HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 '• • ` C- C. Sc;��i26U+=F��
a � TOWN OF YARMOUTH BOARD OF HF,A�.TH"� b0 �'y
�� APPLICATION FOR LICEN�R��T��049,�.�q
�; :.
a �� � . Q�' � � 0 M '� DD
* Please complete form and attach all nece�d�n y Decemb 1 S 2�0�
Failure to do so will resuk in the r of your applicarion pac • N O V 1 2 2008
NAME OF ESTABLISHMENT: S� � u TEL. � � � /�
LOCATION ADDRESS: 2 - �6
MAILING ADDRESS: o "v�
OWNER NAME: Z TAX ID FEIN or SSN :
CORFORATION NAME (IF APP ICABLE). D / ' /��
MANAGER'S NAME: G UI'�N I'JQ TEL. #
MAILING ADDRESS: I � �
POOL CERTIFICATIONS:
' The pool supervisor must be cerri6ed as a Pool Operator,as required by State law. Please list the designated
i Pool Operator(s) and attach a copy of the certification to tlus form.
1. 2.
Pool operators must list a minimum of two employees cmrently certified in basic water safety,standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
cenifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a 61e at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
_ _ _
— — _ _ - -
Each food establishment must have at least one Person In Chaz•ge (PIC) on site during hours of operation.
1. 2.
HEIMLICA CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich
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' rewrds.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
�
' RESTAURANT SEATING: TOTAL #
i
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMI?# LICENSE REQUIItED FEE PERMI'L#
_B&B S55 CABIN S55 MOTEL S55
_RVN S55 _CANIl' �55 _SWIIvINIINGPOOL SSOea.
_LODGE S55 _IRAQ,ERPARK SI05 _WFIIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMII'#
_0-100 SEATS 585 _CONTINENTAL S35 NON-PROFIT S30
�>100 SEAIS SI60 -0�I LCOMMON VIC. $60 � -�8 _WHOLESALE 580
RETAIL SERVICE: —RESID.KI"I'CFIEN 580
LICENSE REQUI2ED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUQ2ED FEE PERMII'#�
_a50sq.ft. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD 325
_QS,OOOsq.ft. 580 _FROZENDESSERT S40 I'OBACCO 555
�a:��cKa�cE: sio AMOLTNT DUE = S Z 2-0_o�
'""«•pLEASE TUR:V OVER.AA'D COMPLETE OTHER SIDE OF FORVI•****
� • .,
ADMIlVISTRATION
Under Chapter 152, 5ection 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 haue 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 Yannouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES NO ��
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe 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 ofresidence 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 s'vc(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered uansiern. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as aa►ended, shall generally be considered Transient.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m 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, 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
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Departmern by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtsined at the
Health Departmem.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHeakh.
OUTDOOR COOHING:
Outdoor cooldng,preparation,or display of any food product by a retail or food service establishmem is prohibited.
NOTICE:Pemrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITI'TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQIJIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MO'I'EL OR POOL (i.e., PAIN'TING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMME CEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �� � 0 � � SIGNA'I'[7RE: G���J'"�'� I�/�J d � �/� �
PRINT NAME&'ITTLE: C%�GG li J t TI II i � i ��19'-�-
io�ziros
r
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�
�
NOTICE NOTICE
TO 4 TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 3Q this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC 7010845012008 12/06/2008 - 12/06/2009
POLICY NUMBER EFFECTIVE DATES
200 Lincoln Street, Unit#001
C T Financial Service Co Boston, MA 02111 (617) 292-0388
NAME OF INSURANCE AGENT ADDRESS PHONE
Cape Cod Super Buffet Inc 228 Main Street W Yarmouth, MA 02673
EMPLOYER ADDRESS
10/14/2008
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF r1NY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensadon Act.
A copy of t6e First Report of Injury must be given to t6e iqjured employee. The employee may seleM his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably comected to the work related injury. In cases requiring hospital attention,employees are 6ereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
_
� � WORKERS COMPEN�AND EMPLOYERS LIABtLITY INSURANCE POLICY
`� INFOR ATION PAGE
` Associated Industries of Massachusetts Mutuai tnsurance Company
Burlington, Massachusetts NCCI NO 26158
(800)8T6-2765
pOLiCY NO. AWC 7010845012008
PRIQR NO. AWC 701084W12007
ITEM
t. ihe Inaured Cape Cod Super Buffet Inc
Maifir�g Addrsss: 228 Main St W YertnouU� MA 02673
(Na 6VBe� Town of Cky Cwiry 8�ate Zip Cotb
❑ Intlividual ❑ Partnership � Corporatlon ❑ Other FEIN
Other workplaces imt shown above:
2. The pdk:y perfod Is from�y��8 ip���009 �2:01 a.m.standard tlme ffi the Insured'a malling address.
3. A Workera Campensation Insurance: Part One of itse pdky applfea ro the Workers Compenae0on Law of the states Ilsted here;
MA
B. Employers Liability�nsurance: Part Two of the pdicy applies to woric in each state listetl in ttem 3A.
Thglftnitsofour119NINyunderPartTWOar6: BOdilyin�urybyACdtlBnl$ 100,000 �chaCckkM
�IylnjurybyDiseaSe $ soo 000 pp��ylimi(
BotlllylnjurybyDisease S_ 100,000 �hemployee
C. Other States f�urance:Covera�e Repl�ed By EndorsemeM WC 20 03 06A
D. This poiicy rndutles these endorsemer»s and echedulas: SEE SCHEDULE
4. The premium far this pollcy will tre detertnined by our Manuals ot Aulea,Claseificatlona Rates and RaGnA plana.
All iMorrnatlon required below is subJect to v�erificatlon a*W change by aWtt.
���� Premium Basls Rates
� Ealtrneroo Per5700 Eetmetetl
No. Totel Amuel a Mrwei
Ranune�etbn Aemweiatlon P�emlum
I!�"CRA 423833
SEE IXT N310N OF INFOR T10N PAGE
Minimum premium$ 278.00 TWaI EstimBted Amwei Premium S 1,114.00
As indlcated,iMerim adjusUrienb ot premium siiell be made: Deposit Premlum $ 1,787.00
� Annua�ly ❑ Semi A�nually ❑ Quarterly ❑ Monthly
MA RssessmeM Chg.
$839.80 x 6.3000°A, $53.00
This poiicy,inciuding all endorsements,is hereby countersigned by ��^-,� _ — ' `�-KXa 10/14/2008
Authaeed spnmure �me
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDR OFFICE OPFICE CHECK GflOUP C T Financial Service Co
MA 9079 704 200 Lincoln Slreet.U�rit N001
WC 00 00 O7 A(11-88) Boswn.MA 02I 11
IntluMa copyriphrotl mMedel a111ie Natqnel Counni m Canpensetbn h�wfarae,
usetl MN iia permbcion.
, ,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMITNUMBER: #09-011 FEE: 5160.00
. In accordance wi[h reeula[ions promulga[ed under authority of Chapter 94,Sec[ion 30�A and Chapter
L 11, Section�of the�`General Laws,a permi[is herebp granted to:
Zi Qian Zhang, 228 Route 28, West Yarmouth, MA
Whose place of business is Cape Cod Super Buffet
� Type of business: Food Service
To operate a food establishment in: Town of Yannouth
Per[nit expires: December 31 2009 BOARD OF HEALTH: ,`�feeen S�aPt, JZ..Iv., �%�aixe►[cut
CFutneeo .fE. .7Cel�ihen `llice C'l�av�marc
Jn`2�a-B���ct `.�. :Q�l3Kawn, C�e,1Y�Fi
+SE:1TI!�G:200 ljl`�!�[,I,QL���,�1l?QJlV�J((Y�U�/�i,E.���.✓►'.
. ""c.�'�" �' "�.'
�
� �Io�ember 14.?008
� Bmce G.Murphy,MP . .,CHO
Director of Health
� --------------
I
� THE COMMOIVWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #09-008 FEE: 560.00
This is to Certify that Zi Oian Zhang d/b/a Cane Cod Super Buffet
228 Route 28, West Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensine authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof. the undersigned have hereunto affixed their official sienatures.
BOARD OF HEALTH: ,�ePeit SP1aI�, J2.✓V., CK,av[mlilt
Clfcv�Ped ,�. 9fe�ili.e�c `Uice C'Purinman
SE.aIR:G: 200 �O�Q![t �, ��C¢(WL� �
Qiut ��J`2.✓Y.
Nocember 14 200R
Bruce G.M y,MPH . .,CHO
Director of Health
� �.C.���SyPE13,B�FFE'�
�°� """� TOWN OF YARMOUTH BOARD OF�E�L� ���'f
s� � ' APPLICATION FOR LICENS�lP . '
�y = /PER�,-��
� = M � c � � NOV 1 4 20�7
* Please complete form and attach all necessarya do�iments by Decemb�r 31, 2007. '
Failure to do so will result in the retum of your application paclfet!.: __- _
NAME OF ESTABLISHMENT: C � S , ��' , T�3,�(� — —�//D
LOCATION ADDRESS: 2 � , _
MAILING ADDRESS:
OWNER NAME: Qi✓1 T IN r N � (
CORPORATION NAME (IF A�PLICABLE):
MANAGER'S NAME:��j1R� , .,Z/ TEL. # D — — //J�
MAILING ADDRESS:ZJ14B�1 �� �2�. ��� � l � r. n-���3
POOL CERTIFICATIONS:
The pool supervisor must be certi5ed as a Pool Operator,as required by State law. Please list the desi¢nated
Pool Operator(s) and attach a copy of the certification to tlus form.
t 1• 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
eertifications to tlris form. The Health Departmeat will not use past years' records. You mast provide new•
copies and maintain a file at your place of business.
L 2.
3- 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
I All food service establishmeuts are required to have at least one full-tnne employee who is certified as a Food
j 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. 3'he Health Department�viN not use past years'records.
You must provide new copies and maintain a file at your estabGshment.
� i. �'t��C7 �r� � ,�.� z.
� P�R�9N�1��-IARGE;
_ --- __ _ _ --- _ _ __
i Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. C Ll ��'� l�� , ,�-I 2.
HEIMLICH CERTIFICATIONS:
, All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. T6e Health Department will not use past years' records.
You must provide new copies and maintain a File at your place of business.
3. �f,tll�/C� I�lI�O . L� a.��2- fl% l,Yi1�u/d�—
RESTAURANT SEATING: TOTAL# �CJ�
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PER`�fIT* LICENSE REQL-IRED FEE PER�91T= LICENSE REQL'IItED FEE PER�III =
_B&B 550 _CABIN S50 _MOTEL SSO �
_INN S50 _CA1�fP � Si0 � � � - _SR'L�f:�4ING POOL S75ea.
_LODGE S50 _I'RqILERPARK 5100 _k'HIRLpOpL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# � LICENSE REQL7RED FEE PERMIT R LICENSE REQtiIRED FEE PERb11T=
_0.100 SEATS S75 _CONTINENTAL S30 _NON-PROFII' S2i
� I >100 SEATS 5150 �FO$-00� / C01�ION VIC. S50 �0$-OOa- R'HOLESALE S�5
RETAIL SERVICE: —RESID.KITCHEN S7i
L[CENSE REQUIItED FEE PERMIT= LICENSE REQUIRED FEE PER\97= LICE:v'SE REQC7RED FEE PER�iII'_
_<SOsq.R. S45 _>35.00Osq.B. S?00 \'ENDING-FOOD S20 �
_Q5,000 sq.8. S75 _FROZEN DESSERT 535 . _TOBACCO S50 �
v,�:�cxa_vcE: sio AMOUNT DUE _ $_e'�oo .00
""`**PLEASE'IIIR�OFER�VD C0�IPLETE 07'HER SIDE OF FOR\i**"•*
,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Tow►i 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 taues 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 OCCIJPANCY: 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 ofresidence elsewh�e.
