u-p ta-$t,�v�.�8��/vr�� - c ' � i� , , a��ii as�i�i�penaiti�s in tii�fcrn a�a S"FOP`�TflRK eR�3ER ar�c�a:��e � of up to $250.00 a day against the violator. Be advised that a copy of this statemenf may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,und r th ans and penalties of perjury that the information provided above is true and correc� te: /r �llb i e• Da S atur . Phone#: Nh���� U'�1(�� Official use anly. Do not write in this area,to be completed by city or town officia� City or Town: Yermit/License# ; Issuing Authority(circle one): ; 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: i www.mass.gov/dia DATE(MM/DD/YYYY) � A���� CERTIFICATE OF LIABILITY INSURANCE io/ia/Zoi6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the poticy,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 NO2'W211 Risk $011t}1 NAME: PHONE Eastern Insurance Group LLC ac No exc: (a,�c,No1: _____ _ 77 Accord Park Drive E-MAIL ADDRESS: .. Unit Bl INSURER�S)AFFORDING COVERAGE . _ __ NAIC#__ _ _ -- Norwell MA 02061 iNsurteRa:West American Insurance Co 44393 __ _— --__ INSURED 1NSURER B:TT3V212rS Prop. & Casualty Amer _. __ PK Associates Inc, DBA: Briggs Engineering and iNsuRertc:Admiral Insurance Company __ _ P O BOX 3E>9 � INSURER D: � � �- - -�_.__�- - .__ __ � 100 Weymouth Street #Bl wsuReRe: _ __ _ —_ Rockland MA 02370 INSURERF: COVERAGES CERTIFICATE NUMBER:2016-2017 Master MA REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO'tHE INSURED NAMED ABOVE�OR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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 BEEN REDUCED BY PAID CLAIMS. - - - INSR TypE OF INSURANCE � � ADDL SUBR pOLICY NUMBER� �� MM D�D/YYYY MM/DDIYYYY LIMITS LTR X COMMERCIAL GENERAL LIAB�LITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED � � 100�,000 A CLAIMS-MADE �X OCCUR PREMISES(Ea occurrence).__ $ _ BKW53268560 10/18/2016 10/18/2017 MED EXP(Any one person) $ 15,000 PERSONAL&ADVINJURY� $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 _ __ _ X POLICY� PR� � LOC PRODUCTS-COMP/OP AGG $ 2�000�000 JECT -___ ___ _ - OTHER: � �Schedule Mod Factor 1 $ AUTOMOBILE LIABILITY �� COMBINED SINGLE LIMIT -$ Ea accident) _.__ __._ ___— ANY AUTO � � � BODIL•Y iNJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJl1RY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) __ ___ _ $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED X RETENTION$ 10 000 ZUP13T66623-16-NE 10/18/2016 10/18/2017 $ .._._ W6RKEI�S�ZSNfPERSATI�tT._ _. ___- -- --- . ._-� --- ----...----- ---- - -- - __.. . _. _ _- �PER _ _. .._ ._ . .. --- AND EMPLOYERS'LIABILITY _STATUTE __. ER . ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N N�A E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below � E.L.DISEASE-POLICY LIMIT $ C Professional Liability E0000030864-02 �, 10/22/2016 10/22/2017 �Limit$2,OOO,o00/$2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Certificate Holder is named as Additional Insured for General Liability if required by written contract. Umbrella Liability is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Harborview Hotel Investors LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN D/B/A Hyannis Harbor Hotel and ACCORDANCE WITH THE POLICY PROVISIONS. Newport Hotel Group LLC 213 Ocean Street Drive AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 �„�� ���� John Koegel/KTR �— 'z� ___ __ -- - - . d'i98$-201d ACORD�OHI�ORATI��1. AU rights reserved- ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD �N$�25(201401) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY—INFORMATION PAGE Servicing Office: Insurance for this coverage part provided by: SCHAUMBURG ZURICA ANIERICAN INSURANCE COMPANY 1400 AMERICAN LANE TOWER 2 FLOOR 9 SCHAUl�URG IL 60196 1. Pdicy Number Binder Renewal of Number WC 0140080-00 Named Ins�ed and Mailing Address Producer and Mailing Address NEWPORT HOTEL GROUP, LLC ETAL GENATT V LLC 28 JACOME WAY 3333 NEW HYDE PARK RD STE 400 MIDDLETOWN RI 02842-5793 NEW HYDE PARK NY 11042-1205 Producer Gale 60085-000 Other workplaces not shown ab�e: See Schedule of Locations FEIN: 0 6-14 8 6 013 NCCI Company No. 10863 ❑ New ❑ Renewai ❑ Rewrite af Prior Policy No. WC 0140080-00 This information page,with policy provisions and endorsements, if any,completes this policy. Insured is: LIMITED LIABILITY COMPANY 2. Pdicy Period: From: 11-15-2015 to 11-15-2016 at 12:01 A. M. StandardTime atinsured'smailing address. Insured's Iderrtification number(s):See Schedule Locations 3. A. Workers Canpensation Inst.rance: Part One of the pdicy applies to the Workers' Compensation Law of the states listed here: CONNECTICUT, MASSACHUSETTS, NEW HAMPSHIRE, RHODE ISLAND B. Emplc�rrers Liability Insurance: Part Two of the pdicy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: l, 000, 000 each accident Bo�ily lnjury by Disease: 1, 000, 000 policy limit Bodily Inj�y by Disease: 1, 000, 000 eachemployee C. Other States Insurance: Part Three of the policy applies to!he states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY AND THOSE STATES LISTED IN 3 A. D. Tlvs Pdicy includes these Endorsements and Schedules: See Schedu�of Forrns and Endorsements. 4. The premi�an for this pdicy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All ir�ormation required on the following Classification Schedule is subject to verification and change by aucGt. See Classffication Schedule TOTAL ESTIMATED STANDARD PREMIUM $ 310, 028.00 PREMIUM DISCbUNT $ —2 9, 621 .00 If indicated below,adJustrnent of premium shali be made: EXPENSE CONSTANT $ 338.00 PREMIUM FOR ENDORSEMENT $ � Annually � Monthly TAXES AND SURCHARGES $ 4, 645.00 ThisisaThree TOTAL ESTIMATED ANNUAL PREMIUM $ 287� 611 . 