HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010i . . �., .
' � °' � TOWN OF YARMOUTH BOARD OF HEA�ia�H� � � �D
' APPI.ICATIONFORLICENSE/PE�'y�19 � -' NOV 2 S 2008
� �'
*Please complete form and attach all necessary do en1�'K`Decemb
Failure to do so will result in the return ofyo�applicahon pac . DEPT.
NAME OF ESTABLISHMENT• G�QK��� leo�-�TEL. # — 0 -�B�j t�
LOCATION ADDRESS: 31 GUYj'IB /�4 �
MaiLrtvGaDDx�ss: S�4 � ,Bov— •
OWNER NAME: 90A1C-� TAX ID FEIN or SSN : ���
CORFORATION NAME (IF APPLICABLE): n ,�/?C .
MANAGER'S NAME: � p� pI•( TEL. # b`a - o-a460.
MAILING ADDRESS: c� �r10
POOL CERTIFICATIONS:
i 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 ttris form.
1. � � 2
Pool operators must list a mivimum 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.
I Please attach copies of certification to tivs application. The Health Department will not use past years'records.
iYou must provide new copies and maintain a Tile at your establishment.
1. ��U �tON �-O� . 2.
PERSON IN CHARGE: —_ - ____ __—___ ___ __
- ___ _ -- --. _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operarion.
1.__ �O c� C.�n Orl '�19t� ' 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee mained in the Heimlich
Maneuver on the premises at all times. Please list your employees uained in anti-chokmg procedures below and
attach copies of employee certifications to tlris form. The Health Department will not use past years' records.
You must provide new copies and maintain a �le at your place of business.
1. 2.
3. q
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMII'# LICENSE REQUIItED FEE PERMIT# '�
_B&B S55 _CABIN S55 _MOTEL $55
_1NN S55 _CAMP 555 _SWA�IQ�IGPOOL 580ea. �
_LODGE 555 _1RAII,ERPARK SI05 _4��fiIRI,pOOL $80ea I
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMI"I#
LO-100 SEATS S85 -O(o _CON7tNEN1'AL 535 NON-PROFIT S30 �
_>100SEATS 5160 LCOMMONVIC. 560 a9-ay�J _W(-IOLESALE S80 �
RETAIL SERVICE: —RESID.KTICHEN 880 �
LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIItED FEE PERMI'I# LICENSE REQUIRED FEE PERM[T# �
_<SOsq.B. S50 _>25,OOOsq.ft. 3225 VENDING-FOOD 525
<25,OOOsq.ft. 580 _FROZENDESSERT S40 _IOBACCO S55 i
NAD�CHANGE: SSO . AMOITNT DUE _ $ /�S.04
***"'PLEASE TURti OVER AND COMPLETE OTHER SIDE OF FORM"**� �
I
ADNIINISTRATION
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
AFFIDAVTl'MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED V
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taz�es and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
1VIUTEIS AND OTHER LODGYNG ESTABLLSHIV�NT5
TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transiern occupancy shallbe
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 cominuous occupancy of not more than tlrirty (30) days, and an
aggregate of not more than ninety(90) days within any s'vc(6)mornh period. Use of a guest unit as a residence or
dwelling unit shall not be considered transiern. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' �
by the Health Department prior to opening. Contact the Health Department to schedule the inspecrion five(�days
prior to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been mspected
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.
I
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 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 obtamed at the
Health Departmern.
FROZEN DESSERTS:
Frozen desserts must be tested on a mom}ily 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 yow Frozen Dessert Pemut urnil the
above terms have been met.
i
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor co_oking preparation,or display of any food product by a retail or food service establishmern is prohibited.
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBIIdTY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATTONS TO ANY FOOD ESTABLISHMENP, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMIvfENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN.
DATE: � �-3 b� SIGNATURE: � '
PRINT NAME&TITLE: YB O��C .�� -�
, ionvas
11 /25/OS 10 : 41 : 17 AM 4170 � 03/03
ACORD CERTIFICATE OF LIABILITY INSURANCE iiiz5iz e'
PROd10ER (508)540-2400 TAX: (506)2B9-4111 THIS CERTIFICATE IS 133UE0 AS A MATTER OF INFORMA710N
Mnzra 6 MacDonald Iaaurance 3ervicea, Iac. ONLY AND CONFERS NO RIOHTS UPON THE CFRTIFICATE
Y HOLDER. 7HIS CER7IFICA7E DOES NOT AMEND, EXiENO OR �..
550 MacArthur Hlvd. ALTER T}iE COVERAGE AFFORDEU BY THE POLICIES BELOW. �
Sovxae IA 02532 INSl1RERSAFFORDINGCOVERAGE NAIClt I
��s� iusiiRFaa BhoeniX IasusaIIce Co. 25623
BP71?IDON, INC. DSA WO[C-N-ROIS. wsuReae�.
1319 ROVTL+ 28 wsuRwc:
MEURFP G: t"��? i
SOUTI{ YAFmPD[T17i D9� 02664 iNeuaEr.�E: � � I
ES
THE POLIGIES OF INSURANGE USTED BELOW HAVE BEEN ISSUE�TO THE INSURED NAMED B q�I DICATE�.NOTMhISTANDING ANY ',
REWIREMENT,TERM OR CIXJDITION OF ANY CONTRACT OR OhIER DOCUMENT NATH RES MAY 8E LSSUED OR MAY PERTAIN, '�
THE INSURANCE AFFORDE� BY THE POLIqES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION3 AND CONDITION3 OF SUCH POLICIES.
