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HomeMy WebLinkAboutB. Good - 12/31/2020[/p0 5 q - '� _!5' o c FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Q� + Establishment Address c�5� �G6 AA f i C i r v I� Establishment Mailing Address (if different) Establishment Telephone No � M- *o-HS35 Applicant Name & Title: ee ne y�W Applicant Address ACV t rdeTi�, s{ 9 it stn ISG rnAA Applicant Telephone No.: G O - � � (� � � 24 Hour Emergency No.: � � 7 - S? %-- 0 D S� tt_� Applicant Email • cAkt S fJ dOfA ® (� Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or H An Association partner. H A Corporation Name Title Address PPnFsJ (L SCC 50t Z�isv.P� Ili WA HAnIndividual � e�nnc{ tfin�#f �rACC fttEt r g i�✓YI(Aefi�ff �8iixr Ja(k V �kt'tsc� CIAPartnership-LLL Jj H Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title:isr Address: ` viCv S# r}�t(Qlnit lfd ��v T Telephone No: i 24 Hour Emergency No: -77H- 2 ,� a - 1 '2 05 FAX: E-mail: gVA ��G0.�RC�S�II Cjr1o(�s Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: M1 t` ~ SEWAGE DISPOSAL: MI DEP Public Water Supply No: (If applicable) No. of Food Employees: j.. DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: %ei r"CLcte 'U'Clt l �t� dice's Name of Person(s) In Charge Training in Allergen Aw�are01 }Certified (ness � Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared.U Yes -- v,�nc e w �N Does this establishment require a FOG permit? ✓ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ® Retail Food $125.00 0 Mobile Food Consession Temporary [ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 H Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up l0 201 + $300.00 ®Pushcart $50.00 # of Pushcarts: Temporary Time: ® Supermarkets $400 ®Residential Kitchen $100.00 Rain Date: Q Milk R Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food (time4emperature controls required) (Check all that apply): Non-PHFs-non-potentially hazardous(ood(no timeAempereture cmntrols required) RTE - mady-tout foods (Ex. sandwiches, salads, muffins which need no fudher processing) Sale of Commercially Pre -Packaged Non-PHFsPHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held EB Sale of Commercially Pre -Packaged PHFs !l Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service H Delivery of Packaged PHFs Q PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sete of Raw Animal Foods Intended Q Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities n Prepares Food/Single Meals for ts?; Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590,000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perI64 that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. C �^ g-� If'7C' CJ 70 Social Security Number or Federal ID: C Gra -✓tt ��E` Signature of Individual or Corporate Name: /� f ( LLC—, TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. tC C� Ltd Signature of Individual or Corporate Name By: rporate 04r (Mandatory, if Applicable) 3<�y SgZ9 "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N Address: City/State/Zip: Phone #: " L.kjo-- tig�_s Are you an employer? Check Oe appropriate box: 1.W I am a employer with ) G employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box 41 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 H 1. I am are employer that is providing, workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1 E ii (AUG C 1.jj 4%C Insurer's Address: Ll(lCJ t v ((2 i,L City/State/Zip: VV Cq f ✓vd t"'\ U 1 V) Policy # or Self -ins. Lie. oc9'D_ �' GS Expiration Date: 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 cerdfv, under the pains antipenalties ofperjury that the information provided above is true and correct. 