00 ❑ �mi-Annually ❑ Year Flxed Rate MINIMUM PREMIUM , $ 750 . 00 � c�uarterly Policy DEPOSIT PREMIUM $ 128, 166 . 00 Agent a Producer Countersigned by Resident Licensed Agent Date WC 00 00 01 A U WGD-314A(07-94) Page 1 of 1 BINDER Workers Compensation and Employers Liability `� Insurance Policy ZU RI C H Schedule of Insureds and Locations Branch Policy Number Producer Code MELVILLE NY 11747--234 Binder 60085-000 SCHEDULE OF INSUREDS AND LOCATIONS 229 GEORGE STREET LLC FEIN: 203508918, Risk ID 913728548, SIC Code: 7011 229 GEORGE ST NEW HA�IEN CT 06510 BRISTOL HARBOR INN FEIN: 474895001, Risk ID 913728548, UTAN No: 0001841076 259 THAMES BRISTOL RI 02809 FTRST BEACH, LLC FEIN: 050497781, Risk ID 913728548, UTAN No: 0001841076, SIC Code: 7011 1 WAVE AVE AND 20 WAVE AVE MIDDLETOWN RI 02842 HARBORVIEW HOTEL INVESTORS. LLC FEIN: 043457109, Risk ID 913728548, STC Code: 7011 213 OCEAN ST HYANNIS MA 02601 INN ON THE SQUARE. LLC FEIN: 651251944, Risk ID 913728548, SIC Code: 7011 40 NORTH MAIN ST FALMOUTH MA 02540 JONDOUG, LLC FEIN: 020512469, Risk ID 913728548, SIC Code: 7011 72 COMMON CT NORTH CONWAY NH 03860 NEWPORT HOTEL GROUP, LLC � FEIN: 061486013, Risk ID 913728548, UTAN No: 0001841076, SIC Code: 7011 28 JACOME WAY MIDDLETOWN RI 02842 7710 GRANITE LOOP ROAD TETON VILLAGE WY 83025 OCEAN MIST LLC FEIN: 364701508, Risk ID 913728548, SIC Code: 7011 73 SOUTH SHORE DRIVE SOUTH YARMOUTH MA 02664 97 SOUTH SHORE DR SOUTH YARMOUTH MA 02664 SNAKE RIVER LODGE HOTEL INVESTORS, LLC FEIN: 455511131, Risk ID 913728548, UTAN No: 0001841076, SIC Code: 7011 Issue Dace: 11-15-2015 wc�ooazcEa.io-�� Page 1 of 2 BINDER i }-�--- . ._ . . _.._ .. . _ . -- _- . .. _ _... . . __ . . - - - - � -_.- - QaO�y;o s��ew pa�a;si6aa a�e o60�pue aweu abO�b'a41 �60/460Z)5Z 4210�`d • an�a�ys�� � 1 d?JO�a210�t/460Z-8866 O �� �iozg � �dd Y .� 3A11tl1N3S32ld321 O32RIOHlfltl ���'�^�� 499ZOt/W H1Nf10W2iH.l H1f10S �J ' NOISIA02Jd l.�ilOd 3Hl H11M 3�NtlO210��tl 8Z 31f102J 94L L e-�lf IlON `d03a3H1 31t/0 NOI1tl211dX3 3H1 Hllt/3H�O a2�F108 H1f10W2�b'l.�O NMOl 3Hl 3i10�38 03113�NV�38 S31�1'lOd 4381a�S3o 3A08b'3Hl�O ANtl Olf10HS ; SA`dd 0£ NOI1�dll3�Nb�� 2l34�OH 31b'�1�11213� � � � b99Z0 b'W H1flOW2�t/.l Hl(lOS'3/�Ria 32lOHS H1flOS ; EL'8 L6'�ll 1SIW Nb'3�0 dNtf 109Z0 t/W SINNb'.lH `133b1S Ntf3�0 E6Z`�ll S2iOlS�/�NI 1310H M31/��1092it1H S1�3dS3b S`d i (pa�inba�si aaeds a�ow;i payaeue aq Rew'a�npayag s�yewaa�euoi;ippy'�OG 0210�tl)S3l�IH3A/SNOIltl�Ol/SNOLLb213d0 j0 NOIldRI�S30 � � 000'000`l S llWll A�IIOd-3Sb9S10'l'3 MolaQ SNOIlHN3d0 