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HomeMy WebLinkAboutApplication and WC : � � � ��e...�� � � L:'A..i� ` �' � � . � , JAN 12 2017 °� �c��c�v c���A�o�,Trx B � �� ���i:r�_ ' � � � � A�`PLICr�..TI4N�`t)R�T.I�EI��a�l�'�'d���4'[[T-2017 �,�At_T�-i DEPT. `'� � I'Iease complete fcarm and attach all nece�sar�r cic��uurr�ents I��r I"ler.�mber 1tS 2t1i6. '�� ��ailur�t�a c�o sc��ri�l res�lt in t�se r�ttarn c��'your�pplica�t�n�s�c��t. =�" E i`i'A��IS�-��,1�'C N:�S.Ivt�: �: ,<� ���. ,:�;� � . ;� LOCA�°TC)�t ADI7R�SS ��7 , � � � ' , � ' ' T£L.�#; ,; .� �~�z.,:' ��� M4IL,INtx�I)�2E�S, �,.. -� �r �'�_ .. _ g .`� 3N�/ �`a�YA�JJt"��s./���• .8 , €`•f �. � . .�. ` 5 ..... � ...� _.... .. „ n p�g g�1p �,7y,gg s � ���.. . l3 d.>LL,lV.AdVtL. "�`.,. .3 "r�,_�,�� �� � � � �,' . — . ..._.�,.,. �yg� � R . �, . ����iJi1t1314..idV AV�.i\`,}�-�it"� .[�SL'L�� � ,.^SdJA.......�. ��¢ P'. , , � 19`i��V��:.&.A"..S4i,.'1 11't"1.�€'„ .. 3 �„. € . 1. g � . ,�' '= � <ps � ' � ` ` �`�'� �� G. �1b U ��T�I,.#�: °� ���° �"` � �, , ,� ���, � ���ILT�U ATJll�t�?��: � � �� ��.,�� PC�C3L CEFt'�I�TCAT�Q�I�: �, he paca�supervis��mu�st be certified�s a Pc�al�peratnr,�s required b��State law. P�ease l��t tlze desi�nated �ool(�per�t�ar(sj dnd atta�h a cc�py af t�a�c�rt��catic�n tci�k��s F�rrn. , �. � Pc�ol o�erat�r� z�t�st�ist a m�im�zm c�f�wro em��a�=e�s curr�ntl}���rciFi�d i� starz�rc� �'irst�zc�arzci Cc�m.r�sunity Cardi�pu�z���,nary k�suscita�ian (CPR), ha�fin� €�t�e e�rti�ecl ernplc�yee az� premises at a�i tirnes. Ple�as� list the eznpir�ye�s t�elc��v aaxd a+�t�ch copi�s of th�ir certifica�ic�ns#c�t�i�f�rm.fihe Heatth Departznent w�11 nat u�e�:�st years' rec�rc�s. You m���t provide�new copie�at�c!main�ain a �te at your pPac�r�f busittess. ' 1. � , 3. �D �o ktF-IS—(SI I—6Z. �o�?P-IS-(SI 2-02 . Ft��IZ�I'R�7T�CTIC�'<_�'�l��A���`r�Ii� u�Fk�'I�IC:��I���s: !�ii 1aoc� servic� �st�blzshzz�ce;n�s ar� req�airet�tc� h��.�e �t k�;as��ne �11-trrrae emplra���e who is e�rtifi�d as a F�t�t� Prt�tect�iaz��a.����er,as c3e�in�d in the Si��at� ���itary �ad� �or�'r�ad Sercic��stabii°hm�nis, t�S Ch�R ��{�.�p0. �� Pie�se a�tach eopie�c�f certificati�sn tc�il�is��1�c�t��n. T��.