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)manth 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�enerally be considered Transiern.
* NOTE: Enc�o�Motel Census must be completed and returned wict►this appucat�on.
rooLs
POOL OPENING: All swimming,wadin�and whidpoois which have been closed for the season must be' �
by the Health Department prior to opening. Contact the Health Department to schedule the inspection Sve(�days
prior to opening. '
POOL WATER'TES'TING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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 SER'VICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Departme�t by fiting the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuks must be sent to the Health
Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Permit urnil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must 6ave prior approval from the Board ofHealth.
OUTDOOR COOKING:
Ouc�oo�'cootdcrg;preparatioq or display of any food product bq a retaz�ar�ee�service establishment is preLibited•
NOTICE:Permits nu►annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISI-IIlv1EE1VT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMME?10EMEVT. REVOVATIONS MAY REQUIRE A SITE PLAN.
DATE: r' IY'I� SIGNATURE: ��'�' �'/t�'� ` �'
PRINT NAME&TITLE: �I�G�C I3/� (I � ,L
�o?o o�
�'\ The Commonwealtk ofMassachusdts
Deparrinent ojlndrts�trinl Accidents
�pN�1s
' 600 Washington Streey �"Floor
Boston,Mass. OIIll
Workaa'Compeasatioa I�s�aeee A�davir B�ildiag{Plambiug/Ekctrical Co�trxtors
�: �.u�1? �n� S1f.�2� i3u
aaa�3—T 2
� cirv VV�/S� 7/L�///W�'G siah: � zio: � � ohace# �G(1 �/�.J �a ���
wodc site locatian lfiill addassl: �O)'+1L �b//V'C�
❑ I am a homeowcer perfornring all wak myself: Project Type: ❑New CamstnwKiao❑Remodel
❑ I am a sole proFai�or and have no one wodcing in�y cap�ity. ❑Bwldieg Addition
1[J�I am an employer providing warkkeis'compensation for my employces wodcing ao this job.
comouv ime:. :_ . . . . -.•. _ . . _ . -
�. addfas" .
. citv' oYaae y
1�v��ee� oellw M
�. � . . .. . .x, ,�.. -�
. .. . ._.. . _ . . . . _ . . .� � r� �,-. �
❑ I am a sole�proprietor,ge�val co�tractor,or yomcew�er(cirdt owe)and have hiiad the con4ac Wis lis[ed below wLo have
tl�e following workers'compensetion lices: , �
S C ' �JZ G�S�"/?5 0 /7�a���G=<-�� 1�'!S'l�e
-r" r b � _ � . " o o u G� °itl ` G��
�,ti, Yn�A r7l gD3— 0 97v �,� 617— ���G�6 D
', ���. � � �j�Gla � SP r(/%CIL.���� �w� �17/0 �,�-�.��Zo6�
�..o,.�•
.a�..
��e.: �e r:
_ - -- --- - -- - — ----- -- -- — _---
trv..eeee. . . ... . . . . �y� - - . -----------
LM��i�/ii�tlfar�r�Y
Fdae b secvc w.e.ae a..rqdree ore sedw nw dMCL uz m Isa a ue i�p.rlW.ta�rr pdan.ta f.e R a A,sM-M■w�.r�.
e'c ynn'dpt6wwnt u wd ae eM peyMin h 16e fire Na STOt WORK ORDEB nd t eae e[f1M.M a dty gatnt�e. I odashM t�N•
� apy�UbMat�w�yhetWwndedMtYcOmeeedlsm�M�eDlAfirewerage�tl�e.
/do hatby cer8fy rnder tMe pe/ns anl p9erteklv ojperjwy Mat tJYe IeforaraUoa proviJed ebowe ie bre a�rq r►ect
signmum (TiW�;� �Z/r� , GZ � ��// �J/�/ (�
PriM name (��.�i�/V�� ��lJ �/ ��,( P6one# ;'i�/� / /�� d"���
o�ad ese wy ae e.f w.re r w.a.n r.ne w�plKed bs Wr er w..smd.�
eMy or tewn: � perdtlice�ae N Dcpu�est
��b
❑eYai Nlmse�le rc�ene 6 reqa'uN QSdxl�n'a Omte
�Mh Dep�ds�
cemet Pvaeac Plxe M; ❑�C
. (�.a s.y�.mm)
. ,
TOWN OF YARMOUTT3
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMITNUMBER: #08-002 FEE: $150.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the eneral Laws,a permit is hereby granted to:
i Zi Qian Zhang, 228 Route 28, West Yarmouth; MA
� Whose place of business is: Cape Cod Super Buffet
jType ofbusiness: Food Service
� To operate a food establishment in: Town of Yarmouth
i
� Pernut expires: December 31, 2008 BOARD OF HEALTH: 3fe�e�t S�aR�, J2.N., 'U4awtnta�t
' CR�ax�ee .`�.JCeP�iR�ric `vice CK�w�rnaa
; `J�72�o�B��ent s. `.�iaurwic,mC'�e�x/Pc
'SEA'IING:200 II/NL��QQ�Q{(IIL� ./L../Y�
November 16_2007
Bruce G.Mtuphy, ,R.S.,CHO
D'uector of Health
THE COA'IMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #08-002 FEE: $50.00
This is to Certify that Zi Q'1�u Zhang d/b/a C�e Cod Super Buffet
228 Route 28, West Yarmouth, MA
IS HEREBY GRANTED A
COM1170N VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .`�fe�e�t SI�i, JZ..N., C�rt
e���Q�e���� .�. 3r�x����v��Q� e�«�„�
SEA7ING: 200 JW{1V'u.�, a��L(�(/�/t.� I.CGIlf.
f
Novemberl6 2007
ruce G.Murphy,MP , .,CHO
D'uector of Health
_,� _
� �,y a
� �9G.C. $u��y�T
' 2�Es"o TOWN OF YARMOUTH BOARD OF HE $.�' p � � �� f] ti9 �� DD �
� ,= APPLICATION FOR LICENSE/PER1�7, '-�(F7 ' NOV 2 2 2006
�y * . ,^-� � ,i , . :
Piease complete form and attach all necessar�i doc��#�net,�,t�bece er 31 2006.
Failure to do so will result in the retum qfy�inr application p kb1E/�LTH DtPT.
rraME oF ESTaBLrs�rrr;�a�C� �i w3'-�' �u Pfi > �.. # SZ��1.1`��//o
LOCATION ADDRESS: ou, .P 7 QYM
MAII,ING ADDRESS:
OWNER NAME: ' � z��.�- T X ID (F r
CORPORATION NA�(JF APPLICABLE :
MANAGER'S NAME: �r/ua S�ao - �r�,. # ���— �7 B z9,��
MAILING ADDRESS:
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 wpy of the certification to this form.
1 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Healt6 Department will not use past yeais' records. You must provide new
copies and maintain a t"de at your place of business.
1 2.
3. 4.
i
; FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
j Protection Maoager, as defined in the State Sanitary Code for Food Service Establishments 105 CMR 590.000.
' Please attach copies of certification to this application. T6e Heaith Department will not use past years' records.
You must provide new copies and maintain a£de at your establishmen�
I. 2
' PERSON IN CHARGE: _ _ ---- -- —�-_,__ -___
_ __ _
� Each food estabGshment must have at least one Person In Chazge(PIC) on site during hours of operatioa
' i. ua� � � , z. �sz /�or� _cH7ca�ll�—
HEIMLICH C RTIFICATIONS:
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 rovi n
de ew co ies and main in t"
ta a ile at our lace of bu in
P P Y P s ess.
1. �ua� �iQ� L i z. �s z ,61�y �'</���G�
3. q �
RESTAURANT SEATING: TOTAL# �ZB{�
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT N LICENSE REQ(JII2FD FEE pERM(T g LICENSE REQUIl2ED FEE PERMI1'#
_B&B SSO _CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWA�IIv1IIdG POOL$75ea. �
_LODGE S50 _1RAII,ERPARK 5100 WHIItI,pOpL E75ea.
FOOD SERVICE:
LICINSE REQUIRED FEE pFRMt(T p LICgNgg gEQUII2Fp FEE pERI�q1•# LICINSE REQUIl2ED FEE pERl�.qi p
_0-100 SEATS S75 _CONTINENTAL $30 NON-PROFiT S25
1>ioosEnTs siso -01� / coa,n�oxvic. aso 07-008 _wi-io�sn� a�s
RETAII,SERVICE: —RESID.KTTCIIEN $75
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIl2F.D FEE PERMIT# LICENSE REQiTIltED FEE PERMIT#
_<SOsq.ft. $45 _>25,OOOsq.ft. 5200 _VENI)ING-FOOD $20
_QS,OOOaq.R. $75 _FROZENDESSERT $35 _TOBACCO $50
NAME CHANGE: S10 AMOUNT DITE _ $ ZOO .OU
""••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 COMPENSAITON INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES �/ NO x
.
MOTELS AND OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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 occuparns must have and be able to demonstrate that they maintain a prinapai place ofresidence 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 shail 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 whiripools which have been closed for the season must be ins ed
by the Health Department prior to opening. Contact the Health Department to schedule the inspection Sve(S�ys
pnor to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool tnust be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern 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.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking�prepara�n,oLtlisplay_of any food product by a retail or food service establishmem is prahibited.
NOTICE:Permits run affivally from January 1 to December 31. PI'IS YOUR RESPONSIBIL.ITY TO RE'TIJRN
THE COMPLETED �PLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR ,
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
na�: o siGrraTvxE: �L�' �'I��Gj,
PRIN'I'NAME&TITLE: (�T . �S Z DiD��r,�ll��
.,
✓
�omioc
-,�
; . -
� The Commonweahh of Massachusetts
Deportment ojledwshial Accidents
N�aN�
6en w�h�,gmR rn� >"Fr�.
Boston,Mesc. 02111
�� --. Worgss'Cam.�nnsatiee(isvaea A�davk: . .y�,d„6ug/Ekelriesl Cowtractors
�: � e
�: � or,� -2 2 /`i , �/
. � cilv �.�� /u/�GIifAL��sWe: v"(!�'1 zio: �`R// � o6me# J "�/ -/ ���lJ ��
wark site locati�(foll�sk �
❑ I am a homeowner perFo�ing all waak myself. Project Type: ❑New Cmsf�an�Remadel
am a sole 'dnr and Lave no me w in an ❑ Addition
I � I am an emPb�P�'��B w`�'compeasatim fa�r my empbyces wodcing on iLis job. . .
: C.u.h2�od\ St.tp�' gu�Pi�
� .aao.: 2LPs �o�,G�'2 ��
�: uJ�st �a��u�, ��: S`�$=� �-�/l�
I�II ❑ I am a sole pra�iUoy ge�al e�trxtor,�hemawoer(eirelt owe)�d have ltiiod the�tois lis[ed below wlw have
the followin8 workas'compensaGon Policesr
��
�
s�rs aY�el: �
�ea.