GGR G D D 9V I �
INSR 00'L TypEOFINffiIRANCE POLICYILMBER Pd'���EC�NEPOLICVEXRRATION
N pATE MN/OOIW OA1E M�DdYY UM�
GENBtALUPBILfIv EPCHCC'URR=NCE $ 1.0�0��00
X ��, O?MAGE TO R�JTEG
MA1=RCL^L3C�CRALLl4�ILIT" PR NL S Eau�wience 8 300,000
A c�o.iusmaoe Q cccu. 7esos7a5aso5 9/3/2008 9/3/2009 MEDENP M cne erscn� a 5,000
PFP.60w.1&FDe'IN.UR� $ 1�000,000
GEnEa.x?.G::ftEGATE 5 Z.D00,000 I
G'_Po'LPG3REbATELMITA'PLE3PER�. $ 2�000�000 I
X POLICY PRO- LOC '��
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Si]1EUULEDTU C.S (Perperaor)
H RSD�UrO: OO�ILY INJUP.Y
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U�CRIPTIDN OF OPEMTIdNSLOC�TIONSIVEHICLE8�E%CWBIONS AOpEp BY ENOOR8BAENfiSPECIAL PRDVISIONS II
CERTIFICATE HOL�ER CANCELLATION
(506)398-0836 SHOU�O ANV OF TIE ABOVE �ERCRBED POLIdES BE GNCELLEO BEFORE THE
Towa o£ Yazmouth E�wirsanoH onre n�e�ov, rHe issutic iHsursae vv�� a�oEnvon ro uu� :
on
1146 Route 28 SO pAYSN'IUfTENNOTICETOlHECER'fIFICATE1qLDERNNAIEDTOTHELER,BVf I
South Yaxmouth, [�a 02664 FAILURETOD0808FNLLIMPOSElIDOBLIG4TONORLIABILf1YaFANYKINOUPONTiE
MSORER.RS RGHRS pR REVNESEMRTYEE. I
AUIHOPo2ED REVRESENTATIVE
S Harrington/SMH rX'��n�_ N��%���
ACORO 25(2001NB) e,ACORD CORPORATON 19�
�N$�$�019J7�Oa Fagaicf2
9323
12/2/08 11 : 31 : 28 AM 4170 a 04/04
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PRODUCER THIS CERTIFICATE 1818SUED A8 A MATTER OF INFOtiMAT10N
ONLY AND CONFEfi8 NO RIGHTS UPON THE CERTIFIGATE
Murrsy b Mwtlunald Insurence Sank.es Inc. HOL�ER. THI8 GERTIFICATE DOEB NOT AMEND, EXTEN�OR
55D NkcerthurBNtl. ALTER THE COVERAC3E AFFORDED BY THE POLICIE8 BELOW
Baume, Mft 02532 i
GOMPANIEB AFFOROINO IHSURANCE I
COMPANY A GRANITE STATE INBURANCE COMPANY
IN8URE�
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Brrndvn,lnc ;
1378 Rauta 2B
S.Yamrouth,MA 02884-0000
THS�TO CER�IFY TH4T THE POLICIES OF INBl1RANCE LIBTEO BELOW FMVE BEEN IBBt�ED TO THE INBUREO NAMEO ABOVE FOR
TFE POLJCY PERIOD INOICATED,NOT WRF{8'TANOING ANY RC-�UIREIYEM.TERM OR COI�ITION OF ANY COMRALT OR OTFER 'I
OOCUM�M WRN IIlSPECT TO WMICN TNIS CER�IFlCAT!M4Y BE ISSUlOOR MAY PEIRAIµTN!INBURANCB APR7R�C TNE ���
POLICIEB OE8CRI6E0 HERFJ N 18 8U&IECT TO ALLTHE TERMB,EXCUlSI0N6 ANO CONGRIONB OF BUCFI POLICIEB.LIhVTS SHOW N �'�,
MAY HAVE BEEN REOUCED BY PAI�CLAIMB. ���
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CER7IFICATE HOLDER CANCELLATION �
TDWN OFYARMOUTFI 6XOIIIOANVOFTXEABOVEOE8CNI9EDPOLICIE89ECNiCELLmlFFORETXE f
WMTION DATC 7XERCOf,7ML I�IING GOMPANY WILL OIPGWR TO IML]q
1148 RT 20 �AYSN7iIITQI NCfICE TO TXE CERfFIGUE M0.PER NAMED M iXE LffT,917T
SOUTFIYARMOUhI,MA02884 �ALVRETOMAILE�ILNNOTICLlXM.LINPOSENOOBLIGATIONORLNlILf1Y0P
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BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHNIENT
PERMIT NUMBER: #09-067 FEE: $85.00
In accordance with reguladons promulgated under au[hority of Chapter 94,Sec6on 305A and Chapter
I l l,Section 5 of the General Laws,a permit is hereby granted[o:
Brandon Inc. 1319 Route 28 South Yarmouth MA '
Whose place of business is: Wok-N-Roll '
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2009 Bon[tn oF HEALTTI: .�`�EEe�le"'��c'S" IEf/a�t11 `.R-e.'.MzL., @hauxnqeaQre ;
SEAIING: 19 u17.��f(Cp JF ,�CLwfC� v(�R l.Ifp(1Y/R(jn, '..
�.MIL � �' ./�../Y. �
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December12.2008
Bruce G.Murphy, ,R.S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #09-049 FEE: 60.00 I
This is to Certify that Brandon Inc. d/b/a Wok-N-Roll i
1319 Route 28, South Yarmouth, MA
IS HEREBY GRAN"I'ED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless I
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. Tlvs 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 hereuoto affixed theu official signahues.
BOARD OF HEALTH: ,�felen Sf�ah JZ.N., Clkaixntan
SEAIING: 19 � ,�, ��,p,Y, v(� � �I
�e�wrt `3.�Bwmis, P.lerk
Qren(�'ree��auine, `.R.N.
£�r�yx�• .�failee
December 12.2008 '
Bruce G.Mmphy,MP , . .,CHO '
Director of Health
. (�'�dK'N-ROLL
�` Y"��` TOWN OF YARMOUTH BOARD OF H�IL'� ,�N ' �' -
���y,s APPLICATION FOR LICENSE/PERA�I'�'�;;3�����1�
NOV 1 6 2007
• Please complete form and attach all necessary docu�ts by December 1, 2007. :
Failure to do so will result in the retum of yow appGcarion packet.. E' ' ' ' = : � ,
---_ _ _ _ -_ _:_,. ___,
NAME OF ESTABLISHMENT: /.�90 K — n — ,P_0 LL . TEL. # d`-DS-76o 3060 .
LOCATION ADDRESS: l � 14 mou n � , S� Y�r-mo�l, ✓�a o�� �6�
MAILING ADDRESS: / /Gl , ✓Yt a:�n <S�-/- �- Y��e�A•9't. M a r9�66�F
OWNER NAME: son J.�vJ . T X ID (F IN or Nl� �
CORPORATION NAME ( APPLICABLE):_ QYY.1 nrlon .Zn c . ,
MANAGER'S NAME: �4m ¢-� P�i o TEL. #5D8— 7 6 0 -�0 60. '
MAILING ADDRESS:�1g Mci.i n � .P. �a.rrn o . /�G� O � �6�
POOL CERTIFICATIONS: �I
The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to tlus form.