�eait�I}eparfinent wil�r�crt use�a�s�'y�ar�'recc�rds. You mc�st�r�v�de new ro�ie�azac� maflntain �:file at yr��ar es#abl���ment, ' t. ,� F'�RSOiti'1N��ARCr�: �ach t"o�c�es�ab�isl�rne�t m�zst have at least c�z��Perscan In C`l�ar�e(.PI�'}�r�site d�xirag haurs saf operati€�r�. l. -� ' AL�,�RC7��d C;EI�.TI�ICdATIC)T��S: AIl ft�ati ser���ce c;std�ilishments are re�€zzreti tc��Sav��t l�:as`cane fia1l-i�zn�emplc�v��wl�a ha�Aller�;en cert�fication, as cie#ined i�the State Sanitary�c�cie.for�'c��d>er��sc�Establzshrnents, 1�5 C;�R S94.OQ9(Cr}{3)(a�. Please attach .�c�pies af certi�icatic�n t�thzs a�piicati�a�. '.�he Fie:etth T)e�artment�°zil n�t use p�st ye�rs' recc�rds, Yau must �: °pra�id��ew cn�zies anrl�t�intain a �]e a#vr��r est�bl�shzn��t< 1. � ' �EIMLICI-I f'�;.R"I'IFICA"I`IQ'_�S: '� �� .�111 fi��d serv�ee�stablis�raaents �vith 2S ��ats or�nor� zr�ust have �.t least �ne empl�yee trair�ed in z�e I��ei�nlich �`V,�aneuver on th�premi��s at al] time�, Please list yc�t�r�rm�alc��ee�traz�e�i iz�anti-�h��za��prncc�d�ares b�l�w�nd att�ch cc�}aies c���mp�c�ye�certi�ica�i4r�s tc�thi�f�rn�, T`�r�He�It�Department wii!nat us��ast��e�r�'ree�rt�s. 'You���t pravide new cop�es and �n�i�t�in a �le�t yc��r�]aee of busin�ss. ' 1. � x 3. �.. , .... �, �'� �E�`I"�t,.'RA?�'`I'���A7'I�C�: TC}'�'<�1L# �-_____._,,,.�........ '����� � �o�cr��: t)F�"'�CE IJ�_��3�I�'� � � s.zc;��s�z����t���a �c� ��rt.�t`r� �3�E3 ��� LI�'�:�'SF,RF�t��ilR�£� I���:' P�;72�4T"!"� LIC�?�SE C�E",�LX[RE� FE� P�:€��I'l'# .�_�,�- �S� __. �'A�li:v $5� �'�2f}Z"E� � �I,�[>C`xE $S� "� �?lMP �... �S'y�,'Ilt��ltiCi PQt�L.Sl I�. "`" s ���:ar�.,�r���r�s. ��ri� ���� � �r��r��r��►� �t�€�.�,�--�-- c�r�s�z�vzc:�: ------�- ..._ z��c��:�����c�r��;r� �Fr, ���n�zr�� �.x��;�se r�r�a�,rr�� �r� ������r� , __ _ o z������rs �a�� � �...ccarir�rr,r������ �;s �A��c�r����:c��;���r� ���° ��t��u�r� .�����s��rs ��� _.___�.rv� _...��oMt�zc�r���rc. ��o ��- :�4caz�..���e�s' ��� RETAIL SER�tdCE: -----_.__ .�,��I-IQL��ALE $80 __.�_.�_� ' � I.�����tS� �E:C�tJII��;L� F�F' P3;Rtvit'f� -"—R�$��.�T"f'<;kfF'T� ��{) ;,,�'_��-_ �,5���.�. ��p LIC�ENS��tt;C�C;(Tt�;� T`� PGR.;�1I'f�tt LICT'�3�,�;ZtEC�isE(�L°�� �'��; FEk�v16'T"# 1�_<�'S,s���3 sc�,�t. S1S� �`?�>C��t3�q.it. �285 �'�tvI�TI�Cz=fif101) �25 ��� -�FI2C)�I:7�L��S��;RT ��fl � � _`�'r"J�AC'C'(3 St�i� .s 7� �'�MECTTriNtrE':: g;(5 �����--xo "' �.:'VIQLT.�T I)�>E ^ � .2.�C7 ` ' �'�`*%aT'I,�.�tSE"�`t?Ft�C�Y�It t�l�t}��}MI'L.1;TF;t�Tfl�It Sii:►�(3F'FC1T2M'��'�'�* ' ,, ' ��. C11�vCt,Etti� ui.dzt 3udi1 &4cl€.vc lJvi.a.5�uv.lti.�u t,teu.wa4,.ri. L,vs�u�.,ua.u� r.a.,.