�
adMm:
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I ._ .__._..,
Faine r aave s�v�ee o�eqyed uiQ 8eetlr 2SA dMC.L 19 m kad b 1Ye I�pilY�Kai�Yd pmMn da 6�e�b t1,1M.M aMlr
weynn'dpNw�ta�wdueMpmMbhNebr��[aSIOtWOBKO6D6Rndame121M.MaUryapint�e. tadenuWHua �i
npy�Mb flakiot my he fiewaNd b tle Omce�fl�s[IYe DIA 6remnge ve�nHw �
/Jo Aenbq ceeqfy rnler HYe P��6�+olD�d+�Y ai�Ms isforweNoa provlral abave tr trrs ad
�
SZ � � �� ��
7 � G��i
� Ptint name Z P6oM#
.m�.:«�y a..a..r�r�r.,.�v�a.ew�aerwr.r�...ma.�
a�y�r.wu: p�tua�r n��
❑�te�.��.Ry�a O�*.o�m�
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i
,; WORKERS COMPENSATION AND'�h+1PEQYERS LIA8ILIN INSURANCE POLICY
INFORMATION PAGE
~ Associated Industrfes of M ais 9 achM��ttnuM�ual Insurance Company
NCCI NO 26158
(800)876-2765
POLICY NO. AWC 701P84501
PRIOR NO. AWC 7010845012005
' ITEM
i 1. The Insuretl Cape Ca1 Super Buffet Inc
. Mailing Address: 226 Mein St W Yamwuri� MA 02673
�No. s� raMacry cwmr sunaocods
� ❑ Individual ❑ Partnarship � CoryOratlon ❑ Other FEIN
I
�� Ofher workplaces rwt shrnm above:
2. The polfey peAod is from�y�2008 �017J06/2007 12:01 a.m.standard tirt�e at the insured's mailinp atldress.
� 3. A. Wakers Compensatlon Insurence: Part One of ihe Oolfcy aDPlies W Me Workers ComPensefion lew Of Ihe states lisled hara:
MA
B. Empbyers Llebility Insurance: PeR Two of the polky applies to work fn each state Ilsted in ilem 3.A.
TheNmksofourliabllityunderPaATwoare: BodilYlnlurybyAaident$ 100,000 eachaccidem
8odilylMurybyDlsease E 500,000 policyHmil
� Bodily�MuryDyDisease S 100,000 eacJiempbyee
C. Other Sta�s Insurance:Coverege Replaced By Endorsement WC 20 03 0&4
D. This policy indudes theea endorsemaMs arM sd+adules: SEE SCkEDULE
4. The premium for this pollcy wlll be determined by our Menuais of Rules.Classificatlons,Rates and RaUng plans.
Ait iMortnation required below is subjed to verincation aM chanps by audk
Clas�cations Premlum Basis Ratas
, Code Estlmem0 FerS190 £s4mHeC
romi a,�a a .M�
� '�' Rmwnere4m �mation vrxmum
INTRA 423833
SEE EXT NSION OF INFOR TION PAGE
�. Minimum premium$ 218.00 Total Estimated Mnual Premium $ 1,286.00
� As Indicated,irtterim adjustments of premium sheU be mede: Deposit Premium $ 1,308.00
� Annuaity ❑ Semi Mnualy ❑ Qwrtery ❑ MOMAIy
MA Asaessment Cfq.
5885.20x 4.782096 SA0.00
This policy,includinp sll erMorsemeMs,is hereby countersigrred by �-_��'`�""'�-'��� 1 01182 0 0 6
AutlmzeA Sipnafwe Dak
GOV GOV KIND PLACING CL41M NAME SAFEN
STATE_ CLASS AUDIT OFFICE OFFICE CHECK__ GROUP C T Finenaial Service Co
MA 9079 704 200 4i�oln Street,Unit#OQ]
WC 00 00 Ot A(t t-88) Boston,MA OZ l l l
mdWe¢wpy�ipA�etl mabrbl N tlis WEbru�Cound on ComOnsatlon I�uraMe.
ubetl MM 4c permselm.
.: ^
----�._,
Schedule of Endorsemerta
Remarks:
. AIM-1 A D.vidend Classi£icatlon Endorsement
' AI[9-2 AIM Mutual Policy Conditions Endorsement
WCO00000 A Policy Conditions
WCil00113 Tecrorism Risk Inaurance Extension Ac: Endorsemeat
, WC000404 Pending Rate Change Endorsement
WCOU0919 Notification oE Change ia Ownetship
i wC2003C1 App1 Lim Liab
WC200302 MA Asaess
wC200303 9 MA Notice
4¢C20D306 A MA Lim Othez States
tPC200307 Massachusetts Assigned Risk Pool Eligibility
WC200401 MA Pend Prem Change
� WC20C905 MA Premium �ue Date Endo=sement
� WC200601 MA Canc
WC200b04 Massachusetts Policy Defin:tion �
m���eo�»m�s enacnea ro ub raky inake�ee ee�ow aoc�s enearye m me aaie.w�.a�n.m i2:o�wu.,m�ara amo
st Ne aderats M Nc Wuretl an tleattmW:n IM�formalion wW�
Policy No. Group Eupiratlon Dale of Policy EifedWe Date of ErWorsement Endorsemeirt No.
AWC 7010845012006 12/06/20Q7 12/06/2006
Iasued W Additionsl Premium Retum Premium
Ca Cod Su er Buffe[Inc
ISSUED BV: ASSOCIATED INDUSTRIES OF MASSACHt�SE7TS MUTUAL INSURANCE CAMPANV
camerW�aa �_���
AUMo�xeO ReVreeenletlw
.
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMI'f TO OPERATE A FOOD ESTABLISHI�IENT
PERMIT NUMBER: #07-015 FEE: $150.00
i In accordance with regulatious promulgated under authonry of Chapter 94,Section 305A and Chapter
� 1 I 1,Section 5 of the C,rneral Laws,a pemut is hereby giaz�ted to:
I
Zi Qian Zhang, 228 Route 28, West Yarmouth; MA
Whose place of business is: Cape Cod Super Buffet, Inc.
Type of business: Food Service
� To operate a food establishment in: Town of Yarmouth
� Pernut e�cpires: December 31. 2007 BOARD OF HEALTH: B `.lS. �o�do�,M.`.a., '
I d��i�k�, R./K, 'Uios G�lrci�i.,s4�c
� Rod�et 4. Bao�.r�,. C��/se�
'SEATING:20Q P�M6�B3NWti
R.�.z�.�d�.,�, R.N.
I
i
rro��at�2s,zoo6
� ruce G. Miuphy, H� S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOVI'H
PERMIT NLTMBER: #07-008 FEE: $50.00
This is to Certify that Zi Qan Zhang d/b/a Cape Cod uper Buffet Inc
228 Route 28, West Yarmouth, MA
IS HEREBY GRAN"I'ED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2007 unless
sooner suspended or revoked for violation of the laws of the Commonweaith respecting the
licensing of common victuallers. Ttris license is issued in confomvty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned haue hereunto affixed their official signatures.
BOARD OF HEALTH: B �5. M.25., G��urs
a��t�/� �rv.,°�v� e�.�
SEATING: 200 R��. �3�j �
n�M��
�4.uc 4'�iee. rsN�, R./V.
November28.2006 "
ruce . Mucphy; H, HO
Director of Health
'.r : CI��3I�Z$ r"�:`�,, C.C. SUPERBUPFET
3?�� TOWN OF YARMOUTH BOARD OF�A`L�'$ ' ' �
�`e"�s
� -; APPLICATION FOR LICENSE��T-2�106`
* Please complete form and attach all necessa y documents by December 31�2005 R 2005
Failure to do so will result in the retum of yow appfication packet.
rr.� oF ESTasr.is�lv�r: C a Co S �. � � 7�u �L. t�38� .l— //�
LOCATION ADDRESS: 2 at o
MAII_ING ADDRESS: aMe
OWNERNAME: 7` n Z � " TAX ID(FEIN or SSIv; �). �� ° .
CORPORATION NAME IF APPLICABLE):
MANAGER'S NAME: ucih TEL. # �
MAILINGADDRESS: rlaDd o
POOL CERTIFICATIONS:
The pool supervisor must be certiTed 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.
1. 2.
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 employce
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
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. T6e Health Department will not use past years' records.
You must pro/�vide new copies and maintain a file at your establishment.
1. lSl 11/AM.A 1`�/D� .�, � 2.
PERSON IN CHARGE: ___ /�_ _ _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
t. � 2. �SZ 1-P�b C����
HEIlb�ICH CERT CATIONS:
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
attaefi eopies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your piace of business.
3.. ��IQO. L/ �. / s� l.rl���
RESTAURANT SEATING: TOTAL# �
OFFICE USE ONLY
LODGING:
, LICENSE REQUIItED FEE PERNIIT# LICINSE REQUIItED FEE PERMIT# LICINSE REQi7IRED FEE PERMI'I'#
B&B S50 CABIN $50 MOTEL $50
INN S50 CAMP $50 SWIIIMI�IINGPOOL$75ea.
_LODGE $50 _TRAII.ERPARK $50 WIIIRI,POOL S75ea.
FOOD SERV[CE:
� LICENSE REQUIItED FEE PERMIT I! LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERM[T#
0.100 SEATS $75 CON1'INENTAL $30 NON-PROFIT $25
t >ioosEnrs siso � (�a- i co�oxvic. aso �06�_ _wiro�sai.E s�s
RETAIL SERVICE:
� LICENSE REQUIItED FEE PERMI1'# LICENSE REQi1Il2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_<SOsq.ft. $45 >25,OOOsq.ft. $200 VENDING-FOOD $20
_<25,OOOsq.ft. E75 _FROZENDESSERT $35 _TOBACCO S25
NAME CHANGE: E10 AMOUNT DUE _ $ 2a0 .Op
*`"'•pL6ASE TURN OVER AND COMPLETE OTHER SmE OF FORM•••'•
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth is now required to hold issuance or renewal '
of any license or pemvt 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 INSLJRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES V NO
NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEIVING FOR Tf� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISI�ENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COMR�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDTfIONAL REGULATIONS
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.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products aze required to post
Consumer Advisories.
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
Heatth Department.
FROZEN DESSERTS:
F7ozen des�erts must 1�e7�sted on a monthly basist�ya State certifiect fatr- '�esfremlts-mus4 be sem to the�Ieakh
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHeatth.
OUTDOOR COOKING:
Outdoor cooking, prepazatioq or display of any food product by a retail or food service establishment is prohibited.
DATE: � B,S� SIGNATURE:�,I[7�n..�7�Ar` C� �
PRINT NAME&TITLE:
ovnsios
i , • �
—=--3 TTie Conunonwealtb ofMassachuse�ts
_ Depa�teeent oflndwsAialAccidentc
— �Ii�
, - = 60o wasl�;agu►e Shrey �"Froo,
Boston,Macc 02I11
�Workers Com�na�tio�Lsvuce A�davk: bi�g/Eteebrical Co�traetors
�
k _ _ _,
* ��+c-kt s ,�%;���.a �
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�:n. R )es� ��r.�.���G. �: rv�A aP: az6'l� �� ��� �l.f"��/1a
�S�n��m«�8�
❑ ��a�„���,,.�m,�: Project Type: ❑New Caoatxucdm OR�adet
I�a sole 'dor and Lave m�e w in� Addition
❑ I am aa m�o�r�n��B�'«kas'�on sar my�ployees wodCing m rhis,job.
