HomeMy WebLinkAboutApplication and WC � i
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� TOWN OF YARMOUTH BOARD OF HEALTH NOU O b �0�7
� APPLICATION FOR LICENSE/PEIt�I _ 2 g� j
,,,,,. * �= : U���1 �.
� Pl H L?E�T
ease com lete form and attach all necess
�D�c 1 S
Failure to do so will result in the return of�"�ur ��� ri� et:
ESTABLISHMENT NAME: dt��f�' AX ID•
LOCATION ADDRESS: /DG�j_!2f �S( �SA�7'�fP �i�ra.�lf /l�/a- TEL.#:��35�1'-�
MAILING ADDRESS: �/�v�t�sv6F Q� �'S�yis.vs �,1F as�3�-
E-MAIL ADDRESS: ��if�ilNyY��9 CO�i d�.t/�T
OWNER NAME: ��[,��d'��i� �ytr� ��
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: /��'?7R�t City�o�?Sec.- TEL.#:S�$'S•3G'/91'V
MAILING ADDRESS: � 5` 3j0�j 'TARr. RI yit��fW' �^ !ni$' D�G�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operat.or,as required by State law. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form.
-- -__ _ _
L 2,
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 a11 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. 2.
3. 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
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please atta.ch 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.
L �'-�.�tr �a�.�bc-�� 2:
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
_ 1.=-�-c� �-��d l� - _ _ .__ .__ ___ _ _ � _ ,. _ - - _ . _ _ __
ALL�RGEN 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. r�c r-- ��►�r I 2. � �.�,a��,�.� c•1
HEIMLICH CERTIFI�ATIONS:
A11 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.
1. �'<� �`�'�P�`' 2.
3. 4,
RESTAURANT SEATING: TOTAL#
— - - --^- (�FFICE USE ONLY
__ —
-- _ _ -- _ —
LQDGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
BBcB $55 CABIN $55 � MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
/ 0-100 SEATS $125 ���� CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC. $60 �t0 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: $is AMOUNT DUE _ $ IBS•OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
3 0�!r r-I�-636 Z--a�{
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. ADMINISTRATION �
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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 �
� Co�ipensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE '
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED '
OR •
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
I
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEA�E CHECK j
APPROPRIATELY IF PAID: �
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS `
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TRANSIENT OCCUPANCY: Far purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be f
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 j
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
dwelling unit sha11 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, sha11 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. . i
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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 prior to opening, and quarterly ;
thereafter. . �
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POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of "
elosing. 1
: . - FOOD SE�2VICE i
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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.
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CATERING POLICY:
Anyone who caters within the Town of Yarmouth mus�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 �
obtained at the Health Deparhnent,or from the Town's website at www.,varmouth.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 Boazd of Health.
OUTDOOR COOHING: I
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. '
NO'i'ICE:Permits run a.nnually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I�
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIlZED FEE(S)BY DECEMBER 15,2017. II
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE PLAN.
DATE: ,�l—� "/ 7 SIGNATURE: ��—�'r-- ',
PRINT NAME&TITLE: �` J4 e C '
;
,
Rev. 10/12/17
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
tl 1 Congress Sheet,Suite 100
<
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERNIlTTING ALJTAORTTY.
Anplicant Information Please Print Legiblv
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; Business/Organization Name:Ryan Family Amusements
Address: 116 Wate�house Rd
City/State/Zip:Boume Ma 02532 Phone#:508 759 5464
Are you an employer?Check the appropriate box: Business Type(reqnired):
� �oo s. p x��
1.�✓ I am a employer with employees(full and/
or part-time).* 6. �RestaurantBarlEating Establishment
2.❑ I am a sole proprietor or partnership and have no �, �p�ce 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. ❑✓ Entertainment
their right of exemption per c. 152,§1(4),and we have 10.Q Manufacturing
no employees. (No workers'comp.insurance required]*
4.❑ We are a non-pmfit organization,staffed by volunteers, ll.0 Health Care
,
12.�Other
w r om .insurance re .
with no em lo ees. o o kers c
P Y � P 9�
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infonnation.
**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'coinpensation insurance jor»ry employees. Betow is the policy informatian.