+.�.-+ u*+vpw'+�. �+�^ •••� +�+�*��^w�••.�'•• �^^•"�..••_. ..�__,.�....__..� . �x�ise,�s de�n�;d�i�a��.G.L.�. C4C�c�r 83f}�`M�2�i4Cr, as am�ncled,shal3 �e�xeir�ll�r�a��c�nsiderec�`I'ransier�t. ��� � � � Pt�C3L�s � . PC�t��,�PE�114Gs All swizz�ming,��a�in�an��vhirlpc�r�ls�vhi�h have�i�e�closed fcsr fhe seassc�n must E�e zns�ected by>the He�.lt�i 1�epartrn�n��iric�r t�oper�in�;. C;c�ntact the I-�ealth��partment ts�scheduie the ins�ection three(3} ' da�s ���icrr�c� apenin�.�L��,S�I'�f�T�:Peopl�are iv�3T a£�a�vec�tc�sit in t�s��?c�ol area until the�oc�l ha�b�e� ; ins��ct�d�d ap�n�c�. ' Pt�OL�'t'ATER'�`"I+;S'I°INU> 'I'1he��at�r�ust be t�steci fcrr psea�damoxzas,tot�t cc�l'zf�arrn anc3 st�.nd�c3 piate c;c�unt by � �tate certzfied �ata, anc� subza�i�te� ta �he H�altki D�p�rtm�nt�hre� �a) d�ys �aric�r�� op��z�n�, and �u rIy ther�a�er. ' 1'4t�L+�'I..a4S�iN+t�:�v�ry c�utdoor xxa�;rc�u��c�swxm�zir���n�I must b�dr�inecl c�r�t�vered��thin sever�(7)days af cP����g� '' �'C������ �'� S�S#�NAL F�}t}D��Rt%I(:L tJP�NI��: Al[`�'�cad servic�establisl�enis m�st�e i��}��cted bv the�Ieait�I�epartrr��r�t�arzo�•�a€�p�eni��. Ple��e contact tl�e ' H�atth T7e��rtrmen:t to sehe�iule 2he ir���3ect�on t�ree{3}c�avs�r�r�r�c�c�pen�n�. CATE I�G I't)i,I��: A��yn�ze va�Z€� caters �ithin the "i`ov��t� c�f'�a.zmouth ���ust notiFy tl�e Yannaut� �-Iealih I��partment by �ilin� the requir�d Tempc�rary �at�sad �ervic�e Appl�catic�n �`c�r��� 72 �e�urs pr�csr tc� the cat�xed e�e��t. '�`hes� �`orms c.arz �e c��tain�ct�t�e I-�ealt�s D�p�tmezzt,o�from t�z�Towrr��s wehsite at ww-�%,��a���uth.m�.us un+��r�ea�th l�epartmez��, I3c�wr�loaciable Fc�r�t�s. �'Rt�Z�:,N DESSERTS; ' T'roz�r�des�erts must be te�te� b��a��ate certi�ied lab�rior t��penzn�az��i mc��:t���r th�rea�ier,wi��sampl�results ' sul��°�itted tc� th� I3ealtkz I�epartm�e�t. Failure to dc��rs ��ili. r�sult z�#he �c�spens�can or xc°vocatic�n c�f yc�ur Frc�zen U�ssc� �'ermit urzt�l �he al�c�ve tea�rns}�ave k��e��z�et. " UtJTS�DE��.1�1:'S, ' C)utszde ca£�s{i.�.,outdcacar�ed���g with��it�rl��raitress�ervice},must��ave;prior a�agaroa°�1 fra�n the Bo�rd c��Health, UC�:'TDC}Q�2 C(�� l'�Gt , fJutc�ot�r coraki���,�re�r��iaz�,r�r ci�spl�y��f`any fi�sc�d�rc�duc�:�y a xet�i�c�r�ac��service establzs�unent is�rrt�hz�titedl. '��� �'a�(?TICE: ��:�nit�z-un annusliv�'ram Januarv 1 tcs���e���a�er�1, TT I�YtJ�F�I��SPt)I��II3�L�TY�"C}RETU�1`�i �l`H�CC��PI�ET�I�RE�E��'AL!