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Home My WebLink About2022 - App-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $335.00 Food Establishment License Number: BOHF-22-1198 Issue Date: 11/8/22 Mailing Address: Location Address: BUENOS AIRES BAKERY& SUPERMARKET 80 ROUTE 28 80 ROUTE 28 WEST YARMOUTH. MA 02673 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Retail; 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. Conditions 40 SEATS Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge �1 Health Eric Weston / 1 Bruce G. Murphy,M .,CHO/James G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Print Form J Department of Industrial Accidents 'r� +„ Office of Investigations ammo - =111'- 1 Congress Street, Suite 100 ,ii= Boston, MA 02114-2017 'moo www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1 e n3S Aire 5 x e( y • p, 't t f1C Address: SO k w (1 ST 2-40c_ Zb City/State/Zip:t j ."jQ1 mOuiif M.i1 O26i 6 Phone #: 508- 5 (-.1 - ' kH 1 1 Are you an employer?Check the appropriate box: Business Type(required): 1.18,I I am a employer with 111- 5 employees(full and/ i 5. ❑ Retail 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 1 1 ❑ 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#l 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#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 4 cmo k.i Qr /Sc - 1 e Q.�e\ , 5C�te(rt. � ran n5 . ra c e. Insurer's Address: 11 Ova (1 .j.4 vv City/State/Zip: 11JQ5+ YQf(14.oU1 .'-- Policy#or Self-ins. Lic. # IT! A Z 2 OctExpiration Date: r I -03 - 20Z 3 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 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,and ains and altiesofperjury that the information provided a ove i true and correct. Signature: • Date: I i 3 22 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 7/2010 MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL ONLINE APPLICATION FOR WORKERS' COMPENSATION INSURANCE Processed By: The Workers'Compensation Rating&Inspection Bureau of Massachusetts 101 Arch Street Boston.MA 02110 Requested Effective Date: 11/3/2022 617-439-9030 Payment for the MA Workers' Compensation Assigned Risk Pool Online Application (OAR) must be made by electronic check. Coverage will not be provided unless the electronic payment is processed through OAR within two business days from the date the application status is set to Assigned Pending Payment. Under no circumstance will coverage be assigned if: the declination requirements are not met;there is a record of coverage in force for the entity making application;the applicant is in default of premium for prior workers'compensation coverage;or,the applicant has an audit or inspection from a prior workers' compensation policy that remains incomplete due to the applicant's failure to cooperate with the prior insurer. The earliest possible date coverage can be bound is at 12:01 a.m.the day after the application is submitted to OAR. The undersigned employer has failed to obtain workers' compensation and employers' liability insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Workers'Compensation Assigned Risk Pool and expressly represents that such insurance is sought in good faith. I. GENERAL INFORMATION BUENOS AIRES SBAKERY AND SUPERMARKET Name of Employer(Name the sole proprietor,general partner(s)or the trustee(s)along with the trade name of the business.) 