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HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH ,.44-4 fr.N.) APPLICATION FOR LICENSE/PERMIT - 2022 MAK .! 4 2022 * Please complete form and attach all necessary documents by Deceit 1M IDEPT. Failure to do so will result in the return of your application pack-t ESTABLISHMENT NAME: 1- V 13oiq TS TAX ID: LOCATION ADDRESS: II AO i N (-m T, W . yAr? o,ITEL•#:(5c�) -715 -6V 33 MAILING ADDRESS: E-MAIL ADDRESS: -fed e..---hA�j ba e cope c'aoI- c vv- • OWNER NAME: \ (nwp0 Ddd 7dwA0 ]\-5 CORPORATION NAME (IF APPLICABLE): A hole_ -f f- 4-ar jo r _ MANAGER'S NAME: RO) Q ( Tro u O� TEL.#: (cb b 6 p-, r - 5 7 27 MAILING ADDRESS: Z Z/ G-&f-- /nose 'X, ec.c/L �Jczce ha y i'vl 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 copy of the certification to this form. I. 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 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. I. 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 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. I. eI' riS7vpAe ( 6-/ay 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. Ch 1-( h�v 6 ret 2. A cl9 P r j rd �1, — 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 as file at your establishment. I. e -%�Sk 46( (�'- l2 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. I. CA. n SADph P I Co /cam V2. /235,9 r //v(>y� 3. pg-7t, r ri C� 4. RESTAURANT SEATING: TOTAL # 2,9 41 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —INN $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$1 lOca. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $I IOea. FOOD SERVICE: LICENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FEE P1 RMI'I'4 LICENSE REQUIRED PEE PERMIT# _0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >l00 SEATS $200 )- COMMON VIC. $60 V-- —WI IOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED PEI: I'ERMI"T# LICENSE REQUIRED PEE PERMIT#. LICENSE REQUIRED FEE PERMIT# <50 sq.1.Nit. >25.000 Nil. $285 VENDING-FOOD $25 _<25.000 . $150 _FROZEN DESSERT $40 _"TOBACCO $110 NAME cuANGE: $15 AMOUNT DUE = $ 60 *****1'LF.ASF,'rum OVER AND COMI'LE:I'E OT1IE12 S1DE OF FORM***** 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 COMPE SATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or 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 dwelling 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 prior 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 obtained 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 CAFÉS: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January I to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER I8, 2020. 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 REQUIRE A SITE PLAN. Jam_ DATE: 03I/V/Z 2-- SIGNATURE: PRINT NAME & TITLE: %hi e oCkr--e ZC 44-6e/1 j r� �c r Rev 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-22-3500 Issue Date: 01/01/2022 Mailing Address: Location Address: ABOVE THE HARBOR INC 21 ARLINGTON ST TUGBOATS WEST YARMOUTH, MA 02673 21 ARLINGTON STREET WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • Bruce G. Murphy, i' .S., CHO Health Director The Commonwealth of Massachusetts Print Form 1 w: Department of Industrial Accidents Office of Investigations 11 _ 4 1 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: L° ,Bd/9-T— Address: 1/ / 67h/ .S City/State/Zip: 1'57 ,4ditt� Phone #: 1a,., _,> �'y 777P-57 Y Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with Z-L) employees(full and/ 5. ❑ R)Iail or part-time).* 6. Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *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 w rk rs'P/li corn nation insurance for my employees. Below is the policy information. Insurance Company Name: dam ° J" Insurer's Address: /'(7. /4f4 City/State/Zip: W! k/E 5 %. 