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HomeMy WebLinkAbout2022 Licensing The Commonwealth of Massachusetts Fee Town of Yarmouth siio.00 Swimming Pool Operations License Number: BOHSP-21-3578-01 Issue Date: 1/1/2022 Mailing Address: Location Address: CAPE WINDRIFT MOTEL INC 115 ROUTE 28 115 ROUTE 28 WEST YARMOUTH, MA 02673 WEST YARMOUTH, MA 02673 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, MPH, R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-21-3576-01 Issue Date: 1/1/2022 Mailing Address: Location Address: CAPE WINDRIFT MOTEL INC 115 ROUTE 28 115 ROUTE 28 WEST YARMOUTH, MA 02673 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Mu phy, MPH, R.S., CHO ft... ' P.---- Health Director .at TOWN OF YARMOUTH BOARD OF HEALTH rlAit .1 b 2022 APPLICATION FOR LICENSE/PERMIT -2022 HEALTH DEPT. * Please complete form and attach all necessary documents by Dec,eri[bei 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: C.4-0a tArt.NDoxpr Mori Tnte TAX ID: is 6 - i`5 3 9 13 q LOCATION ADDRESS: 11 y (Zit)a r ..tg YAA i wmr1144O.U67ifEL.#: -7 7 4- , 6 g -(-110 3 MAILING ADDRESS: I (r P ourfz. .4.is 'I4Arrwviki M)1 c4'573 E-MAIL ADDRESS: W Oitt -i-mo rrL- 115 CV%l toil. Lu,v7 OWNER NAME: /3 HA-ne-F Sq i 4f$ CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 3f/H P-E34 P ✓L TEL.#: 1 7 ti_ ig -q 10 i MAILING ADDRESS: 115 kg u TE. ..Z>s y a-p n i fin /11,4- 0,-473 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. -1 s 1f 13 P( iS L 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at 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. 1. r Nf}o 0-es If I PrNTL 2. LP .- 3. S y( 1-�-,s if p —f 4. 11/dn-91 poS , 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 prov' e new copies and maintain a file at your establishment. 1. NA- 2. 1\1)A PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. iv /A 2. A' 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 a file at your establishment. 1. /4- 2. ii1)11- 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. Nh- 2. '' )fi 3. r1 4 RESTAURANT SEATING: TOTAL# 6{ 4 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LI ENSE REQUIRED FEE PERMIT# —INN $55 —CAMP $55 MOTEL $110 INN ,'SWIMMING POOL$110ea. _LODGE $55 —TRAILER PARK $105 _WHIRLPOOL $1 l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS 0 SEATS $125 25 —CONTINENTAL $35 _NON-PROFIT $30 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <25,000 sq.ft. $1$50 50 >25,000 sq.ft. $285 _VENDING-FOOD $25 q _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 22_0 *****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 C� 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. 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 permitenpitation 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 THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 3 'I SIGNATURE: geks,, t..- k 1144. 4 PRINT NAME& TITLE: © my,✓ O! 13Juttlfesk 4k1' Rev. 10/15/19 The Commonwealth of Massachusetts • Department of Industrial Accidents Office of InvestigationsV ; �l 1 Congress Street, Suite 100 M1?h' ,-<!2022 4 Boston,MA 02114-2017 HEALTH °Epr 1. www.mass gov/dia • Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: .) E{ Address: 115 k U i City/State/Zip: 'y,')-i rri o U 771 Phone #: 7 7 - S _ `7 10 3 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 1. employees(full and/ 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] • v 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]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other v T / ,f p 141n,'1r'`1 *Any applicant that checks box HI 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 workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 'j i Oil (AStj, —try Lin-v1.0—j Insurer's Address: P. j) \.),‹ e. r 3 City/State/Zip: N\ecv i v(, 1v y 10 [ ,i Policy#or Self-ins. Lic. # uki ;i 4 ). cg s }� � Expiration Date: ;J 3 12-tiZtk i 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,under the pains and penalties of perjury that the information provided above is true and correct. Signature: echcLiW1-- `t ���'"`'I Date: 3-- I ( - '� Z 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 CAPEWIN-01 ATHAKKAR 'e%CC-3/2 o CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 3/17/217/2022 