881779710 1 Federal Employer Identification Number(FEIN) Total Niimher.of MA I orations: 80 MAIN ST WEST YARMOUTH MA 02673 508-364-6984 Mailing Address City State Zip Phone 80 MAIN ST WEST YARMOUTH MA 02673 508-364-6984 Principal MA Location City State Zip Phone 80 MAIN ST WEST YARMOUTH MA 02673 508-364-6984 Location of Records City State Zip Phone Other Massachusetts Location City State Zip Phone Years In Business: None-New ❑ Employer Website: Legal Status: ['Sole Proprietor Partnership ✓❑Corporation ['Trust Limited Partnership LLC El Municipality LLP Other(Explain): II. ELIGIBILITY REQUIREMENTS To be eligible to obtain assigned risk coverage: •The employer's application for voluntary Massachusetts workers' compensation coverage must have been rejected by two (2) carriers licensed to write workers compensation in Massachusetts; •The employer must not be in default of premium for Massachusetts workers'compensation insurance; .The employer must have complied with all laws, orders, rules and regulations in force and effect relating to the welfare, health and safety of employee and; •The employer must not have an audit or inspection on a prior workers' compensation policy that remains incomplete due to the employer's failure to cooperate with the insurer. 1. List the names, representatives, dates of discussion, and phone numbers of two insurance companies from different NAIC carrier groups, who are licensed to write workers'compensation in Massachusetts and who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must be an employee who has authority to bind coverage for the insurance company. A failure to reach such a representative cannot be construed as a refusal to write coverage. Name of Insurance Company Full Name of Representative Declination Date Phone NGM CHRIS NAZZARO 10/31/2022 800-258-5310 HANOVER CHRIS WHELAN 10/31/2022 800-922-8246 la.Has the employer's coverage,either voluntary or assigned risk, recently terminated or expired? ❑Yes ❑✓ No Note:If Yes,a copy of the cancellation or nonrenewal notice must be attached,and the reason for the cancellation or nonrenewal must be indicated on the notice. If the coverage was in the voluntary market within the past sixty days, the cancellation or nonrenewal will serve as one of the two required declinations. Generally, coverage must be replaced in the voluntary market if voluntary coverage was cancelled or nonrenewed at the employer's request. 2. Have you received any offers of voluntary coverage? ❑Yes ❑✓ No 2a. Does the offer of coverage include multi-line,deductible,or retrospective rating terms? ❑Yes ❑No 3. Is there any unpaid workers'compensation premium due from you or any other commonly owned enterprise? ❑Yes ✓❑No ❑Unpaid Premium ❑Premium Dispute ❑Payment Plan (Select most appropriate) If Unpaid Premium selected,provide: Entity Name Ralance Policy Number(s) If Premium Dispute selected,a copy of the letter sent by the employer to the carrier disputing the premium with full explanation must be attached to this application for WCRIBMA consideration. If Payment Plan selected,a copy of the signed payment plan agreement between the employer and the carrier must be attached to this application. 4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy? Li Yes ✓❑No If yes,provide the name of the insurance company and the policy number(s). Insurance Company Policy Number(s) 4a. Has an audit been scheduled? ❑Yes ❑No If yes,provide the insurance company contact name and phone number. Insurance Company Contact Name Contact Phone# III. CORPORATE OFFICERS, SOLE PROPRIETORS,PARTNERS& MEMBERS For Sole Proprietors,Partners,LLC Members and LLP Partners: List the Name,Titles,Ownership,Duties of all Proprietors,Partners or Members. Select'ELECT'to indicate whether each is electing coverage;otherwise, select'EXEMPT'. Sole Proprietors, Partners and Members are not covered unless they elect coverage.To elect coverage, a letter must be attached on company letterhead in accordance with MA Regulation 452 CMR 8.07. Refer to the MA Workers Compensation&Employers Liability Insurance Manual,to the Rates Page with Miscellaneous Values,for Sole Proprietors', Partners'and Members' Basis of Premium.In Section VI include the Basis of Premium for all sole proprietors,partners and members electing coverage. For Corporations: List the Name,Titles,Ownership,Duties and actual Salary of all officers listed in the Corporate Articles of Organization. Select 'EXEMPT' to