�1'��I�A°�'IC?I�;{Sj A�D R�C��;°�I�.F��`�'�(S}�3Y"t��CE�B�R I6,201f. ALL I�E;i�]t�Vt�.�"I`Ji`�TS "I`(7 �1:'�Y FC}C)I) ESTA�S��S�i���E�T, MC�TEL OR PC)C1L {f.e., P�TI�TIt�G, I'���A�' ��UIP`�1��1T",�TC.),:"v��tJ��'��:��F'O�.°T"�I�Tt��?�D ���'I'R�7"�'�.1� I3°Y T��I3C).t�..i��3�F H���TH �'RI4R ��. �4+ $..�V.i,sl.ivAA.F}��$..r'AY�.f�..+�j. �A.J}.�\./Yr���ifA,p� `.l'��j7 � �"��A3���4.��J�iY. D.r�1�:: �� �'� SIGNATi_'R� �R���`°�; � _ ,�� � �,M.�---- ;;.��...�,��-_ � -'� � �: P�iP�;T IvA�E cS'��TIT�,F �`� ���`,�` �'a �� ���.�'�.';, �`�< � ,,; F; ,,«� .,�-_ �--�-----��� � £- �'._ ' Ra�. dt�li�ltfi � � , , ,: ' ' A�MIN��T`TtA'I'If):� ; � t7nde��h�zpter 1 S'?,Sectican�SG,�ubs�ctiQn b,fihe'Tc�e�c�f�Yarz��utl�zs�ac�w requzre�to hrs2d iss�aaaice c�r rene�al: of any license ar�em�i�tc� operat� a l�usir�ess if�pe�son c�x c�rnpany do�s r�cst l�ave a (:derti�cate �af Worker's G+��np�nsat�nn �n�uraaac�. T�IEE .A;�`��CI�iE �`TA'I'� WG R'� �`Q��I'�:.��A�`IChN IN�tiR��'CE '�- . ��l'lSAt7t.Y�.l IYA��aal�i7L`�i..#.li. l�L" Z���&,YAl�7.YlZ:•TiZ/j�Vi\ .. . . .� � . � .� . . �, . � . . . . ,��� . _ . .. . .... . . 1..1i.1\.t, 4l1` 1.i.V�,7C.tl\.t'1�.`li..d��d t�.�Z-1.GL/�*�� � .. . � . � . � L/� � � � � W(J�K�;R'S CC�141�'. ��FiI�A�TI`T SIG��T�A?�I3 r�T��C'HED <�" : �'c�wn c�f Yarmau�a t�es�zad tiens mc�,st be��,id�ricar t�.renewal c�r issuarace o�y€�ur pezmi�s. .�L�ASF'CH�CK APPRUPR.IATEI.,�'I�'PAII�. ' �'�. I'�S ; °�,,, Nt? �(7TELS A�I)fJTH�I�I�E�U���t�F�°I'Ali�IS��,N"I'S T�2A,��SIE?�T C?C'CLJP�ItiG'�'': �'�r purposes ofthe Iitra�tatzv��s c�f��c�teT€ar Hotel use,'�'ratasiezat ac�ccupancy sh�ll be . lir�aited t�th�f�mporary and sht�rt temx c�c�upancy,arc�inaz�1y anc��,�asta�naaaly�ss�sci�t�d wi��r�avte�anci hrat�;1�se. Tz�ansi�nt r�ccu�ants musi have �.rzd be �bie t€� c£�znonstrate ih�� they maintair7 a principa� pla�� of reszderice else�vhere,Tra�si�nt occug�ancy shall gener��y r�fe�to cs���z�atzc�u�or.:�upazacy o�`z�ot mc�re�han " �3(})days;and an aggr��;�te c�f not mor���an n�nety(90 j ciays�itt�in aary sz��{a,�mnz��i perzc�d..T.Is�t�f'a�xest�z%t as axesidenee ox . c�we�lxn� cznit s�all saat be cc�nszdereti�ansient. Qcc��ra�cy tic�t i���ject t�r the cv11�c�Qn c�f Roc��rz C3ceupa�cy �xczse,as d���ed in M.C�.L. �. �4G c�r 83�C1�R�C,�s�rnenc�ed,shall�enerai�y be�r��sid�red T�°arisient. 