1. 2;
Pool operators must list a minimum of two employees currently cenified in basic water safery, standard First Aid and I��
Community Catdiopulmonary Resuscitation(CPR). Please ist these employees below and attach copies of employee
eertifications to tk►is form. The Health Department will uot use past years' records. You must provide new ;
copies and maintain a fde at your place of business. �
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fuil-time employee who is cenified as a Food
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertificationtothis application. 'fhe Health Department wiH not nse past years'records.
You must provide new copies and maintain a file at your establishment. ,
L N��t'? ,��1� . 2. I
P��tSQN�T�I�RCiE: ___ ____ ____ ___ _
- - _- _ _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ���h B�'t�-�fI t,l' . 2. 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 ai all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to tlus form. T6e Heatth DepartmenY will not use past years' records.
You must provide new copies and roaiutain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# C
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERA9T* L[CENSE REQL IItED FEE PER�9T� LICENSE REQL'IItED FEE PER'bflT= �
_B&B S50 _CABIN S50 _MOTEL S50 � �
_1NN �550 _CAIvIP �� �-- S56 � _SWIYLb1tNG POOL S75ea. � �
_LODGE S50 _TRAILERPARK SI00 _�l'fi1RLPOOL S75ea .
FOOD SERVICE:
LICENSE REQUQtED FEE PERMIT# LICENSE REQUIRED FEE PE&�IIT= LICENSE REQti IRED FEE PERIIIT�
�0.100 SEATS S75 �(yQspD�j _CONTINENTAL S30 u _NON-PROFIl' . S2i � ' �
>100 SEATS Sli0 1' CO:�Lb10N VIC 550 .#OQ��6� _l�1-IOLESALE S�i �
REiA1L SERVICE: —RESID.KITCHEN S73
LICENSE REQUI1tED FEE PERMI7= LICENSE REQUIRED FEE PER�9T= LICENSE REQL7RED FEE PER�9T= j
�
_<SO sq.ft. S45 >25.000 sq.t1. 5200 _VENDING-FOOD 520 i
_<25,OOOsq.B. S75 _FROZENDESSERT S3i _TOBACCO S50 �
�i21!1�CAA_'YGE: S10 AMOUrT DUE _ $ l25.00
'*""*PLEASE iL'R\OVER A�D C0�IPLETE OTHER SIDE OF FOR\i**•**
i
.,._ _ I
,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuaace or renewal
of any license or permit to operate a business if a person or company dces not have a Ce�tificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COM�ENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
- _ _ __ _ __
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocwpancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hote(use:
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresideace�sewhere.
Transiem occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, aatd an
aggregate of not more than ninety(90) days within any s'v�(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transi�t.
* 1vOTE:Enciosea Motel Census must be comnleted and returned w;w cnis apphcauon.
rooLs
POOL OPENIlVG:All swimming,wading and w6irlpools which have been closed for the sea.9on must be inspected
by the Health Department prior to openu►g. Contact the Health Departmem to schedule the inspection five(S)days
pnor to opemng.
POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certiSed lab, prior to opening, and quarterty thereafter. -
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within scwen('n days of
closing.
FOOD SERVICE
CATERIIVG POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Depaztmenk by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These fom�s can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certiSed lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Fmzen Dessert Peimit urnil 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:
QDtdOpLLnn___kin��j[Pf1A1'A}l�fl�splay_ofan�food productby a retail orfoodsenrice establishmeatis.prohibited.-.
NOTICE:Pemtits run azmually from January 1 to December 31. IT IS YOUR RESPONSIBILiTY TO RETCJRN
Tf�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�vVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCEME�IT. REVOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGVATURE:
PRINT NAME&TITLE:
io�o m
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�'\ The Commonweahh ojMassachusetts
Departinent oflndwstrial Accidenis
�d�
600 R'ashii+gtoa Strecy �'F[oor
Bostox,Masc 02111
Workera'Compe�satio�Inva�ee A�avk:B�7di�g/PLmbug/Eleetrical Ce�tracters
Aootlp��iWn P'kue�'Ril�1T lee�1�
�: �oK - n ^ �a��
,�,�: t 319 , rvl cu n s-f , �Q. �'cumo�,�'h
s�, ��: �a a�- D�-664- ¢�# .�t��3 - 76o —ae6�. '
���«�,:
� I�a 6omaow�r perfoimiog ali w�k myself. Projec[Type: ❑New Consfcuc�m�R�adel
❑ I am a sole proprietor and Lave no one wotfcing in any capxity. ❑Buitd'mg Addition ��.
� I am an e.mpbyer providiog wotke�s'compeasatim faz my�loyas wo�cing ae this job. .
�o�.�. ,6r Gt n Qrov� � C, .
�: �3 rq , .�a�n S'-f ,
�- S'. �Gt�mo�"G� Mo� �266/-� �a� �c�' — 76o-2-a��
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r w,�.:�..
❑ I am a sole propcieror,geiaal ca�hactar,or rsmoewKr(cfiode swe}and have h�d the comractas Ested below w6o have
ihe followinS N'o��s'comPensaLon Pplices:
o9oouv�ane: . . � . .
�'�f:. .. . . .
�ih" . . nYe�e�1'
��a-.. _ . . :,. . . . . .. �T*.. _ _ < , :.�:. .'_'"^':,` . x..t.,.....
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weynn'h�pt6wwetnwNneMpeWtlesiafYeBer�at�3TOlWOWC09ULAd�medSlM.Namy�aMtve. lade�dHtla '���
t�pydtld��tdyhe 1�NeOmeedlu�W�sdlYeDlAtrcn+qs�eve�niN, ,.
!lo hersbyce»ayy rade ai prlws w�tgert�olD�nY ur tlYe brfsna�rred�el.berr ia nttr�a a�nK '��.
�;� � � ll — f� -fJ� . �
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ah K� pvdwa�ee e ^,6.�m.pcpataat i
❑e6aet if i�we�ie'oM�N R9�N �4�ce ��I
�Deprdest i
t��• �� �
II
_ - - . _ _ _ . ._ . . . ��
NOTICE TO EMPLOYEES i
�, I
— - __ _ _ __ _ _ -- — -- _ ____ ,
�co��tr�ott���n� .
DEPARTMENT OF INDUS"fRIAL AC(:IDENTS
6pp Washingtoa S1rear,B�ton>Massachusetts 02111
617-72711900—httpJ/v+ww.mass-gov/dia �
ps required by Massachusetts General I,aw,G3apter 152,Secrione 21,22&30,this will give you norice I
tbat I(we)have�ovided far payment m o�u injured e�loyees under the above-mentioned chapter by
.. . . . .. . . .ias�sing�wiih - � . .. .. .. .. . .