indicate whether each has chosen to waive coverage in accordance with MA Regulation 452 CMR 8.06; otherwise, select 'ELECT'. Corporate officers will be included unless a Form 153 has been submitted to and approved by the MA Department of Industrial Accidents.A copy of the DIA stamped and approved Form 153 must be attached to this application. Corporate officer salaries may be subject to payroll limitations; refer to the MA Workers' Compensation Employers Liability Insurance Manual, Part One - Rule IX. Include the salary, subject to minimums and maximums, of all non - exempt corporate officers in Section VI of this application. Name Tide I%Ownership ( Elect/Exempt 1 Duties Salary _ CARLOS A SUAREZ PRESIDENT 100.00 ELECT SUPERVISORY 14,560 IV.INSURANCE RECORD 1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? ❑Yes ✓❑No 2. If Yes.complete the following for the most recent three years: Po Insurance Company Policy Number Fromflcv PeriodTo Premium 3. If No,complete: New Business ❑Uninsured ❑Self Insurance Group ❑Self-Insured ❑Other(Explain): 4. Was the applicant self-insured within the last twelve months or was the applicant's expiring policy subject to the Premium ❑Yes ✓❑No Determination Endorsement—Former Self-Insurers 1? If Yes, former self insurers who are subject to Premium Determination Endorsement— Former Self-Insurers 1 cannot submit an online application through OAR. A paper application must be submitted. Refer to the Pool Procedures for New Applications for details. Former members of self insurance groups are not subject to this endorsement. 5. Has the employer received a Stop Work Order from the DIA? ❑Yes ❑✓ No 6. Is the employer in bankruptcy? Elves QNo 7. Does this entity or any other commonly owned entity have operations in states other than MA? 0Yes QNo 8, Has there been a name change within the last five years? ❑Yes 0 No 9. Has there been a merger or consolidation within the last five years? ❑Yes QNo 10. Has there been a sale,transfer or conveyance of ownership interest within the last five years? ❑Yes ✓❑No 11. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last ❑yes ✓❑No five years? 12. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? ❑Yes QNo V. BUSINESS OF EMPLOYER 1. Completely describe all operations of the employer. If there are multiple locations. provide a description for each. SUPERMARKET AND BAKERY 2. MA law provides that you,the employer,are liable for injury of employees of uninsured subcontractors.Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontracted labor will be utilized during the policy term? ❑Yes ❑✓ No If YES,estimate payrolls made to subcontractors without certificates of insurance. 3. Do you use independent contractors? ❑Yes ❑✓ No If Yes,you must maintain documentation which supports that they are,in fact,independent contractors in accordance with MGL c 149§ 148B. If such documentation is not available,or if the designated carrier finds evidence of an employment relationship,then premium may be charged as if the individuals were employees. 4 Does the employer lease employees to other businesses? ❑Yes ❑✓ No 4a. This application is for: ❑your own employees not subject to an employee leasing arrangement. ❑employees leased to a client company. Client Name Client FFIN Street City State ZiD 5 Does the employer provide employees to other businesses but not consider their arrangements to be employee leasing arrangements in accordance with 211 CMR 111.00? ❑Yes ❑✓ No 6 Does the employer lease employees from or regularly have temporary employees supplied to them from another business? ❑Yes ❑✓ No 6a. Is this application for your own employees not subject to an employee leasing or temporary help arrangement? ❑Yes ❑No 7 Does the employer operate a trucking or delivery business? ❑Yes ❑✓ No 8 Does the employer operate as a general or subcontractor in commercial or residential construction operations? ❑Yes ❑✓ No 