HomeMy WebLinkAboutApplications/Licenses �'��Y 'i C�'��84�'(�x
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? ., o TOWN OF YARMOUTH BOARD
�C�s APPLICATIONFORLICENS,�lRERNTI�'�'�OA7 ' NOV �$02OOE
� * Piease complete form and attach all nece�saliy d�re'uments by Dece b$�ff l2'�IIQ�DEPT.
Failure to do so will result in the retlz�of your application pac et.
Nt1MEOFESTABLISI-Il�IENT: (;APE ISLANDS ��?F F�dD TEL. # 5�� ,7 '�� ��F�
LOCATIONADDRESS: 54�} MAfN Si. w_yARMou 'rN MA U' �' �3
MAILING ADDRESS:
OWNERNAME: � (�L WANN �LyE TAXID (FEINorSS1Vl
CORPORATION NAME (IF'APPLICABLE):
MANAGER'S NAME: 5 (�Z W�1 NNA ��L y�,Q TEL. #
MAILING ADDRESS:
POOL CERTIFICATIONS:
The poal 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 employees currently certified in basic water safety, standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this 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. 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 EstabGshments, 105 CMR 590.000.
Please attach copies of certification to this appGcation. T6e Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishmen�
1. �I�NET lveyoMSIN 2_ VARONG' RONd SAwAN`TAI�AT
PERSON IN CHARGE:
Each food estabGshment must have at least one Person In Charge(PIC) on site during hours of operation.
1. pICNE7 NZY6/"� S�N 2. VA�ON�I,RON�' SA6v�NTARAT
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the H jmlich
Maneuver on the premises at all times. Please list your employees trained in anti-c �-gr�� id
attach copies of employee certifications to this form. The Health Departme not use past ye �' records.
You must provide new copies and maintain a file at your place of busi s. g vppoSEU ' ftAdlE PQaI!
1. 2.
ca-�ss w a� �o k`o�o
3. 4.
RESTAURANT SEATING: TOTAL# 5�
OFFICE USE ONLY
LODGIlVG:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE pERMIT k LICENSE REQUIl2ED FEE PERMIT t!
_BBcB S50 CABIN S50 MOTEL $50
INN $50 _CAMP $50 SWIIvA9NGPOOL$75ea.
_LODGE $50 1RAII,ERPARK $100 . WIIIRI,POOL $75ea.
FOOD SERVICE:
LICENSE REQUIl2ID FEE PF.RMI1'# LICENSE REQUIRF.D FEE PERMIT# LICINSE REQUIRED FEE PIItMIT t!
I 0-100 SEATS $75 07�6?j� _CON77NEN1'AL $30 _NON-PROFfI S25 .
_>100SEATS $I50 1COMMONVIC. $50 O� �—oa� _Wgp�SALE S75
RETAI[,SERVICE: —RESID.KTTCI�N $75
LICINSE REQIIIRED FEE PF,RM[1'# LICENSE REQIJIItED FEE PERMI1'# LICINSE REQUIl2F.,D FEE pF.,RTqT p
_<50 sq.ft. E45 _>25,000 aq.ft. $20D VENDING-FOOD $20
_Q5,000 sq.ft. $75 _FROZEN DESSERT S35 TOBACCO S50
NAME CHANGE: E10 AMOUNT DUE _ $ /2 S.00
"'""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••^•
t
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 INSURA.NCE
AFFIDAVII'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCP: 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.
Transieirt occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient.
POOLS
POOL OPENING: All swimming,wading and whirlpools 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 five(5�days
pnor 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 gound swimming pool must 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 Sling 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 Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food prosluct by a retail or food service establishment is prohibited.
NOTICE:Pemuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIII'1'TO RET[JRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
nA�: si�rra�: ��zFG�-e��vNA ��L �l�✓�-
PRINT NAME&TITLE:
ivnioc
� The Commonwealth afMassachus�u
Depertnrent of I�irs�triwX Acci�eats
MCrrN�Ms
6(t0 Washtngtoa Street, 7"'Ftoor
$ostarr,Mass. 921Y1
- Worlcers'C'.a��aestlne I�sa��ee A�davk:Ha7 M�g/Electritai CnYtractars
. . , , _��, ,p�p,� _. p ye'� ,�,g��
-- - GA �E' ZSLAtvDS 'rHAz �o0n
�aa�: Sq�fi MA �1v 5fi. , _ _ _ ,, _ . �
�, w. yAR +1'11duTh �� M A �;o:c74,��3, ..�..�.a 508 ��I 2�
wo,�siu to�aacm�rnit ad�sr
❑ I am a Lomaowna perfom�iog aII wo�c myeelf. Projxt Type: New Cmshu�.tim[�R�odei
I am a sole 'dor and Lare no ona w in may B ' ' Addition
❑ I�an employer psoviding walceca'com�e�elion for my employees wo�cing on this job.
m _
■idr�•
dn, PII��'
,a, ______ w�s if
�'I am;a sole pm�nietoy geaerat ca�tncter,or iam�evner(drete owel md have 6inod 9ye co�ctnss Irstad laelow wlw have
tl�e followivg w�kecs'compet�sation Polices
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FaMe b fteea owca�C�s�syreed odv SeeWa 2SAdMC.L lS2 m Isd b1k krpwlMM�derW W P�*f aLe R MS1�MN arWr
a�c yan'i�ptfa�west n wd a eM pl�dHes te ric fir�sta STO?WQRK ORD6R atl�Bac etSIM.M a day�el ec 1 advr�h�d WK a
apy dltl�W�e�t my he fiewndM M Ne(M�ce�tLv�Ntlu DIA IraNaaye vvMnlW.
/lo IYarby cae�'y n�Jer Me pdea md ptedNra oJ jyd Ms b�faaraNai preddel aborr h aue wrid nrract
� �,e r l.r��v1�,r� �`�f'L `11.'/-� � i� t�o t6 6
p�� �ry R S wAN N A (3 E L}��A P6one#
./&LI oee.wy a..N w�la w we a.ra b ae aa�plefed 6r dls.r w,r..ma.� �
tlly�tnrn: p��
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❑ehedc H�e8�1¢�apeeae b rcqirM �'a O�;e
❑IkaMk Dept�nt
c�tpmea; p�xe ri; 1�1Dua�
t�.aon sy�maa� .
TOWN OF YARMQUTH
Bf1ARD OF HEAI.TB
PERMYT TO CIPERATE A FdOD ESTABLISHMENT
PERIvIIT NLJMBER: #0?-Q37 FEE: 75.OQ
In accorQacice with regulations proneulgated un�r authoriiiy of Chapier 44,Section 345A a�t Chapter
I I I,Section 5 of the General Laws,a�r;miit rs hereby granted to:
Sriwanna Belyea 594 Route 28 South Yarmouth, MA
Whose place of business is: Cape& Island Thai Food
Type of business: Fond Service
To operate a food establishment in: Town of 1'armouth
Permit exgires: December 31 2007 BOARD oF HEAI.TH: � 95. �a�e% M.$,, '
��t��"`'sr� .�., v�e�
SEATING: 37 n�M�,
Qisrc��ie�n���� �.1�.
.�� �
.r��zs,zoo� —
s��.ht,�ny, ,x.s.,cxo
Ikirectar of Health
1'HE COMM(7NWEALT$OF MAS5AC1iUSETTS
TOWN i)F YARMOUTH
PERMIT NL7MBER: #07-025_ FEE: 50.00
This is to Certify that Sriwanna Belyea d/b/a Cape& Islands Thai Food
594 Route 28, West Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICT'UALI:ER'S LTCEIVSE
In said Town of Yarmouth and at that place aniy and eacpires Decernber thiriy-first 2007 unless
soonet suspended ar revoked for violation of the laws af ihe Commonvdealth respecLing the
licensing of common victualler's. This license is issued in conforxnity with the authority granted
to the licensin�autharities by General Iaws, Chapter 140, and amendments ihereto.
In Testimony Whereof, the undersigned have hereunta a�ed their official signatures.