7'�ae�`a vnw�a�ih caf"�lrrss�ehr�setts ' .l�e�ar� e�ai esf Xr�rlr�str%al Ae��e,��s : (3.�'�e�v,�`°I�vestrgaxtinns , , 1 �'r�re�ess St're��,;� t�1(1� ' �t�s�crn, �1,2,�.I4-�111�. w��v. s�r�v/�iu ' Wc�rkers' Cc�mp���atic�n Insur��ce ��fxdavi�; �enerr�i�u�i�esses ' �i licant Inf�rma�i��e Ple��e Prin�L� °bl , �3�����sslgr�a�iza�i�n�raz�ae; � ������ �"E ;��� �� °�� �,��� ��� Addres�: �' �" �` �� ��` � �:��IS�ate/7ip: �,�, : �� '�� � `e P P�c�ne#�: �K ;�� �_ ' Are ybu az�emplayer?Checlk the ap�rop�eate box; � Business TY�{r�u�reci�: I.� I azn a emplc�yer wi�k°i s�n�Ibv�es(�`iail andl 5. ` �.�'�a,ii ' c�r part-t�m�}.� �-$µ�� � 6. �Restauraz��lBarl�a�ing Esta..�lishmeaat ' 2,� I arn a sole proprietar or p ershig and have no � 7. �t�ffice andlor S�d�s(is�c;1.r�a�esta�e,��t�,etc.} empl�ay�es�*rorkinb for me in�yr eapaeity�. ��a,�arkers' com�.insurance req�iredj � 8. (�Nati-pr��� .�.(� �e are a�r�aoratior��nd�ts o#�'�c:�rs�a�e�x�reis�d ! 3. ��r�i�r�t�inme�t their ri�it of e�ezn�pti�zt per c. 15?, y�1{4),and w�hav� � 1C�.� �tfanufactur�n� n€s employees. [No c�c�rkers'camp.insur�ce requirecl�* � 1 l.Q �€�alt�CGu� � 4.� ���are a r�c��i-proft c��ganiz�icss�,�s��'sd by vai�as�teeza, � � ' with r�a��r,�plcaye�s: ('vt�u�ork�rs' c�mp.ins�c�req.] � �•12�,Q C:1ti:��r � *Any�ppliraa�t ti;at c}�ccks box#i rnust also fxti out thc saction t�lo�u show�rig cheu�v�rkers'cc>m�ensaiian poiicp ittformatian. ' "�ift}a�coa�pcerate affzc�rs 3��ve oxem�tcd�,*�em�etves,but rhe corgoratscar.kars ufl�er employees,�workers'comper�sati€m pQlicy"ss r�q�;ir�c3�nd such au ; c>rga�iz�ian shc�ukd;taeck box�1. X sa�n an ernpCnye�th�ct is pr�vidr'ng�wr�rk�rs'c€� �trsatin�rrt�ura.�ce for my�mplayee�: �eZcaw is the��ti�y irrf'rtr �torc, Insnrance Cc�zr,pany Namex ���=�;��.�.����;�����`.�, � �; . � ,. ,� � Insurer's Addr�s ��, �. ��'��,�` �� ',�:, �,„ ;���.�..�....�"� ; ,� �,�z ��_ �"`�° ��r _. �_,� ' � �^°q ,� ���` � ��"� ,. ���t�.7��[.�4���. e� � �,__„1 4` .�'� � i X�� �...., � t�fi,..��,�� � . y� ' P�Ii��°#csr Self-ins.Lic.?� , �xpiratzc�n�3at�: . Attach a copy of t2�e workers'cam�ae�sati��poifcy deciarat�c�n page{shr��izag th�pc�l�cy numi�er�nd e��sira�ion date}. Pailur�tc�s�cure c�vera�as requires�under S�c�a4n 25A of�+rIG�,c. 1�2 c�n Ie�d to ika�izn��sitic�n flf crimin�.I pe�altr�s��a fin�up to�1,5f�Q.f?