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Home My WebLink AboutApplication and WC —� � �-«� � TOWN OF YARMOUTH BOARD OF HEALTH - � APPLICATION FOR LICENSE/PERMI ,201� : ' ti '' ��`�� ! i � t •�( � + * Please complete form and attach a11 necess document��y "' b ' ��13 Failure to do so will result in the retw�yo{'n'ap�5licahon acket. LTH DEPT. ESTABLISHMENTNAME: �� Ktv�r' �c}.1"' CIu� Znc TAXID• I LOCATIONADDRESS: a� F� TEL.#: �d�� — d'I I MaiL�rrGavD�ss: � o x rg � �•- ouTh �,R oar�y OWNER NAME: 1Y1�rc�1z�'s -- CORPORATION NAME (IF APPLICABLE): ��.ca � �"�y'a�f.-I'C lk b Si1c. ; MANAGER'S NAME: '�o6,ec-1" I�{�2rc'=ron . rn ma1 or_�.�� TEL.#: 50�-��/9� I MAILINGADDRESS: Pn Ra�L a°�O �, �� c,ri��, (11A Oa6i6r� POOL CERTIFICATIONS: ' The pool supervisor must be certi�ed as a Pool Operator,as required by 5tate law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. i. No }�oof z. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must i provide new copies and maintain a tile at your place of business. i 1. 2• I� 3. 4• I I FOOD PROTECTION MANAGERS - CERTIFICATIONS: ` All food service establishments are required to have at least one full-time employee who is certified as a Foetd Protection Manager, as defined in the State Sanitary Code far 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. �"C�r I� r"to t,J i c2 _2. II PERSON IN CHARGE: I Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i �. Q�fie�r �k� rfiot��o c2 z. r'c� ' ( il � 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-chokmg procedures below and , attach copies of employee certifications to this form. The Health Department will not use past years' records. i You must provide new copies and maintain a �le at your place of business. I 1. PE"�ie�!' � �r�0 ,,.7� •2 2. �rrev�!•eS ��e¢rrYan ' 3. 4• RESTAURANT SEATING: TOTAL# /00 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# � g&g $55 _CABIN $55 _MOTEL $55 � w�r..� n R :�nV $55 _CAR4P ... $55 _ _S\.3.AAING.00L .80ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. .. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100SEATS $85 _C.ONTINENTAL $35 1NON-PROFIT $30 �#�13-L6� �.. >I00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 � <25,000 sq.ft. $80 —FROZEN DESSERT $40 TOBACCO $95 I NAME CHANGE: $15 AMOUNT DUE _ $ I ****"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** I I 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: / j YES V NO ! MOTELS AND OTHER LODGING ESTABLISHMENT5 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 aze NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Departrnent three (3) days priar 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 I 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. I CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth 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.yannouth.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: I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. � _ - - -- — _ - - - - - --- - - __ _ ; OUTDOOR COOHING: ; Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITl'TO RETURN j THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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: ;o�/o�av13 SIGNATURE: ��, � �� PRINT NAME& TITLE: � % ,- � ' Rev. 10/09/l2 � 4 , ` � The Commonwealth ofMassachusetts Depar[ment of Industrial Accidents Office oflnvestigations 1 Congress Sbeet,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance�davit: General Businesses Auulicant Information Please Print Legiblv Business/Organization Name: �rtisS K�vF�yGtc{Yf-Uwb � �n c. Address: �� X 18•a C�� I� �a 1'��-o^o'r"�i nq t1Gm . �1�hu Stca.�/`}/j.� i� t City/State/Zip: �t,'�l�jrmdu��0'�Phone#: �08- 34g--9�0! Are you an employer?Check the appropriste box: Business Type(required): 1.� I am a employer with�employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/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] g� � Non-profit 3.