Insurance Company Name:AmGUARD Insurance Company
Insurer's Address:16 South River St
City/State/Zip: W�Ikes-Barre, Pa 18703-0020
Policy#or Self-ins.Lic.#RYWC729668 E�cpiration Date:12/31/2017
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penaities in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c�rtify,un r the i a a[ties perjury that the information provided e is ue and correct
�
Si ature: Date: �
Phone#:�8 759 5464
Official use only. Do not write in this area,to be completed by city or town of,�iciaL
City or Town: Permit/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#:
www.mass.gov/dia
,
: i-'� RYANF-1 OP ID:MJ
.a►CORo�� CERTIFICATE OF LIABILITY INSURANCE °"�`"�"°°"�"�'
`--r' 10/11/2017
THIS CERI1FICdTE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE HOLDER. THIS
CERIIFICATE DOES NOT AFFIRAAATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER T1iE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'MIEEN THE ISSUING INSURER(S), AUTHORI2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the ce�cate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGA710N IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorseme�rt. A statement on this certificata doea not coMer rights to the
certificate holder in lieu of such endorseme s.
j PaooucER �bE Willlam B.Marklterd,CPCU
� McLaughlin Msurance Agency P�E Fnx
! 828 Lynn Fells Parkway arc No�a:781-665-2TT5 �N,;7$1-665-0295
I Melrose MA o2176 A�'�,wmarkhaM claughlinins.com
William�.Markhard,CPCU
i INSURER(3)AFFORDIN6 COVERAOE NAIC X
'� INSURER A:HOUSt011 C8SU8I�/COli7p9rly
iNsu� Ryan Family Amusements,Inc. ,N�,�B:Commerce Insurance Compan 34T54
Attn: Mike Crowley ,�,�a c:Torus Natlonal Insurance Comp
116 Waterhouse Road
Bourne,MA 02532-3867 iNsu�R o:Guard Insurance Group
IN�IRER E:
INSURER F•
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WIi1CH 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 POIICiES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�� TYPE OF INSURANCE pOLICY NUMBER Y E F � V�S
A X COIIAMERCIAL(iENERAL lW&LITY EACH OCCURRENCE E �,�,
CLAIMS-MADE �OCCUR $C����A ����l��� ����/��$ pREMISES Eaoccurtence S ��.
MED EXP(MY wre person) S EXCIU
X LIQUOR LIAB PERSONAL 8 ADV INJURY $ 'I�OOO,OO
GEN'l AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z,�O,OO
POLICY❑PR�� �LOC PRODUCTS-(�AAP/OPAGG E 2r�,�
JECT
OTHER: uQU�': S �111/1
AUTOM081LE LIABILITY MBINED I LE LIMIT S ��
Ea axident � .
B ANY AUTO 17MMBDPRLQ 04/10/2017 04/10/2018 BO��LY INJURY(P�person) s
ALL OWNED �( SCHEDULED BODILY INJURY(Per eaadeM) $
AUTOS AUTOS PROPERTY DAMAGE $
NON-0WNED P���t
X HIREDAUTOS X AUTOS
E
X UMBRELLA LIAB X pCCUR EACH OCCURRENCE S S,OOO,
�'i �CE��B CtAIMS-MADE 70531N172AU 05101/2077 05/01/2018 pGGREGATE S 5,��,�
DED X RETENTIONS �0�� t
AN�EMPLDY�ERs l�.lA�&�Un X STATUTE ER_ _
D ANY PROPRIETOR/PARTNERIEXECUTIVE Y�N RYWC729668 1?J31/2016 72I31/2017 E.L.EACH ACCIDENT S ��
OFFICER/MEMBER EXCLUDED'? �N�A
(Mandatory fn NH) E.L.DISEASE-EA EMPIOYE $ 5�,0
N yes.desaibe under
DESCRIPTION OF OPERATIONS b�ow E.L.DISEASE-POLICY LIMIT S �,
DESCWPTiON OF OPERATIONS/LOCAT10N3/VEHICLES(ACO�701,A�Itlo�al Remarks ScMdule,m�y be atGched if moro spaee is reqWred)
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
YARM001
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Yarmouth TME E7�PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOYYfI Hall ACCORDANCE NIITH THE POLICY PROVISIONS.