BOARD C!F HEALTH: B `11. (�y M.`�., .
dJ���l� r.N., 'U«���
SEATING: 37 Qobeit�4. 89owsc, G�l�li,�a
llczf��Mc`�,�uxo�
�9 �' � t2. .
.r�,�y zs.zoa� �.
ntce r. z�TP Y, , . >�H�
IJirector of Heal
c.Pc�� ,���
� � c�+ ts�.-r,+a,
r �^-R.tia TOWN OF YARMOUTH BOARI�AF''H�.��, . � � � � � M � �o
; y APPLICATION FOR LIC: , � �;2005
�� "'' � ' '. ����'° � NOV 2 4 2004
* Please complete form and attach all necessairy�_cJo ents by Dece er 31, 2004.
Failure to do so will result in the retum of your application p k}p�ALTH DEPT.
NAME OF ESTABLISHMENT• Gq PF_ SG�N j 1-1 I Foo� TEL. # 5�& 77/- � 9
LOCATIONADDRESS� 5R`� MR�^� sl'• W�ARM4�Tt/, MA . ayC73
MAILINGADDRESS• 5qy MAIN 3f- W- �.9RIYDV7H, M�- 0�-673 .
OWNER/CORPORATIONNAME• cR�F � zsLAi✓D THAI FflaD Co�P.
MANAGER'S NAME• S�C I wANNA BFG�r'A TEL. #7Sr-3 3y'-35Z6
MAILINGADDRESS� �°32 MRII� sT• LyN�FiEGD MA B/qy0
���
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (vCPR). Please list these employees below and attach copies of
employee certifications to this form. T6e Health Department wiR aot use past years' records. You must
provide new copies and maintain a t'de at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS -CER'ITFICATIONS:
All food service establistunents 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 EstabGshments, 105 CMR 590.000.
Please attach copies of certification to this application. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. Sv�vYq� �A �eNAPAuDF 2.
—�
PERSON IN CHARGE: . .
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1 �c�NY�R ►�A7 ehlA (�Aic�G 2.
HEIMLICH CERTIFICATIONS: '
All food service establishments with 25 seats or more must have at least one employee trained in fhe Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Departmeut will not use past years' records.
You must provide new copies and maintain a£de at your place of business.
i. SU�yAR wA�cNAPAKc7� 2.
3. ' 4.
RESTAUKANI' SEATING: TOTAL# .3(� -
OFFICE USE ONLY
LODGWG:
LICENSE REQUIltED FEE PERMIT# LICINSE REQUIRF.D FEE P&RMIT N LICENSE REQUIltF.D FEE PERMI'1'#
B&B $50 _CABIN $50 MOTEL S50
INN S50 _CAMP S50 _SWIIvIIdII1GPOOLS75ea.
LODGE S50 _7'Rnn Fu pARK S50 WIIIRLPOOL S75ea
FOOD SERVICE:
LICINSE REQUIltED FEE PERMIT t! LICENSE REQiIIItED FEE PF.RMIT N LICENSE REQUIItED FEE PF..RMIT#
I O-100SEATS S75 �aS-o3� _CONTINENTAL $30 _NON-PROFTT $25
>100SEATS $I50 �, I COMMONVICT. $50 'I�'OS��S _�OLESALE $75
RETAIL SERV[CE: �
LICINSE REQUIltED FEE PERMIT N LI�INSE REQUIItED FEE PERMI1'# LICENSE REQiJIItED FEE PF,RMIT H
_<SOsq.ft $4S _>25,OOOsq.ft. 5200 _VENDING-FOOD S20
_�LS,OOOsq.ft.. $75 FROZENDESSERT S35 _TOBACCO $25
NAME CHANGE: S10 AMOUNT DUE _ $ �a S o0
•••""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 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of yow pernrits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.IT1'TO RET'IJRN
THE COMPLETED APPLICA'ITON(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONALESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR Tf� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTE�I PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
� ADDTiTONAL 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 WA1'ER TEST'ING: The water must be tested for pseudomonas, total coliform and standazd plate count
by a State certified lab, priar to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pooi 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.
CATERING POLICY:
Anyone w o caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application fonn 72 hows prior to the catered event. Thses forms can be
obtained at the Aealth Department.
FROZEN DESSE�i�'S: _-
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heaith
DepaRment. Failure to do so wili result in the suspension or revocation of your Frozen Dessert Pemrit 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 ofHealth.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retaii or food service establishment is prohibited.
DATE: t� `�' Q SIGNATURE: r✓'
PRINTNAME& TITLE: Sr'//yVd3R ��j'CtfA/9i�4/.r9� C�dr/rier �
10/22/04
_ ��\ _ The Commonwealth ofMassachusetts
� � D�partwrent of Irahtsdial Accidents
- �//�
-= � 600 R'as6iwgmn SYreeK �"Floor
-,, Boston,Mass. 02I11
� N'orlcen'Compaaauo�I�sva�ee A�davih B�il ' bl�g/Elxtrical Cwtrxtors
. . � _ .
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.�:=`�' �"";;� .� � ., ,�.- � �,,�';�� . ,
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add�ess: �J 9�1` M N 1N 9�'.
cav W YAR I'�lOUTN �m• Mq �0 03.673 oeo.eu/�5b$) 77/ - 25�$9
�.
wotk sih locatim(full add�essl•
❑ I�a homeow�perfoming all wak my�if. Projxt Type: ❑New Caoatmctim ORanadd
I am a sole aad have no aae w in� g� ' p��
[✓]�I am an�P1oY�R'�'��8 w'akets'compensatim for my�pbycea wodcing on this joy, .
ca e, 1's.�an� h � oL.
�: 59� M AiN 9T•
a�: w. �ARAtarrFfy Ha. os6�� �.�Sms) 7�/- zy�89
�� A!N Mvf'ua.� .1'v► vr�nce �o . . 600S �3m1400
❑ I am a sole proprietor,ge�sl eoitrxtor,or homeew�(rnrle owe)�Lave hired the contractois listed betow wlw Lave
the following wodcas'compensation Pulicesr
�drsse
�' or�e lN
#
�r we:
3�lM'
£�14:_... !. �
F Y«n Ispcb�a�eetnwdaaeM � tYefirs$LLSZwledblYe�tludvi�iWpsYYn�f�ie�pbASMMatdhr
cwea�e �M�iradWcSee�25Ad11IG
� a S10r WORIC OBDBH nd a�e atS1M.Na Aay apiW�e. I udeshW 16�t•
tepydtibMaie�mtmyhe Ommdl�rdHeDlAhrawvaSevpipe�W�.
I/o hereby crrdfy rwdsr Me ' ojperjary M�t Me ufawdJon provWel ebave 6 et�e m,I arwtct �
s��re -� n.0 f��9'��5�
Print name f/K N'A J C Phoce# C��7 7 7�' Q�f�9 .
a�lafesaly doeotwdfeYthisawb6ecNPkfdbYdl7xYwnemeLl
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mM�ct pvaea: �.
tm�s�7aml
CERTIFI�ATE OF INSURANCE 'SS"En��`"'""°°,YY'
PROI}UCEA '�AIS CERTIFICATE IS ISS17E➢AS A:NAITER OF INFORMATION ONLY ANB
CONFERS NO RiGHTS UPON 17II�:CER'I'II+ICATE ROLDER. THIS CERTt[7CATB
E11Zab0CI1 $ P111C0 IRSllI'ailCE DOES NOT AMLND,EXTEND OR ALTI+R THE COVERAGE AFFORDED BY THE
POLICIES&ELOW.
Agency
6 Munroe Street COMPANI�3 AFFORDING COVF,RAGE
Lynn, MA Q1901
.; ---.�. .,
_ .—_. :, ._ ,
IN517R&D .. _� � . .