❑ We aze a corporation and iu officers have exercised 9. ❑ Entertainment the'u right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance requiredj• I 1.0 Heakh Caze (� � 4.❑ We aze a non-profit organizarion,staffed by volunteers, � �C�c�� uJo��itaC�.�T" with no employees. [No workers' comp.insurance req.] 12•�Othe� t't�(p_ 'Any applicant that checks box#1 must also fill out Me section below showing the'v workcrs'compensation policy information. "If the corpomte officers have erzempted themselves,bu[the corporation has other employees,a workers'compensation policy is required and such an organization 56ould check bax#1. I am an employer that is providing worke�rss'compensation insurance jor my employees. Below is the policy information. Insurance Company Name: �u �clb l�rotQ� 6'��;,��t�[� ` L�(1��25 Insurer'sAddress: %� lll0ftv�fiGUv! �p� �, 1AlGN'i'�PI� N J 070�i0 City/StatelZip: Policy#or Self-ins.Lic.# 1�� — 3. g E�cpiration Date: �D�i�S��y Attach a copy of the workers' compensation poticy declaraGon page(showing the policy number and expirstion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to$1,500.00 and/or one-yeaz imprisonment,as wel►as civil penalries in the fonn 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerBfy,under the pains and penalties of perjury that the information provided above rs true and conec[. Si lture• 'lL�x¢c1 �T t'G�i2i Date• �ii �D/o'�O!`� Phone#: �I�Ff-39y 7�� OJj4cial use only. Do not wrue in this area,to be comp[eted by city or town officia[ City or Town: yA{L/1t6(T}f Permit/License# �ing Authorit} (cir one): .Board of Health 2.B ildiog Department 3.City/Town Clerk 4.Licensing Bosrd 5.Selectmen's Office . her CoatactPerson: Phone#: �-39�^�a'J� X �Z�� www.mass.gov/dia m � ' � The Contmonweallh ofMassachusetts Department of Indushzul Accddents Offzceoflnvestigations _ __---- _ __ 1 Congress Street,Suite 100 Boston,MA 011l4-2017 wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AuoGcant Information Please Print Leeiblv Business/Organization Name: 4}fs �v�A- y�Gf/7 �[,cl 0 � fN� Address:p v �X /�'✓( M�11�� 'w Fh�il,✓C/¢�.ry �IY�1Y1�-A/e��-� �� City/State/Zip:�� A'�+N6u71F �� Phone#: �� - � P - • Are you an employer?Check the appropriste boz: Business Type(required): 1.�I am a employer with employees(fiill and/ 5. ❑ Retail or pazt-time).* 6. ❑ RestaurantBaz/Eating Establishment 2.❑ I azn a sole proprietor or artnership and have no 7, � Office anNor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• �Non-proSt 3.❑ We aze a coiporetion and iu officers have exercised 9. Entertainment their right of exemprion per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp.insurance required]* 4.❑ We are a non-profit organizarion,staffed by vohmteers, 11.❑ Heakh C e with no employees. [No workers' comp. insurance req.] 12. Other Tt�_�l.4b W�TIF SNA4(- "My applicaot t6at checks box It 1 must also fill out the section below showing thev workers'wmpensation policy infortnation. '•If the coryorete officers have e�cempud themselves,but the corporation has othm employees,a workers'compeosation policy is requ'ved and such an organization s6ould c6eck box N l. I am an emp[oyer that is provirding workers'/com��p�ensation insurance jor my employees.//gelow rs the po[icy injonmtion. Insurance Company Name: ( -E/GN�6 Cy�P d � /KJN�'^��E (�6�Q��'�J /� c.nirfr..v (iY6zc1 A9 � ��'s aaare�: h� � �1�f.cns� . N�, o7a6 0 � CiTy/State/Zip: Policy#or Self-ias Lic # �� '�� 3 � �3 '�� Exnirarion Date: �/Yf � � Attach a wpy of the workers' compensation policy dec►aration page(showing the po6cy numbe aad piration date). Failure to secure coverage as required tmder Secrion 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalries in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigarions of the DIA for insurance coverage verification. I do hereby ceNify,under the pains and penaUies of perjury that the injormation provided above is bue and correct Si�nature: �� lY ��.