'I'I�ROUt@ ZS AUTNORIZEDREPRESENTATIVE
So.Yarmouth,MA 02664 � ���
a 7988-2074 ACORD CORPORATION. Ali rigt�ts reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
f.
V1foi�Ce�as�,NNp�tion�,f m�Q� Li f�y Poticv
� �Bt���4SI�11 r£.' H+t'�'�!I�Wc"�, " AmGttl�RD It�uran;:e Campa�y-A Stock Co,
�. Pati�y Numb�-R'Y{1VC7296fi8
����� Insurance Renewal af RYV1iC65�240
Gt3mp�nies NCCI No. j21873�,
Palic�r InfQm�at�on Pag+a
[i J Nar�d Insursd and Maiiing A�dc+ess - Agen+�y►
Ryan Family Amuserr�nis Inc TPA INSf1RANGE AGENCY II'�K.
116 wat�rhous�Raad 1U NEW�"alAN�7 BUS CTFt
B4urne,MA E}2532-3867 5UITE 3{t3
Antbver,I+�A 0181t?
Ager�cy Cc�de: MATPAAIO
Fed�r'a! Empl4y�t'S ID It�sul�e+ci is Gorp�ratican
itisk ID Nuimt�er 9175652$7
LoCatiot�t on Poli�/' - 5ee Exter�iofl of Infarmatic3n Page- Schedule c�f Lacations '
ja] Pot�cy P�'iod
Frpm December 31, 2t}16 to Qecember 31, 2017, 12:01 AM,st�ndard time at the insur�ed's rr►ailit�g
�:
[3� Covera�
A. Workers'Comper►sation Irtisurarx�-Part One of this poticy applies tcs the 1Nc�rkers'Compensation
. l.a+nt af tf�e f�i{owir�states: Massachu;setts,R�de island
B. Ernplc�yer's Liabiiity InsurarrcQ'- Part Two�'this pvlicy a�i�s to work in each a€the stat�s C�ed
in item [3]A. The limits of our liability under F>art Two�re:
8�ociily Injury by Acciderrt-each acciderrt $5QQ,�t}U
B�dity Injury by t3isease-e,4ach�mpioyee $500,�Ot}
Badily lnjury by Disease-poticy tirnit $50Q,�t��
C. Other States Insurance-Part Thr+ee�t#�s poiicy applies ta ait states,ejcc��ar�y state Iisted in
item[3]A, ar�the states c�f Narth Dat4ota,Ohio,�4fashin�Qn,and 1N�ming.
� .
a, This�1icy includes tt�:se end+�rserr►�and schedutes.
See£:xtension of Ft�#ormatior�Pz�ge-Schedule aF Forms
[4] - Premium
'fhe Pr�mium Basis and,ther+efore,tI'��i�21't'ttlM11 WfI) �tI�tTTt1t'�I3}�Ot31"M2!'11J�I Of RUILSR
Gassificatiorts,Rates,and Rating Plarta_ A11 required i�rmation is subject to verific.ation and�t�ange by
audiC. {Cor�iriued cu�artothea-page)
Tota1 Est+imateE!Rolicy Pnamium $ 23,i�ti
Tar#a�Sttccfiae+gesjAs�essns�ts $ 1,189.OQ
To#at Estima�ted C�st 2 37'S.00
�I�2n�a�tJSE xx Page-1- Inform�tion Page
MGA : RYWC729658 " WC OOOOOiA
Dab� : if/25j2D16
FRf�,N(?TE
7�ssain�Clfic�:P.Q.�ox A-H,18 5:R��Stre�YViNces-Barre,,PA i8743-Cf0�0��vwrv.�uard,corn
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� ��,.�mo�sa�on artd Em�Q,yer's Liabilifir Palicv
~ ��erksh i re Hathawa ��°���ca��,-�s��ca.
�. Poticy Number RYWCi396fs�
� ����� Compan es Re�ew NGCI No. [21873j.