9 Provide the employer's revenue for its last fiscal year: $1 and the fiscal year end date: 09/30/2022 VI. MASSACHUSETTS CLASSIFICATIONS, PAYROLL, AND PREMIUM CALCULATIONS Shift Clans g Actual Estimated Location # Code Classification Phraseology L Number of Payroll for Payroll for' Rate Premium H Employees Past 12 Months Next 12 Months 1 1 2003 BAKERY&DRIVERS,ROUTE SUPERVISORS 5 0 208,000 3.13 6,510 Admiralty Employers Liability Limits Selection: Factor ❑Standard$10,000 ❑$50.000 ❑$100,000 Manual Premium _ 6,510 Waiver of Our Rights-No Employers Liability 9845-Standard Limits Admiralty Liability Deductible- None VII. DEPOSIT REQUIRED: Experience/Merit Rating 1.Installment Options ° MA Construction Credit- 0% Total Estimated Installment Deposit Additional Standard Premium 6,510 Premium Basis Factor Payments Under$5,000 Annually 100% Nnne ARAP 0.00 At Least$5,000 Semi-Annually 75% Ono Loss Constant At Least $10,000 Quarterly 50°/ Three Expense Constant 338 Terrorism Premium .03 62 At Least$25.000 Monthly 25% Nine Premium Subject to Total Policy Minimum Premium 6,910 2.Is premium being financed through a premium ❑Yes ✓❑No Total Policy Minimum Premium 269 finance company? 3.Any binding of coverage is conditional until the electronic funds have cleared. If Total Estimated Premium 6,910 the electronic funds requested are denied,the employer will be given ten(10)days DIA Assessment .0418 272 to provide the carrier with a bank check or money order for the full amount of the required deposit. Only if sufficient funds are received by the carrier on a timely Total Estimated Premium Plus DIA Assessment 7,182 basis,will coverage be effective as of the tentative binding date on the Notice of Deposit Premium- Annual 100% 7,182 Assignment issued by the WCRIBMA. VIII.APPLICANT'S AGREEMENT By signing this application,I certify under the pains and penalties of perjury that: (i)I am the employer or have been authorized by the employer to complete this application and any necessary Supplemental Applications on its behalf; (ii)All information provided on this application and on any Supplemental Applications and attachments is true; (iii)I understand that the WCRIBMA and the assianed carrier are relying on this information when providina coveraae: (iv)I understand that I have a continuing obligation to promptly notify the assigned carrier of changes in the type of work conducted,the amount of payroll,the business name,legal status or ownership,or a change in the mailing address or business location;and (v)I have read and understand the following statements to which I agree by signing this application. In consideration of the issuance of a Notice of Assignment and subsequent policy of insurance, I hereby certify, under the pains and penalties of perjury,that: 1. I made a good faith effort,but failed to obtain coverage through the voluntary MA workers'compensation insurance market; 2. I am not knowingly in default of premium on any MA workers'compensation insurance policy; 3. I have complied and will continue to comply with all laws,orders, rules and regulations in force and effect relating to the welfare,health and safety of employees, including but not limited to: a. Allowing the carrier to make a careful inspection of my operation for the purpose of measuring the hazards, making recommendations for the health and safety of employees,and determining the rate or rates which are adequate and reasonable; b. Complying with the carriers'reasonable recommendations aimed at controlling or reducing the hazard(s)insured against; c. Keeping records of information needed to compute premium and providing the carrier with copies of those records when asked for them;and d. Fully cooperating with the carriers'attempts to conduct premium audits or inspections of the premises for loss control purposes. I understand that the employer's compliance with each of these certifications is material to