C�tanite Sffite Ins�uance CO ARP
NAME OF INSURANCE CON4PANY �
i
5 Wood Hollow Road,3id Floor,PO Box 409,Panippany,NJ 07054-04(19 j
ADDRESS OF INSLTRANCE C01vfPANY i
WC4470301 9/3/2007
POLICY NUMBER EFFEGTNE DATE '
Muaay 8c MecDonald Insuiance Sen'ices,Inc.406 Jones Road,Falmouth,MA 02540 508-540-2400 I
NAME pF INSiJRANCE AGENT ADDRESS PHONE# �
Brandon,Inc., 1319 Route 28,South Yazmoutli,MA 02664 ;
EMPLOYER ADDRESS ;
�
EMI'LOYER'S WORKERS'COMPENSATION OFFICER(IF AN1� DATE �
� MEDICAI.TItEA1'MENT i
The above named ins�uer is required in cases of pecsonal iajuries arising wt of and in the coiuse of
employment to fiunish adequate aad reasonable hospilal and medicai services in accordance with the
provisions of the Wotker's Comg>ensation Act.A copy of the Fast Report of Injiuy must be given to the
injured employee_The employee may select his or her own physiciaa The reasonable cost of the services
provided by the heating physician will be paid by tl�insurer,if the lreat�nt is�cessary a�reasonably
comiec:ted m tt�wo�ielated inj�uy.In cases cequicing hosPital atoention,employces are hereby notiSed
ihat the ins�er has azranged for such attention at tl�
Cape Cod Hospifal 27 Pazk Sheet,Hyannis,MA 02601 j
NAME OF HOSPTl'AL ADDRESS i
TO BE POSTED BY EMPLOYER
wc�so6g�z-02>tn�o�
,!
� . . ,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISFIA+IENT
PERMIT NUMBER: #08-009 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter
I 11,Secrion 5 of the General Laws,a pern�it is hereby ganted to:
Brandon Inc., 1319 Route 28, South Yarmouth,MA
Whose place of business is: Wok-N-Roll
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 2008 BOARD OF HEn1.rH: .��E�e`le"'��t�S� R��7a�Fi,q�J��26.�.A���.,���C'�!�ati�tauc
SEATING: 19 � t.lLIVL[�O .7l�.J�!!l¢7. V(CQ ���[a[��lRllQll ��..
J`2a�4nt �.J`3��auut, 'C.�e� '
Q�ut(s'xeertg6aum, `J2..N. '
November19.2007
Bruce G.Murphy, .S.,CHO
D'uector of Health
THE COMMONWEALTH OF MASSACHUSE'TTS
TOWN OF YARMOUTH
PERMIT NUMBER: #08-008 FEE: $50.00
T'his is to Certify that Brandon Inc. d/b/a Wok-N-Roll �
1319 Route 28, South Yarmouth,MA I
IS HEREBY GRANTF..D A
COD�VION VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December tUirty-first 2008 unless
sooner suspended or revoked for violadon 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 authoriries by General Laws, Chapter 140, and amendments thereto. ',
In Testimony Whereof, the undersigned have hereunto affixed their official signanues.
BOARD OF HEALTH: .fEe�eit SRta�lE, J2.JV., Cl3aixntaa 1'
sEaararc: i9 (',lfaxlee .�E.�Celli�e�C Nice C'kuuw�man '
��e s. �o�u�c, e� I
Qruc C�'ieenBaurn, J2..iV.
�
i
November 19 2007
Bruce G.M hy, , S.,CHO i
Director of Health
I
�
f
j
R _ _
,
� `?oFi a,y TOWN OF YARMOUTH BOARD OF HEALTH , ��K-N' R�u-
o � CC� � � �? � �
a y APPLICAI'ION FOR LICENSE/PERMIT�-:20�� � U E C 1 1 2006
r�� Please com lete form and attach all nece '
" p ssary documeirts by���� r 31, 2006. �
Failure to do so will resuit in the retum ofyour application pac .HEALTH DEPT. �
I
NAME OF ESTABLISF�IENT: G� � � - �1- RO I-L TFT.. # - �0��06a . !
LOCATION ADDRESS: +�l � -Ya�rmo l^ , M a �� i
MAILING ADDRESS: ��1� 13� �160�'E I
OWNERNAME:_ TAXID(FEINorSS1�� j
CORPORATION NAME �PLic�sLE): �R�n1 D o t�1 Sr.tC'. _ !
MANAGER'S NAME: �M 1.l�1- P H a TEL. # 50¢3-76 0-a.o6'e !
MAILINGADDREss: 3 �VD2�A- C,�Anl7ont , nM� v�o�.l
POOL CERTIFICAITONS: I
The poot supervisor muat be ce�tified as a Poot Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
L 2.
Pool operators must list a roinimum of two employees currently certified in basic water safety, standard First Aid and �
Community Cazdiopulmonazy Resuscitation(CPR). Please fist these employees below and attach copies ofemployee (
certifications to this form. T6e Healt6 Deparlment wi� not use past years' records. You mast provide new i
copiea and maintain a t"de at your place of business.
1. 2. ;
3. 4. '
(
FOOD PROTECTION MANAGERS - CERTIFICATIONS: �
All food service establishmems 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' recoMs. �
You must provide new copies and maintain_a fde at your establishment
i. �00 Crit7 N , �0 � • 2. I
PEIZSOAT-IAFEHt�ItG�: _ _ ___ __ __ _ _- -- _ . . __ ____ - - _ f !
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � �
/ I
1. �v � CHo�.i ,�o �.J � 2. �
,
HEIMLICH CERTIFICATIONS: '
All food service establishmerns with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all rimes. Please list your employees trained in anti-choking procedures below and I
attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. �
You must provide new copies and maintain a fde at your place of business. ,
i. 2.
3. 4.
RESTAURANT SEATING: TOTAL# �-` • ��Q- a�'� " !
l
OFFICE USE ONLY �
LODGING: i
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICINSE REQT.IIl2ED FEE PF,RMI1'N I
_B&B S50 _CABIN S50 �_MOTEL $50 ��,
INN S50 CAMP $50 SWIIvIIvIIIJGPOOLS75ea. � �
_LOIXiE $50 _TRAILERPARK 5100 � _Wf-IIRLPOOL $75ea. i
FOOD SERVICE:
LICENSE REQUIltID FEE PERMIT# LICENSE REQiJIRED FEE PERMI'[!i LICINSE REQIJIRED FEE PERMIT N
�aioo ssa.Ts s�s b�-o9�I _coxru�xrar. sso NON-PROFIT szs
_»oosEnnTs siso LCOMMONVIC. S50 �ko7-o�7 _u�ot.�saT.E s�s �
RETAII.SERV[CE: � —RESID.KITCHEN $75 '.
