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HomeMy WebLinkAbout2022 App-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-21-3581-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NOBERT GINTER 170 SEAVIEW AVE OCEAN BREEZE MOTEL SOUTH YARMOUTH, MA 02664 170 SEAVIEW AVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE 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. Conditions OUTDOOR SWIMMING POOL Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, ! 'H, '.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-21-3583-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NORBERT GINTER 170 SEAVIEW AVE OCEAN BREEZE MOTEL SOUTH YARMOUTH, MA 02664 170 SEAVIEW AVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel 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 MP .S., CHO Heal Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-21-3585-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NORBERT GINTER 170 SEAVIEW AVE OCEAN BREEZE MOTEL SOUTH YARMOUTH, MA 02664 170 SEAVIEW AVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast 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. Murp , MPH, R.S., CHO Health Director TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2022 *Please complete form and attach all necessary documents by December 18,2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: GCE-4 ' 1 EEZ E ./440/-6-4- TAX ID: LOCATION ADDRESS: /74621 •S'E•9‘,/vt✓ Adam, `19 th' TEL.#: sog -393E . MAILING ADDRESS: l7 S vtt'.i 9 4A7 6, E-MAIL ADDRESS: IF► �'�©Cl°5►hbv"«Le7/9d-ha✓:f•S OWNER NAME: NC%Ra5 P-i 64.4-4-e CORPORATION NAME(IF APPLICABLE):_ 6-1,4J Z W trfr f 9l•/ry cl c MANAGER'S NAME: /J O 6r6vT42 TEL.#: 617- els--4 o G MAILING ADDRESS: /7.0 -56-441/c'41 qvc� '/. i2 s, Cia.6 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operra,rr((s))and attach a copy of the certificationtito this form. 1. / k OF-166(2-r- �It1 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' `/ i�records. You must provide new copies and maintain a file at your place of business. 1. /V IegC r`/ < ' - 2. 1,t,)JL.4' CS-fAire-l_ 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. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 OTEL $110 _INN $55 CAMP $55 WIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 _>I00 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 = $ asS.ac7 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE 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 COMPENSATION 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 prior to 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.MG 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 CAFES: 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 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 18,2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY :OA MD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT 'LA DATE: 31,E z t/ SIGNATURE: PRINT NAME&TITLE: /" i % 64 Rev.10/15/19 w d U U O C Co Q 0 I gm Co .a -a o 13 N 2 I Y▪ = cn a° ■® ✓ia az L ° s a (I) L a 4; v Lw ■� — a N v = o �, m ro 71 0 o W a CSS ••� "" Z 6 L •.� .P a) --.1 8 V .111 as ...c E E ^' /1 J o °; I- - V I- d-a E— o z z aZQ 1, •� ' a Q L. ai ai 6 O , ■-d . N Ifb z a ,N 0 d o Q z C = a ID Q U♦ O - U ..40 cu c0 Q a 0Ilia C0 N6 '6 w � C Q am Z & 0 i Cr) _O 0 U Q a. 4J > ula CU 1 111 MI c as I N. Z u_ ■ " o L 4' Cr)CO 0 Certificate of Completion American Norbert Ginter Red Cross has completed the requirements for Adult and Pediatric First Ald/CPR/AED a • ti•• jJ conducted byj American Red Cross 1, •:-'z} Date Completed:08I15/2014 ti • Valid Period:2 Years D• _• Certificate ID:GYBKQD Scan code or vSI: https://www.redcross.org/take•a-class/circode?certnumber= GYBKQD uocualgn tnveiope Iu:I-1)9/9B2B-4844-4F4B-942A-3C04106C092E A`CC)?J WORKERS COMPENSATION APPLICATION DATE(MM/DDJYYYY) 12/14/2021 AGENCY NAME AND ADDRESS COMPANY: A.I.M.Mutual Insurance Companies Richardson Insurance UNDERWRITER: 205 Hanover St APPLICANT NAME Ginter Hospitality LLC DBA:Ocean Breeze Motel OFFICE PHONE MOBILE PHONE: 617-835-4068 Hanover MA 02339 MAILING ADDRESS(including ZIP+4 or Canadian Postal Code) YRS IN BUS: 170 Seaview Ave SIC: PRODUCER NAME CS REPRESENTATIVE NAILS: NAME: South Yarmouth MA 02664 WEBSITE — OFFICEPHONE ADDRESS: (A/C No 781-826-5161 E-MAIL ADDRESS: nginter@verizon.net MOBIMOBILE E: SOLE PROPRIETOR CORPORATION X LLC TRUST UNINCORPORATED FAX 781_829 9287 SUBCHAPTER ASSOCIATION C.No) PARTNERSHIP "S'CORP JOINT VENTURE OTHER: MAIL info@insurewithrichardson.com CREDIT ADDRESS: BORE LLNAME: ID NUMBER: CODE SUB CODE: FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER OTHER RATING BUREAU ID OR STATE EMPLOYER REGISTRATION NUMBER AGENCY CUSTOMER ID: STATUS OF SUBMISSION BILLING/AUDIT INFORMATION BILLING PLAN PAYMENT PLAN AUDIT X QUOTE ISSUE POLICY BOUND(Give date and/or attach copy) v X AGENCY BILL ANNUAL AT EXPIRATION MONTHLY — ASSIGNED RISK(Attach ACORD 133) DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL QUARTERLY %DOWN: QUARTERLY LOCATIONS LOCft HIGHEST FLOOR STREET,CITY,COUNTY,STATE,ZIP CODE 1 170 Seaview Drive,Yarmouth,MA 02664 POLICY INFORMATION PROPOSED EFF DATE PROPOSED EXP DATE NORMAL ANNIVERSARY RATING DATE RETRO PLAN PARTICIPATING 12/17/2021 12/17/2022 PARTNON-PARTICIPATING 1-WORKERS PART 2-EMPLOYER'S LIABILITY PART 3-OTHER DEDUCTIBLES COMPENSATION(States) IN/A In WI) AMOUNT/% OTHER COVERAGES $ 500,000 EACH ACCIDENT — STATES INS MEDICAL (N/Ain WI) — MANAGED MA U.S.L.8 H. CARE OPTION $ ,� DISEASE-POLICY LIMIT _ INDEMNITY VOLUNTARY — COMP _ $ 500,000 DISEASE-EACH EMPLOYEE FOREIGN COV DIVIDEND PLAN/SAFETY GROUP ADDITIONAL COMPANY INFORMATION SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTS(Attach ACORD 101,Additional Remarks Schedule,if more space is required) TOTAL ESTIMATED ANNUAL PREMIUM-ALL STATES TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES TOTAL MINIMUM PREMIUM ALL STATES TOTAL DEPOSIT PREMIUM ALL STATES $ $ $ CONTACT INFORMATION TYPE NAME OFFICE PHONE MOBILE PHONE E-MAIL INSPECTION Norbert Ginter ACCTNG RECORD CLAIMS INFO — INDIVIDUALS INCLUDED/EXCLUDED PARTNERS,OFFICERS,RELATIVES(Must be employed by business operations)TO BE INCLUDED OR EXCLUDED(Remuneration/Payroll to be Included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo. STATE LOC# NAME DATE OF BIRTH TITLE/ OWNER- RELATIONSHIP SHIP% DUTIES INC/EXC CLASS CODE REMUNERATION/PAYROLL MA 1 Norbert Ginter LLC Manager All 100 Exc 9052 15,000 ACORD 130(2013/09) Page 1 of 4 ©1980-2013 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD uocuoign tnveiope w: I-U9/y626-4B44-4F4B-942A-3C04106C092E GENERAL INFORMATION (continued) AGENCY CUSTOMER ID: EXPLAIN ALL"YES"RESPONSES Y/N 17. ANY OTHER INSURANCE WITH THIS INSURER? N 18. ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED IN THE LAST THREE(3)YEARS?(Missouri Applicants-Do not answer this question) N 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? N 20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES? N 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If"YES",#of Employees: N 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE(5)YEARS? (If"YES",please specify) N 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES,EXPLAIN INCLUDING ENTITY NAME(S)AND POLICY NUMBER(S). N SIGNATURE Copy of the Notice of Information Practices(Privacy)has been given to the applicant.