the issuance of assigned risk pool coverage. Business Name of Applicant BUENOS AIRES BAKERY AND SUPERMARKET Signature CARLOS ARIEL SUAREZ Title PRES Signer's Email Address BUENOSAIRESBAKERYCAPECOD@GMAIL.COM Date 11/2/2022 Original Signature For Printed Copy: NOTICE: This insurance is being provided through the MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL, and not through the voluntary market. The employer's non-compliance with certifications 1,2 and 3(a-d)may,to the extent allowed by Massachusetts law, cause the carrier to initiate a mid-term cancellation. FRAUD NOTICE: Massachusetts General Law,Chapter 152,Section 14(3)provides: "(A)ny person who knowingly makes any false or misleading statement,representation or submission or knowingly assists,abets,solicits or conspires in the making of any false or misleading statement, representation or submission, or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment, coverage or other benefit for the purpose of obtaining or denying any payment, coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...shall be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars, or by both such fine and imprisonment." IX. AGENCY INFORMATION AND PRODUCER'S STATEMENT The producer hereby certifies,under the pains and penalties of perjury,that all information provided is true to the best of his/her knowledge and belief and that he/she made a good faith effort to place the coverage in the voluntary market as required by M.G.L.,C.152,Section 65A. SCHLEGEL&SCHLEGEL INSURANCE 043304026 1782209 Name of Agency FEIN Producer License# 34 MAIN ST Mailing Address of Agency WEST YARMOUTH MA 02673 508-771-8381 City State Zip Phone JIM HINDMAN Producer Name JHINDMAN 11/02/2022 Signature of Producer Date Signer's Email Address JIMMY@SCHLEGELINS.COM Original Signature For Printed Copy: �✓ By checking this box,I certify that I am the producer of record. Q By checking this box, I certify that I have reviewed Section VIII of the application with the applicant prior to his/her signing. 0 By checking this box, I hereby acknowledge the signatures to this application as original signatures. I request, on behalf of the applicant, the designation of an insurance company to provide insurance in accordance with the provisions of the Massachusetts Workers Compensation Assigned Risk Pool,and I certify that I have reviewed the applicant's responsibilities with the applicant and will retain a copy of the completed application with the applicant's and the producer's original signatures for a period of not less than five(5)years. • "Asitm PEST CTRtL _P.O. Box 464 • Yarmouth, MA 02664 �72 Route 28, Unit 4, West Yarmouth, MA 02673 www.aandmpest.com Service Address Billing Address Name: OA 4i OS K` 2 Name: Address: U t IV! I i ST . Address: City: U3 S � `. f i/►1 aA I I/1 City: Home Phone: tip t� Home Phone: Business Phone: 502 ` 3(0l� - r ( 4 t Business Phone: Area to be Serviced: 3,i kf. The services will be performed as follows: (7-NS-IfittAit d i ) 01 2 RAI S ih-t l NiS oiL 7ftii7ryi Z 04_ AtAirs A(4t) 0-1ti iAo ci tic For this service the customer will pay A&M Pest Control the amobt of: $ 5 3 O , o payable at the time of service. If additional service is necessary to control the problem within "( ),S-- days from the date of the initial service this will be done at no additional cost. If additional service is needed after the contract expiration date there will be an additional char e for this service. Additional services will be done at a cost of $ Pest Services ❑ One time service ❑ Quarterly services: The extermination company will service the property 4 times per year. v4 Ants only: The extermination company will service the property 2 times per year (Summer) Ed Mice only: The extermination company will service the property 2 times per year (Winter) Termite Services ❑ Termite spot treatment liquid ❑ Termite liquid treatment ❑ Advanced baiting system Termite Renewal Not Included, would be Gnats, Mosquitos, Flys or other free flying insects. A&M Pest will inspect for evident of Termites. (Early detection can save you costly repairs, should Termite infestation go unnoticed.) _ 1/— 3- Z. Company Representative: Date: Customer Signature: Date: All service charges are due within 30 days of service rendered. Upon failure to make such payments, the customer agrees to pay all cost of collections, including a reasonahle attorney's fee. 4 . 