LICINSE REQUIItID FEE PIItMCf# LICII�ISE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT tl '�..
_60sq.ft. $45 >25,OOOeq.ft. $200 _VENDING-FOOD $20 il
_QS,OOOeq.R. S75 _FR07.ENDESSIItT S35 _TOB.4CC0 S50 I
NAME CRANGE: S10 AMOUNT DUE _ $ /Z S.O O
••'"•PLEASF TURN OVER AND COMPLETE OTHER SIDE OF FORM"•""•
� ;
,
ADMIlVISTRATION
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"I'ACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTI'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 to renewal or issuance of your pernrits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISffi1�NTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient ocwpancy 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.
Transieirt 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 transiem. Occupancy that is subject to the collecrion of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools wlrich have been closed for the season must be ins ected
by the Health Department prior to openmg. Contact the Health Deparhnent to schedule the inspection five(�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 ground swirrvning 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 Yazmouth Health Departme►►t by Sling the required
Temporary Food Service Application form 72 hours prior to the catered everrt. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Fmzen 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. I
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. I,
OUTDOOR COOKING: �
-- �utdeer-eeel�in�grcparatien,-er�sglay�f'any feed-produstb}�a rgtail oF-food service establishment is gro6ibited.
N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILIT'Y TO RET[JRN
Tf�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
AT.i• RENOVAITONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO CO1�Il�fENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �"Z" 6 �� SIGNATURE: �"
PRINT NAME&TITLE: Y60 �i.� �PR�
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Depmdsent oflndwsf►iwlAccidents '
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Boslen,Mass. 92111 i
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. _ . . . .. .. . . .. !
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMiT TO OPERATE A FOOD ESTABLISHM�NT
PERNIIT NUMBER: #07-084 FEE: 75.00
In�cordance with re�1ations promulgated under authoriry of Chapter 94,Seclion 305A and Chapter
111,Sec;tion 5 of the Uen�al Laws,s petmrt is ha�eby grented to: . ',.
Brandon Inc., 1319 Route 28, South Yarmouth,MA
Whose place ofbusiness is: Wok-N-Roll
Type of business: Food Service
To operate a food estaUlishmern in: Town of Yazmouth '
Permit e�ires: December 31 2007 Bonitn oF IIEALTH: B is$. /�;�,,��,/�?M.$., G�lraarixw� �
sEa�rttacr. 19 d��e��, K./1'., %/ics�ui3�rra� I
/�a�tia�/No.$e3�a1� '
A.��j�.� R.N.
Febmary 26.2007 '
Bn�e G. Mucplry, RS.,CHO
Diractor of Health
THE COMMONWEALTH OF MASSACHUSETTS '
TOWN OF YARMOUTH '
PERMIT NUMBER: #07-057 FEE: $50.00 I
�
This is to Certify that Brandon Inc. d/b/a Wok-N-Roll
1319 Route 28, South Yarmouth, MA '
LS HEREBY GRANTED A ,
COMMON VICTUALLER'S LICENSE �
In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2007 unless �
sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the �
licensing of common victuallers. Tlris license is issued in conformity with the authonty granted to
the Gcensing authorities by General Laws, Chapter 140, and amendments thereto. '
In Testimony Whereo� the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: B�s�wx' uc$. rrotdo�a M.$., '
SEATING. �9 � ����er.�.� ��'�..�.,.,
�YA�ItdOlip�i R.N. �
�
'i
Februatv 26.2007 ',
Bruce G. M�uphy, , S.,CHO
Director of Health
i
� ' a-„ �4•bK N-,Qacc. �
o �R.y TOWN OF YARMOUTH BOARD TH � � -
3? � APPLICATION FOR LICENS T,� � pG (��� � r � ~ ` I
��; � _ ,.�, . ' _ �
* Please complete form and attach all necessary documents by December 1, 2065:` -' ��-7
Failure to do so will resuk in the return of your applicatwn pack � HEALTH U�PT, i
NAME OF ESTABLISFIMENT: ��K - � - ���-�- • TEL. # �OS-7�o�b 6 0. �
LOCATIONADDRESS: 13 Y�l.ouh 3• 0.�mp �-
MAILING ADDRESS: f 'n 3 8 - ��mo B
OWNER NAME: �{eCt.l Ei LocJ TAX ID(FEIN or SSN):�� �
CORPORATION NAME(IF APPLICABLE): �f[�n CI on �.-n G •
MANAGER°sN.�: nnU +�ko . �L. # � -76o-�a6a. �
MAII,INGADDRESS: t 3 I , YVIa.�. n �-i- � � . `i��mo VL�a O�-�6� .
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 oftwo 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 Henith Department will not use past yesrs' records. You must provide new
copies and maintain a£de at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS -CERTIF'ICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as deSned 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 maiotein a file at your establishment. I
1. \."dn n� �t'`,`) ' 2.
—�
- PERSON�i1-GI-I�RG�--------- -- --- - -- - _---- - — _ _ _ _
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
i. �am u�1 Pk� � z. �
HEIIt�:FCH CERTIFICATIONS:
All food service establistunents 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-choku►g procedures below and i
attae}i copies of employee certifications to this form. T6e Health Department will not use past years' records.
You must provide new copies and maintain a fde at your place of business.
i
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# �C� 3�
OFFICE USE ONLY
LODGING:
LICENSE REQiJIItF.D FEE PERMIT# ISCENSE REQiJIltF.D FEE PERMI1'# LICFNSE REQUIItED FEE PII2MIT# �'�,
B&B S50 CABIN $50 MOTEL $50 I
INN $50 CAMP $50 _SWIIvIIvIIIdGPOOL$75ea. �
_LODGE $50 _TRAII.ERPARK $50 _WI-IIRLPOOL 575ea. �
FOOD SERV[CE:
LICINSE REQiJIItED FEE PERMIT# LICENSE REQilII2ED FEE PERMIT# LICENSE REQiJIliED FEE PF.RMIT# I
�0.100 SEATS $75 �Q6-o46 CONTINENTAL $30 NON-PROFIT S25 �
>100 SEATS $150 / COMMON VIC. $50 G'O7O _WHOLESALE S75 I
RETAII.SERVICE:
LICENSE REQLJIRED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIItED FEE PII2MIT t! �'�
_<SOsq.ft. $45 >25,OOOsq.ft. $200 _VENDING-FOOD S20 !