�9�: _ _ _
�•
dtt: . sYrel:
�p. a�Y�x1F
❑ I mm a sole propri�or,geferal e�trxtor,or 4omeow�er(cirele owe)�d Lave hiied the contractas liated below wLo have
the following wake�s'compeaeation polices:
���
tl#m:
tHv: oY�ef:
M
�ae�e•
ad�a�•
db• �re{�
_ _-. __ - .-_ ___. ._. _ _ __ -__ _ . __ ___ _..__. _ .
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/
Faie�c r arsee svsr�e n mq�ed oAQ BaYH 25A�MGL Iffi m kad b He i�itlr Kat�iW pmMb da ie�b 31.iM,M aNx
we yan'6ytYwrst a�wd n eM pwltln�tYe f�Na S'fOr WORK ORiI&R arl�me df1M.N a dry ap�t s. 1 admeu9 HN a
c�py NIYs Mataeft dy be hrwaM[d b IYe Omee dlm�tlw NIYe DIA frewaa�e�tlr.
i�wm,rey ce,eyy,��.j�'e pdna odP�o�oJP�l�►Y M�tlYe iwfeneden prewVed abaw 6 are w/ �.x
s��� CSLU�-�. (��c� �,i � ( ��
Ptiat name Phone#
s�ehl�see�ly MdtwrifeYWsurabhenr�fdb9dlYerMw�a�id
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POIIGY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
BUfllil9tOfl� IY�8Si8ChU6@KS NCCI NO26158
(800)876-2765
POLICY NO. AWC 7010845012005
PRIOR NO. AWC�0108450120Q4
ITEM
1. The Insured Cape Cod Supar Buflst Inc
Matling Address: 228 Main St W Yertnouth MA 02873
lNo. Streat Ta.n a Ciry cwnty Sleu Zq Cotle
❑ Individuel ❑ Pertnorship � Corpore6on ❑ O�her FEIN
Otlrer workplaces rrot stiown above:
2. Tha policy perio0 is hom�y��6 �12/OB/2008 1Z;0� a.m,standard time at the insurod's me�ing address.
3. A. Workers Compensation Insurance: PaA One ot thg policy applies to Me Workers Compensation Law of the states lisled here:
MA
B. Employers Uability Insurance: PaR Two of the policy applies to work in each state listetl in item 3.A.
ThelimifsofouriiabilHyurMerPartTwoare: BodilylnjurybyAccideM $ 100,000 @acheocfdeM
BodilylnjurybyDiseaae $ 500,000 ppNcylimit
BodllylnjurybyDiseaae $ 100,000 �qiempbyee
C. Other States Insurance:Covsrage Replaced By Endorsement WC 20 03 OBA
D. This poliq inGutles these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determirred by our Manuals of Rules.Classifrcations,Rates and Ra6ng plans.
All infOrmaUon required below is subject to verification and change by audit.
Classitwatlais Premium Basis Rates
��s E6Ymeled �M3100 ENIme1M
�. TpqlMnwl al p�xxiyi
RemuiroraUon Rem+rwratlon pr�ym
INTRA 423833
SEE EX7 NSION OF INFOR TION PAGE
Minbnum premium$ 218.00 Total Estimeted Mnual Prem(um $ 1,118.00
As indicated,iMenm adjustmeMs of premium shall be made: Deposit Premium $ 1,154.00
� Annualty ❑ Semi Annually ❑ Quartxiy ❑ MoMhry �
� MA Assesament Chp.
$817.95 x 4.4000°h $38.00
This policy,inGuding all endorsemenls,ia hereDy countersigned bY ���--�-�s. 1 012 120 0 5
�— Autlwr¢eo SiprrWe oam
�. �uV GOV KIND PLACING CLAIM NAME SAFE7Y
� STATE CLASS AUDIT OFFICE OPFICE CHECK GR_OUP C T Financial Service Co
PAA 9079 704 200 Lincoln Street,Unit#0(Il
WC 00 00 Ot A(11-88) Bosroq MA 021 I i
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�roed wIM Its pvmiaim.
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�NT
PERNIIT NLJMBER: #06-002 FEE: $150.00
In accordance with regulations gromulgated under authority of Chap[er 94,Section 305A and Chapter
I 11,Section 5 of the General Laws,a peimit is hereby ganted to:
� Zi Qian Zhang, 228 Route 28, West Yarmouth, MA
�
,� Whose place of business is: Cape Cod Super Buffet, Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pemut eacpires: December 31, 2006 BOARD OF HEALTH: l�ercfa�wuc `.15. 4'dicfo.r,i61..`a. '
p��w� v�ef.�
Rod�it�.`8n'ou,.�,A��
•SEATING:200 �cQIf�N�� R✓�. A,
. ' 1QKIL�$6�id4Kllli Q✓I.
November 15.2005
Bruce G.Mwphy, ,RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #06-002 FEE: 50.00
This is to Certify that Zi ian Zhang d/b/a Cane Cod Super Buffet Inc.
228 Route 28, West Yarmouth, MA
IS HEREBY GRANTED A
COMA'ION VICT[TALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�ires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. Tlus license is issued in confomuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affuced their official signatures.
BOARD OF HEALTH: �Qe�cini+a 25. (�'o+�Org /��5. G��
��� / - ,� M���,���v� e�.�
SEATING: 200 R!!�� �. Q�101�llKj
_ __
a� st�, R.iv.
_ A� � R . __ __
rro��� is.zoos
s�,�G. M�rny, , s.,cxo
Director of Health
� sv� -
���� Yq�'�o TOWN OF YARMOUT
�{� y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644 51 � ''i'�';
" MATTACHEES � �..��.. �' . �.�`'��
��o,,,,.,�o�,*� Telephone (508) 398-2231,Ext. 241 — Fas (508) 760-3472
B OARD OF HEALTI3 HEALTHDEPT.
' To: Yarmouth Boazd of Health Permit Holders
i
From David D. Flaherty Jr., RS. ;�D�
Heahh Inspector �
Town of Yarmouth
Re: Federal T�ID Nutnber
j Date: March 22, 2005
The Massachusetts Department of Revenue is now requiring that we furnish detailed information
to tbem regazding all permits and licenses ti�at we issue. One of the details thaY they require we
j send to them is every establishment's Federal Employer ldemification Number(FEIIV)otherwise
' known as yow"Tax ID Number". This is purely for administrative purposes only. .
�
' Some businesses use the owner's Social Security Number (SSl� for Uvs purpose_ If this is the
case for your establishment, be assured that we will �rot allow this information to be public
� record
� Please fill out the fields below ami return this letter to
I , Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
Thank you for your amicipated compliance. If yon have any questions regarding this matter,
nlease do not hesitate to ca11. The office hours are Monday to Friday, 830 a.m. to 430 p.m. The
te hone numbet is 508 398-2231 eact.241.
�P
� ) ,
Establisliment: Q CB 2� FEIN or SSN: ���� � ���
LocationAddress: 2��% 2d � U/QS� ��'l�2d�1�1 - �-/1 ��,.�
Signature: 17AklbG// � ��i
Print: �,r�l(1 vLU .�/CIO , 1� Title: � � ' y,'
.e .
L�( Printe
R
3
- c�.�a7Sl ���
�s^q1 TOWN OF YARMOUTH BOARD OF HEAL'�'���" '
3= g �' G? != CGI� �. , , I� DD
APPLICATION FOR LICENSE/PE1�M1T �O�S
�°r i ;
* Please com lete form and attach all neces L "�����ember 31,��42 3 2004
Failure to do so will result in the r m o�a c�,ah'on ack
� P � P � HEALTH DEPT.
NAME OF ESTABLISHI�IENT: a1�2 /� S'i,��Pn' L�.� .2 � TEL. �b7�fr' 77 d"�/�
LOCATION ADDRESS: �2 APA � . ,, oct I'���n , �s9 oz T� .
MAILING ADDRESS: S P ' �
OWNER/CORPORATION NAME: G -
MANAGER'SNAME: dX � TEL. # � ���
MAILINGADDRESS: , -��
POOL CERTIFICATIONS:
T6e pooi 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. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please Gst these employees below and attach copies of
employee certifications to this form. The Heaith Department will not use past years' records. You must
provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PRO'I'ECTION 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 Healt6 Department wiR not use past years' records.
You must provide new copies an�aintain a file at your establishment.
1. -„����--�- 2.
PERSON CrE: --
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. G� e ,b Q 2. S� lrp���7
HEIMLI 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 fde at your ptace of business.
�. ���� z. TZ l�e�, C`/��� ,
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQLJII2ED FEE PERMIT# LICINSE REQUII2ED FEE PERMfC# ISCENSE REQUIltED FEE PERMI1'#
_B&B $50 _CABIN $50 MOTEL $50
_INN S50 _CAMI' S50 _SWIIvIIv1II1GPOOLS75ea.
LODGE $50 T'Rl�FR pARK $50 WIIIRI.POOL $75ea.
FOOD SERVICE: �
LICINSE REQi1IltED FEE PERMIT It LICENSE REQUIl2ED FEE PFRMIT# LICENSE REQiJIItF.D FEE PERM[T# �
0.100 SEATS E75 CON1'1NEN1'AL $30 NON-PROFIT $25
I >100 SEATS $150 �s'(�.� �COMMON VICT. S50 #65-UdD _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQiTIRED FEE PF.RM['1'# LICINSE REQUII2ED FEE PERMIT# LICENSE REQiJIl2F.,D FEE PERMIT#
_<SOsq.ft S45 >25,OOOsq.ft. $200 _VENDINO-FOOD $20
_QS,OOOsq.ft. S75 _FROZENDESSERT S35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DiTE _ $ 0���•00
. ,""•"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 A1"1'ACHED 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 ta�ces and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII,ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIVIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN.
ADDTI'IONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opemng.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSUMER ADVISORY:
Each food establishme�which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
reqwred Temporary Food Service Application form 72 hows prior to the catered event. Thses forms can be
obtained at the Health Department.
FR(}ZEN�ESSER�S:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: f I � � SIGNATURE: (,��� �Z � /�Z
PRINT NAME& TITLE:
10/22/04
--�_= The Com�aonwealth of Massachusdtc
_ De�ent ojradrtsdial Accidexly
� _= �VIf�
_= 600 R'ashiwgms Stree� �'Floor
- Boston,Mass. 02111
i :x.
' Worlws'Com�esatlo�Leeuee A�d�vi� �gJEktirical Co�haeton
.� -
.
,t �,� „ �na,: . �u;.�:'..r. �, . , . . ..
� name: � � GO � �� '� ..
iadd�e's3:
I ciri W � ��'m0 �e' I�� zio• �/ ` � " ��
�
I wark site locatiw(fiill a�ressk
❑ I mm a homeow�perfotmiog aD wuak myaelf. Projxt Type: ❑New Cmsuvcuan❑Remodel
�� I a sole 'etor and have no o�ee w in an pdditepn
am an�pbyer aoviding wa�Cas'compeasalim for mY�P�Y�W'�o8 on this job.