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CERTIFICATION CARLOS SUAREZ for successfully completing the standards set forth for the ServSafe""Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection (CFP). 10780 IF1c '\ i E AIL ,- : ER EXAM FORM NUMBER 9/24/2022 9/24/2027 DATE OF EX -\A\ICI:\i ICNI DATE OF EXPIRATION Local laws apply. Ch•cl "`iu -,,i1; u, ato t.;'arty for recertification requirements. ANSI ACCREDITED PROSRAM American National Standards Institute ♦ /� C and the Conference for Food Protection (a ,ptFtta , "'� Sher,. $raven } #0655 .a,ti l `i': nacl-)1. �c ci t II ' si::it , ; ':ociation Solutions ;;�;0 Kr T' Inaccordancewi:, ,. _,.,..l frrs .i. 'n ',,:.,d�`l`i :C11' ).•.-.i3? ' ,, :,I �:.'. .t. I.'..• t A..-.---....:.!, -t, I i..r..;... ,i,': =1 s I-.''-.: I ; ..-.'. ..;.-. ServSafe logo ore trademarks of the NRAEF.Notional Restaurant Associatwntte and the atc design ! l' 1'1 I i'.31 I - '.1 ''1 Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL.60606-6383 or ServSate@restaurant.org. fi. " s` • It fi is 4.-•-•"•,,i --- ,..0 4. ,- r ,:.: R A J 't • ... tJ• Ws • • • ,',4-.-:-A:,-7.4..:,4- - -- - --.:T-.L,=,--.31--, LI .... -,A. ', ,„:',4i.:*14.1,01'-,=: ,,,A".- ' :.:6, -.4....,..-`, ' •qq� ve • MOPSrL R r ' t 9 a:;-tea "t} i ^,** VN -, ,, if 1,- -'-.1 ''..''••-•'•.,,,,,_.„.6.-4,-:. ii.,,,,,-,-.: F 4p r ' , ,. .„. 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Name of Recipient: CARLOS SUAREZ 4.,7- J 1 Certificate Number: 5981883 - Date of Completion: 11/3/2022 , `'' T N Date of Expiration: 11/3/2027 et$ , r.r • ��J ••'' -�T (`r a 0' -°r' t~ ,N.a„fin t.C� V41 Issued By: M K, The above-named person is hereby issued this certificate mRIM re �; „7 r .„J for completing an allergen awareness training program �..�r.....� RETS,.ITAAUURANT , � recognized by the Massachusetts Department of Public Health 1114 _ """r" ASSOCIATION® w in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 ;-tom+7 333 Turnpike Road,Suite 102 www.restaurant.org "Ir , �; Southborough,MA 01772 .r This certificate will be valid forfive(5)years from date of completion. 508-303-9905 r -74,e) www.marestaurantassoc.org /t'r ., fial is J J I- , I J I J L I 1 I. „, 4,..•li..%,. ,„,, ..„ * .•*•:1,, 64- ,. ,__..., - ‘-'” 4,-t•Jk- ,- r;._ ...- , , .., ; . 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' 1.,7'" -,F=", ..t, , ' ,• -iF,•,4"'6•-''',„,. *''.:'''.' ..' ,;,:.,'Y "' "4 .' •.• ' - • , ,,.. •':. '• ,$"*".,"1-• . 't'1',. ..,.; ' ' . . ., a.-. -4 ;,. n if •"7 -•„,'.0, ' ' f 26 ' .'A. ' i fl ; + -, ; ' i n' ° [ ,I, $ 4 , . ;ac ' 4 1 , i 1 , '- - ..e.1�c9-e„�c,�.e��.jc�-e.�%: e9-e1r�,. �.eSve� e�trc� a JC,• .-rrrarrsrrra'r:rrrrrrr ( - urrazarrs« riaaisrmsr�rac-re-ati-crr«rsarirr.a�ra«« �}c•.«««rsrs-c+-rrrr«« - c .a,ri..rrr .,... .,> 1. CE RT I F I C AT E OF Sa: ** .14'S' Z17 ;I; , 0104C.., ALLERGEN AWARENESS TRAINING 4 .t> 44 n t"cam, C,• . : Name of Recipient: ANDREA M SOSA 4,,,\� :4) Certificate Number: 5981167 )r.4" R 4.4..11":3' ' Date of Completion: 11/2/2022 "�4� : \ : Date of Expiration: 11/2/2027 Z r.,......k t1/4C,. s , Ot • •' r Issued By: ,.;7 : ?he above-named person is hereby issued this certi sate ®� L NATIONA " 4114 for completing an allergen awareness training program ..... RESTAURANT �� . recognized by the Massachusetts Department of Public Health ASSOCIATION, in accordance with 105 CMR 590.009(C)(3)(a). Massachusetts Restaurant Association 800.765.2122 *.:t3:jV 333 Turnpike Road,Suite 102 www.restaurant.org �"C + 4Southborough,MA 01772 This certificate will be valid forfive(5)years from date ofcompletion. 