Cape&Island Thai_Food Corp i�2ER Y A A.I.M. MuNat Insurance Co NQY 1 $ Lt1U4
594 Main St
VJest Yarmauth, MA 026�3 �f-�.ALT1-j j��p-(
COVERAGES . . -� � � . . � . . .. � . � . � �
THLS 2S TO CERTIFY THAT THE POL[CI£S OF IN3URANCE LISTED BElAW HAVE BEEN ISSUEb T0 THE INSURED NAMED ALiQVE FOR THE POI.ICY PERIOlJ
[N➢i('ATFD,NOTW'[THSTANDiNG ANY REQUiREMENT,TERM OR CONI7tT[ON OP ANY CONTRACI'OR tiTNEADAC:UMEN7 WiI`H RESPECTTS�WHICH THIS .
CERTIAICAI'E MAY BE 15SUED OR MAY PERTAIN,THE INSURANCE AFFOR[7ED BY T}�,ppLJCIES DESCRIBED HEREIN IS SUB7ECT TG ALL'I'fiE 1'ERMS,
LXCLUSIQNS AND C6NllZIf4NS OF SUCH POLICIES. LA{7TS SHOWN MAY IiAVE REEN REDUCED BY PART CLAIMS.
CO..... qy�pg INSUAANCE �LtCY NtIMBER ��CY EFFEC'f1YE AOGCY EXPIRATIO LIhf7T5
y� AATSiMMIDDlYY} DATti(MMIRU/YY)
GE�RAL LLIBILTTI' GENERAL AGGREGATE T ....
f.OMM6RCIAI.GEN6RALLIABILITY PRODUCfS-COMP/OPAGG. S
_ —__ ....
LAIMS MADE�t7R PERSONAL&ADV.tNNRY Y_
pWNF.R'S&CQNTRAGTOR'SPROT. EACHUCCURRENCE 5
CIREDAMAGG(Acryrncfi�e) S
MED.EXPENSG(A�ry ore per.vae) 5
AUTOMOBILE4IABILITY COMBINEDSINGLE �
ANY AUTO U�� .....
ALLOWNEDAUTOS 90DILYINIURY �
' tIEDt)LEDAUTOS iPerRrvsn)
HIRB6AUT05 BODILYMIUR� g
Psr acchkmp
NON-OWNED AVTOS
GARAG6LIABILITY
FROPERTYDAMAGE S
EXCE5S LL18I11TY E•ACN(X'CURRENC6 S
MBRELLA FORM AGGREGATE S `
THEft THAN UM&RLLLA FURM
.... _ ni T , .. .. . __.
"". ORKEA'SWMYtiN5AT10N.v`WU ..__. . . ._ . � . . �. . 1-
YLOYERS'I.LiS[L,tTY ELEACHACCIDENT S IOO�OOO
6005913q12004 08/27/2004 08�29�2005 -
A HE PROPR1ETqR/ X INCL PL DISEASE—MN ECY L1hOT 5 SQQ QQQ
AATN6RStEXLCUTNF, 6L DISF.ASE--EACH EMP60Y5E $ ](p OOO
PFICERSARE� EXCL
OTHER
ESCRIPCIpN OF IIPERAT[ONS/I,OCATIONS/VA.IIICLIiRlSPECIAL CCEMS
CERTIFICATE HOLI7ER � CANCELLATION � �
SHOULD ANY OF THE ABOVF.DESCRIBED POLICf6S BE CANCELLED BEFpRE THE
TpWlt OF Yitl7llOt7YI1 EXPRATION DATE THERE4F. THE ISSUING COMPANY WILi. ENDEAVOR TO
MAIL 15 pAYS WRtTCEN NpTICE TO THE CERTIF[C'ATE HOLDF.R NAMeD TO THE
' BO$i[� OT HCdItI! LEFi',BUT PAILURE TO MAll..SUCA N6T2CE 5HALL IMPQSE NO OBLIGAT[ON OR
LZQG ROU[0 Z$ LIABILITY OF ANY KWD UPON THE COMPANY, CfS AGENTS OR
REPRESENTATR25.
A[JTHCIRIZED REPRF.SEM7'ATIVE �
Soutl� Yarmouth, MA 42673 �i���.`_.
row�v oF Yr.�au�
soa�o�m��nr.�
PEI2MIT TO OPERATE A FOOD ESTABLIS2IMGNT
P.ERMIT NUMBER: #OS-032 FEE: 75.4Q
In accordance with reaulations pmmulgated under antho�ity of Chapter 94,Section 3QSA and Chapter
I I 1,Sec,�tion S of t6e Zieneral Laws,a pe�t is hereby granted to:
Cape&IsTands Thai Food Corporation, 594 Raute 28, South Yara►auth,MA
Whose place of business is: Cane& Islands Thai Food
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yarmouth
Pemut expires: December 31 2005 BOARD oF I]FAI.TH: Ber�arxlK. `�. � M.$, '
Pa�tica�{a Mo.`a� ?lica 'Lfu�,wtwra�c
sBATnvG_ s7 Ro6�t�B�� G'l�rk
��` a R.N.
a�,�,zoos
a��.�ny> .s.,exo
Director of Hea1W
T'I�E COMMONWEALTH OF MA.SSACHLJSETTS
TOW1Y OF YARM4UTH
PERMIT rtUMBER: #d5-025 FEE: SO.pO
T6is is to Certify that Cane&Islands Thai Food Co�oration d/b/a Capg&Islands Thai Food
594 Route 28, West Yarmouth, MA
IS IIERF.SY CrRAN'TED A
CQ3IZA�ON VICT[3ALLER'S LICENSE
In said Tawn af Yazmouth and at that place anly and�p ires Llecember thirty-first 2005 unless
sooner suspended or revoked for violat�on of the]aws of the Commonwealth respecting the
ficensing of caztunon victualter's. 'This license is issued in co�£armity with the axathority granted
to the ficensing authorities by General Laws, Ghapter ]40, and amendments Lhereto.
In Testimony Whereof, the undarsigned have hereunto affuced their official signatures,
BOARD OF HEALTH; Be/wja�r�i�c.$. Cfoadorq M..b. '
Aal3rc�s�a.$�. ?licrs+G'�s�irr�sc
SEATING: 37 /la�e��. L�hoawg �
�q�' R�.N,
r
38IIll91}'7.2�Q�J - .
Direct�of H�ealtli .�,
.- . . {^S'�
� �� crt -nta�
' �`�Ry TOWN OF YARMOUTH BOARD OA�� �, _�
�_ � APPLICATION FOR LICENS�'J'1� _ �
DEC 2 2 2003 ��
�� * Please com lete form and attach all necess docyme�sfs b� December 1� �,{�o3
p � Y NEAL7H DEPT.
Failure to do so will result in the return of your application packet.
N MF OF . T I H1�LFNT• G'�Pt� -� f//J O!� C'O"� . T,T #p-5'OS- 77/ �'��
L N S • �'1 N S''7 . �'F'/d �'/��d T%'
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ER' A S !�lfJN _B�L 9 T L - 33 -3.�(
L aD ttE • M /�v �'-'. N' /�� O
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated
Pool Operator(s}at:d-attaeha-c:rpy ofthe cectificaiion to this fonn.
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 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 aew copies and maintaio a file at your establishment.
1. 2.
PERSON IN CHE1R�'iE: _ _ _ _
Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation.
1. JUlU��I� V�/f/J�f��l�/� f�� 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. 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.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMfT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABiN b50 _MU'TEL S50
_INN 550 _CAMP S50 _SWIMMINGPOOLS75ea
_LODGE $50 _TRAILER PARK S50 _WHIRLPOOL S75ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# GCENSE REQUIRGD FEE PERMIT# WCENSE REQUIRED FEE PERMIT#
I 0.100 SEATS S75 �� _CONTINENTAL S30 _NON-PROFIT S25
>IOOSEATS 5150 �COMMONVICT. S50 6�-1��, _WHOLESALE S75
RETAIL SERVICE:
LICENSE REQU[RED FEE PGRMIT fl LICENSE RBQUIRGD FBE PERMIT# LICENSB RGQUIRED FEG PERMIT#
_<50 sq.ft. S45 _>25,000 sq.R. $200 V ENDING-FOOD S20
_<25,000 sq.ft. S75 _I'R07,F.N DIiSS1iR'f S35 TODACCO S25
IYAMECHANGE: $10 AMOUNTDUE _ $ 125.Do
"•"'"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••*"«
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The Commonwealth ojMassachruetts
: Deparrment ojlndustrial.-lccidexts
; 011lceal/er�stloalliis
- 600 Washrngmn Slreet
Bosron, Mass. 01111
` R'orkers' Compensation Insurance Affidavit
Anolicant infarmaHon: Pfe*�ePRINTT�si1�Fy
n,m� �A�g � l��N� `�T��� r��� �,��.