Po�icy Ls#orntation Fag�
E�ctensiort of Inf�rmation Pat�e
s�$a��e��{� - '
{L2} 24Q Main Stree�, Buzz�ar�Es Bay, MA(}2532(12j3#.JZt�16-12J�1/2t317}
(G3} 441 Main Street, Hyannis, MA�26Q1 (�.2/3If241fi -12/31J2017)
{L4� 1067 Rte 2$ ,�uth YarmQt.�h, MA(326b4 �I2J31/2t�16 -12J31j2t?17)
{L5) 115 New State HwY, R�yrtharn, MA t}2'�f7 (12J31/2�].b - i2/31/��17}
(L6} i17t?Main SCreet,Millrs,MA 02`OS4(12J31j2{316 - 12/31/2Q27}
;(!.8} 23 Town Halt Sq. ,Fatmout�, MA Q2S4a(12/31/2U16 - 12/31J2�17)
(L9} 19 Carcuit�ve,Uak Bluffs,•MA Q2S57 {12/31I2016 -12f31/2017)
(Ll�) 268 Thames St,Newport,RI 02844 t12j31j2016- S2/31/2Q17} .
(Lii� 769 Lyannaugh Road, Hyannis, MA t32603 (i2/31J2Qi6- 12j33/zD17}
(L12) Cape Cod'Ir�ft�tatsie Park, S12 Ro�e 28,Yarmauth, MA i32664(12j31/2016-1213tJ2Q17�
(L13} Cape Coddna-Resort, 1225 Iyanr�ugh Etoad, Hyannis,MA 026#31{12(31J2f}16-12J3iJ2{�17}
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��t� � �9�-�- Information Page
MGA : RYIAfC7Z9668 Yt�C 0�b001A
�ate ; 11125/20i6
MANCffE
Isstlinq Otiics: P.O:BoX A-H,16 S.RiYe�'St�eet,Wi(k�-�atrte,PA 18703-OQ20�www„ywtM,Com
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Ten Pin Prices
Games
Bowling Mon-Fri 10-5 $30.00 +shoes
Mon-Thur 5-C $35.00 +shoes
Fri 5pm-Sun $35.00 +shoes
VIP Mon-Fri 10-5 $40.00 +shoes
Mon-Thur 5-C $45.00 +shoes
Fri 5pm-Sun $45.00 +shoes
Mon-Thur $199.00 incl shoes °e,r1^��r
Fri 5pm-Sun $299.00 incl shoes P�y,�
Laser Tag Single $8.00
Double $15.00
Games Bonus$ $20/$5
$40/$12
$60/$20
$80/$25
$100/$50
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Empower Retirement �
PO Box 173764
Denver,CO 80217-3i64
EMP4WER
RETIREMENT'"
i
October 27, 2017 Plan Number: 331949-01
Plan Name: Ryan Family
Amusements,Inc.401(k)
Plan
RE: important Investment Option(s) Updates
Please read fhis notification carefully to understand the upcoming investment option changes to your
Plan. If you are a{ready eligible to participate in the plan or will became eiigible to participate in the plan
priar to the upcoming investment option changes,you may want to take action with respect to your
investment option(s).
Periadically,the investment option(s)oifering in your retirement plan ("Plan")undergo changes. These
updates are made so you may cont�nue to s+elect from a diverse and competitive array of quality
investment option(s). Ryan Family Amusements, Inc.401(kj Plan has directed Empower Retirement to
complete some updates regarding the investment option(s)in your plan.
New Investment Option(s)
The following new investment option(s)will be automaticaHy added to your plan on December 18,2017:
Vanguard Energy Index Adm
Asset Class Cafegory:Specialty
To change your future contribution allocations or move your current account balance to the new
investment option(s), please review the Voice Response System and/or the website instructions included
with this communicat�on.
Discontinued Investment Option(s)
Effective December 18,2017,the following investment option(s)will be discontinued and a process called
mapping will axur. Mapping is a process b�which the account balance in a discontinued investment
��
option is transferred to a new investrnent opt�on at the direction of your Plan Administrator. During this
time,future contribution allacations a�d current acxount balances in the discontinued investment option(s)
will be mapped to the new investment option indicated in the Discontinued Investment Option(s)and
Mapping Chart located below. During the mapping process,your assets will remain invested and will
cont�nue to gain and/or lose vaiue depending on market conditions.
Discontinued Investment Option: BlackRock Energy&Resources Port Instl
Replacement Investment Option:Vanguard Energy Index Adm
Assef Class Category.•Specialty
You can make changes by:
� Vsiting your plan's Website at empowermyretiremen�com.