508-303-9905 www.marestaurantassoc.org (D/IL-y �'e>v�- + � � ` hrY" , �� 4 �itifr�.' J � +�'i! ` �ctjY ' � �1 ` fi�t>t ' -Iv � ` ^„ ' M'►N. �'v.{ t �K47' � � '= �►7 �v u� A v`. ,� Pl u Py t�'v A F--v e * v"� It U ,... fx w ', dk T 4 , a• ."}fie, Y i ?, is k w H4'4 r t x '19T r d e s ;,, + F :. ;e..a if & S+ ..a i I . i :ice • 4. a M ke,z., • EMERGENCY CARE & SAFETY INSTITUTE „' tsu : x ay, rt k t The Education Center, below, verifies that Carlos Suarez has successfully completed the knowledge and skill evaluations for the Emergency Care & Safety Institute Course. Adult,Child,Infant CPR&AED/Standard October 15,2022 October 15,2024 5WZWH183K3NR First Aid Course Name Course completion Date Recommended Renewal Date Student Authorization Number Cape Cod CPR&First Aid Training 508-364-4750 Laurene Scripter EFW7EYG3WOCB Education Center Instructor Name Instructor ID Number info@CapeCPR.com This certificate does not guarantee any future performance or suggest any form of licensure.Skills deteriorate rapidly when not Education Center Email used. Periodic retraining is strongly recommended. Student Authorization#: 5WZWH183K3NR Cut along the dotted line at the bottom of the certificate and along the dotted lines around Education Center: Cape Cod CPR&First Aid Training Education Center Email: info@CapeCPR.com the course completion card. Fold the card in half. Course: Adult.Child,Infant CPR&AED/Standard First Aid Education Center Phone#: 508-364-4750 Instructor Name: Laurene Scripter Name: Carlos Suarez Instructor ID#: EFW7EYG3WOCB The Education Center verifies that the above has successfully Completed the knowledge and skill evaluations for the The ECSI course meets the most current international consensus guidelines on cardiopulmonary resuscitation(CPR)and emergency cardiac care(FCC) Emergency Care&Safety Institute Course. October 15,2022 October 15,2024 To verify course completion,visit www.ECSlnstitute.org and enter the above student authorization number Crnc sn CI, ,pied Renewal Date ECSI Phone Number:(800)71-ORANGE www.ECSInstitute.org EMERGENCY CARE & SAFETY INSTITUTE The Education Center, below, verifies that Andrea Sosa has successfully completed the knowledge and skill evaluations for the Emergency Care & Safety Institute Course. Adult,Child,Infant CPR&AED/Standard October 15,2022 October 15,2024 4QV7NL68R4M2 First Aid CfAtz' ?a = rti Course Completion Date Student Authorization Number Cape Cod CPR&First Aid Training 508-364-4750 Laurene Scripter EFW7EYG3WOCB Education Center Education Center Phone Number Instructor Name info@CapeCPR.com This certificate does not guarantee any future performance or suggest any form of licensure. Skills deteriorate rapidly when not Education Center Email used. Periodic retraining is strongly recommended. Student Authorization#: 4QV7NL68R4M2 Cut along the dotted line at the bottom of the certificate and along the dotted lines around Education center Cape Cod CPR&First Aid Training Education Center Email: info@CapeCPR.com the course completion card. Fold the card in half. Course: Adult,Child.Infant CPA&AED/Standard First Aid Education Center Phone#: 508-364-4750 Instructor Name: Laurene Scripter Name: Andrea Sosa Instructor ID#: EFW7EYG3WOCB The Education Center verifies that the above has successfully The ECSI course meets the most current international consensus guidelines on completed the knowledge and skill evaluations for the Emergency Care&Safety Institute Course. cardiopulmonary resuscitation(CPR)and emergency cardiac care(ECC). October 15,2022 October 15,2024 To verify course completion,visit www.ECSlnstitute.org and enter the above student authorization number. Coerce Completion Date Recommended Renewal Date ECSI Phone Number:(800)71-ORANGE www.ECSlnstitute.org