(Not required in all states,contact your agent or broker for your state's requirements) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE: USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES.YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.THESE RIGHTS MAY BE LIMITED IN SOME STATES.PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,or WV. Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials): Applicable in AL,AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly(or willfully)*presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies, Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony(of the third degree)*. `Applies in FL Only. Applicable in KS: Any person who,knowingly and with intent to defraud,presents,causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,or in support of,an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties(not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN,VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties(may)*include imprisonment,fines anc denial of insurance benefits. *Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than ten thousand dollars($10,000),or a fixed term of imprisonment for three (3)years, or both penalties. Should aggravating circumstances[be]present,the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. APPLICANT'S SIGNATURE(Must be Officer,Owner or Partner) DAT PRODUCER'S SIGNATURE 12/16/2021 1 :44.&—RM PST NATIONAL PRODUCER NUMBER Ml'k44 Aklu Mi Luh.fa.„,50„ Ato 130(2013/09) Pad 4"ar4 r.-7uwnrLvwAwrrwusAkanvsaNa tyrrata s 'AducL mt06C092E N STATE RATING SHEET# OF SHEETS 6. ARE SUB rnMTRRACTCRR I ISFI Y ES".give%of work subcontracted) STATE RATING WORKSHFFT '.Fd "IEI H'al rF AFEH AN ADDITIONCE?NAL PAGE"2 OF Il for this work THIS FORMust be included in the State Rating Worksheet on Page 2) N .RAGTANOtIIf E 91A1'PONOGGRAR1 PERATION? N -te - app � ,DUTIES,CLASSIFICATIONS . • 'IfED d. ANY GRDUP l RA PCI�BITION PR RIESFULL PART `IC ESTIMANAICS REMUNERATION/ RATE ANNUAL MANR4L TIME TIME PAYROLL PREMIL M gg�� ��� Hotel 10.1 ANY ER%P��WYEES LNDER 18 OR OVER 60 YEARS OF AGE? 2 35,000 N 11. ANY SEASONAL ENPLOYEES? N '12. IS THERE ANY VOL JNTEER OR DONATED LABOR? (If"YES",please specify) N 13. ANY EMPLOYEES 1MTH PHYSICAL HANDICAPS? N 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and fiequency) N 15. ARE ATHLETIC TEAMS SPONSORED? N 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? ACORD 130(2013/09) Page 3 of 4 PREMIUM STATE FACTOR FACTORED PREMIUM TOTAL N/A $ FACTOR FACTORED PREMIUM INCREASED LIMITS $ SCHEDULE RATING• DEDUCTIBLE' $ CCPAP $ EXPERIENCE OR MERIT $ STANDARD PREMIUM $ MODIFICATION $ PREMIUM DISCOUNT $ EXPENSE CONSTANT N/A $ ASSIGNED RISK SURCHARGE• $ TAXES/ASSESSMENTS' ARAP• $ N/A $ • N/A in Wisconsin TOTAL ESTIMATED ANNUAL PREMIUM MINIMUM PREMIUM DEPOSIT PREMIUM $ $ $ REMARKS(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ACORD 130(2013/09) Page 2 of 4 +.�.�..+y1-liveiupe ruaI b-4ts44-4r4ti-U42A-:3CU4106C092E PRIOR CARRIER INFORMATION/LOSS HISTORY AGENCY CUSTOMER ID: PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER&POLICY NUMBER ANNUAL PREMIUM MOD #CLAIMS AMOUNT PAID RESERVE CO: POL# CO: POL#. CO: POL#: CO: POL# CO: POL# NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS,OPERATIONS AND PRODUCTS:MANUFACTURING-RAW MATERIALS,PROCESSES,PRODUCT,EQUIPMENT;CONTRACTOR-TYPE OF WORK,SUB-CONTRACTS;MERCANTILE-MERCHANDISE,CUSTOMERS,DELIVERIES;SERVICE-TYPE,LOCATION;FARM-ACREAGE,ANIMALS,MACHINERY,SUB-CONTRACTS. GENERAL INFORMATION EXPLAIN ALL"YES"RESPONSES YIN 1. DOES APPLICANT OWN,OPERATE OR LEASE AIRCRAFT/WATERCRAFT? N 2. DO/HAVE PAST,PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING,TREATING,DISCHARGING,APPLYING,DISPOSING,OR TRANSPORTING OF HAZARDOUS MATERIAL?