��,<«2 ��� ��in� �
4,�, �- yq,e��a�iN . �,� ehone���- ���_���y
� 1 am a homecµner pertortning all work myselE y
� f am a solz proprieror �c,', ha�t no one��orkin� in am capaein•
�I am aq employer pro�i�ino µorkers' compen_satinn for my employees workine an this job.
�J /!( ��1 I� �/�,�/ 1� 7� /�} /�
comnanrname: ��1l�" � k--��''�{N!J /�7���� /�C.J `� CjCf'�
,aa��t5:���/Cf ����lN �
[itr: ✓ " ' /�/��1'�V�/'7 phene u. J� lJa ' � / � ' � �'�9 .
�surance co. / /�" / �1 ���1" lN�• �a� eolicv q ��'S�9 /� � 1z0� 3
� I am a sole proprietor. general contractor, or homeowner(ciicle anel and hace hired the contractors listed below ��ho ha�e
thr follu��in_ ��arkzrs compensation polices:
comoanv name:
address•
cin�: � �Aone p�
insur�ncc co nelie�•p
comoanv name:
addresz" . . _ . . . . .. .
tiM � � ehoee M•
insurance to. eelkv M
t
. F�ilure to ucure covenee�s requircd under Seenoo SA of MGL I53 u�Ind/o t0e iepaidw of erid�l pe�dtla of a O�e op ro Sl¢00.00��d/or
oee ye�rs'imprisonment u w�di aa eivil pendHa io the form of a STOP WORK ORDER nd a flee ofS100.Os�dar qNo�t me I��denta�d t��t a
copy of thia snumen�m�r br for.r�rded m Me Otliee ot InratiQniom of Me DIA for eovew�e verilkatba
� /do hrreby ctnijp under rhe pains and pena! ' ptrjury�hm!ht injonnation provid[d abovt is bn[and eosntt
Signaturc �O''� � � �2/Z!��3
Print name S f/M� re YVf}J'�'�H Pf��l7� Phone N �� � �7�'z 5''` 8�/
.. olTicial use onl�� do no��ri�e in tAis�rea to be eompleted by eity or towv ollkial
ciry or town: Y�M�DTQ _ permiNiteaee k nBuildiog Dep�rtmtot
pLieensio`eo.ra
p check if immrdiate resporoe ie r�quired 261 OSeleetmen'�ORee
(508) 398�?231 eEt. �Hea1tE Department
ronuct person: pAone M:_ __ _ nOther
' CERTIFICATE OF INSLJRANCE 'SS�°"�`"`"';°°,YY>
PRODUCER 7'HIS CERTIFICATE IS ISSOED AS A MATfER OF INFORMATION ONLY AND
CONFERS NO RIGHTS OPON THE CERI7FICATE HOLDER. THIS CERTIFICATE
EII23UCU1 $Pu1C0 IRSuiNICC DOES NOT ALYIEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
AgCI1Cy POLICIES BELOW.
6 Munroe Street COMPANIES AFFORDING COVERAGE
Lynn, MA 01901
- _._�___
_ _ _ �_: = i
uvs�n
Cape&Island Thai Food Corp � - ' 2 `Jv 2003
594 Main St i°TTER A A�LM. Mutual Insurance Co + -`"
West Yazmouth, MA 02673 i H�ALTH DEPT.
COVERAGES . � �
THIS IS TO CER"1'1f�Y TNAT THE POLICIES OF INSiJRANCE LISTED HELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDTT[ON OF ANY CONTRACT OR OTHER DOCUMLNT WITH RESPECTTO WHICH THIS
CEBTIFICATE MAY BE LSSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIC�S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDTTIONS OF SUCH POLICffiS. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO -��ypg OF IIiS1JRANCE POL[CY N[IMHER PoLICY EFFECTIVE POLICY EXPLLLITTO
L DATE(MA1/DD/Yl� DATE(MM/DDIYY) LIMTTB
GEN6RALLIABll.ITY GENERALAGGREGATE 5
COMMERCIAbGENERALLIABiLITY PRODUCTS-COMP/OPAGG. $
LAIMS MADE�CCUR PERSONAL&ADV.INIDRY $
OWNER'S&CONTRACfOR'SPROL EACHOCCURRENCE S
FIRE DAMAGE(Any oce fre) $
� M6D.6XP2NSE(Airy ore persoo) 5
AOTOMOBILE LiABIf.ITY
COMBINEDSINGLE S
ANYAUTO � � � � LIMIT
_ . . _ _ __. --._
. .__ -_.___ . _..
ALL OWNED AUTOS BODILV INIURY
SCHEDULED AUTOS
(Perperwn) 5
HIRED AUTOS
00DILYINIURY S
NON-0W NED AUTOS (Per accident)
GARAGE LIABILITY
PROPERTY DAMAGE $
XCE55 LIAHILITY EACH OCCURRENCE f
MBRELLA FORM AGGREGATE S
HER THAN UMBRELLA FORM � .
WORKER'SCOMPENSATIONAND µ'CSTATU- O'IH . �
EMPLOYERS'LIABILITY X TORY LIMITS R
6005913012003 08/27/2003 08/27/2004 EL x n �0 5 .
A THEPROPRIETOR/ X MCL
PARTNERS/EXEWTNE � ELDISEASE-POLICYLIMIT 5 SOO OOO
OFFICERS ARE EXCL EL DISEASE-EA EMPLOYE6 S ]OO OOO
O]FIER
ESCAIPI'fON OF OPERATIONS/LOCAT[ONS/VE�CLES/SPECIAL CCEMS
CERTIFICATE HOLDER � � � � � � � CANCELLATION � � � � � � �
SHOl1LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TOWN OF YARMOUTH E3.TIRATION DATE THEREOF, THE ISSUAIG COMPANY MLL ENDEAVOR TO
. MAIL IS DAYS WRI'I"I'EN NOTICE TO THE CERT[F[CATE HOLDER NAMED TO THE
BOARD OF HEALTH � � LEFf,BUT FAILURE TO MAIL SOCH NOTICE SHAL[,IMPOSE NO OBLIGATTON OR
1146 ROUTE 28 LIAB11.1'1'Y OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
� REPRESENTATIVES.
� AUTHORIZED REPRESENTATIVE
SOUTH YARMOUTH, MA 02673
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-204 FEE: $75.00
In accordance wi[h regulations promulgated under authority of Chapter 94,Section 305A and Chapter
11 l,Section 5 of the General Laws,a permit is hereby granted to:
Cape&Islands Thai Food Corporation, 594 Route 28, South Yarmouth, MA
Whose place of business is: Cane& Islands Thai Food
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Perntit expires: December 31, 2004 BOARD oF F�n[.TH: Beic�wxf.s$. �'o+�ois, �'1.`.b. '
p�.rf� v�e�
SEATING: 37 Ro��. Bdorrws, �
� �k, R.N.
� �j�, R.N.
August 5,2�4
Bruce G. Murphy,MPH,R S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #04-113 FEE: $50.00
This is to Certify that Cape& Islands Thai Food Co�poration d/b/a C�pe& Islands Thai Food
594 Route 28, West Yazmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in confornrity with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affuced their official signatures.
BOARD OF HEALTFI: Be�yrs.r•$. ljosdar,M.�. '
SEATING: 37 ��+�oawg �e3� e��
� cQltG.�t, R./V.
� �j�, R.N.
au�r s.zooa
nice . urP Y, H,R- .,
Director of Health
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,�,��� TOWN OF YARMOUTH BOA Y H � � y ,�
' � ��� APPLICATION FOR�LI �� �003 � � � � � � �
t�;i �qS�e q�� 2 5 2003
* Please complete form and attach all neces � d ments by Dece r l, 2 0 .