� �cse�aYL Date: �o vb �0[3 Phone#: ,�,O�S-�1�/ -7/�S Officia[use only. Do not write in this area,to be completed by city or town o,fJiciaL City or Town: Permit/License i� Issaing Aathority(circle one): 1.Board of Health 2.Bnilding Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: P6one#: www.mass.gov/dia . ;. � Chubb Group of Insurance Companies INFORMATION PAGE WORKERS COMPENSATION AND � cHus6 15 Mountain View Road,Warren, NJ 07060 EMPLOYERS LIABILffY POLICY Item 1.Name &Mailing Address of the Insured Issued by FEDERAL INSURANCE COMPANY BASS RIVER YACHT CLUB a stock insurance company P.O. BOX 182 incorporated in INDIANA SOUTH YARMOUTH MA 02664 N.C.C.I.Carrier Code 12890 FEIN Policy Nunber (14)7173-93-18 TEL#: # of EMP: UI#: Insured is:CORPORATION Name&Adckess of fhe Proc&�cer Previous Policy Number (13)7173-93-18 GOWRIE, BARDEN & BRETf, INC.-THE BURG 70 ESSEX ROAD WESTBROOK CT 06498 Producer Number 4-60435 000 DIRECT BILL OTHER WORK PLACES NOT SHOWN ABOVE- SEE ATTACHED EXTENSION OF�NFORMATION PAGE Rem 2. POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 06/25/13 TO 06/25/14 Item 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the states listed here: Refer To Extension of Information Page °Covered States' B. EMPLOYERS LIABILffY INSURANCE: Part Two of the policy applies to work in each state listed in kem 3A.The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: All States, 5ccept states designated in ttem 3.A and ND, OH, WA, WY, D. Endorsements (Form No.j Refer To Extension of Information Page 'List of Endorsements & Schedules' Rem4. The Premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Refer to Extension of Information Page Minimum Premium: 219 Total Estimated Premium $ 611 Minimum Premium State: MASSACHUSETTS Total Stafe Surcharges $ �2 Expense Constant:MASSACHUSETTS ( $250 INCL) Total Estimated Charge $ 623 Premium Adjustment Period:AT EXPIRATION Deposit Amount $ 623 CHUBB GROUP OF INSURANCE COMPANIES: 555 LONG WHARF DRIVE NEW HAVEN, CT 0651 1-61 07 ��—.�.`i.�w�__S/� Authorized Representative and Date Signed Issue oate 05/14/13 NHO CLD 15g Form WC 00 00 01A(Rev.5-88)Includes copyright material of the NaOonal Council on Compensation Insurance,used with its permission.Copyright 7 987,Nafional Council on Compensa0on Insurance C : cr�uss Name &Mailing Ad�ess of the Insured Attached to and Fortning Part of BASS RIVER YACHT CLUB Policy Number (14)7173-93-18 P.O. BOX 182 SOUTH YARMOUTH MA 02664 Policy Period 06/25/13 to 06/25/14 FEIN Effective Date 06/25/13 Name &Adckess of fhe Producer GOWRIE, BARDEN &BRETf, INC. -THE BURG Name of Company 70 ESSEX ROAD FEDERAL INSURANCE COMPANY WESTBROOK CT 06498 Endorsement Nunber Producer Number 4-60435 000 DIRECT BILL EXTENSION OF INFORMATION PAGE ITEM 1. OTHER WORKPLACES AND LOCATIONS OF THE INSURED RATED NAME/LOCATION LINK ADDRESS #OF EMP. SIC CODE UI# 0007-20-0001 NO SPECIFIC 7997 LOCATION MA All Other Terms and Conditions Remain Unchanged Authorized Representative IssueDate 05/14/13 NHO CLD �Sg WC 00 00 01A(Rev. 5-88) . t � . � . . . . . . ... criuBs Name &Mailing Address of fhe Insu�ed Attached to and Fortning Part of BASS RIVER YACHT CLUB Policy N�nber (14)7173-93-18 P.O. BOX t 82 SOUTH YARMOUTH MA 02664 Policy Period 06/25/13 to 06/25/14 FEIN Effective Date 06/25/13 Name &Address of ffie Producer GOWRIE, BARDEN &BRETT, INC. -THE BURG Name of Company 70 ESSEX ROAD FEDERAL INSURANCE COMPANY WESTBROOK CT 06498 EndorsemeM Nwnber Producer Number 4-60435 000 DIRECT BILL EXTENSION OF INFORMATION PAGE ITEM 3.A. COVERED STATES tt is agreed that Item 3.A of ihe Workers Compensation and Employers Liability Policy Information Page includes the following states: S�� Risk I.D. Sfate LD.No. MASSACHUSETTS All Other Terms and Conditions Remain Unchanged Authorized Representative Issue Date OS/14/13 NHO CLD �5g WC 00 00 01 A(Rev. 5-88) C � cHuss Name &Mailirg Address