(e.g.landfills,wastes,fuel tanks,etc) N 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? N 4. ANY WORK PERFORMED ON BARGES,VESSELS,DOCKS,BRIDGE OVER WATER? N 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? N 6. ARE SUB-CONTRACTORS USED?(If"YES",give%of work subcontracted) 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If"YES",payroll for this work must be included in the State Rating Worksheet on Page 2) N 8. ISA WRITTEN SAFETY PROGRAM IN OPERATION? N 9. ANY GROUP TRANSPORTATION PROVIDED? N 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? N 11. ANY SEASONAL EMPLOYEES? N 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If"YES",please specify) N 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? N 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and frequency) 15. ARE ATHLETIC TEAMS SPONSORED? N 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? ACORD 130(2013/09) Page 3 of 4 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-21-3583-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NORBERT GINTER 170 SEAVIEW AVE OCEAN BREEZE MOTEL SOUTH YARMOUTH, MA 02664 170 SEAVIEW AVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel 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 MP , 9.S., CHO Heal p„ Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-21-3585-01 Issue Date: 1/1/2022 Mailing Address: Location Address: NORBERT GINTER 170 SEAVIEW AVE OCEAN BREEZE MOTEL SOUTH YARMOUTH. MA 02664 170 SEAVIEW AVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast 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 ' r Bruce G. Murp ,MPH,R.S.,CHO Health Director r, - •= --_,-- =..._- -.--„,_ r pp II Iti,Ilh�.�j nl` ,III, 1 III, p1�41 I�i�l"� iNle.,,l...,„, _, Ilr �If 'Io`N ,, r r+ ,q,I, fit ,u�41�'. i llll ,"'ll�ilir' �. . ■ wwww.capecodsaf etytraining.c�c(in) ■ ■ G NSC CPR Course National Safety Council Adult, Child,lli�l�� f lit ii , : I & AED j)1911i1 i' 11,91111aiu�l I Iu'.- ,q411 I i�l�i I, �h�l��li llli �.�l llll .0,1111;Ai h4l l Name: Alexander Ginter 'I'J iile,1,1, �ll',Ily ritii,,�I ,II;°, Illlliil�ill ',II;1,, Security Control No. Address: Ocean Breeze Motel 1,II.,,I ,I Iq i I�,,'II; I,,, nod�lm 948709 Address: 170 Seaview Ave - City, State, Zip: South Yarmouth,MA 02664 uI .�,li ailp lII\I, tli.,IlP ,III�#11 Ili Course Completion Date: 0512212023 Training Center: Cape Cod Safety Training Expiration Date: 05/22/2025 Instructor Name: Rick Todd Instructor Number: 1040918 Alexander Ginter has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. F llilli ��� tII liI 1,I %0 „,,,Ile i u'� � , , ..1.11 41inlla -", \ The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining . F' THIS DOCUMENT IS VOID IF REPRODUCED 1plill�i�,d.. 7 ,,I it lliill\lrii 01�, ✓ N U. hSC Security Control No. """n"° yCow.. 949709 • • nsc - Alexander Ginter National Safety Council has completed the, We want your feedback! - NSC CPR Course Adult,Child,Infant FBAO&AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to " completion Date: 05122,2023 take a brief survey and share your opinions Expires: 05122/2025 Instructional Hours: about the NSC course you completed. 71,' ...,;-r.