Failure to do so will result in the ret ' of your application packet. HEALTH DEPT.
d
ISHM N : --Q e � I � L. #.iZ'� �/"S Sy
LOCATION ADDRESS: 5q�` Mat n 3 • kv Yarmov M�4• 0Z67 3
MAILINGADDRESS' �P MA�Y� S�. V�. YpY�� A O ��J
OWNER/CORPORATION NAME: ;C.A� E � ��G�r''c� `f�Y?G�-s_ � .OYPO �d�-�.
� . .s � c,r. rv;v� � z�.� ��� TEr. # � •-� .�.-`��
MAILING ADDRESS: ��A /l! �`- /Ui(//�'/fa'�� �, tt-(L� ���L�D
POOL CERTIFICATION�
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
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 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.
L 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICAT[ONS•
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.c�,a K �AiGE ��tZ� � ) '�2RSS,q-Mf4' _
n �G�DG�ko�e " �„�,r z,�r)'�'C'�A�mz.N [n �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation.
n _.��< �
i.�ur�� ��a�ek�r,�akd� ���t` " 2.
HEIMLICH CERTIFICA'fIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' rewrds.
You must provide new copies and maiatain a tile at your place of busiaess.
1. 2:
3. 4.
RESTAURANT SEATING: TOTAL# �l�
OFFICE USE ONLY
j�ODGING: . �
' LICENSE RLQUIRED FEE PERMIT#- LICENSE REQUIRGD F8E PF.RMIT H � L(CENSE REQUIRED PEG PERMIT#
_B&B � � $SO � _CABIN S50 _MO'fEL S50
INN §50 _CAMP � $50 _SWIMMING POOL$75ea.
_LODGE $50 _TRAfLER PARK S50 WHIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT f# LtCENSE REQUIRED FEE PERMIT# LICENS6 REQUIRED FEE PERM[T#
�0-100 SEATS S75 . O3'G 7 _CONTMENTAL 530 _NON-PROFIT $25
_>100SEATS SI50- 1COMMONVICT. S50 O�J�I _WHOLESALE $75
RETAILSERVICE: � � �
LICENSE RGQUIRED FEE PERMIT# � WCGNSE RGQUIRF.D fG8 PERMff# LICGNSE RCQUIRBD FEE PERMIT N
_<50 sq.ft. $45 � >25,000 sq.R. 5200 _ _VENDING-FOOD $20
_Q5,000 sq.ft. $75 _I'RO'ZfN DHSSF,RT S35 � _TOI3ACC0 $25
N^"tE�H^NGE• $i° AMOUNT DUE _ $ /Z.S,OD
.+.«.PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""••«
��
.._. —� —.- - - -- .,r _ � .
`, '
ADMINISTRriTION � � �
�
Under Chapter t52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permif to'operate a business if a person or company does nat have a Certificate of Worker's
Compeasatian Insurance. TFIE ATTACHED 3TATE WQItKER'S CCtMPENSATIQN INSUI2ANCE
AFFIDAVIT MLtST BE COMPLETED AND SIGIVED,OR
GERT. 4F INSURAI*3CE ATTAGHED � �� �,6y,,,,��
�
WORKER'S GOMP: AFFIDAVIT SIGNED AND ATTAGHED
Town of Yarmauth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
Y�S *f NO
NQTICE: Permits run annually from January 1 to December 31. IT IS XOLTR RESPONSIBILITY TO RETiJRN
THE COMFLETED APPLICATION(S}AND REQLTFI2ED FBE(S}BY DECEMBER 31, 2d62.
SEASONAL ESTABLISbIMENTS ARE TO CONTACT TfiE HEALTH DEPAR'I'MENT FOR INSPECTIdN 7-10
DAYS PRIOR TO OPEIiING FQR,THE SEASON.
ALL RENOVATIONS �'O ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMEN`l', E'I'�.}, MIJST BE R�PORTED TO AND AFPROVEI7 BY THE BOARD QF HEALTH PRIdR
TO CQMMENCEMEN'I". RENOVA'FI(7NS MAY REQUIRE tl SI7'E PLAN.
�1)D1TIQIYAL�T,�A T[ONR
`,
: PQ4LS
PUOL OPElYIP7G:All swimmiiag,wading and whiripaais which have been ciosecl for the season must be inspected
by the Health Deparhnent prior to opening.
PC10L WATEI2'TEST7NG: The��irater must be tested for pseudornonas, tatal coliform and standard plate caunt
by a State certified lab,prior io apenang, and quarterly thereafter.
PQOL CL(XSTNG. Every outdaar in ground swimming pool must be drained or covered witttin seven (7)days of
closing.
;
FQOD SERVICE
CONSUMF.R VI ORY•
Each food establishment which serves�or seils ready-to-eat,raw ar undercooiced anima3 pmducts are required to post
Consurner Advisories.
CATERIYS�PO.I�
Anyone who caters within the Town of Yartnouth must notify the Yarmouth Health Department by filing the
reqsured Temparary Food Serv'sce;Application form 72 hours priar ta the caiered event. Thses forms can be
obtained at the Health Department:
FROZ�'N�ESSERT�:
Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be senY to the Health
Department. �Failure to do so will resuit in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
QUTSIDE CA1+�S:
4utside cafes{i.e.,autdoor seating wifh waiterlwa'stress servsce},�have prior approvai from the Board of Health.
4UTD0012 CUQI�IAIG:
Ouidoor coaking,preparation,or display of any food product by a retail br food service es 'shment is prohibited.
I�ATE: (� ( � ��1 �l SIGNATURE:X � � 'N "— `
PRINT NAME&TITLE: �(AYlUf7R �� �G�1Ll�Ol�G
10/18/02 � � �� '"3��, ,
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4 1t+ . i. , �
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' i The Commvnwealth ojMassachruetts �����" ��'
_ � Department of Ixdustriut.-lrridents �� � �, � �}
dl1lCe o1lerersal0adiis
600 Washington SJreet QE �j��j�(�� .
Bostan,Mass 02111
" W'arkers' Compensa[ion Insurance Atlidavit
anniicant information: PtegseFRilp7'Tes�"i�
- .
mm. S t/NY/}!�,' 1N 1j<IG 1fl���KD iE.
�7� � �52 �'�1��R q Prt �Z�
,u, D�'nrnris poRT_ ono�t„�8> 3e �-/�s9 _
Q t am a hameouner penormin;atl work myself.
� I am a solz proprietor�r..'.ha�z no one +�orkin� in anc capacity
� �m an emplover prol iding workers' compensatian far m}ernplotiees working on ttsis job.
comn3.�l.koame• ��� � �slL7�G'g ( ftCLl� F�Oc7'-
a�,a�� 5 �1�f' M a�i� s ��
til.y � �'ritY m2dYr1} +�f�•�a� 73 ohoec . �,�as�1 �?71"Jr�'JF�-
insur�nreco�"Ii5{ i'lY��GtGt� �Y�UYt�1�. �(j CsI.ISY# t"'J �� J��l l- 7 f l/�� 2��1��
� 1.-Lo4��p F �r�cl6n� A .t. /`� P1.t,t-{'u�'t.. i r�s.c�� �
I am a s e ro�rietor. genera{c traetor, or omeawnar tctrcle onU an ha�'e hired tfie contractors Gsted below ��ho ha�e
the foHoG+in_ �1or}:zs;' .ompensation polices:
Zq(}ana^v name� �
py_(Irts • — -
� phooe a� —
-- �ncr co Doliev N
tomRany rtame•
lsl���<'
iTtY' e�n.t.i1�
insurance co RQ�n'p
F:iiure�p secure covenea as rrQn�rcd under Secaoo 25A of MGL IS2 ai iad to�be i�paitfa�af tridW pertitla 4f t O�e sp m Si,S00.Q0 a�dlor
onc ynn'imprisonment a w�etl a airil ptaalNa io tht torm u!a SfOP WORIC ORDER aad t(lee of 5100.00 a dar K�inst m� 1 ndtnta�rd ritl�
eopy af ihia statemsnc m�y be tor.v�rded io�he 01Gco otinvatigtllom of t6e DU ta severa�e veri0ut{sa � �
1 do hr�eby crtrtij}'andtr�he paint artd p ajpery'ury thN tLt injormatlon providtd abort it due and[pneel.