�,: Se C
tn,: ��-
❑ I am a sole pr�ietor,ge�aal eo�traetey or bmeowoc(codi awe)�d have hiied 9�e�Wis lisled below w6o lmve
� the following wakecs'compensation polices:
�;
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�oe yan'i�pt6wrat n wd n dv/pndtln Is Oe 6n a(a S70?WORIC ORII&R ad�me d S1M.N a dq a�ut�e. 1 adneOW IW a
dpy�[Uie Malewat wy he hrwatMed Y t�e Oma dl�r�t He DIA trewpyge svlentlN.
/do hereAY tt�lY+�1n+M�!ls�rpe�al6e efper�xry t1Y�Me Afonw�atoa proAdeAebnre 6 are ad
Sig°°t°m�� Date � -1��
Printname Z� 1 l Phone
.md�l u�e.nry a..r.rrNe r[Y.aru b ee p�As dh.r mw..mrLl
cilyet�wn: �g r-._ _" ��
❑�edc K�le rapse�e b�eqWd �6 Baard
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• Nov 17 04 12: 08p Tam 617-292-0988 p. l
ASSdCIATED {NDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
� RENh1NAL QUOTATION
il
WORKERS' COMPENSAT7QN
� PLEASE MPKE REMITTANCE T
� TEL.# (800)876-2?65 �
AJ.M.MuWa;;nwrence Co
Date !19l21i2004 F.O.Box 407G
� Bud'rngton,NA 018C�3-OBTO
I `
i
'�. Cape Cod Super SuHet Inc IMPOR7AhT', COVERAGE'NILL NOT BECOME
i' 228 Main St EFFECTIVE UNTIL YOUI4 POLI�Y EFFECTIVE
W Yermwlh,MA 02613 DATE.
I
PLEASE PAY THE TOTAL AMOUNT
DUE SHOWN BELOW NO LATER
THAN:
iwuaEo 11I1672004 �
' C 7 Flnanclal Service Co
� 65 IlaffiSOn P.venue%505
eorion,!AA 02110
Pfi00u!'-ER OF RECORO
Polity EHeclivaDate ty06f2U04
PalicyNumEer AYVC��7 98 4 501 20G4 UIH,� .
Estimaled Total �ales Per Eatimatetl Annua!Premiums
CODE Mnual S1a0ol 4
� NO. �muneretien Remun- I Subjecl ta :�I OlFier
� I
I I I
SEE EXTENSION OF INFORMATION PAGE I i
TOTAL ESTIMATED ANNUAL PREPAIUM i :,yal
TOTAL MA ASSESSISENT � ��
1JBBM 4.900M,F �
55
DEP0.SIT PREMIUM �,aa1
DEPOSIT ASSESS41ENT � 5�
i I
)
Eshaw
TOTALAMCUNTDUE 1, 54J
FOR COMPANY USE ONLY
. Net Amount of Check
mitial8 Oale
plecs�goifi^_e', 704
AP4g�1(5-39) .
i
' • IYov 17 04 12: OBp Tam_ 617-Z92-0988 p, 2
IWORKERS CONPENSATION AND EMPLOY723 LIABILITY POLICV POLICY NO. AWC 7070845012aLW o00
EXTENSICN OFINFORMkTI�NPApE
ITEM 4.CONTMUED PAGE NO. �
Estlma!etl Tp;al a1eS Pef Estlmatetl 4nnual Premiurro
CLASSIPICATION OF OPERATIOHS ��E ����� E100 W SuD ect to
� AllOtller
NO. Remuneratlon e�ation 4od�icati�n
MA-20 Ir.t=astate I.D. 923833
I
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22B Main ^>treet -
w YarmoutS, tS4 0?6?3
; P]o. o= Empleyees Per Loca^.Sor. g �
I
� RESTAOAF.KY YOC 90i9 64,'S2 2.85 1,198
A�.�ezaq= Numtex ot Employees: p
TotalSAvbrage Number cf Emp1o}�ees: E S�a�ns� a"��$
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�� • _ Nov 17 04 12: 08p Tam 617-292-0988 p. 4
WORKERS COMPEN3ATqNANO EMPLOYERS uAe4LITY POLICV POLICY NO. AWC 7010845012004 000
EXTENSipN OF INFORMATION PAGE
f�EM 4.CONTINUED PAGE NO. 3
Rates et
CO�E E3timated Tota1 =�W of Estimatetl Annual Premiums
CL4551F�CATION OF OPERATION9 tY0 P.nnual Remun- Suuject to
- Ra�nuneraGon �tli NI0111ef
NA-27 Intsasta'_e S_U. d73E33
I
Total Estinated SCznflartl ?remi�. � I 1,LB
� I C90� . j 269
Axper,se i,cnscant ,
� Tecmr:sm Rink I,^.s. Act of 206? - �=erti:ied Loc.ses 5748 I! - 1�
Subject to '.?asa .9ssessment . I� 1,198
i Poiicy Tctal � � 1'96� 1
Maas F+ssessmer.t I � d.9006I 59I
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� ' nov 17 04 12: OBp 7am 617-292-0988 p. 3
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� E:[TENSION OF tNFORMATION PAGc
REM 4.CONTINUED PHG�NO. Z
� Reks Per
CODE EalimaledTotel Et00at EstimaledAnnualPremiums
ICLAaSIFICATiONOFOPERAPON3 N0. '�"a� Remon- Subjectto
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MA-20 Intrastate I.C. 423833
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'I TOCal Sch�duied Premiom Fcx =eriod 1,198 .
Tarrorism Risk Ins. Act of 2002 - Cert=£iac losses 9790 19
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTP TO OPERATE A FOOD ESTABLISHIY�NT
, PERMIT NUMBER: #OS-024 FEE: $150.00
1n accordance with re�uIa��ons promulgated under authoriry of Chapter 94,Section 305A and Chapter
I 11,Section 5 of the�ienerxl Laws,a pem�it is hereby gr�ted to:
Cape Cod Super Buffet Inc. 228 Route 28 West Yarmouth, MA
Whose place of business is: Cape Cod Super Buffet
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yarmouth
i Permit elcpires: December 31_ 2005 BOARD OF FIEALTH: Be�in$, y'o+u�a„M,$, •
. P��f�� v�ef�
Red�+at 4. B�u,w.r, e1�.6
•sra�ruaG:zoo dValen S�ra1i, R.A!
� R.uc�.r� R.N.
December 28.z004
; B�uce G. urphy, S.,CHO
Director of Heahh
i
�
�
i 'I`HE COMMONWEALTH OF MASSACHUSETTS
I TOWN OF YARMOUTH
PERNIIT NUMBER: #OS-020 FEE: 50.00
This is to Certify that Ca�e od per Buffet Inc d/b/a ane od Super Buffet
228 Route 28 West Yarmou MA
IS I IEREBY GRANIED A
COMMON VICT[TALLER'S LICENSE
In said Town of Yarmouth and at that place only andc�pires December thirty-first 2005 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respectin�the
licensing of common victuallers. This license is issued in confornuty with the authority granted to
the licensing authorities by General L,aws, Chapter 140, and aznendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: B �!. M.�l. G��%Tixws
A�o.`b �vice ��
SEA�r[t�rcr. 200 RQ��. BR(Ntt�L�e��yU�
�s!� R R.�v
December 28 2004
ruce G.Murphy, .,CHO
Director of Health
, . � aa"� �' �:�. �����y�e��''
}��'�<
3=°�a q1e TOWN OF YARMOUTH BOARD OF A#,3'H NOV 1 7 ZOQ3
o ,., APPLICATION FOR LICENSE/P���2004
�`C�? ,�^*,, � HEALTH DEPT.
* Please complete form and attach all necessaryi'documents by December 31, 2003.
Failure to do so will result in the return of your application packet.
T• U P� � - /17
L N ADD S : Z K a✓ �.t /1YJ�
Same
C ON • G� 2 u
i A ER' NAME• u n ` - �//J,
i MAILING ADDRESS: �rn�
I
iPOOL CERTIFICATIONS:
T6e pool supervisor must be certiSed 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. 2.
; Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary 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
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fte at your establishment.
1. ��_ / _,_,T_ 2.
I .I'ERSvi�t�"i i,iil�kii�. -- ___- --- __ _ --- - ---- _ _ __ __ _ - --- _ _-- -------
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
�. (�t ana� �% � . � i z. 7S� Glt .��i
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 tir�les. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Health Departmeut will not use past years' records.
, You must rovide uew co ies and maintain a file at our lace of bus�ness.
P P Y P
, ' / ,/
1. �IAGI� �/Q� , �� 2. �.SZ /��� ��/�l/�� �
3. �— 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGINC:
��. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR6D FGE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S50 - _CABIN S56 _MOTEL $50
_INN S50 _CAMP S50 _SWIMMMG POOL E75ea �
LODGE $50 TRAILER PARK SSO WHIRLPOOL S75ea
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT H LICGNSE REQUIRGD FBE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0.100 SEATS S75 _CONTINEN"CAL S30 _NON-PROFIT S25
I >I00 SEATS SI50 � �COMMON VICT. S50 O`I'O�� _WHOLESALE S75 �
I RETAIL SERVICE:
UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT H
_<50 sq.ft. S45 _>25,000 sq.ft. 5200 _VBNDMG-POOD 520
_QS,OOOsq.ft. S73 _FR07..ENDGSSIiRT S35 _TOAACCO 525
NAMECHANCE: $10 AMOUNTDUE _ $ ZOO.00
� «...:pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*""
,. ..
ADMINISTRATION
Under Chapter 152, Sec6on 25C, Subsection 6,the Town of Yarmouth is now reyuired to hold issuance or renewal
of any license or pernut 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
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Tovm of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE: Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTf Y TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED F�E(5) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPAR"I'MENT FOR INSPECTION 7-]0
DAYS PRIOR TO OPENING FOR THE SEASON.
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.
ADDITIONAL F, U ATION
POOLS
POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. ,
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSU F.R VISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
AT • iN PO I Y•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
reqmred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
__ FR07.F.N DF.SCF.RTC� __
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heaith
Department. Failure to do so will resu(t in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSID . FM�C•
Outside cafes(i.e.,outdoor seating with waitedwaitress service),p�have prior approval from the Board of Health.
OUTDOOR COO iN •
Outdoor cooking,preparation,or display of any food product by a retail or food service establisiunent is prohibited.