- #104091g Instructor Signature Instructor No. Keep this card for your records.Void if reproduced. SOM11092021 2020 National Safety Council 79174-0000 II)I 1li„lyr ,il„,(„,„,,l:. Dili II�l illt,Vll hill Y ilill'lllllof lulln,i 4c IIIIII 'll IIIPm,'' ll,,,,9Iii, ', II�II I�pl �Illl l" ll4www. apecsfyaa.con I .,nSC - ,, 1 ■ • NSC CPR Course National Safety Council Adult, Child, Infant, FBAO & AED Name: Norbert Ginter Security Control No, Address: Ocean Breeze Motel 948711 Address: 170 Seaview Ave City, State, Zip: south "17 a,t}IloL1 .0 02664 Idlillll ll'$Iq 'q N lj,,u I IqII,,ull II;IIqI�q ulel lI•I I i'lliqll I iI'pl li i "I i4111",. III li Course Completion Date: 05122,12028 TrainingCenter: i Cape Cod Safety Training Expiration Date: 0512212025 Instructor Name: Rick Todd Instructor Number: 1040918 u41 ilyl �l , l " ,Illi l,I INorbert Ginter = 1,, I�,l;g ,; 111l��, oh,l ,iL lNN,u has successfully completed the NSQ CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED _.. lllllllilllll Ill1l IIIIllI I Ill�lli � Ill i0II1171111V�ii • - ,q II I��Ih014;ll u", Ijilll • II'II lllllilll;u IIIII I d1., '" I jll11lllllli�1"1,'lull � ::nSC Security Control No. nsc 948711 u, '� ' 1i' Norbert Ginter •National al • Safety Council ,,. Nlili�'iltt 4 N I iii ii"�I 1 r ryw i. l' Ili��� o9 il','':: ' 1 ,i�: has completed the We want your feedback! - NSC CPR Course Adult,Child,Infant FBAO&AED Training Center: Completion Date; Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to 05/22/2023 Expires: 05122/2025 Instructional Hours: I take a brief survey and share your opinions 1 about the NSC course you completed. L- 104O918 �- 1�T s iI Instructor Signature Instructor No. K ,, ' ,,,,,, ,,,,:,,,, , ,,,'',',,,,,,, _} Keep this card for your records.Void if reproduced. 50M11092021 ©2020 National Safety Council 79174-0000 u Qilllll I II II Iliill IL q I I III,, .,,;II II www.capecodsafetytraini .grconl ■ . flSC NSC CPR Course National Safety Council Adult, Child ,Infant FBAO & AED Name: Joanna Ginter Security Control No. Address: Ocean Breeze Motel 948710 Address: 170 Seaview Ave City, State, Zip: South.Yarmouth,MA 02664 Course Completion Date: 0512212023 P Training Center: Cape Cod Safety Training 1.1 Expiration Date: 05122/2025 Instructor Name: Rick Todd Instructor Number: 1040918 Joanna Ginter has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. will II II i`'It 1411a11 04Idl II I MINI II��'I II Illlr I'll I t 'I I IILI 'l P The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED _ .., li �I III I I III 11 1I,4 PIT I I 'Ii hll l ll Il a hit II ti f Ill1�l,r "N`I Ill II� �N yl ��A�gNI Iryll 111 l Idlgtlll h� Ilnlll- tiI rl -,'4d�lh• .. I I 141�Ii" I �"illlllilhi°j • / ■:nsc SeOurlty Control No. 948710 r1SC'► Joanna Ginter National Safety Council has completed the We want your feedback! NSC CPR Course Adult,Child,Infant FBAO&AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date; p512212023 take a brief survey and share your opinions E"p_ ' 05/22/2025 Instructional Hours: about the NSC course you completed. #1040918 Instructor Signature Instructor No. Keep this card for your records.Void if reproduced. 50M11092021 ©20 20 National Safety Council 79174-0000 n sc ., Tulll ' III,"., �IIh IF ' 'Qlyll�lll o IIIhPlllllllll Ild Il,li LEARNING www.capecodsafetytraining.corn NSC First Aid Course II II ,,,„„I I 9,,;1 i III f IIIIhIMIf OSHA 1910.151 Name: Alexander Ginter Security Control No, Address: Ocean Breeze Motel •:;, Address: 170 Seaview Ave City, State, Zip: South Yarmouth, MA 02664 Course Completion Date: 05/22/2023 Training Center: Cape Cod Safety Training Expiration Date: 05/22/2025 Instructor Name: Rick Todd Instructor Number: 1040918 Alexander Ginter y4 1 „; I'IICI I II I��IIQ'I Ip� Illlh i p , IIII '.�,i,llr'I III,I„ �Vlhl,ml has successfully completed the NSC First Aid Course. 