Signaturcx .��+� �'ZZ�d�
Printname �J'v.Yll��i� W� C.AnU-DA� a{e PhoneB 'J�`6 — �7� — �$ �2
.. olTicial use onW do not w rite in this aro ro be sampleted by tity or town olHtial
riry or rown: YARMODTq pemiNieeaee M r'tBuildin;Departmeot
. � � �tieeesioe Sotrd
� (]chetk if immcdiate response if requirtd 26� QSdeetmen's 011iet
QHeNtE 4rp�rtmea� -
contact person: p6ont Mt_ �SOS� 398-2231 eat. nOthe�
08/25/2009 11:40 FA% 7815816050 E PULEO INS AGCY �01
ELIZABETH S.
V ���
INSURANCE AGENCY
6 Munrpe Sireel + Lynn,Massaohusetts 07901 • TelAphan9: (7B7)587-5856 � Farc:(791)SB1-8050 � �
August 25, 2003
TO WHOM IT MAY CQNCFsftN:
Please be advised that Cape and Island Thai �'ood, Corp.
has applied for Workers Comp�'nsation InsuranCe through th�
Workers Comp PQoI.
Upon zecelpt of trie Assignmen� and the Gbmpany name with
binding date, we will fax it to your office.
Thank you.
Sinc ely,
c
��
Eliaa h S. Pu� o, CPIW
��ZL�v 3�
� � r3c,��.o-o-aw � �- ��l�o —
� �o(ac�, fs i7� �Ff£c.Q`•
�Vf,(,J �'1b�ic.� �:1� � f�Al �'�u'�" � 62e,+,� r� Cwe'i�t
� - ��d pa(��y r�3 �f� �af�z�� r S ;� �'a-cP
Complete i�tsut'2nce tailnmA ta yqur persona!arttl bostness needs.
. P8/28/Z00� 11:5p FA% 9815816050 E PUL.EO INS AGCY i¢�O1
ELIZABETH S. PULEO INSURANCE AGENCY
�3 �t� � � � � D
F�t co�tt s�ET
At�� 2 s zaa�
��A�rH dE�r,
DATE, g/zs�a3
'j'Q: Mr.Flatery Town of Yarmou�h Town Hall
�p}��: 1 508-398-0836 �
���M: Elizabeth S. Pulea, CPIW
RE: Cape s Island Thai Food Corp. ,
Cape 6 Island Thai Food
,
MESSAGE: �
Enelosed, per your request is a Copy of the existing
policy. It will be cancelled onCe tue receive the
binding 3ateJNotice af Assignment from the Mass.
Workers Cpmp Bareau for the new entity.
Thank yau! ' .
Policy is in full force as of taday for Cape 6 Zsland
Thai Food.
. �
i
I
TOTAL NUMBER QF Pf.CrES SENT� INCLUDING F�A7C COVEIt SHEET )
PLEASE RESPOND AT ONCE 1�THERE ARE ANY TRANSMISSID13pRpBLEMS,4R iF YOU
HAVE AIVY QUE.'�'TiflMS_
�
ivIAIL ADDRES�: 6 MCTNR(7E ST. LYNN, MA. 01901
TELEPHONE # 781-581-5656 FAX # 781-581-6050
•0�/26/2009 11:50 FA% 7815818050 E PULEO INS AGCY �02
• RS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY �I r��O�
..� INFORMATION PAGE
Associa dustrics of Massachusetfs Mutual Insurance Company
Burlington, Massachusetts NCCI N026158
(B00) 876•27fi5
roucv No. ���ss�+�
PRIOR NO- NEW BUSINESS
REM
7_ The Insured Olasone Mdlay�ha�p dba Ca�and Island Thai Food
��^8���= 206 B�shop Ten Hyannls � ��
�rb. sveei " ro.�n 6y tum�r s�eieap faea
� Indhridual ❑ PaMership ❑ Coryoralian ❑ Olher FEIN
Other wakplaGes rwt 6hown a6ove:
2 Th8 poQey period is from 0326I2UO3 � 03/2W2004 1201 a.m.slsndard time at Ihe insured's maling address.
3. A. Workers Compensation Insuiance: Part One of the poficy appGes tn tlie Wnrkers Compe�aUon Law of the states Gs[ed here; .
AAA
B. Empbyers Uablllry Insuranee: Part T.va of Ihe pdiry epplies lo wwk N Bach sfale fsted'n item 3A
The 6mits of our liadliy under PaA Tvro are� Bodily Injury by Accident $ 10 0,0 a o each accident
8odlylnjurybyDisea50 $ 500,000 pofiqfrtnit
Bodly Injury by DiSeabe S 10 0,0 00 eg��nplpyaB
C. Other Slales Insurance= Sea Endorsi3ment WC 20 03 O6 A
0. This policy includes ihese endoreemenls and schedules: SEE SCMEOULE
4. The premium fof thls polky w116e deterr.iined by our Manuals of Rules,GaSalBra�ns,Ratca and Raling plans.
All Information required below is suhjeG to veiifitaUon and diange by au[LL
Classifications Premium Basls Rales
fcUmeW �rStm EWmaYO '
� TotellWY�BI � �W
� flB111WIBIBlbl1 �� PInIl�illll
INTRA 093202
SEE NSION OF INFO TION PAGE
�
AANmimprerniumS 278.00 To�lEsGmetedlVUWalPremWm S 995.OD
Aa edimted,inle�lm adJus4nents of premium shall be made: �eposit Premium 3 506-OU
� M�wetlY ❑ 5erN Mnually ❑ Qusrte�ly ❑ Monthb
MA Assessment Chg.
5248.OU a 4.500D% 511.00
rnis polley,lnauduig all eMorsemen6,Is heroby munlersfgned by �3
' nunntred 9ponre cwa
GOV GOV KIN� PLACING CWM NAME SAFETV
STATE CLASS AUDIT DFFICE OFFICE GHECI( GROUP Elizabeth S Pulrn fnsursnce
MA 9079 601 ASrn%
' WC OD OO Ot A(1t�8� 6 Munroc Strmt
Lynn,MA 01901
hdudas caeY�O+ed malerial�We wfia�d cnYw�m ta�pa�sa��m teu.arca.
�ed W m i6 pamkdm.
�rowrt aF Y�mouTg
BOAl2D 4F HEALTTi
PERMIT TO OPERATE A FQOD ESTABLISHMENT
PERMIT NiIMBER: #03-197 FNE: $75.00
In accordance with regutations promulgated under authority af Chapter 94,Sectioo 305A and Chapter
31 I,Section 5 ofthe Gettra!Laws,a parnsit is hereby granted to:
Cape&Islands Thai Food Corporaxion, 594 Route 28 South Yaraiouth,A�€A
Whose place of business is: Cape&Isit�nds Thai Food
Type of business:, Food Service
To operate a food establishinent in: Town of Yarrnouth
Pennit expires: December 31. 2003 BOARD oF xeA[.'17I: �a�ea'r{�• �"eU:k�n• �.c
' '11. Cjmrd�c. 7K.2�.. ?lree
,� �. '�rearK. L�
����
:"i�etu.^x4ak. �.7Z.
_�gust26 20p3 �
Bruce G.Miaphy, . .,CHd
17ireckor of Health
THE COMMONWEALTH QF MASSACHUSETTS
TOWN QF YARMOUTH
PERMIT NE7A�IBBR: #03-113 FEE: 550.00
'r'his is to Certify that Cape&Islands Thai Food Corooration dlbla Caoe&Is3ands Thai Food
�
594 Route 28 West Yazmouth, MA
IS CIF,'REBY GRANTED A
COMMQN VICTETALLER'S LICEIYSE
In said Tawn of Yar�uth and at thai place on(y and eap ices l�eeember thirty-fusk 20(?3 unless
saoner suspended or revoked far vialation of the laws of the Comrnonweahh respecting the
licessing of com�n victualler's. This licex�is issued in conformity with the authority granted to
the licensing autharities by General Laws, Chapter 140, and arnendments thereto.