� Contacting a representative at the Voice Response System at 1-800-338-4015
(1-800-338-401k)during normal business hours.
DOC TYPE:PFUDCC_STD 01:0724174Q1K GM9
DOC ID:443329171 EV ID:783071825
IND ID:0
Page 3 of4
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; f
Acaess to the Voice Response System and tl�e v�bs�e may be limi�ed or unavailable during pe�iods of peak demand,market volatiGty,
systems upgrades/main�nance or othe�reasons.Transfer requests made via the website or ihe Voice Response System received
on busir�ss days prior to do$e of the tVew Yodc Stodc F�ai�ar�ge(4:00 p.m.Eastem Time or ea�'ier on sorr�holidays or oq�er specc�al
arcumstances)will be initiated at 1he dose of business tl�same day d�e request was received.The actual effective date of your
transadlon may vary depending an tlie investmerd option selected.
The aa�unt owner is responsible for keepirg Uie assigned PIN ooMidential.Please contact Cfient Services immediately ff you suspect
any unaulhorized use.
; More detailed information about the investment o�tion(s)may be availabie in the prospectus, if applicabie,
, which you can get by logging onto the Plan website. In addition,you can find out more about the Pian in
� other documents, including the Pian's Summary Pian Description(SPD)and any Summary of Materiai
� Modifications(SMM).
j Empower Retirement will take all reasonable steps necessary to execute the above transactions on
± the dates and by the terms specified. During these transaction periods your account may experience
I a period of limited accessibility. However, Empower Retirement's ability to execute the transactians
� may be affected by the policies or restrictions imposed by the underlying investment providers and!
or marke#conditions beyond its control. In the event Empower Retirement ts not able to execute any
of the transactians on the dates specified above due to circumstances beyond its control, Empower
Retirement will comptete the author¢ed transaction(s}or remaining transaction(s)on the earliest business
day if it is reasonably able to do so. In the event Empower Retirement fails to execute any or all of
the transactions due to its own actions, pa�ticipant accounts will be adjusted as if the transaction had
accurred in accordance with these instru�tions.
P/ease consider the investment ob%ectiveS, ►isks, fees and expenses carefully before investing. The
� prospsctus cantains this and ather infarmation abouf the investment options. De�ending on the
investment options offer�d in your plan,your registered repnssentafive can provide you wifh prospectuses
for any mutual funds;any appliceble annuify contrects and the annuity's underlying funds;and/or
disc/osurr�documenfs for investment options exempt from SEC registrafion. Please read them carefully
before investin .
9
Contact Us
If you have any questions,please contact us at 1-SOQ-338-4015(1-800-338-401k).
Sincerely,
Empower Retirement
Speaalty-Specialty funds invest in a limited number of c�mpanies and are generally non-diversified.As a resuft,chenges in mar�cet
value of a single issusr crould cause greater volatility than with a more diversified fund.
Unless otherwlse noted,not insured by FDIC,NGUAINCUA8IF.Nat a deposlt or guara�eed by arry bank afliliatie or credit union.
Not i�ured by a�r fe�ral govemment agency.Funds rnay loae value.Not a condkion of any 6anktng or crecNt union a�tivity.
Core securiti�,when o�fered,are offiared througfi GWFS EquiNes,Ina andlor ati�r broker dealers.
GWFS Equifies.lnc.,Member FINRAfSIPC,�s a whoqy oHrt�ed subsidisry of Great West Life 8�Mrwity Insurance Company.
Empower Retiremerrt refets to tl�e produds and services otfered in the reUrement markets by Great-West lJfe&Annuity Insurance
Compamr,Corporate Headquarters:Greenwood lfdlage,CO;Great-West Life&Annt,ety Insurarx:e Comparry of N�nr Yoi1c,Home Office:
NY,NY,and their subs�iiaries and afF�iates.The trad�naAcs.logos,senrice marks,a�d�gn elsments used are rnrmed by their
respedive owners and are used by perrr�ssion.
DOC TYPE:PFUDCC_STD 01:072417 401K GP19
DOC ID:443329171 EV ID:783071825
1ND ID:0
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