6 4, 2E, / 1; /52-203 Policy#or Self-ins. Lic.# t ' 4 17 Expiration Date: a/0 0 r 2 2— Attach Attach a copy of the workers' compensation policy declaration page(showing the policy number and xpirat',n 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 penalties 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 certify,under the •ains and penaltie r ierjury at the information provided above i true nd correct. &nature: Date: 3 / ' 7r Phone#: Official use only. Do not write in this area,to be completed by city or town official 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 /'-/'1 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/14/22 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,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 NAME: PAUL SCHLEGEL Schlegel&Schlegel Ins Brokers,Inc. acNNo,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ATEGRITY SPECIALTY INSURED INSURER B: GUARD INSURANCE ABOVE THE HARBOR,INC. DBA INSURER C: SAFETY INSURANCE TUGBOATS 21 ARLINGTON ST INSURER D: SCOTTSDALE WEST YARMOUTH,MA 02673 INSURER 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 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 1,000 A Y 01-C-PK-P20025697-0 06/17/21 06/17/22 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY CrELOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea aBINEDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ C OWNED SCHEDULED AUTOS ONLY AUTOS COM5535672 06/25/21 06/25/22 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB X OCCUR EACH OCCURRENCE _ $ 2,000,000 D X EXCESS LIAB CLAIMS-MADE Y XBS0146316 06/17/21 06/17/22 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY B OFFICER/MEMBER EXCLUDD?PROPRIETOR/PARTNER/EXECUTIVE N N/A Y ABWC183736 06/08/21 06/08/22 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below LIQUOR LIABILITY EACH OCC 1,000,000 A Y 01-C-PK-P20025697-0 06/17/21 06/17/22 POLICY LIMIT 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) LISTED AS ADDITIONAL INSURED ON GENERAL LIABILITY AND LIQUOR LIABILITY: HYANNIS MARINA,HYANNIS MARINE SERVICE REALTY TRUST,S&L REALTY TRUST,MARINE REALTY TRUST, 146 LEWIS BAY ROAD REALTY TRUST,162 LEWIS BAY ROAD REALTY TRUST,OCEAN REALTY TRUST CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE D IVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. rfallon@yarmouth.ma.us 1146 Route 28 AUTHORIZED REPRESE• ' • South Yarmouth,MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD American 11 IP k Red Cross c mo ce < d n = ' W woo E.I> fD c N _ = y. N'..°o _ a 3 n n X. A U` o MO m O Ow aa z 3 'O n tia S iLU n V O 7 ° t7 aH x ry 0d n 3.- '"8 's d ONGN O N N 5,'" + ) 3O nO N CC N rt VA.fi .p n O 7 iD S <'� .. ry n N p W 8 11 Di ro n O m - N �1 'may Vo o O d F. 0, BASIC LIFE SUPPORT BLSAmerican Provider HeartAssociation. Roger Troupe has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 eCard Code Training Center City, State 205503338080 Pembroke, MA Training Center Phone OR Code Number (781)826-2011 To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 r, d + � ' . ' " r.- 7 ,-- ,: - ,,yn �� - tt .� sxr ,i raticertificate.lalip?ic : ? 9, 149 '''""4-e.44':'''''' :it-, Pa A'''\ Read aloud Draw . ,Pr (:a:1,1/l> O//wrwec,/// (/ -,,//,.,,04e.t,/ti,,,,G'//; IN t: ,rllii//��c` t/ "il ///// . irJf _(.1CGJ�Il,v , { r,., f/(A- a,-.4,,,,,,,,-.4.,-(/' ,/,— r9Cl�drlt;,r, t7r +_ x '' V.r. ''.., (',4600,) (7,://,-,-,.. ,--/?/,,--.. ,......:51,;;„4,, ,',_-_,.../;„,,,,,,- , 71,--6,,,,,,,A7m.-6/ ,-,., ,, ,.--..,-4, ,-.. 