DATE: • SIGNATURE: `����� �2`'`� ZL,
PRINT NAME& TITLE: �UQII ����� ,L / ��)')')���/' '
�� r
10/22/03
` ` � The Commonwealth ojMassachusetls
= Department ojlndustrial.�ccidents
; Olflceol/mstl�adiis
600 Washington Slreet
Bosron.Mass. 01111
" Wbrkers' Compensation Insurance Affidavit
ARnlicant information: Pf A•eFRI1V7'Tir.7.Ty
m. u. P� �L
r-
on: "2
� , s �aYm ��h . �a6� a � �
� I am a homecwner pznortning ail work myself. ,
� I am a solz proprieror�-,+, ha�e no one ��orking in am capaein�
�m an employer pro�iding workers' compensa[ion for my employees aorkine on this job.
comnanr name:
81�(�fC55: � �
citv: nhone�•
iDsurance co. poliev p
� I am a sole proprietor. general contractor, or homeowner(circle onel and ha�e hired the contractors listed beloµ ��ho ha�e
the follu«in_ «orker .ompensation policas:
comp��v namr. �
. � address. �
cin�: ehone k:
insurancc co. oeiiev#
comoany name:
address:
[iLv. phoee M•
insuranee eo. �itev A �
�
Failure to secure corenae�s requlred under Secnoa ZSA ot MGL 152 n�lad w Ht iopaitlw W erisiW peultln of�O�e ap to 51,500.00 a�dlor
ooe ynn'imprisoamen�u wxli��eiril penaiHa io tAe lorm of�STOP WORK ORDER ted a Ilee aff100.00�d�y apiest se. [a�denu�d Wt a
eopy of thia shtement m�r be fonr�rded to tAe 011ice of foveatlpuom of t6t DIA tor eoven�t veriBaWa
- l do�hrreby certijp under rhr pains artd perta!(ia o/pery'ury thm the injornmtion provided abavt ir bwt and rorreee
Signaturc �i�u'�`"� �24^ �z � �3
� '7 /
Printname L oneM�/�/ ��/( �.
.. olTiciaf use onh a no�r rite in this arta ro be complettd by eih or Imva ollkial
ciry or rown: Y���T$ _ permiNieeox M nBuildine Departmtot
� �Lieeosio;Bovd
�cheek if immrdiate response i�required Z61 �Stleetmen'e 011fer
(508) 398-2231 p,at, OHedtO Depanmmt .
vonuct person: phone M•_ __ _ nOther
r
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
RENEWAI DUOTATION
P�EASE MAKE REMITTANCE TO �
� 7EL.# (800)876-2765
A�.M.MU'NAL
� Date 1Q/01/2063 P.O.BOX3500.59
� BOSTON.MA 02241-0559
j Cape Cod Super Butfet inc IMPORTANT: COVERAGE 4VILL NOT BECAME
228 Main St EFFECTNE UNTIL YOUR RENEWAL DATE,
W YamwuN,MA 02673 OR UNTIL ONE DAY AFTER VYE RECEIVE YOUR
� DEPOSIT PREMIUM PLUS ANY ASSESSMENT3.
i WHICHEVER IB LATER.
TO AVOID TEFiMINASION OF COYERAGE
YOUR REMIT�ANCE MVST REACH US
�Y:1112112003
aasuAEo� . .. . . � .� . . � . . . �
i . . . � . ... - . . .. .
C T Financfal SerWce Co
65 Harrlson Avenue#505 PLEA3E PAY AMOUNlS SHOWN BELOW fOR
Boston,MA 02110 DEPOSR PREMIUM AND IAA ASSESSMENT.
�
' PRODIICER OF RECORD
aresen�e�cp,anon as�e ,z,osizoo3
, . Poticy Number AWC 7010845012003 000
CODE EstlmatedTolal $��o� EstimatedAnmialPremiums
Ann�
� N0. Re�mmeratiore ��^' M�n Aq Ottier
'I
�
�' 3EE EXTENSlON OF INFORMATION PAGE
TOTAL ESTIMATED ANNUAL PREMIUM r,zsi
TOTAL MA AS9ESSMENT
981 x 3.7000°k 3 6
DEPOSIT PREMIUM i,asi
DEPOSIT ASSESSMENT as
TOTAL AMQUNT DUE 1,297
� � FOR COMPANV USE QNLY
Nd Amaeit of Chedc
ae
IraOat&Date
� phddng oR�ce: 707
. AP 4921 (9�89) .
i
, k.. . 1
�WORN£RS CQMPENSATION AND EMPLOYERS LIABILfiY POLICY i'OUCV NO. Aw['�mnnevf Z(1p3 000
� � - EX*ENSION OF INFORMATtON PAGE
, ITEM 4.COPITINUED PAGE NO. �
CODE EstimatedTotal a��o4� EsWnatedAnnualPremiums
� CIASSIfICATION OF OPERATIONS Np_ �^� Remum SubJedto
RemuneraUon �� on ''����
I MA-20 Intrastate I-D. 423833
I, Cape Coa Super Buffet inc
228 Main Street �
W Yarmouth, MA 02673
iRESTAi3RANT NOC . . 9079 53,040 1.85 981
I
TOTALS $53,040 .$981
! Total Average Nvmber of Employees: 0
�
�
I
�
�
i
j
i
I �
AP 4921.Q1(8-89)
` WORKERS COMPENSATION AtdD EMPLOYERS LIA81LtTY POUCY POLICY NO. AWC��108450ti2003 000
E)CYENSlON OF SNFORMATION PAOE pq�NO. Z
� [TEM 4.CONTINUED
� Esymeted ToTal R�g � EstlmaOed A�inual Premiwns
CODE a���
� Ci.ASSiFICATiON OF OPERATIONS ryp, ��� RemUm S�bject to
Remunero5on eretion cadon Au OMe�
MA-20 Intrastate I.D. 423833
�
12/06/2003 TO 12/06/2004
' 981
Total Scheduled Premium For PeriOd
Terroriam Risk Ins. Act of 2002 - Certified Losses 9740
16
i
1'otal Satimated Standard -Premium - � 98i
Sxpense Constant 0900 264
� Terroriam Riek ins. Act of 2002 - Certified :.oeaes 974Q 16
�
ISubjeci to Mass Assessment 981
Policy Total 1,261
� M.ass ABaeasment 3.'7000 36
I
. . . _ ._. ... ....._.. . ... .
�
I
AP 4921.01{9�89)
I
i TOWN OF YARMOUTH
BOARD OF HEz1LTH
PERMIT TO OPERATE A FOOD ESTABLISffiVIENT
PERMIT NUMBER: #04-024 FEE: 150.00
i
i In accardance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter
� 11 I,Section 5 of the al Laws,a permit is hereby granted to:
I Cape Cod Super Buffet Inc., 228 Route 28, West Yazmouth,MA
I
Whose place of business is: Cape Cod Super Buffet
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pemut expires: December 31. 2004 BOARD OF HEALTH: BeKyw�rl�c$. (joadoic, �9.$. '
p�.sf���rt, v� e�
R'o/dw'ytt 4. B�uu�c,,1�Glm�
� �SEATING:200 � �BLC� eQ�� R✓►.
���.(-'L� '�"
' November 25.2003 � /J � Y� �
i S� hr� ' Bruce G.Mwphy,MPH,RS.,CHO
�ir � Director of Health
GJ� �C � �
`A�t..
THE COMMONWEALTH OF MASSACHIJSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #04-014 F'EE: $50.00
Tlus is to Certify that Capg Cod Su�er Buffet Inc. d!b/a Cane Cod Su�er Buffet
228 Route 28, West Yarmouth, MA
IS HFsREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only ande�cpires December thirry-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. Tlus license is issued in confornuty with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereumo affuied their official signatures.
BOARD OF HEALTH: /.�e�risc $. �a�osz, /N.�S. G��uLux�ra
p�M���t, v� e�
sEn�ru,rG: 20o RoGe+tt ,�. L��rou�c, �
�ele.a �S'l�li„ R./Y.
November25.2003
Bruce G. Murphy,MPH,RS.,CHO
D'uector of Health
- ' � C•C.SuPe7cQuF{�T
ofe R,y TOWN OF YARMOUTH BOA TH''���
3� ° APPLICATION FOR LICE �DO t,1
� � �? � �, '�✓ �a i >; � -� �.;' -
* Please complete form and attach all necessary d ents by Decemt r 31, 2002
Failure to do so will result in the retum of your application pac et.[,�i_, �3 3 C(1u1
T I - ���
I
nMe
TI Z' h, ot ��0
� � #
S: ��
POOL CERTIFICATIONS:
The pool supervisor must be certi5ed as a Pool Operator,as required by State law. Please list the designated
�001 Operator(s3 a�&attaeh a eopqt3€ihe certification to this form.
1. 2•
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 certificarions to this form. The Health Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS•
Ali food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your eatablishment.
1.��Q, �, � 2.
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1. (s�tkt t�ai �hi Q�. L� Z.�.SZ ,�� ��.
HE�jyILICH 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 anri-chokmg pmcedures 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.
t. Gr�+ iao L? z.---1 sZ !-�� - CN�!(i►
3. 2, �i 4.
��,-r
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQTJIRED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL S50
_INN $50 _CAMP $50 _SWIbA�fING POOL$SOea
_LODGE $50 _TRAILER PARK S50 WHIRLPOOL S25ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0.(00 SEATS $75 _CONTINENTqL $30 _NON-PROFIT S25
I >100 SEATS $150 �Q�� I COMMON VICT. S50 d�J�O _W[-IpLESALE E75
RF�p�i,�F.RV_ IGE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _e25,000 sq.ft. S75 `TOBACCO $20
_<50 sq.R $45 _>25,000 sq.ft. a200 _FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ 2po.0o
•*•**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 ATT?;CHED
2�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid pri to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETiJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
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.
ADDTI'IONAL REGULATIONS
POOLS
POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected
^ by the Health Deparhnent prior to opening. •
POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standazd plate count
by a State certified lab,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
CONSUMER ADVISORY:
Each food establishment which serves ar sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Departrnent.
FROZEN DESSERTS:
- Frozen desserts must be tested on a motrthly basis by a State �ertifted iab. Test results must be sent to the HeaIth
Depar[ment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: I.I J� SIGNATURE:
PRINT NAME &TITLE: �GQp��1_/_ /i(an��
10/18/02
. � �
The Commonwea/!h of Massachusetts
: Departmenr of Ixdustria/.-1 ccidenls
; 011lcsol/arasUDsWu
600 Washington Strett
Bnston. Mass. 02111
��y'` W'orkers' Compensation Insunnce Affidavit
n m.. � e ,
, 2� .� . v�5'r ryjd a �7�
ctt�_ ehan k ) �/b ! ��!/ �•
�� �
� I am a homecwner pertorming all work mpself.
'�� am a sole proprieror _-d ha�z no one ��orkin_ in am capacity
-am an employerpros-i�ing worker� eompensation for m�:empbyees workine on this job, -
cmm�am� name:
address:
city: ehon 16
insurance co. Dolicv M
� I am a sole proprietor. qeneral contrac[or. or homeowner�circle onel and have hired the contractors lisced below ��ho ha�e
thz follo�cin_ ��orkrr• compensation polices:
tompanv name: �
address•
citv: phone q• .
insur�ncc co. Delie�•#
companv name: �
_. __.. _ . . . _-- -- -- � --. ___ . --- -..
address: . _ ___ . _- ._ __ __.. _. - - - - - . . .. . .
�y: phoee M:
insuraneeeo. eellevM � � �
t
Failure to xeure covenge�s requlred ueder Setaoo ZSA of MGL IS3 n�Ind to l�e iepaiOoa W triW W ptultlo of�B�e ap�o f1�00.00 aWlor
ooe ynn'imprisoament�e w�ell a eivil pendtla io the torm of�STOP WORK ORDER�ed i Ilet ofS100.00 a Mr Kaiut m� [��denhW�hat a
copy of tAy etatement m�y be fonvvded to the ORee af Inva�iptlom of the DIA for emra�e verillntlx �
� /dn hrreby cmifj•under�he poins and � o ryary 16m 1ht injorinaNan provrdtd abovt it nue and rnrrcci
Signaturc � Dme � � � �d 2,
Print name Phpne N
. oRcial use onl� do not+.rite in this arca to be eompleted by tily or towa ollltial
city or town: Y�H��Ta _ � penniNiame N nBuildiog Dep�rtmcnt
� �Litemieg Board
� cheek if immediate response ie required Z61 �Stleetmen'�Oflice
�Health Dep�nmeet
connct penon: phoneM;_ �508� 398�2231 eat. nOther
. DRo 03 02 01 � 15p � p. l
�� / ���.--... � sar101t o�S9�GelEn tc�bw wu.