_QS,WOsq.ft. $75 —FROZENDESSERT S35 _TOBACCO S25
NAME CHANGE: S10 AMOUNT DUE _ $� /2S,O�
"•"•"pLRASE TURN OVER AND COMPLETE OTHER SIDE OR FORM'"""" �.,
I
p T
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required 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
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES �� NO
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN !
THE COMPLETED APPLICATION(S)AND REQUIltED 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.
Ai,i, RENOVATIONS TO ANY FOOD ESTABLISIIl�IENT, 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 REQUIItE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whiripools 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 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 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 Departmem by filing the required
Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtained at the
Health Department.
— -�RAZEN��SS�R�S:_ _
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must 6e sent fo�e Heatfh
Department. Failure to do so will result in the suspension or revocation of your Frozen DesseR 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 ofHeahh.
OUIDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: �1 - -27 - �� SIGNATURE:
PRINT NAME&TITLE: '�u o n� �-t�� �,Pie1��
09/28/OS
. ,
- -� The Coniinonwealth of Massechuseltc
� ---�—� Depas�unt ojlndus�dial Accidewtc
-. �YN�
_ _- 699 R'ashixgtoe SY►rey �Floor '
— Bosto�,Maxc. 02111 '
�
Y wu.tas'campeas.tio■I�eca�a w�d..� �/Eleetrfed c.o.traela„ '
, � �
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OBmC' t�'� I
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c�n, � 1`Q/'mol.lT-l'� �VIGi ao� D�� nn�a �O 700 .�Or10 .
��i«mm�rnu�:k � °� 1 q �{c� � . I�armo� i'V14 ��66�
❑ I am a homoowra�perFom�iog all wak m � �
Y� �.I�TYPe: ❑New Cmstcuctim ORanodel I
I�a sole ' aod l�ve�me ' in anY � • B � � pddit� I
I am an empbya p�oviding waicas'�on f�mY�PbY�N'akinS m this job. �
; &r�ndo� 1r�C ��2'� - �a� - h - Ro� . _
� ��r9 , Rt �8 , _
�,: � �a�mo�tG, ,,,�,. �08 - 7 60- 2o�D •
+t�n��f2. S'-{a�e .X+� ur n ce Co W C 27$ -9.�-
�
❑ I am a sote pmptietoy Se�a�l eatrxbr,or Yamaw�er(cnele owe)md have hinod tbe mntcactas lis[ed below who have j
ihe following wakas'comp�fon polices:
�[�•
��
e�': oiael. I
. ;.. -�-:�.d�a'5,.;....a�: _�:sn.a . r-�r s.;efF. �,., , .y.r: .., r*&,r , �^..* I
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. ..... .. ..�., , n{.tiva °` ' i..'^" -i�.'�`.,ai:.�*'Yi`sY�.vFvs"£A�my� - .. .:3x.� . -... ::+ �
FaYue r�eeae aReade e�eqyed oAe SeAMi 2SA dNGL L4 en led b Me �•�.:�• .
iq�ilY�daW W pa�Wn Ka 5e R a fI,SM,N�aN�r
�Y�'�t n wd n eM pwMb h 16e 6r�Na Sf0?WORIC ORDCR atl�6e d Y1N.N�Aay�lOt�e. 1 odenUM Wt a
nrydtlb�rylehrwardMbNeOmeedLveMlplYrafHeDlA[wc�ngeverlentlM, �
!Ao hereby ' r /er tFe peles awdpene!lies afperjrry dYrt dYe iwfonndon provl/ed above k 6we od arw+ecz
s�g� � I! -e2 7-0.5 �
e�� ' ovn WtiI ' Phoce# � - 76o-2o6a-
emd�lmeo.ry a..a.rrkeMl4h..e,r.eecaPle�bsdls.rrwna�L1
ciy ar fawo: pcdtlBemee X flReanti..p��
❑ehect HimmsdVie rt�eme b rcqmad ❑��mrd
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l
GRANITE STATE INSURANCE COMPANY 70785-0000 WC 278-95-23
13102 -------------------------------------------
013-66-0905-00
PENNSYLVANIA
BRANDON, INC.
1319 ROUTE 28 Member Companies of
S. YARMOUTH, MA 02664-0000 � American International Group
ExEWT1vE oFRCEs: __.- . _...
- -- - -
—_--78-P1NE�ETRlET. NE1N V6N�K, N.Y. 10270
SEE NAME._AN� ADD&ESS SCHEDUtE - WC990610
I.D� � ,
WORKERS COMPENSATION AND EMPLpYERS 406RJONESMRODONALO iNSURANCE SERVICE ING.
LIABILITY POLICY INFORMATION PAGE FALMOUTH, MA 02540-3913
INSURBD IS PREVIOUS POLICV NUMBER
CORPORATION RENEWAI 006801444
OTNER WORKPLACES NOT SH07NN A80VE:SEE NAME AND ADDRESS SCHEDUIE - WC 0610 �
rtEw z voucv aenwo rm�wr.:++nmm n�e,e ene m:wea�a
m�r�.aa.�. � 09/03/05 io 09/03/06
�a A. Workers Compensatioa Insurance: Part One of the pollcy appliea to the Wo�kers Compensatfon l,aw oi the stetes listed '
hera
MA
6. Employers Liedility Insurance: Pert Two of the policy applies to tha work in each state iiated in item 3A.
The limits of our liability undar Part Two are:
Bodlly Injury by Accident =.. 100,000 each accident
Bodity In�ury by Dis9asa S 600.000 ppllcy limit ����
. 6odiJy Injury by Disaase S 100 000 �ch amployee
C• Othar Staoas Insuronce: Part Three W the policy applies to the states, N any, Ilrted hare:
SEE ENDORSEMENT - WG200306A
�M� The prqnium for Mis policy will be detormined by our Manuals of RWes, ClassifiCations, Ratas and Rating Plans. �
All iniormatlon rcquired below is sybjeCt W veri8eation and change 6y autlk.