11, �,a�+l 'C=ertificate of Completion i iilliiiipiriil, ',Ihzs certifies tli,rt 1,1 ilIl 1111011't Hedrick.Ntarsden Succes f iffy a»npfeterf tfie ('r''olud Elia izager'Irainiitg cPrcg rain In accordance with 527 CMR 1.00:20.1 5.6-Designation of a Crowd 41anager << _ Date issued:Jw)e Ie.,.2021 ry -, , Exiiiue,,:Jude 16,2024 Certificate it:ZLtGrLutx)5AGcnc Peter Ostroskey rr.. Butte Fire \1 trshal 0 0 aii- A `,,,,,po r 1-,3.44 :,i1;35-69 " D*LL • -..,..,,..,,,,,„,,,,...„„,,,,,...:::„.,- -r, .v. ,' ',./,,,'';''''.',,,,4„4,„'"7"'''''V''';'''� °..,.- fir, �a`"� �. ._� • 'd°1-40P' ry S ate • ServSafe® CERTIFICATION WINSTON ROBINSON for successfully completing the standards set k far the SamSafe•Food Protection Manager Certification Examination, which is accredited by the American Notional Standards Institute(ANSI)-Conference for Food Protection(CFP). • 10749 :ER EXAM FORM NUMBER 1/14/2021 1/14;'2026 DATE OF EX DATE OF EXPIRATION •`total laws apply Ch- • for recttconon re9vt t` ANS! tat 00655 • tatty.Solution; tq Q}t4 StwSa4 levo....a1.,.c.{.d th•htN:'t h..sohd 4.two0 A........i od h o-s...y t_ Canted vs.*4++hrns d 233 S Wacky Dm,Sw 3600 Ormpo.l 60606 6343 a.Sr.SdA..*w aro T c ro Q E C U — a) ra Cliel4 MNkil r- u_ lig C4 Ln N N aJ 5 O LLJ 76 Q L N �c in O d-- t.., a) _C `—C Z a. F- C Cr) u CD i O Ci LU Q N O V N 4-1C QJ 4411111111. C r0 L - CU V v 411111111 Z ca -CCC Q 0 to c —'�+ o°Jo U > U (I) a) - Iliglim _ V) W -o U) /1 NO UM p Q '5 C 0 0,LL N Q„ ON ,_. I- 2 .1...,) m aJ 13 IX 0 •. W VE U 0a) O V i1 Q — (1) a)� a) 0 � o (13 U V 47-v a^ Q ro a, 0 U p N V N in O m coQ �� ° Q� V o4- y E V1 aJ co O -, >%:0 Uo � o 75 ,.._ > no } � _ 3 0 Qa) rn 1 H c F ���soncF N111 14 1114 1 Rcl'i`Ir)"I l(,nrl Sgiity I'ridessionals h4 CERTIFIED FUt)D SAFETY M ANAGER F • i. CHRISTOPHER GRAY y ,t —I 6751 Foeum Drive Suite 220 Orlando,P1.32821 Tall Pre (800)446-0357 Certificate No:21477065 Phone(407)352-3830 Issue Date:June lI,2018 Paz(407)352-3603 FFxpiration Date:June 11.2023 ww*.NRFSPcom This recognizes that C tn is u 0 Christopher Gray has completed the requirements for d Chokesaver w//Restaurant Emergencies E 4 Q 12 conducted by Cape Cod and Islands Chapter Date Completed 10/25/2010 The American Red Cross recognizes this certificate as valid for N/A Year(s)from completion date. www.RedCross.org Instructor's Signature g n Chapter { Cape Cod&Islands Chapter IHolder's Signature BASIC LIFE SUPPORT 0 BLSAmerican Provider Heart Association Roger Troupe has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Training Center ID Instructor ID 02112303145 MA00640 Training Center City, State eCard Code 205503338080 Pembroke, MA Training Center Phone QR Code Number Eli. - o (781)826-2011 x - '';, To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 BASIC LIFE SUPPORT 0100 BLSAmerican Heart Provider Association. Theodore zambelis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Training Center ID Instructor ID 02112303145 MA00640 eCard Code Training Center City, State 205503338083 Pembroke, MA Training Center Phone QR Code Number (781) 826-2011 i 7 To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 BASIC LIFE SUPPORT BLS lkip American Provider Heart Association. Angie zambelis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 eCard Code Training Center City, State 205503338082 Pembroke, MA Training Center Phone OR Code Number 1E' (781)826-2011 31'} i,_ To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 BASIC LIFE SUPPORT ele BLSAmerican Provider Heart Association. Theodore zambelis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 eCard Code Training Center City, State 205503338083 Pembroke, MA Training Center Phone QR Code Number (781) 826-2011 of o i4-?.1 yrt# To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20