� �-� °�/J,�,{�-(S��� S�CtiUSEYs9 WOFKERB �SATION INSUFANC�
if�l �vr�.�nor+roRwDR�tB' 1 t�
`; p• / T � :a-(rL, 1
� '1'He WarkMa'CmnWMW m1 RatlnY 61mD��n 6unau aE M�xacnuaNtn
MNLTO: P.Q4�88005 BeRMn, NA �5
(0171 �•9oa9 -_ , ,
IMPORTANT: .
n eNn�NP6ce[+On muYt W fMd f9e aa6n�apd d�1fY. W tl�a B/a1u. SM IICs�b4 mo�J�Itt�'m ro4��ranw�Vt aN:tnl m�: �.
ThMnPDlwafW+m�Wtm��addChmaii�nrclemtlau0�lo�inM�°�° � �,,,,,�� ,av. �.�,��,mwnr�:
� unaor w orsum.s�wnwlh ewenoo Se o�19�k 7Mynw�m"wv� a�+m . a.
ln,e(elca�afto�eratpinbaefarlM�erffiq'�!I�PPf.dWn� t1ieD9PIIOM4�ndMa�rdCR����.aWiwaM�P�"'��Mf�IMDIwFirtil�eS�)�
IhR�XGY11 MG MI�OG!W��M4MYI�YVIWYP.C011[�k�P��r tW MKYIf YI��1��NRd1@p IM�
th��alMn pmw'W�doM�eatf Eo Wvd br�2.07 AM,��dayanrtt�r ePP�Ceucer.na apa�r�c+�um src recwcf:,vw c�ms N�w tiv�u
1M undwva�naU MAlloqa'K14WNGA b GOA+hwdlm�Ca�0onL6on uMeRO��N�p[Mh�Y���n Ihrud�lVaMmahd andlMYeb�'�DD�IRc fatautl5 i+XuiaY.�:
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RWI�� ..'��.L/ �a 01
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1. GENERAL�NFOR►tA7�N
k � Suif"i- F .��.:�� G.T . �f r•i. —
,._C R_C , C o �..�._..—
� NAMEOF6MP1.OVEfY Wnsc�weaouroano�x.B�+'"�psm�Me)xtnra�WawnDvmntt�veaorc+�uw.nu�mm.l pPtNPING
.
z.�.4-_.�3,..'.�='!• `—. ._,
FEDQiti.EMPI.OYERS IDENTIFK'.ATION NUEIBER 4�FFsndNW.ffitaC�a WR'OIYfe Ift3�an,i
- 1�.�' ha�a J"� W �/+�h' Mn.�-t� M� vs� '(3 {S-�•� 17i- 3iic
MeuLMGADORkSS Numb.r �trwt GCs 'n"' � �"n`�
a. 4�:taw.� "I�,6n,.T.. . " Phnni,
AN48SAC1'iU3t7T5 LOCHT�Otr NumCn Slron+ � CiH st2tn 7Jv
'u..._ � Fiwno
Dl'MtiK NUl LOCATION9 R'umGwr Snm!� Cily 3ta4� Lq �
B._'_._.. .. ��� ' - _
LOCA"IUNUFREGORUS NumGo� 9Vmet (SN 3taU Zlp � i+Nana
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❑LLC �L�P �OA6t(tlAp1dIP} ,_, . ._....._
II. ELIGIBtLitY REQUlR�MiNTB �
Tp hn niler6lp b aNain ma6ipiqdn�k cawtogN.
Tho amPlal�"s 1pp1ia10on fur vdu�6�^/Ma4aCdufBtlti WMiPRF'�11Ps'rlton Oove1E'�E�ua�hare bo0n roi9WJ.7 W�lwo C2)carNas�
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FROM : CRPECODSUPERBUFFET PHONE N0. : 508 775 8033 Dec. 06 2002 11:24AM P1
` G� ���'� NOTICE OF ASSIGNMENT 2�
� EMPL�APE COn 3WPE� BUEEET r�� OOMBOI.O. � ST4TU50P iLAYER
'L28 MAIN ST 000423799 CorporaL'icn
� W YAAMOLT:Ii, MA 02673
COVERAGE GROUP
0423833
,,,,Y.:,. The,, q'aiyer,�of C�ur Right to Coverage ux�der this ass'ignmenn
Recover from 0:liezs Eradorseaent apg2-iesrto Massscliu9etEts - -
� is availabla on Pool policiea. operationH only. For cwerstge
i Contact your agenk for details. outside of [4assachuseets, contact
the appropriete Pool or Plan for
LYA3L statE.
�. AGEMT C :. FINANCIAL SHRV'ICE CO IN&tNiANCECdMPANY: ._....�
OR 65 HARRISUN AVE #505 ATM MUTCDIL IE'S CO
PFlOOI7CER: BOSTON. MA 02111 MS. JUDSTIi 3ARRX
11 NORT:I AVENUS
BU+tLINGTON, A�.A Q1803
(800) 876-2765, Ext: 1666
AOENCY FEIN:
�'i CLP55ZFICAT7�JN OF OP3RATIU*7� ��CLASS ESTI.taTED RATE �yM���ES?SMATED
CDDE 1`OTAL ANNUAL FREM?UM
P.s*sv�-e4.arxo�
--------------------------�----------- ----- -----�-------- ---------- ----------
RESTAUWINT-NOC 9079 $51,000 2.19 $1,117
,E�PTrCY�tS LIABTL3TY 100L100/500 98�5
—'S�aal�eal�'"pR'ai�sfiUe2' _. .__.,.,_,.._ _. __... _. _ S1;1T7.
_._.
?XP�'?h5F C6NSTANT 0900 � ����5244 ��� --'
ESTIMATED At�ATiJAS. PRSMI�JM Sl,361
DIA ASSESS. 4.Sg OF STANDARD PREM. $50
BST. ?lNNfJAI. PFEM. P7.US ASSESSMENT $1,411
!►�i'ALLMENT BASIs: 6nnual RECUIRED DEPOSIT PREMIUM $1,411
COYNENT9
Coverage ef£ective 12:Q1 AP. on 12/06/02
^_opies of c*�e i.=isured�e frnxr zrtosc rec¢ntly filed Foxxa 9&is or D�T Form is d_d not
acco�any thE apDlicstion as req�xired in Part VT o= the a�ylication. Plaase fosward these
records ir:¢nediately to =he ins::rance eo¢pany liated above.
DAIE OF NOiICE: I2/04/Q2 PREAAREG BY: Maxy2llea 1Pee
&%T 532
� w • �V'SCI31C C1�1tRL9R ASSI�II�Pl' ' • • .
IETfER17. 3452`.._._.�... � _ ,:�— � ,,....c._._ . . .. ._ .... . _.�--_. ... . � � �. �.. � . .
�7 CAPY: EMPLOXcR
The Workers'Compe�etion Rettng and lnspection Buraau of Massachuaetts
107 ArcA Street•Bostqn,bIA02110
(6t7�9030•FAX(617)439�6Q55•www.wcrl6ma.org
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
' PERNIITNUMBER #03-082 FEE: $150.00
In aawrdance witb regulations promulgated�mder authority ofChapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby ganted to:
Zi Qian Zhang, 228 Route 28, West Yarmouth, MA
Whose place of business is: Cape Cod Super Buffet
Type of business: Food Service
' To operate a food establishmern ro: Town of Yarmouth
�
! Permit expaes: December 31, 2003 BOARD OF HEALTH: ekwrlia�. �eUtkes, �a,c
� • a. �, m D.. ��
���. �. G�
� �a�ru�c:2oo Pa�rtu67KtD�watt
?��a�s SF�k. R.71.
i
� December 19 ,2002 /
mce G. hy, .,CHO
; Director of Health
�
�
i
i - --—
,
i THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER #03-055 FEE: $50.00
Zi
This is to Certify that Qian Zhan��/b/a Cape Cod Super Buffet
228 Route 28, West Yazmouth,MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only andexpires December thu�ty-first 2003 unless
� - sooner suspended�r g�vok�far viohtion ofthe-laws of the Commonwealfh res�eeting-the _ —
licensing of common victualler's. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws;Chapter 140, and amendments thereto.
In Testitt►ony Whereo�the widersigned have hereurno affixed theu official signatures.
BOARD OF HEALTH: ��f, i�dluFec. �iFaimxaa
�D. Cjo7d�c. '�ll.D.. ?/ice �ai�uxa�
Ssa'ru�rG: 200 �a�0zt�, "btoccvr, �
pa�rEek�e�.xat�
�f S! . .7Z.
Decemberl9 ,2002
nlce . urp ,
Director of Health
' ���.. �
.. , � _ L•G SdPe(L (3JFFc-�r
TOWN RD OF HEALTH
., APPLICr� �� E/PERMIT-2002
``� G�/7 sy ./IF.�E�PT t� a00• va
�* Please complete form and attach all necessar�documents by December 31, 2001. Failure to do so will result in
the return of your application packet. a3�a
NAME OF ESTABLISIIMENT: (�.a�'e o u pQ✓ P T L # 0 77S - /,/�.
LOCATION ADDRESS: 2 2 t� RT Z.FL � � Ya�'iHou,�
MAIL G ADDRESS:
•Cct S'� ?N 13a f �
'S NAME: uan � ,� ,< % L. � �7�— //o
MAILINGADDRESS: 2� R,� -Z� I,v a ou F� D2��3
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 certificadon to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary 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
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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 certificaUon to this applica6on. The Aealth Department will not use past years' records.
Yoa must provide new copies and maintain a£de at your estabtishment.
l.�� ua� l��wo � 1. 1 2.
PERSON IN CHAR�i�_--------- _ ___ -- -- -_ __ _--- -
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
,
�.�u�, Z- I z.
� 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. z �- m CH�u,�l� 2. ��4 / Kk , C�ieu�-q
3. � � � o j 4. XvQ _—�
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50 _MOTEL $50
INN $50 _CAMP $50 _SWIMIvIING POOL$SOea
LODGE $50 _7RAILER PARK $50 _WI-IIRLPOOL $25ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-t00 SEATS 575 _CONTINENTAL S30 _NON-PROFTT $25
1>l00 SEATS $150 Da-0/0 �COMMON VICT. S50 �Od'6�7 _WHOLESALE $75
RR7'AII.SRRVICE:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
TOBACCO � S20 _<25,000 sq.ft. $75 _TOBACCO $20
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT S35
NAMECHANGE: $]0 AMOUNTDUE = S 200.00
•**"*PLEASE Ti1RN OVER AND COMPLETE OTHER S[DE OF FORM*'**' -
/ ��
�„ � . . ,. . � ' • � �.
�
ADMINISTRATION ti
��
�
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
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED `
Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: j
YES `� NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'[JRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TF�HEALTH DEPAR'I'MENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
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.