�}and�c�r c��e-ye�r imprisr�nn3ent,as�ell as ci�i3 p�na:�ie�%�T.Iae forrt of a S`�{��'��R.I�t�R.Z�ER and a�ne : caf up tcr$2�C1.(}tJ a da�against thu��ic�la�or. ��aciuis�d 2h�at a c,apy ofthis stat�rrse�t rz��y be farwar�ed to the t�f�ic�af Inv�stigati�ns csft3�e��fer insurazace c�ver��s�eri�cat�t�n. 1 r�o hereby eerft,�'y�u�er t���r�z��d p,�atatties af'perJ�ryt tha�`tJee�n�'armata�sn�rrvvtated abvve is true ara�'c�rrect. � � � S��nnat•�re: � � �`��`" � L)�e. °"� � � �_ � �""�' ���a � � Phc�ne#: � � ( �, � .,, ��, ��- k.,�"� (1.ffaczral us�nnty. ,i�c�rsot write zr�th�,s�rerz,ta b�cvtnpl��d b,y ciij=�r ruwn affaciu� City csr Tc�c�n; lPez snittLice�se�# �s�uing Aut�roriiy(circle otza�. 1.Board af�3[e�iti�"2.]�u�id°z�zg 13eparta�cent 3.t'ity,�'c�. Cle�1� �i,7Li��r€si��lBcsxrr� S.Selectmen'�C}flTce �.C3�her C�ntact Perso�: �'ha�e#• � �'�+,�a��'r�r,�'�i� � . . ' 1R, k , m �ti a d E: `s ' il P � N�ar�tJARD In�urance Ct�rnpany-A�tocic Co. ����E��'t"�S�11t'� �c�'�h��11�'� �oN��y+��m�er cav�rc�s���� t �1 �nsur�nc� �,enewas o�cAwc����o� �am�an;es �v+��� r�o� Cz��a�� ' Policy Infi�rmation P�g� �'2�I��med �nsur+�d�nd ailir�g Addres� Agen�y ' Cape Gc�d�arms IT;t�t� AUTC}�A'i`TC DP�TA PEt�CESSIN�If�1SURAt��E A�EPdCY, , 252 ��in�S:'R�2f3 I�+IC, ' VJest`i�rrr�csuth, MrA t�26?3 ° 1 A;DP 8oufev�c'd ' Rc,sel�:nd, NJ (37Q68 , Agency Code: 3�7ADPI11 . �'�tl+�rdl Empl�yer's I Ittsured is i.i�nited L€�bil€ty Cr�. {Lt,�} Risk ID Nctmber s79i13 ���. [2� POliCy Period � Fr�m.7une i0, 20i6 to lune l�q 2p1�, 1�;(ll I-�M, standard time�t the ansurecS°s rnaifir;g address. � L�j �overage A, Wpric�rs' Car�p�n�atiora Insurance - Part Gne of this po(icy�pplies ta t�r��11c�rkers' C�impensafiic�n , Lav��f tl���r�ifawing sta�es; Massac�u�etts 8. Employ�;r`s Lt`abil{ty Insurance - Part Two of th�s goEicy ap�iies ta work in each of the states li�ted � in ttem j3�A. �"he li�its�r�f our(lability unde�P�rt Twc���are: � ; Bt�dily Injury ksy Ac�ident- �aett �cc�d�nt �1tlGi,{}OQ ' �odily Ir�jury by bise�se - each em�lc�ye� $it�Q,OC10 . Bodily Ir�jury by E�isaase - policy lim�t $5A0,�04 C. CJther�tates Insurastce - Part�hr°��of tF�i� pcsficy�ppli�s to al! st�tes, except ar�y staga 36sted `srs item [3]A. an�l tl���t�tes of North Dak�rt�, C3�sir, Washirsgfian, and t�'yar�ninr�. [?. This pfl#icy inclaades these e-adc�r�emer�ts and schsdules: ' See �xtensian of Infor;�sation Pag� - Schedule�sf Forms [4� �remium � � '?'