4 l y„ 1�;.1pp 11 Ilht VNtpllb°alllll I141111,�� III IIII ��'I'� III �IIIIII IIoIII0 �IVIII IIII 'I, II ,,u,udlll II The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining • THIS DOCUMENT IS VOID IF REPRODUCED II IIII;,. IIIIIIIG I II'uuP I°nII����� ,'I,�P� ,IIII�,IIifi, I'rl+::v @IN S, I IIII�II�I �IUN�I' iIllllliill H�I 1911II IIIIII�iIINlill'r IIN %N �l llllll l I'I ppII r, � elr I,Imull ,I �Inlll �III',l.;l„ II .gl�4,llh ._ illlp IIkI, S I ty CohtibioNo. nsc ::nsc LEARNING 257874 LEARNING Alexander Ginter has completed the NSC Ffrt Arl,d ,Course We want your feedback! Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 0502/2023 take a brief survey and share your opinions Expires: 05122/2025 Instructional Hours: about the NSC course you completed. /—"gyp.---' 41040918 Instructor Signature Instructor No. IVSC-in it for life` nsc.org/fatraining) Keep,this card for your records.Void if reproduced. J � Il r,ndllil �I'I, it+a�,n 1,,1.� lull wf - 20M08112022 1015 900008129 02016 National Safe,,,y Coi ipcfl 7$,1'3 o(�pp, I. dllPllll I ,., 11sc II,I.,,,,, Iir,,,Il 'I til,y a �IPI • • . . . I,plit +.h„IIII IIIIII"IIII 4,m qki a WW.C_c1pecousa,�tet t'c`f..iiiiri .cpr . , 11�,. L EA R N I N G lug °,l i�'I „�"III �NSb First Aid Course 'I'II° I 0 III 1 p;I°I .'rWm rl,),„ 1 I ''I I,,i,l $0,:,. II,I Iy1111Y :i ll Il pll I I,,,, 1 141 1 ��Ilq �PI�IIII Illlull �nl0llp;„l1 OSHA 1910.1511I II ,iI" ,,hh,li iit,l,lp, ,„ihh. ^IIJ;' Illtlllld!,,,,II Ih„IIII .°�n,IIP.,,I II IIIIIIIduI �� ; III IIIIL- I II III,. -1 IIII, II �� nlllnun I IIII I l it . ,I'r I�,t, I,'lo iilI�hltw,„IM, Name: Norbert Ginter ;,I'o IiI�f. r Iln l t ; Iu��iN' dlr,; Security Control No. I�1411.IIM I,I I'I h9,, I,iln Ill i.:I I Address: Ocean Breeze Motel II,.II.. IIII IIIIuutI11.,ii l t1,14.:. �IIIII�IIpoll'' 2 �1 8„,,„,, '16 Address: 170 Seaview Ave City, State, Zip: South Yarmouth, MA 02664 IgII l.ii, ,Il�lplln I,,;miilllll,l Ill,lllll ll�: III ,� i �N �G I Iiy „ ; I IIIr,"�I�)III 'IIIIIII IIIHI alllllll I P Ih\illllnllllgll,� Il llill dill I M l i I,I" h II'+� li I I I I„ 1 I I DII Ilu 'i IIIIII"„ I IIIII I itlll llll,., III,9 III\11,,„,� Course Completion Date: 0512212023 Training Center: Cape Cod Safety Training Expiration Date: 0512212025 II$il,l .III i Il!I I°h l Instructor Name: Rick Todd hl�' II� l 05 p' I"Hid Ih4,,, I� dI ,,, illirt ll'u 4loi 0 iln, Instructor Number: 1040918 4; ""' II . I IINd I 1IIIdl' I;ii • k ,,,, ., w, a b'� l; uII 'I wI '� I�gll 1,I; , ll;� �1, I I lh ,llIII,„IIi;�� Norbert Ginter u9p Pli ll ;," I I has successfully completed the NSC First Aid Course. �IIIIyI IIII I IIII II'.,;;k IIIII IIIIII ..hiil, o f 6iII I,d I.°tl.',!- The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining __ _� THIS DOCUMENT IS VOID IF REPRODUCED ITA'tH 1,!.�I II�ItIIIIIII III Iil�llp iPl" I."" I Itl 4 II I d4 dlllll�I �'�I i, 9' rg1'1,1 I,will !�Il yll :,'•,I+I,IN II5 Illll�lil I�I WI' Iho IIV,II:41 IIW' "� 'I;;IIIIIII;l II II III'�11 II 11' III III IIIII,1 II III / 3" III I / 9 d',,a II��,�I"1 l';'.,"' II IIII Im 'h .• nsc ■.nSC Security Control No. LEARNING LEARNING 257876 O lu IIhll l" IIIIIIII Norbert Ginter ll u'''' , gl ,,,,:i ll I II Ill '4' has completed the I. ° I " Hxh " NSC First Aid Course u I I,. ul. I" � We want your feedback! . Please visit nsc.org/firstaidevaluation to Training Center: Cape Cod Safety Training take a brief surveyand share your opinions n,1i�igl ,I I, Completion Date: 05��g p lllllll, yq IIIIII ,II illl IIIII Expires: 05122/2025 Instructional'Hours: about the NSC course you completed. 11,!1 I.lull "''I i Ili. /7' m , 81040918 Instructor Signature Instructor No. I•.SV/�-in it for !Ifs. nsc.org/fatrainin) Keep may this card for your records.Void if reproduced. s' "IIIIII,:: �I II Ip(%I''„ "�.� -. .. °h I!,II!,IIIVup` d -I Grl' °Ih F 20M08112022 1015 900008129 ©2016 National Safety Council 79173-0000 .. 1�1I 1"ylil� �N'tlll ,"i1 I� Iul