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 ';ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED EPRESENTATIVE 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 AJAY THAKKAR Thakkar Insurance Agency PE FAX 134 Cambridge Steer ,end floor (aCHO,NNo,EA:(781)262-0800 Ira,No(781)996-7225 Burlington,MA 01803 SS: INSURER(S)AFFORDING COVERAGE NM* INSURER A:The Ohio Casualty Insurance Company INSURED INSURER B: Cape Windrift Motel INC INSURERC: 115 Route 28 West Yarmouth INSURER 0: 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 TYPE OF INSURANCE ADDL SUER W POLICY NUMBER POLICY EFF POLICY EXP LIMBS LTR INSD VD (PAMIDD/YYYY1 (MMIDD/YYYYt COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jPa LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) J _ OWNED SCHEDULEDO BODILY INJURY(Per accident) $ AUTOSIRE� ONLY AUOTOOSyy D � D AUTOS ONLY AUTOS ONLY (Per a dent AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE XWO62982221 3/28/2022 3/28/2023 500,000 QFFICER/MEM R E.L.EACH ACCIDENT $ EXCLUDED? N I A andatory In Nil) 500,000 E.L.DISEASE-EA EMPLOYEE $ tf yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space is required) MAN ; 1022 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MA-28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD k laoa CPO C) Q CERTIFIED POOL (/ — $SPA OPERATOR`" &HoiTuo Zt- Pr APesstono, ASSOC Certified Pool & Spa Operator Certification for Harsh Patel as an Operator of Aquatic Facilities issued by the Pool & Hot Tub Alliance on Certification Date:June 20,2021 Expiration Date:June 20,2026 Certification Number: 3ygdoxq Instructor Name(s) Lauren Broom Sabeena Hickman,CAE President& CEO POOL &Anlio Pool&Hot Tub Alliance �„ HOT TUB-. ALLIANCE Foi veri5icotior,,teleph000 PHTA at 719-540-9119 or email service:a phta.org } } } ig ItID N a Insert Name Here Certified: Insert Certification Date Here Certification Number: Insert Certification#Here Instructor Name: Insert Instructor Name Here Expires: Insert Expiration Date Here Signature CPO CERTIFIED POOL SPA OPERATOR'^ Pi HEALTHDEN Qm n s v -I rt (D 3 O S �o S. O 3 �'Oa m to m 3 3 ' w O 3 g q " tD 3 n :< n. v:' 7i tO y N IT,' w Q. rr a v 5' 5 A T 3 o -Na' Ooa °'D 8 c () (D - N O inO) rD. C rt C (D gi U 7 in d 0 S SD 07 O� _ 25 DC -Ot. n rt O N 0 0 3 K 00 N CT Q .1 < O_ SD 0 O O O O ,0 o (ZZu 3 5• o - TIO -n D) U rt n O1 .< (D r-e O 5• rrh V N et 7 {D 7' n N 7 OR C y O O_-O 0(: a O r N 3 Sh w 3 V www.capecodsafetytraining.corn r//// jlgglgg''------------Thto,L NSC First Aid Course cg < OSHA CPR 1910.151 Includes Epi-Pen Name: Shailesh Patel G_'L. UG': Security Control No. Address: Windrifi Motel r,p. 022 2 0 2 0 3 3 Address: 115 Main Street, Route 28 city, State, Zip: West Yarmouth, MA 02673 HEALTH DEpt • Course Completion Date: 04/3012021 Training Center: Cape Cod Safety Training Expiration Date: 04/3012023 Instructor Name r Rick Todd . Instructor Number: 0409 118 • Shailesh Patel has successfully completed the NSC First Aid Course. . . * -----) 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 o+..s". Security Control No. sa,, -V. Shailesh Patel 202033 —( has completed the • NSC First Aid Course We want your feedback! Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 0413012021 take a brief survey and share your opinions Expires: 0413012023 Instructional Hours: about the NSC course you completed. f#1040918 iep /c'j.1 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining Keep this card for your records.Void if reproduced. 30M04032019 1015 900008129 ©2016 National Safety Council 79173-0000 www.capecodsafetytraining.corn e ` ollfriiii."°71111111111111111.Aa, NSC CPR Course 111 2 OSHA CPR 1910.151 cb° "'o Adult- Child, Infant, FBAO & AED Name: Shailesh Patel Z= 1uYi D, Security Control�p No. Address: Windrift Motel CAN a 8 7 317 3 115 Main Street, Route 28 Address: 1(]l2 City, State, Zip: West Yarmouth,MA 02673 HEALTH DEPT. Course Completion Date: 04/30/2021 , Training Center: Cape Cod Safety Training Expiration Date: 04130/2023 Instructor Name`. Rick Todd Instructor Number* 1040918 , Shailesh Patel has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. 