of the Insured Attached to and Fortning Part of BASS RIVER YACHT CLUB Policy Number (14)7173-93-18 P.O. BOX 182 SOUTH YARMOUTH MA 02664 Poiicy Period 06/25/13 to 06/25/14 FEIN Effecfive Date 06/25/13 Name &Ad�kess of The Producer GOWRIE, BARDEN & BRETT, INC. -THE BURG Name of Company 70 ESSEX ROAD FEDERAL INSURANCE COMPANY WESTBROOK CT 06498 FndorsemeM Number Producer Number 4-60435 000 DIRECT BILL EXTENSION OF INFORMATION PAGE REM 3.D. LIST OF ENDORSEMENTS AND SCHEDULES It is agreed that Item 3.D. of the Workers Compensation and Employers Liability Policy Information Page includes the following endorsements and schedules: IT IS AGREED THAT THE FOLLOWING ENDORSEMENT(S) ARE PART OF THIS POLICY FORM NUMBER ED/REV DATE FORM TITLE WC 00 00 00B 07 2011 WORK COMP&EMPLOYERS' LIABILITY POLICY WC 00 00 01A O5 1988 INFORMATION PAGE/DEC PAGE WC 00 03 11A 08 1991 VOLUNTARY COMPENSATION &EMPLOYERS LIAB WC 00 04 14 07 1990 NOTIFICATION OF CHANGE IN OWNERSHIP WC 00 04 22A 09 2008 TERRORISM RISK PGM REAUTH ACT DISCLOSURE END WC 20 03 01 04 1984 MASSACHUSETTS LIMITS OF LIABILITY WC 20 03 02A 09 2008 MASSACHUSETTS-ASSESSMENT CHARGE WC 20 03 03D OS 2010 MASSACHUSETTS NOTICE TO POLICYHOLDER WC 20 04 05 06 2001 MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT WC 20 06 O1A 07 2008 MASSACHUSETTS CANCELLATION OS 02 0259 01 2004 COMPL.W/APPLfC TRADE SANCTIONS(WC 99 03 03) 08 02 0261 03 2012 CIVIL UNION OR DOMESTIC PARTNERS 08 10 0239 10 2003 CONFIDENTIAL REQUEST FOR INFORMATION 08 10 0466A 06 2001 PRIVACY POLICY AND PRACTICES NOTICE 99 10 0732 12 2007 NOTICE TO POLICYHOLDERS-TERRORISM RISK ACT 99 10 0792 09 2004 IMPORTANT NOTICE-OFAC 99 10 0872 06 2007 AOD POLICYHOLDER NOTICE . IT IS AGREED THAT THE FOLLOWING SCHEDULE(S) ARE PART OF THIS POLICY FORM NUMBER FORM TITLE SCHEDULE NUMBER WC 00 00 01 A EXTENSION OF INFORMATION PAGE RENL-0001-20-0001 All Other Terms and Conditions Remain Unchanged Authorized Representative Issue Date OS/14/13 NHO CLD 159 WC 00 00 01 A(Rev. 5-SS) I . C : criuBs Name of Insured Attached to and Forming Part of BASS RIVER YACHT CLUB Poticy Number (14)7173-93-18 FEIN Policy Period 06/25/13 to 06/25/14 Location of Operations NO SPECIFIC Effective Date 06/25/13 LOCATION MA Producer Name Name of Company GOWRIE, BARDEN & BRETT, INC. -THE BURG FEDERAL INSURANCE COMPANY Producer Number 4-60435 000 Endorsement Number DIRECT BILL EXTENSION OF INFORMATION PAGE fTEM 4-SCHEDULE NUMBER: 0001-20-0001 (INSD-ST-LOC) ' Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Re- Annual ClassHication of Operations No. Remuneration muneration Premium CLUB-COUNTRY, GOLF, FISHING OR YACHT- 9060 25,000 1 . 13 283 8 CLERICAL INCREASED LIMITS PART TWO 1 .0� CODE 9807 3 TO EQUAL MINIMUM PREMIUM FOR EMPLYRS.LIAB.INCR'D.LMTS CODE 9848 q� All Other Terms and Conditions Remain Unchanged Authorized Representative IssueDate 05/14/13 NHO CLD 159 WC 00 00 01 A(Rev.5-88) Page 1 of 2 . c ' criu66 Name of Insured Attached to and Forming Part of BASS RIVER YACHT CLUB Policy Number (14)7173-93-18 FEIN Policy Period 06/25H3 to 06/25/14 Location of Operetions SUMMARY OF ALL INSUREDS/LOCATIONS Effective Date 06/25/13 IN THE STATE OF MASSACHUSETTS . Producer Name Name ot Company GOWRIE, BARDEN&BRETT, INC. -THE BURG FEDERAL INSURANCE COMPANY Producer Number 4-60435 000 Endorsement Number DIRECT BILL EXTENSION OF INFORMATION PAGE i ITEM 4-SCHEDULE NUMBER: 0000-20-0000 (INSD-ST-LOC) IPremium Basis Total Estimated Rate Per Estimated Code Annual $Y00 of Re- Annual Classffication of Operations No. Remuneration muneration Premium LOSS CONSTANT 20 TOTAL ESTIMATED STANDARD PREMIUM 353 EXPENSE CONSTANT CHARGE CODE 0900 250 TERRORISM CHARGE Rate 0.03 ( 00 Code 9740 � B TOTAL ESTIMATED PREMIUM 6t� MASSACHUSETTS ASSESSMENT CHARGE 0.042000 �p STATE ESTIMATED CHARGE 623 All Other Terms and Conditions Remain Unchanged Authorized Representative Issue Date 05/14/13 NHO CLD 159 WC 00 00 01 A(Fev.5-88) Page 2 of 2