ClassNfeations Remu antion � �16 Pm Estimatetl
CodaNumber :�Npppe P�mium
� A����� 3 YN� ���a�� �q��ual 3 Vear
I
SEE EXTENSION OF INFORMATION PAGE - WC775y
TAXES/ASSESSMENTS/SURCHARGES $ZO
I
D�ENSE CONSiANf IIXCEPf WMERE APPLICABIE BV STAi� S 264 MA i
MIMRMUM PpEMIUM S 217 MA Tv*a.esn�wwrEo vae�uuw S 7;2
11 i d t tl bal i t ri dju t e ts oi p�ym�um shall pp mada. �
� Semi-Annuslly � QuaherlY � Monthly DEPpSR PqENIUM
ENOOp$pA�«"'""""'�"� SEE ATTACHED FORM SCHEDULE - WC990612
OS/30/05 ASSIGNED RISK 66
IUYe Date Is6uin9 pflit¢ --
38887
Authorimpd qeDreeentatNe � WC 00 00 07
INCI IRFII'4 (;C1PY
TOWN OF YARMOUTH
BOARD OF HEALTg
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-096 FEE: 75.00
�a�c°'dance R''th re at'ons P��B��d��horiry of Chapter 94,Section 305A ffid Chapter
1]1,Section 5 of the�erai Laws,a permrt is hereby granted to:
Brandon Inc. 1319 Route 28 South Yazmouth MA
Whose place of business is: Wok-N-Roll
Type of business: Food Service
To operate a food establishmem in: Town of Yazmouth
Permit e�ires: December 31_ 2006 BOARD oF HEnLTH: B $. /��'',�'`/��'��(iJ„�,� �
� sEaa'ruac: 19 dEe�cQ�tali, K./1�., !/foe�iatAixa�c
�.�ta���
�4raa(f�6r�, RJY.
.rga,�y 2a.zoo6
t �
Bruce G.Mucphy, H,RS.,CHO '
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #06-070 FEE: 50.00
This is to Certify that Brandon Inc. d/b/a Wok-N-Roll
1319 Route 28 South Yarmou MA
IS IIEREBY GRANT'ED A I
COMMON VICTITALLER'S LICENSE I
In said Town of Yazmouth and at that place only and �p'ues December thirty-first 2006 unless �'
sooner suspended or revoked for violation of the laws of the Couunonwealth resp�n g the I
licensing of common victuallers. This license is issued in confornrity with the autliority granted to '
the licensing authorities by General Laws, Chapter 140, and amendme�s thereto.
In Testimony Whereof, the undersigned have hereunto affuced their official signatures.
BOARD OF HEALTH: B $. ��$., .
SEA�G: �9 ��s"� �r, v�e�
a��. a� er�
�,�r�,�
.raa 2a 2006
ruce G. mPh3', S., CHO
Director of Health
I o�.Y,�R � S��
� �$ '�� TOWN OF YARMOUTH
� y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026641l451
�.,.r..,c�ccPs"� Telephone (50S) 39&2231,Ext. 241 — Fa�c {508) 760.3472
+`��„a...m,• �r
B O A R D O F H E A L T H
To: A112005 Yarmouth Board of Health License/Permit Holders � � �' � n � � '° �
, MAY 2 4 2005
From: Yarmouth Health Departmem
HEALTH DEPT.
Re: Tax Identification Numbers �
Date: March 22, 2005
3'he Massachusetts Department of Revenue is now requiring that the Health Department fiunish �
to them detailed information regarding all permi4s and licenses that we issue. One of the required I
details is to provide a tax idemification number, whether it be an establishmern's Federal i
Employer ldentification Number (FEII� or, in the case of an individual's license, a Social i
Security Number (SSl�. This information will be used by the FIeakh Department purely for i
administrative purposes only. I
Would you please fiil out the fields below and retum this letter to:
Yarmouth Health Department ,
1146 Route 28 ;
South Yazmouth, MA 02664 I
i
Thank you for your anticipated compliance. If you have any questions regarding this matter, I
please do not hesitate to call. The office hours aze Monday to Friday, 8:30 a.m. to 4:30 p.m. The
telephone number is(508)398-2231, ext. 24L �;
Estabiisnment: }- ( FEIN or SSN: �
WO�-�tJ.��q (�.
Loca6on Address: � 31 Q , ����$ .� . 1'Q.t�tc�c.� , � .0 Z(�(a- '
Signature: � �
Prim: �00v� L0� � Title: �R'E-S _ I
�
L�S P����
R
. :. �,�13� �iz5'
�iAR1 TOWN OF YARMOUTH BOARD � ��. ..._ �� °�-�n
���z APPLICATION FOR LICE�S� ,, 5
NOV � 2 2004
* Please complete form and attach all nece��d�umients by Decem
Failure to do so will result in the retum ofyow application pac ���-��EPT. _
NAME OF ESTABLISHMENT: � — TEL. #50 - 0 — �
LOCATIONADDRESS: l3 i � /YICx,in _4-f' . C�. 'f'��'i»or� dvlcA c9�!
MAILING ADDRESS: �&�T� }� �98Dv � �
OWNER/CORPORATIONNAME: RP.�Nd�ON .ZnG •
MANAGER'S NAME: �Boi.l Ev � � TF.L. # 8 - 76.0 ��o6a .
MAILINGADDRESS: 13 f�j , �'10.�n $+ • alma
POOL CERTIF'ICATIONS:
The pool supervisor must be certitied 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 Gst a minimum of two emplo ees 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 fde 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 EstabGshmems, 105 CMR 590.000.
Please attach copies of certification to this appfication. The Healt6 Department will not use past yesrs' records.
You must provide new copies and maintain a fde at your establishment
1. �oon� �� � 2.
PERSON�TEHAtiGE: _ -- ---_ _ __ _ ______ _ _ _ j
Each food establislunent must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS: � j
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 place of business.
1. Z_
3. q. '
RESTt1URANT SEATING: TOTAL#
OFFICE USE ONT.Y '
LODGING: ;
LICENSE REQUIRF,D FEE PERMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQUIRF..D FEE PERMII'# ,..
_B&B �� S50 � -� _CABIN $50 MOTEL S50 �
_II1N $50 _CAMP S50 _SWIIv4vIING POOL$75ea.
�_LODGE $50 _1RAII,ERp,4Rg S$p WI-IIRLpppL E75ea. i
�
FOOD SERVICE: � ..
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# ..