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 \ J THIS DOCUMENT IS VOID IF REPRODUCED QShailesh.Patel Security Control No. 873173 s "��` has completed the . NSC CPR Course We want your feedback! Adult,Child,Infant FBAO,CPR &AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 04/30/2021 take a brief survey and share your opinions Expires: 3 Instructional Hours: about the NSC course you completed. 40--- /,,4 #1040918 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatrainingJ Keep this card for your records.Void if reproduced. 50M04012020 1015 900008130©2016 National Safety Council 79174-0000 www.capecodsafetytraining.com 4.°gy AIL ) NSC CPR Course cf .4 I. < OSHA CPR 1910.151 4"‘a Adult, Child, Infant, FBAO & AED Name: Bhadresh Patel El INED Security Control No. Address: Windrift Motel 873176 Address: 115 Main Street,Route 28 rich` ' ' ZOZZ City, State, Zip: West Yarmouth,MA 02673 HEALTH DEPT. Course Completion Date: 04/30/2021 , Training Center: Cape Cod Safety Training Expiration Date: 04130/2023 Instructor Namer Rick Todd Instructor Number:' 1040918 Bhadresh Patel has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. 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 ,... J ,.. .2 THIS DOCUMENT IS VOID IF REPRODUCED \ °°•:= Security Control No. • z©� Bhadresh Patel 873176 j NPI yq °O°w.i has completed the �uN` ' NSC CPR Course We want your feedback! Adult,Child,Infant FBAO,CPR &AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 04/30/2021 take a brief survey and share your opinions Ex ires: Instructional Hours: about the NSC course you completed. p 04/30R023 ;R.t c-4 'j;Y7 #1040918 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining_ Keep this card for your records.Void if reproduced. 50M04012020 1015 900008130©2016 National Safety Council 7 91 7 4-0000 www.capecodsafetytraining.corn 15* NSC First Aid Course NC OSHA CPR 1910.151 Includes Epi-Pen Name: Bhadresh Patel Security Control No. Address: Windrift Motel MAK , Z022 2 0 2 0 31 Address: 115 Main Street, Route 28 HEALTH DEPT. City, State, Zip: West Yarmouth, MA 02673 Course Completion Date: 0413012021 , Training Center: Cape Cod Safety Training Expiration Date: 04130/2023 Instructor Name':* Rick Todd Instructor Number: 1040918 Bhadresh Patel has successfully completed the NSC First Aid Course. 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 2 THIS DOCUMENT IS VOID IF REPRODUCED tot � Security Control No. °ot Bhadresh Patel 2 0 2 0 31 gp tlM�e W i �r tltl„‘ has completed the NSC First Aid Course We want your feedback! Please visit nsc.org/firstaidevaluation to Training Center: Cape Cod Safety Training Completion Date: 04/30/2021 take a brief survey and share your opinions Expires: 04/3012023 Instructional Hours: about the NSC course you completed. #1040918 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining Keep this card for your records.Void if reproduced. 30M04032019 1015 900008129 ©2016 National Safety Council 79173-0000 l (' ECSI 11111 ( .;:hdi A wrican(:011ei2t:ol 11) v\ I.nnttcncc Physician, EMERGENCY CARE & SAFETY INSTITUTE Certificate of Completion ao w The Education Center, below, verifies that Ib ' Heena Patel l i has successfully completed the knowledge and skill evaluations for the Emergency Care & Safety Institute Course. Adult,Child,Infant CPR&AED August 28,2021 August 28,2023 Y1JB91UGK2QB Course Name Course Completion Date Recommended Renewal Date Student Authorization Number Cape Cod CPR&First Aid Training 508-364-4750 Janet Radziewicz JC912FHOOXLA Education Center Education Center Phone Number 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. ECSI � QCJ 11�11 � Student Authorization#: Y1JB91UGK2QB t Cut along the dotted line at the bottom of L u ,^ Education Center: Cape Cod CPR&First Aid Training i the certificate and along the dotted lines around Education Center Email: info@CapeCPR.com the course completion card. Fold the card in half. Course: Adult,Child,Infant CPR&AED t Education Center Phone#: 508 364 4750 t Instructor Name: Janet Radzlewicz Name: Heena Patel ' Instructor ID#: JC912FHOOXLA f The Education Center verifies that the above has successfully completed the knowledge and skill evaluations for the Emergency Care&Safety Institute Course. August 28,2021 August 28,2023 Course Completion Date Recommended Renewal Date I r ,I I'L,n...N_u I , (al'h i-C_-i?ANCo.. )