j0 NOIldILI�S�O � � �epun eqir�sap'sa }� OOO�OOOI� 3AO�dW3H3'3St/3SIO'l'3 � (pryu�tiaqepusy�) -- —__, ---- ;.naam��aaawawnia�uag '__ —_- _ .._ -- - ____ ___ __ ---- - OOO�OOO�LB 1N3���VH�V3'l'3� � � � 3N1f103X3213N12JtldR1013RIdO21dAN'd � � N/A A.LIl19Vll�SM3AOldW3 ONtl i -Hl0 31f11a3dS L60ZlSl/Ll 9lOZ/5l/ll Z008004LO�M NOI1tlSN3dWO�Si13NU0M tl $ $NOIlN31321 430 $ 31H`J3iJ`J`JV 30HW-SWM� BtlIlSS3�X3 I ; $ a�r�aan��o H�v3 an��o eyi�yi�3aewn s �uapo�e�ed g � SOlf1V SOlf1H 03211H , 3�Jb'WVO.11Li3dOLld . 03HMo-NON p ' g (�uapebe�ad)ALiflfNl A11408 031f103�H�S 43NM0 llH $ (uos�ad�ad)AaflfNl A11008 � Ol(1V ANV � $ uapi��e e3 JLLIl19VIl3lI80WOlf1tl $ a3H10 $ JJHdO/dWO�-SL�f1O02id �Ol� Oad�A�IIOd S 31VJ3bJJVlb'a3N3J I 213dS31lddVllWIl31VJ321'J�Jtll,N3J $ A2!(1fNIn4V8lHNOS2f3d �' . � $ (uos�ad auo Ruy)dX3 43W $ asuaLnaooe3 S3SIW3ad 2if1��0❑ 34HW-SWMI� 031N3?J Ol 3`JVWtlO $ 3�N321LIf1��OH�V3 ,LLlllBtlilltl2l3N3�Jlt/I�N3WW0� � SllWll � ��Q�WW �Ud�wW 2139Wf1NA�llOd aMA dSNI 3�Ntl2lflSNld03dA1 �� dX3 A�IIOd jj3 A�1'lOd 21SNI 'SWIt/l�dlt/d A8 a3�f1432f N338 3nVH l.t/W NMOHS SllWll'S31�IlOd H�f1S�O SNOIlI4N0�4Nt/SNOISf1l�X3' 'SWa31 3Hl llH Ol 1�3f9f1S SI N13213H 038RI�S34 S31�IlOd 3Hl 1.8 430aO��t/ 3�Nt1a(1SN1 3Hl 'NIVl2l3d hHW a0 43(1SSI 38 Ab'W 31`d�l�lla3� SIHl H�IHM Ol 1�3dS321 HlIM 1N3Wf1�04 b3H10 a0 l�b'2l1N0�.INV�O NOIlI4N0� a0 Wa31 '1N3W3211f1U3a .INV�JNI4NH1SHlIMlON '431V�IdNI OOIa3d.l�llOd 3Hl 2i0� 3/�08V 43Wb'N a3aflSNl 3Hl Ol 43f1SSl N338 3/�'dH MO138 431SI1 3�Nb2i(1SNI �O S31�IlOd 3Hl 1�/Hl.1�11213�Ol SI SIHl �2139Wf1N NOISIn321 �ggg�g�gZ� �a38Wf1N 31b'�1�11213� S3JV2i3A0� __ _ __ _ _ _ __ _. __._�baaasw. _ _ �3 aaansNi :aaaansrm Zb8Z0 R� 'uMo�a�ppiW �leM auao�e�8Z :oa3ansNi �y13 '�l�df102iJ�310H 12iOdM3N :a aaansrm 310HdM3 N aaansNi eoi�awy U�oN y�unZ�va3ansn,� a�ivN a�vaano��Niaaoadv s aaansNi Zb0 6 6�lN�12lt/d 34AH M3 N wo���;eua6�n;�(uuaf� „tlW.3 'OOV 311f1S : LZE£-90L-91S` z� 9998-698-965' aa���d ��ll/�llt/N3J 3NOHd `o'ZI1�212J3�J.NN3f l�'dtl1N0� aa�naoaa •s;uawas�opua yans;o nai�ui�ap�oy a;ea�}i}�aa ay;o;s;yfii��a;uo�;ou saop a;e�3i}�a�siy;uo;uawa;eas y •;uawas�opua ue annba��(ew sai���od uie�aa�`�(�i�od ay�;o suoi;ipuo�pue sw�a�ay; os;�afqns`a3AIb�M SI NOI1dJ0218f1S li 'pas�opua aq;snw (sai)�(�i�od ay;`a321f1SN1 lb'NOI11a4H ue si�a o a e�i� a�a pl 4 3 ;l� 43;1 �1N`d1210dW1 21341OH 31`d�1�i12l3�3H1 ONb'`213�fldOild 210 3A11`d1N3S3t1d321 43ZRIOHlflb� `IS)21321f1SN1 JNIf1SSl 3H1 N33M138 1�b2l1N0� `d 31f1111SN0� lON S304 3�Nb21f1SNl �O 31t/�1�112d3� SIHl 'MO138 S31�IlOd 3H1 A8 a34ZIOd�V 3°J`d2l3A0� 3H1 21311`d 2J0 4N31X3 `ON3Wb� �ll3nI1VJ3N il0 Al3/�ilt/W211ddb' lON S304 31b'�1�112i3� SIHl '2l3alOH 31b'�Ijll?l3� 3H1 NOdfl S1H�JR! 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