In Testimany Whereo£, the undersigned have hereunto a£fiaced their official signatures.
BOf1RD dF HEALTii: 4 'ri�, x't�. (�a
$�7J. C�"azdeeF. �:1J.. ?/iee
�o6ad'�. �. �k
�aArlt�7lE'CllotearetC
'r3�elu Ska+E. R??t.
nu��z� zoo3 v
ruce . urp ry,��PT� . .,
D'uector of Healih
�Fs R1 TOWN OF YARI�iOUTH BOARD OF � FI �
� F2C�s APPLICA'CION FOR LICENSE/PE � Q � 6 � � d � �
° � � �` �13 �PR 0 9 2003
* Please complete#`om7 and attach atl Rece k�by Dece ' r 31, 2002.
Failure to do so wiilresull in the ,,f y "r applicat�on p k9gEAlTH DEPT.
�' !'S��nr� 7'/�`�i �-� �r # ��' �z/ 's'"Sa2
LOCATIONADD F �"i'91,i ;E-�.,c �'.A ��i �i{�Q.,�v�ir�y �a � �-7�
DIAILING ADDRES3:
OWNER/CdIZPOR;;�TIQN I�1AIvtF• ����{,� ���;��„���
IviANAG�R'S N,�MF:` /nAGft v rs�rr�v� U�.a:s�ivc 'r'F #��ra R' 771�-,.�/.3�'
MAiLINCx ADDRFSS� .��9�' R/,SfL,o T�•P h+'v��S /Y�m cy�y 6 r7/
■ � i���.i� ���� ���
POOT,GFJ3TTFICATION�:
T6e pool snpervisor muat 6e cer�lfietl as a�ool 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 curu�ntly certified;in basiqwater safety,standard First Aid
and Community Cardiopulmonary Resuscitation(CFR�:' Please list these emp�a}*ees below and attach copies of
employee certifications to this form. The Healih IIe�isMmeYit will hot use paet years' records. You must
provide new copies and maintain a fle �t your;placeof business.
_ ' :
1• 2.
3 < . . . 4
. ,. . f�r� r14��rri�rl��Y��! R lI���I i��� I�I�r11��Y���r� � � .
F_OOD PROTECTION ANA R - RTIFf dTIONC•
All food service establishments are required to have at least oae full-tiine emiployee who is certified as a Food
Protec4ion Manager,as defined in tlie State Sanitary Code for Food Service Establishmenu, ]OS CMR 590.000.
Please attach copies of certification to this application. T6e Heal#h Department will oot use past years'�ecords.
You must provide new copies and maintaia a file pt�ogr establisl�meet
1� _ 2,
PERS(�jV IN CI•LARGE:
Each food establishment must have at least one Person In Chazge(PIC)on site during-hours-of op.e.�atiun:
1. �. �
r
�iMLICH CERTiFICATI4�IS�
All food service establishm�itts with 2�seats or�imre must ha�at keast one ett�layee trained in the Heimlich
Maneuver on the pretaisesat al�tuttes. Please list}�out em }uyees traSned in anti-ehnkingprocedwes below and
attach copies of gm�,tqy����s t�t��s.f�,,Th�� 6 Dspartment will not use paet years' records.
You must provide new eopies and ma�ntain s C�e at ynnr�ce of basiness.
L 2.
3. 4. .
RR TA TR AN'F SEATING: TOTAL# ,� ,
wi . .��� .. . . r.�
' (1FFIC��i1SE Od�I:Y ''� x
LO�GING: �
• LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMI.T q LlCEN$E REQUIREU FEE PERMIT#
_B&B SSO _CABIN " S50 _MOTEL • S3p ,
_IND1 S50 CAMR'. ' `SSO _SWIMMRJG POOL S'75ea. ,::
_I.ODGE S50 _7RAILER PARK S50 WHIRLPOOL S75ea.
FOOD cFRVICE. .. �. . . . - .. . . . . ' ..�
LICENSEREQUIREQ fE� pgR1o{{.T# L��ENSE-R£�1�I�p FEE pERMIT# i.10ENSEREQUIRCD FEE PEftMITM
I 0.100 SEATS 57� ,� ..:^.CQNFtNEf�PfAl. S3U, _NON-PROFIT S25
_>IOOSEATS SI50 1COtVfMO1JVICT; S50 �'o3-(oS� _WHOLESALE S73
RF,TAI�I A AVIf�F.c . . . : . . . � .. . .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEBMITq LICENSE REQUIRED FEE , PERMIT#
_<50 sq.R $45 >25,000 sq:R S20Q " VENDING•FOOD 520
_QS,000 sq.ft. S75 _FROZEN UE,SSERT S35 �TODACCO f25 � �
NAME.CH,►1V.rsS.". a�a AMOUi�1T DUE = S_-I,Z�.uv
""•""PLEASE TURN OVER AND�COMPLETE OTHER SIDE OF FQRM""•"� `'
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qi(�aH alR ol3uas aq 3snw sl�nsaa lsay •qe� pa3ii�a�a3�1� ¢�q�sts�q",�f{y�uow e ua Pa1�i�q�iit sL�assap uazw3
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a�.�urlg ,Cq �uaw�edaQ y��eaH �lnown�, ai{� �nou lsniu t�Znotuie�3o u�tin,j; ayi un{l�nn s.ia�ao oum auo.fud
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zsod vi��b�;t a.�s�npad leunue pa�ooaiapun io mea`lza-o3-,Cpea�spas io sanlas y�►ym�nauulsqqe�sa PooS�
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•iagsaiayi;i���.rertb pve `Amuado o�ioud `9g1 Pagauaa a�eis��iq
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.�ueuad���l m�d 1t���Q�1ll�H a��q
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s,iax�om 3o a38ogtua� e aneq iou saop,iueduxoo io uasaad.e;� ssat�snq s alv,�ado o; uuttad io asu�dtj Xtre;o
�¢mauaa io aougnss� pioq oi paiinba�hrou st q3not�c���o un�o;�ay��`g u�3��s4�S `�SZ`�!l�5 `ZS I �1��[��P�Il
�����z�i����
. . �
The Commonweallh ojMassachusetls
: DePartmen!ajlndustrial.-1 ccidents
; Ol//ce ol/aresalOslliis
- 600 Woshington Street
Bnston. Mass. 02111
" W'orkers' Compensation Insurance Affidavit
Aoolicant informafion: PleaseYRINTTe�'ida
mmc
location
clt� ehone M
� I am a homecwner pertorming all µork myself.
� I am a sole propriztor �r.,', ha�e no one ��orkin_ in am capacin� [yQ
l.�
�I am an employer pro�iding workers' compensation for my employees workine on[his job. SE� CApY OG UJ- C.
comnanvname: ��"J� �_ 7�S'�AN� %N�jf"�`i11� �SSt6NMEt�T•
aJdress• ,�'�9���T� .�� _
si(v: �/_ ,�A.P✓�FJ/;�f�/ /r��l phenep� 40� Z'7/ �'i �_'S<�`�?
insur�nceeo /<<M� ����'�- ��S . C� � oolieyM �A � _ -
� I am a sole proprietor. _eneral contractor, or homeowner(circle onU and hace hired the contracrors lisred below ��ho ha�e
thz follu��in_ ��orkzr .ompensation polices:
vn
addresr ---
� �y. � Ahone a•
insur�ncc co oeliev H
m :
addre•••
tiN• � � ehoee Ift
inenran�w rn oOR[V N
•
F�iiure to ueure cover�ge u requlred under Seenoa ZSA of MGL IS3 n�iud to the i�paitla�oteri�i�l peultln oh O�e ap ro t1.500.00 a�d/or
ane ynn'imprisonment af w�ell af tiril pentiHn io�t6e form ot�STOP WORK ORDER�ed�Ilae ofS100.00�d�)qtimt s� [�Wmh�d Uit a
topy of lhy sutement may be fonvvded to the ORee of Inrmtig�tlom otthe DIA for eoven�e veriliatlw. �
/do�hrreby certijp under rb pains nd pirtal�ies ojpery'ury thm the infannation provided above is bat and eoned
xSignaturc �� —��
XPrint name i — one K '���T i 7l_ -'i�J`�
.. oRcial use onh� do no�rrite in this arn ro bt eompleted by eiry or tmva ollltiil
eiry or town: YA��DT$ permiNiaeee N nBuilding Depirtmmt
� �Liceosiog Bo�rd
�check if immediate response ie required 261 QS�Ietimen'e Ofliee
�Hnith Depanment .