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 www.mass.gov/dia Phone #: 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 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment W. Mairess: 1� ) � SCL �� Cer � ®w lA G1 Cf i`Ptf� lit Mail Address: e tr'C 0 aoq K Phone/Fax Number:� I �' �R 2:2 -r) lczl Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly, w iy-'A R t Ifa Name of Company scheduled to pump external grease trap quarterly: / .i yj �\ V 1!P Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents istrue, accurateand complete. Signed A � � Date ! { � ' _ Print WIND RIVER ENVIRONMENTAL Invoice Wind River Environmental LLC. 46 Lizotte or Suite 1000 Customer Number: 1548887 Marlborough MA 01752 Questions: 978-841-5080 BILL TO JOB SITE B. Good OG - B. Good Lars 280 School Street 280 School Street Mansfield MA 02048 Mansfield, MA 02048 Service Date: 07 -Nov -2019 Invoice Number: 4422636 Order Number: 0210171132 P.O. Number: Invoice Date: 14 -Nov -2019 Order Date: 11 -Oct -2019 Quantity Service Tyne Amount Tax 1.00 Fuel/ Energy Recovery $24.23 $0.00 1000.00 Commercial Pump Grease $255.10 $0.00 SAVE TIME AND GO PAPERLESS WITH OUR NEW ONLINE E-BILLINGI With Wind River Bill Pay, you can be notified by email when a new invoice has posted. You can search, sort, view, download and pay your invoices through a secure customer portal. Use the link below and your enrollment code to get started! 'PLEASE UPDATE YOUR FILES TO REFLECT OUR NEW REMIT TO ADDRESS" Subtotal Non Subtotal Taxed Tax Subtotal Adjustment Payments Payment Terms Amount Due Tax B. Good Lars 1548887 0210171132 4422636 14 -Nov -2019 $279.33 280 School Street We accept the following credit cards within 30 days of the invoice date. Wind River Environmental will appear on $279.33 $0.00 1 $0.00 $279.33 1 1 $0.00 1 Net 30 $279.33 'T.O NI�y11,AND PAY ONLINE¢ TO s',� hap:/Iwrenvironmental.billtmst.com ODT;`21 BRHQXWDDZ Please detach here and return the bottom portion with your payment. From: Customer# Order Number Invoice Number Invoice Date Amount Due B. Good Lars 1548887 0210171132 4422636 14 -Nov -2019 $279.33 280 School Street We accept the following credit cards within 30 days of the invoice date. Wind River Environmental will appear on Mansfield, MA 02048 your credit card statement for this transaction. For questions please visit www.wrenvironmental.com/policies Ws1 VISA ol� Remit To: Wind River Environmental LLC. P.O. Box 22074 New York, NY 10087-2074 22074 000004422636 000001548887 0000027933 5 CInvoice Wind River Environmental LLC. 46 Uzotte or Suite 1000 Customer Number: 1548887 Marlborough MA 01752 Questions: 978-841-5080 BILL TO JOB SITE B. Good IG - B. Good Lars 280 School Street 280 School Street Mansfield MA 02048 Mansfield, MA 02048 Service Date: 10 -Oct -2019 Invoice Number: 4390925 Order Number: 0238387586 P.O. Number: Invoice Date: 10 -Oct -2019 Order Date: 08 -Oct -2019 Quantity Service Two Amount Tax 1.00 Environmental Compliance - Commercial $18.50 $0.00 1.00 Inside Grease Trap Pumping $107.90 $0.00 1.00 Fuel/ Energy Recovery $10.25 $0.00 SAVE TIME AND GO PAPERLESS WITH OUR NEW ONLINE E-BILLINGI With Wind River Bill Pay, you can be notified by email when a new invoice has posted. You can search, sort, view, download and pay your invoices through a secure customer portal. Use the link below and your enrollment code to get started! "PLEASE UPDATE YOUR FILES TO REFLECT OUR NEW REMIT TO ADDRESS' Subtotal Non Subtotal Taxed Tax Subtotal Adjustment Payments Payment Terms Amount Due Tax $136.65 $0.00 1 $0.00 $136.65 $0.00 1 Net 30 $136.65 TPIE,N,IANP;PAYOfI)_INE6OTO�� hap:f/wrenvironmental.bilitrust.com�UBETFI`,ENft�;lijplON7c, f:J BRHOXWDDZ From: B. Good Lars 280 School Street Mansfield, MA 02048 Remit To: Wind River Environmental LLC. P.O. Box 22074 New York, NY 10087-2074 Please detach here and return the bottom portion with