ADDITIONAL REGULATIONS
POOLS
POOL OPEPiING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Deparhnent prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
('ATERiNG 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. T'hses forms can be
obtained at the Health Department.
_ __ _ _- - -__--- - _ _ __ __ - _ _ __ _
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failwe to do so will result in the suspension or revocation of your Frozen Dessert Permit unril the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
DATE: �� 0 o SIGNATURE: `"I��`��- ��y"� G Z
PRINT NAME&TITLE: �Qv�P�t?r✓
J
09/11/O1
� s
�. j
' , � �
• The Commonwealth ojMassachusetls
. = Deparrment ojlndustrial.-Iccidenrs
a b O/J/CeOJ//ICS!/Y�dIIf
600 Washington Streer
' Bosrort. Mass. OZlll
` w'orkers' Compensation Insurance Affidavit
ARF�icant informaHon: P►ea�cPR[NTTe+��K
n;1ms�. �.t^.{7? ��ErA �`LhE.f I»�IQ'�
��z�_ 2z� r �r 2� > �
��, �-�5-F Y������ ��� o z 6 7 � Rho��� Is 9� ) 7 7l-d�/v
� I am a homeoµner pzn�rtning all work myselE �
� I am a sole proprieror r..d ha�z no one ��orkin� in am capaeity
0' I am an employer pro�idins uorkers' compensa[ion for my employees workine on[his job.
comnanrname: �K.YIP �e>/� s'�{�� ��y�P�
asldres�: �� 2SS � �T 2c��
��t,: �es-(- Y���WIB Ar�. �M� D Z�� 3 — phene u.
io5��,��e�e. oo�����
� 1 am a solz proprietor. _enerai contractor. or homeowner(circle onU and have hired the contractors listed beloµ ��ho ha�e
thr follu��in_ �corkar, ;ompensation polices:
comoanv name:
address:
tih�: nhen tl•
insurancc co. polie�•q
tomoanv namr. �
— _.. _._ . __.._—___ __ _. _ ..-. ____---
-----
addms � -��- - . .--. .
citr pho�r.
insuranee co, pgg�,p �
t
Failure to seeure covenge a�requircd under Secnon 25A of MGL IS2 u�Ind to�!e i�poritloe W eri�i�l peultlea oh��e ap ro S13W.00 ud/or
oee ynn'imprisonment u e�ell u eiril pendtla io the form of�SfOP WORK ORDER�ed�Oee of SI00.00 a dq tpimt ma [��denla�d H�t• .
topy of tAn sntement may be fonvtrded to tht Oflite of lovatig�tiom of Me DIA fa emen�e veriRdtfo�.
/do�hrreby cenij under the paint and prnaltier ajperjury that 1he injoimation provided abovt is nut md ron�ct
I_ 1 ( / c�
Signaturc ��� J�"�``� L 1/ [�r � �� / � / /� /
Printname � UQti� �Kl ��1 >��� —tS��`�
.. oRci�l use onh do not*rite in this�rea to be compkhd by eitv or tmvn oflleial
ain or town: Y�MD�T$ _ permiNiteroe N n8uildiog Deptrtmtot
pLietasio6 Board
Q check if immediate response i�required 261 �Selectmen'f Offier
conuc�person: Pho�i p:_ (508} 398-2231 eat. �nOtherh Dev,rtmem �
r
. FROM : FAX N0. : Dec. 17 29�1 i�i:ibl'M r�
12/l7/BS 12:12 To:MAhK80916fi3713 Fru�n:uindrf 732-683-1900 Page 1/1
Y,I,R17192091tit
The Small Business Underwriters Program
ao aox ssi9 (ra?�s��-�roo
Preehold, NJ 07728 Fax(732)063-l1 I!
DATE: D�omber 1Z,2001
TO: GT FINANCIAL SERVICE CO.
FROM: vice presiderrt of Underwriting
PLEaSE DELIVER THIS IMMEDIA7ELY TO YOUR
UNpERWRITING/MARKETING DEPARTMENT
RE: GAPE COD SUP�R BUFFET,INC.
Pollty N:WC7-1663713 Leglon Insurance Company .
CONFIRMATION OF COV�RAGE
Thank you for the applicatbn that you submiited for the etmve risk. We are pleased to aclvi,se yrn�
that the coverage is etfective as of:
�ziosnoo�
7he policy will be prompth/issued and mailed direcUy to your�ce.
We thank you far the opportunity to do b�iness wit�you and yo�r eyency.
r
, FROM : CRPECODSUPERBUFFET PHONE N0. : 508 775 8033 Dec. 06 2001 01:35PM P1
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLIS�NT
PERMITNUMBER: #02-010 F'EE: $150.00
In accordance with re�u1ationspromulgated under authority of Chaptea 94,Section 305A and
Chapter 111,Section 3 of the G�eral I.aws,a permit is hereby granted to:
Cane('.nci Rnner Ruffet inc_ 22R Rnute 2R West Yarmnnth_ MA
Whose place of business is: C Cod Si�Buffet
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
� Permit e2cpires: December 3 L 2002 BOARD OF HEALTH: ;� Zd!lkec,
��D��{a.s��lee (�,�(radtara.c
•SEATING:IAO � �a��or�oetG
i
� JeolletV 24 �2(bl
ruce G. urphy, .S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #02-007 FEE: $50.00
This is to Certify that Ca�e Cod Suner Buffet Inc. d/b/a Cape Cod Suner Btiffet
?7R Ro rtP R Wect Yarmnnth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yatmouth and at that place only and ea�pires December tlrirty-first 2002 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity wrth the authority ganted
to the licensing authorities by General Laws, Chapter 140,and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: 's�, i�efli�oz, (�at�xaa
D. ��mrdava. '�Jl.Z�.. 7/lr.e �(�(raGr�awc
sEn�,�: 200 �,�� �, �
�ateiek I� e�r
Januazv 24 ,2002
•M , ,CHO
D'uector of Health
,• -1 G� C� � C� � M � L
� TOWN OF YARMOUTH BOARD (J� J U N �
APPLICATION FOR LICEN&F�' ��� 3 ����
• Please wmplete form and attach all neces Y �, HEALThf p~^-
the return of your application packet. �'documents b �cember 31,2000. Failure to do so will result in
----------------------: Cc�
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POOL RTIFI A'i'IONS•
The pool supervisor must be certified xs a Poot Operator, as reyuired by new Stste law. Please list the
designated Pool Operator(s)and attach a copy of the certification to tlus form.
1. 2
Pool operators must list a minimum af hyo 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 uae psst yeare' records, yuu must
provide new copies and maintain a file at your place of buainesa.
1. 2.
3. 4.
HFIMi.ICH FRTTFT('e�rrn�rc.
� --
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 certifica6ons to Uvs form. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1.
3. 2.
4.
RESTAURANT SEATING: TOTAL#a� NON-SMOKING SEATS: TOTAL#aoo
--------------._--_-----_____—___
��.`__.�.___.___._�_.__,..--
LOD IN • �ITICE L",F-QNi V -- --------
LICENSE REQUIRED FEE PERMIT#
LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN
� -- $50
— $50 _CAMP $50
_LODGE $50 --
-- _TRAILER PARK $50
_MOTEL $50 —'--
--�---__ _SWIMMIIVG POOL $SOea
FOOD SE_�F _WHIRLPOOL $25ea.
,. NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective da et for
food protection manager certification is October 1,20111.
LICENSE REQjJIRED FEE PERMIT#
LICENSE REQ[JIRED FEE pERMIT#
_0.100 SEATS g�s .
�'100 SEATS -- --CONTiNENTAi, $30
$150 '�$ _NON-PROFIT �25
I COMMON VICT. $50 �0�- D ----
� _WHOLESALE $75
B�'.TAI- L SF --RVI(F._ -----�._
LICENSE REQUIRED FEE PER�]T#
LICENSE REQITIRED FEE PER�T#
_<50 sq.ft. �5
_Q5�00� sq ft ------- ,_TOBACCO $2�
$75 ____FROZEN DESSERT $35 '—
_>25,000 sq.ft. $2� .
�—
�_
Lvt�'IE C AN('F $10
i --�_.
I
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AMOUNT DUE = S 2pp .00
"""PLEASE TUR1Y pyER AND COMPLETE OTHER SIDE OF FORM+••••
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MA SBU WORKERS' COMPENSATION RATING TOOL
MA Small Business Underwriters
� INSURANCE LEADER ASSOCIATES
LEO TiIM
65 HARRlSONAVE.RMSOS
BOSTON,MA 02717
Phone:(617)292-0388 Fax:(617)292-0988
Policyholder's Name: Cape Cod Supper Buffet Effective:06/12/2001 Quoted:06/l2/2001
Factors and Rating Criteria:
Employer's Liability Limits: l00/500/100
Ezperience Mod: 1
Classificatrons artd Related IrJormation:
Class Code and Descripfion: Payroll: Rate: Empl: Premium:
9079-RESTAURANT �96,000 2.08 8 $ 1,997
Fstimated Premiums and Adjustmenu: .
Total Manual Premium: $ 1,997
Unmodified Premium: $ 1,997
Total Modified Premium: $ 1,997
Total Estimated Standard Premium: $ 1,99'7
Expeose Constant: $ 214
Assessment $ 80
Totsl Estimated Aonual Premium: $ 2,291
Your Total Estimated Cost is: $ 2,291
Thrs is jor Quote purpases only. All Applications are subject to Underwriting Criteria and Approval. �
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7711A ou�N��m�nuv�I�Ylo►AGht� i@ItlI�TA�NflY������f�Y�r��n,iY��i�Ve�.io�i�rv:.n�.n���""f.'YAND
, `
TOWN OF YARMOUTH
BOARD OF HEALTH
i
PERMIT TO OPERATE A FOOD ESTABLISHMENT
� PERMITNLJMBER: #O1-104 FEE: $150.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
iChapter 11 l,Sec6on 5 of the Genernl Laws,a permit is hereby granted to:
� ('ane Cod Ct�ner Ruffet inc_ 22R Route 28 We�t Yarmouth_ MA
i
IWhose place of business is: Ca�Cod Super Buffet
Type of business: Food Service
� To operate a food establishment in: Town of Yarmouth.
; Permit expires: December 31.2001 BOARD OF HEAL'I`H: �d'f11. '�ette¢, �e�
i �a�rlea'�f. Zdlil�. `�/�ce
� ,�oPr�t�.e�"S�rotux, elarr�yye�
i •SEATQJG:200 �QM[pl (/• . /�G•[/•
7
June 14 ,2001
I ruce G. Murphy, R.S.,CHO
j Director of Heaith
�
�
�
I
I
I THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTEI
� PERMIT NUMBER: #O1-104 FEE: $50.00
This is to Certify that Cane Cod Super Buffet Inc. d/b/a Cape Cod Super BufFet
( �
� 22R Route 2R West Yarmouth_ MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2001 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuailer's. This license is issued in conformity with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �'d'f1L, �etYea, �rainn�atx
�lianfea Zdlikai. `Uice �(,lavunax
SEATwG: 200 �a�etZ�, S�aotvK, eP.mt�
�� D. � . 7?l.D.
r a,x,
June 14 ,2001
Bruce G. Murph , ,R.S.,CHO
Duector of Hea