contac�person: phone N:_ �SOS� 398+2.231 est. np�her
NOTICE OF ASSIGNMENT
EMPLOYER: OLASONE MALAYTI-IONG DBA CAPE & ISLAND THA2 COMBO I.D. STATUS OF EMPLOYER
FOOD 000093202 Individual
206 BISI-IOP TERR
HYANNIS, MA 02601 COVERAGEGROUP
0093202
The Waiver of Our Right to Coverage under this assignment
� Recover from Others Endorsement applies to Massacnusetts .
is available on Pool policies. operations only. For coverage
Contact your agent for details. outside of Massachusetts, contact �
the appropriate Pool or Plan for �.
that state. �
AGENT ELIZABETH S PULEO INS AGCY . INSURANCECOMPANY: �
OR 6 MUNROE ST AIM �MUTUAL INS CO �
PRODUCER: LYNN, MA 01901 � � MS. �JUDITH BARRY
11 NORTH AVENUE � �.
BURLINGTON, MA 01803
(800) 876-2765
AGENCY FEIN:042995902 � �
CLASSIFICATION OF OPERATION CLASS ESTIMATED � � RATE ESTIMATED �
. CODE TOTAL ANNUAL PREMIUM . . .,
� � REMUNERATION � .
� ------------------------------- ----- ------------- ------- ----------
RESTALJRANT-NOC . 9079 $10,400 2.19 $228 .
EMPLOYERS LIABILITY 100/100/500 � 9845 � � . . . . .
LOSS CONSTANT 0032 . .. . $20 .
STANDARD PREMIUM . � � . $248
� EXPENSE CONSTANP - 0900 � � $244 �
TERRORISM CHARGE 9740 $3
ESTIMATED ANNUAL PREMIUM � � �. _ � $495
DIA ASSESS. 4.5$ OF STANDARD PREM. � . � � � � - � � - $11
EST. ANN[JAL PREM. PLUS ASSESSMENT . . .�, � .. .. . -. . . - �
$506
INSTALLMENTBASIS: Annual � � . �- � �� �REbU1REDDEPOStTPREMIUM $506 �
COMMENTS � � �. . . .
Coverage effective 12:01 AM on 03/26/03 � � - . . . .
DATEOFNOTICE: 03/27/03 �� � PREPAREDBY: Theresa Schofield � :
EXT 542
* * VOLVNTARY DZRBCT ASSIGI�ID7ENT * * � � � �
LETTERID: 394189 COPY: EMPLOYER �
The Workers`Gompensation Rating andlnspection Bureadof Massachusetts
101 Arch Street• Boston, MA-0211D` - .
_ .(617)439-9030• FAX(617)439-6055 •www.wcribma.org
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIITNLJMBER: #03-182 FEE: $75.00
In accordance with reRulations promulgated under authority of Chapter 94,Sec[ion 305A and Chapter
111,Section 5 ofthe Zieneral Laws,a pecmrt is hereby granted to:
Malavthong Olasone, 594 Route 28, South Yarmouth, MA
Whose place of business is: Cape&Islands Thai Food
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yatmouth
Permit eacpires: December 31 2003 soARD oF HEAL.TH: �fa�les�. �olltkoi; �a«
� D. Cfeufac. '�Jl.D.. ?irce
,�e�. �'�, L�
�a�ie�E'�.�auxetl
'.�tlus.S �. ,�..?P•
Apri1 10.2003
nice G. �sphy R.S,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
P�RMIT NUMBER: #03-105 FEE: $50.00
This is to Certify that MalaythonQ Olasone d/b/a Ca�e&Islands Thai Food
594 Route 28, West Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires Decembea thirty-first 2003 unless
sooner suspended or revoked for violahon of tbe laws ofthe Commonwealth respecting the
licensing of common victualler's. This license is issued in confornrity with the authonty granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testunony Whereo� the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �Fa�rlu'�f. '�eflLFec. �a.c
�D. �C. �ll.D., 4/iee
,�e6art�. �aoaac. �l/mk
�at:tek'jXcrDm.xotY
.'f� x S , ,�.'fl.
Apri110.2003 �
e irp ,
Direc:tor o ealth
��on/71��� �v�5i r�C�SS � ��"/L��=
� 5, C�].ffCdtPS S�d}l M� �. � O� �SSfIi 71'.�_c�..Fim �ilE.4g. ltC.. -
. � � �.�i �Si TI]dPSi �Id�.�•
Any pexs� oonducting business in the cam�aealth under a�ry title oth� than
the real nane of the pexsoai o�ducting ttie buainess, whether indfvidually or
as a partnetship, shall file in the office of the clerk of every city � town
where an ofFice of any such pers� or partnershi.p may be situatea a certificate
New or stating the full nane and residence of each pexsm conducting six3i bus�ss,
R�1e°"�- the place, including street a� rnanber, where, a� the title unda whic�� it
is conciucted, arrl pay the fee as provided by clause (201 of sectian thirty-four
520.00 of chapter tr�o fiu�dred and sixty-t�*o. Stich certificate shall be executed
under oath by each pers� whose nane �pears therein as oonlucting s�h business
and--shati�tre signed by each sucti persrn sir=the presence of the city ar town
c7:�f'k,°�r a pexson designated by him o�fie_� pres�ce of a pexsm autlnrized r.;� ;
Discontin- � take oaths. The city or twm clerk may request the person fi�;.,� su�h
uance certificate to pxnduce ev�dence of his identity ard, if such pesson daes not.
S]0.00 � �st�h.'request. Produce evidence ttiereaf�s�Cfsfactoxy to suchclerk. the <; �-<
c3erk°^shail �ter a notation of that faet-a� tt�e f�e of the certfficabe. A x . �
; per��-who has filed such a certificate-shall. -�n� k�is.discastiming. =etiring .•.
or withdrawirn� fmn such business or partnetship, or in the case of a cLange
of residaloe of such person or of the location wt�re the business is c:mducted,
file in the office of said clerk a statenent under oath that he has discontinued,
xetired ar withdrawn fran such business or partnership. or of sudi chang�e of
hi� residence or change of the locatian o� such business, and pap the fee
regiix�ed by clanse (27 ) of said sectian thisty-four. In the case of the death.. .,
of suoh a pecsm�, such statement may=be fi3.ed by the executor or ac�ninistrator .-..
of:-hti:s:esta'te. The clerk shall keep a:sui.fik.ahle:index qf all certificates sa �.�::.:_
filed with him, setting forth the pertinent facts, including a referencx to ar�y
statanent of disca�tinuance, retiranent o� withdrawal fran, or cYiange cf
lcscati� �sf, such business, a¢� change of sesf€3aree of such pexsrn. Violations :_,.
of -thi� seation shell be pnmi.shed by a fine�f not more thaz� one hmdre8 dolla� s : .
for each mc�nth durin which such violation �eantitwes. f 1907, 539,�'� 7,3; ]948,: ; _.
550, ]5; 1952, 32, � 1; 1959, 63; 1967, 429.1
ffiitorial Note --
The 1948 a�eo3a�art inserbad prwisians as to aerka3n ce-tificafEs �d fees,
a�d added the oaa� 'city or.' . ,. _ • , -
TLe .I452 aa�dmmt �oadaied the soope of:this sectiai by xequirirg i�a�atim,
as to locatian, etc.. a� the business, etc.
398