your payment. Customer # Order Number Invoice Number Invoice Date Amount Due 1548887 0238387586 4390925 10 -Oct -2019 $136.65 We accept the following credit cards within 30 days of the invoice date. Wind River Environmental will appear on your credit card statement for this transaction. For questions please visit www.wrenvironmental.coMpolicies 3 VISA pISCCayE4 22074 000004390925 000001548887 0000013665 6 3 I I 0 D 0 0 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday C �' Thursday �t Sundayt'D Tuesday Friday (� Wednesday Saturday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU Vr 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal V, Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods V`� Floor drains Other: How are hood vents cleaned? (i.e., in threey (3)6 bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? � h f e 2 Yes M rI Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? p i( Yes!! No Size `�Sc2n or Where is the existing outdoor GRU located? .y ry r i& I fcoh' or os If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owners Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied?. Please list the vendor who removes the Please list fixtures attached to each grease trap Grease Trap 1 ika Grease Trap 2� Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? p i( Yes!! No Size `�Sc2n or Where is the existing outdoor GRU located? .y ry r i& I fcoh' or os If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owners Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied?. Please list the vendor who removes the A� a CERTIFICATE OF LIABILITY INSURANCE DATE (MM DO/YYVY) 11/12/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 McSweeney R RIDCI Insurance Agency, Inc. 420 Washington Street Braintree MA 02184 CONTACT -NAME:_ PHONE FAX A/c o Eat • 781-848-8800 A/c No:781-843-8807 _ n'DOARess mrireceptionemcsweeneyncci.com INSURER(S) AFFORDING COVERAGE NAZCA 10/31/2019 INSURER A: The Hanover Insurance COm an 22292 EACH OCCURRENCE $1,000,000 INSURED BGFOODM-01 INSURER B: BG Food Mansfield LLC PERSONAL&ADV INJURY $1,000,000 280 School Street#D 115 INSURER C: INSURER D: Mansfield MA 02048 INSURER E: AUTOMOBILE LIABILITY _ ANYAUTO ALL OWNED SCHEDULED AUTOSNONOWNED HIRED AUTOS AUTOS 1-1 _ INSURER F: COVERAGES CERTIFICATE NUMBER: 1894571158 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. INS,TYPE L R OF INSURANCE INSO Mo POLICYNUMBER MMIDDPOLICY EFF IYVYY POL16Y _EXP MM/ DNYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR ZBND06460703 I 10/31/2019 10/31/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence)—$1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ] PRO- ❑LOC ECT OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ AUTOMOBILE LIABILITY _ ANYAUTO ALL OWNED SCHEDULED AUTOSNONOWNED HIRED AUTOS AUTOS 1-1 COMBINED SINGLE LIMIT $ _(Ea amdent BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Peraccident $._ A X UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE UHNOW55450D 10131/2019 10/31/2020 EACH OCCURRENCE $4,000,000 AGGREGATE $4,00p000 DED I X I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) IL yes, describe under DESCRIPTION OF OPERATIONS below N/A VVND05921303 1011/2019 10/112020 X I STATUTE OERH E. L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Coverage AUTHORIZED REPRESENTATIVE /) y /ate 4 /"� ! 'T" -a.-? ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF Name ofl%�'rpkanti�-- §Nzt s cettiflmc k+ll31ll : +it91 Date OfCo"Tkfion. Date of ENpmtiow ar t 7kv rw':a �-na.;tsipn x (s trc<dF m � 1>h rerty§?au exw��re.dd�t9a�k �.�+atx t.4fnrwrret jtK&#¢lf.r '�'. ix umrlxa c1t.£1e75 CUR Sf§2 (NFr`f7ft ly'xk ASdvxtu+.vn Nsxvumu.i u�e;an t u Y+erydx �w3, Sine lct7 7�7s inrgu�.r:;:vhr�;r.I�4.r(rajS)3:_nfr-=a r{�trm;�"reeyt'ur7ar. a�;a�rwem.mt�:.xag