�e Premlum Basis and,ther�for�,tl���rernlur� wfi( ��_determined by�ur�I�nual p�Rul�s, Classificatic�ns, Rates, and R�tinc� Plars�. A!� r�quir�� in�orrnation is��a��ect ta veri�ication and ch��ge by audit, ��ontinued csn anc�ttser page} T�tal Es�imated Policy Premium $ 1,586 Tcstal5urchargeslAssesscnents � 7t}.0� T°atat I�stimated Ct►st i �58.0� e �v:a � x� � � Pags-4 - Znfarm�tic�t�P�ge MGA : CA6'�C787799 €3ace :(i5111t2D16 iNC�QbO{32,4 MAld�TE ISSUft1+� QFf€Ce. P.IJ. B��t�-!�!, 1$Sr.RiVBc�tt°e8f,irVilksS-$aCt$, PA�5703'0020 r WWW.L,�tlaCti.0013t . , �tC�� C�F�TIFI�ATE fi�F L.��,�3�l�I�"Y` I����AC�Ifi�� o���t�'"���"�"r �2tosr2u,c THIS CERT3�(CATE IS ISSUEE�A3 A lt�AT3ER C3�IM�CURMlK81t'�N ONLY��1D COAiEERS�NO RIGWTS 45t�UN TN�CERT3PiC�TE HOLp�R.TH[S ' CERTiFIGABE DOES tdi7T A��fFiMATlV�LY£}R NEGATiVELY AMEND, EXTEidD C3R Ai�TER THE CdV�RAGE A��'O#2DECs BY 7}#E POLlCIES ' BELOW,Tti1S CERTIFiGATE OF 1NSURANG� D��S NC3T CC�NSTITUTE A GC3NTRR�T BE'fWEEN THE 65�UING fNS13RER(S},AUTHO�iZED , l2EPRESENTATi�E OR PRCS[3UCER,AND TFBE CERTIFIGATE Nf3Lf�ER. � i�tPC�RTA�dT:Bt the certtficaCe haitier ts an At7D1TlC3N,RL iRtSUf'tEC1,iht�pa#iay�ies)must b�e�ndorBed.Ef�UBRt3GATt4N I�WAIVED,s�bject to the terms and¢crnd`ations 4f the pcat�cy.certaitt pai'tcies may r�quire an endarsement.A st�temenf on this certificats dces nat ccrn4er rights to ihe �, cerf€ticate halder in lieu of such snzi�rsament{�), a�onucEre ' ��&: � - _. _ , - � Autamatic L�a€a P��es�ing lns�aranae Ag$n�y,[rra, rac w�i�: _ _ __ __._ ���,� ..� ��.. 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'tf yec,descr�C*�vnder , ` � =:._. _.___ .._.. , __ _ ..__ z��s���r�o�;�r��ea�uTiar�s b�:o•„ �.�.cns�as�-�ouc.r�.n�i� � 50�,£�0� � � 1 I t7F.$CRtPT1tiN L3F 9P�RA71t5N�i E.ACATtON1i/YEM1ClE8(AGE7Rtt tfiA�Addi#ipna€€kemarks Sah�sdgie�m��br.attaelietl tianore&paa�is reqaired} CERTlF1CATE HOl.€3Eit CANCE�.L/#T!�"it� , SHOULCr ANY ofi'CNE ABCsvE Lt�SCRlBEp P41�l�8E5 B�CaNCEIL�D 6�fi0t2E ' � TH� �XPi�Y�7lQN CakTE 7H�i�t�4P, Nb"fICE WILL B� fl�t�iVE��D iN � � +� ������Ld ;./ �� T AC�{7RDAAICE W}TH�TNE POLICY PROVISEONS�. .� .. . � � �. AU7}10RSZEL4 FtEPiiESENTA7IVE � � � � � " ti ��, . . . . . . . . . � . . �i i�m.,.�,. {�f ..��y«.�.,, C�319�$-2tff$A�C)Ftt1 CCIRP�RA'�IQN.J69I righf#S r�SBNeCI. A�4}�R�25{2t}141Q9) Tkse AGG3RE7 narne and aogo�re r+�gist€:r�d ma�Ks�f��{3t�D