�0.100 SEATS S75 �OS'Q3Z'' _CONTINENTpi, $30 NON-PROFIT $25
_>100 SEATS 5150 �COMMON VICT. S50 �O/ _WI-IOLESALE $75
RETAQ.SERVICE:
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUII2ED .FEE PF,RMIT N LICENSE REQIJIItED FEE PERMIT#
_<SOsq.ft $45 _>25,OOOaq.ft. S2W _VENDING-FOOD S20
_Q5,000 sq.ft. $75 FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: SIO AMOUNT DUE _ $ /p7�"j•QQ
"""PLEASE TURN OVER AND COMpLETE OTHER SIDF OF FORM•••••
�
♦. _ '�`„ I
ADMINISTRATION I
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernvt to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RE'T[JRN
THE COMPLETED APPLICATION(S)AND REQiJIItED FEE(S)BY DECEMBER 31, 2004.
SEASONALESTABLISFIMENTS ARETOCONTACTTHEHEALTHDEPARTMIIdTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR TI� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCIIvIENT. RENOVATIONS MAY REQUIILE A SITE PLAN.
ADDTl'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 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 estab'shmem which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POTdCY•
Anyone w o caters wrthin the Town of Yarmouth must notify the Yarmouth Heakh Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered evern. Thses forms can be
obtauied at the Health Departmern.
_FROZ�N�ESSERI'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 Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmem is prohibited.
'' DATE: �1 �l 7� �F SIGNATURE:
PRiNT NAME& TITLE: YO B �-�'� Cn'1 N 6r)
10/22/04
I
- -� The Com�nonwtalth of Mavsachuseets I
_- _—_�
- DeparteAreet ojlndrs/ria/Accidents ��
- — N�'�Niwu� '
-_ -= �w�;��,�� �"F�. '
BosWn,Masx 02I11 I
`wo.t��co� ■�.ag,�e w�a..�_— - �._ _�c..a��c..:
. � " �
y..�.��. .�!"!e°.. � ,
�: a�dlG� �1!— �Yl-l�
i
�g: 3�';�� ,�t�;e��'�# , g�+r,�� , �
ciri aste• � +f7►�CI� rnr C�1��mea �--7po"�-• ''..
wmic site locffiim ffoll add�eaeY. . .
❑ I am a homaowra perfomting all w�k myadf. Praject Type: ❑New Cmst�on ORemod�l
I mm a sole sod l�ve��e " ` m� ' ��
I am an emPbYa'Pm�'idm8 wodcas'�im far mY�P�Y�M'�8 m�J� ',
��e: �Ra�NDEY.f" .N1G ._-_ _ -_ ',
�: I 3 i9 . /1'laa n .4-f , i
�: .__�- �afMo� , �la � oa66� ,,,�,. �'08 - 76o � ao6o . i
��.;;,� 7�avc.re�s �nde�r�n� CD. ...�.. � �37�fs�.5o9 I
,
❑ I am a sole pcoprietor,ge�aal ea�hxbr,or iome�w�(cnrle owe)md have�nod the cofficactas liated below wln have I
the following wadce,�s'wmpmsation polices:
s�tu�v�e:
��
tu.: �,r I
. iir.oeee� . . . . '
�r�uc
siir�
�: �r.
. .- - - --�----------- -� --� ---�� -- --- -- -
. _ _ -- ---- - -- --- --- ._ __ .
�� ��
Faine r+ecne sraqe a�eqid aiQ BeeYr 2SA dMGL 132 es M6 b He�daLIW pmlfoda ie�p as�3KM aWr
�7p�+'uP�mtawdueM�mMleitrebr�d�STOtWOBICOHDSRud�melSlM.Na4yapirts IadenhWtiNa
upydUYYaeeseet�uy6eprwu6N0aNeOmeedl�vnlipYmdtl�elNAArt�e�p�nW�. �
�[o Aeseay ce�y,, We�dwa ad�a olPM�Y a�Ms iufaM�dvw arodlel ebex 6 srr o�a an+rct
��/, �`
SiBouace ��`N nw l('17t"`f'
�� Yeon �o� . P,,�# 5n8� 760 -ao 60 ,
.�Ll.x«y M..►wrkerufsunbieprpkieipydhorrw..�Ll ���.
�M7xtewe �ermWgense/ ^- -- �',
e �
❑t0edt��6e�ppwe 6 rsqed ���d
❑Bdee6�u'�O�a
n�lutpers�: �& ��
ln+ia s�.mm)
- _. . ... . . I�
I
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-022 FEE: 75.00
In ece°rd�ce with regueln��ons Promulgatad under suthority of Chapt�94,Section 305A and Chapta
111,Seclion 5 of the C Laws,a peimit is hereby ganted to:
_ Brandon Inc. 1319 Route 28 South Yarmout MA
Whose place ofbusiness is: Wok-N-Roll
Type of business: Food Service
To operate a food establishmem in: Town of Yarmouth �
Permit eatpires: December 31 2005 Boa,xD oF HEnLTH: Be�f.s 2. (�oad�y�1�y. �
sEa�,�,� 19 . Pab�iC,b M�e�«rof� 9/i�C�i�arxc�c
a�r� a�, ei..�
�� a�v
R.A!
��as.Z�a
Biuce G.Murplry, S.,CHO
Director ofHeakh
THE COMMONWEALTH OF MASSACHUSETI'S
TOWN OF YARMOIJTH
PERMIT NUMBER: #OS-018 FEE: 50.00 I
i
Tlris is to Cerqfy that Brandon Inc. d/b/a Wok-N-Roll �
1319 Route 28 South Yarmouth,MA �
IS HEREBY GRANTID A �
COMMON VICT[JALLER'S LICENSE ;
In said Town of Yarmouth and at that place only andc�p'ues December thirty-first 2005 unless i
sooner suspended or revoked for violatron of the laws of the Commonwealth respecting the �
licensing of common victua((ers. This license is issued in confornrity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimotry Whereo� the undersigned have hereunto affixed their oflicial signatures. '
BOARD OF HEALTH: 8eiafa�n6.s$. (�oadoir, /�$. I
sEaxru�rcY 19 �,�yJ� v���
Ro6�t 4. B�, G!�
�� R R.N. ,
�
,
n�t�zs_2ooa
Bruce G. ►uPhy,MP .,CHO
Director of Health
. � G►oK-N-Q� �,I�'�� ���R�� D I
�`�'?.y TOWN OF YARMOUTH BOARD OF H�At1,T��
; = APPLICATION FOR LICENSE/PF,RM�,T-2004, NOV 1 3 20�3
r �, s • Please complete form and attach all necess �'w�u��ecember 31 LTH DEPT. �;
Failure to do so will result in the returu �:your p �cation packet. ,j60 �
;..�
• WO - v� — L .
: 13[ �' - a�rvi
�
OWNER/CORPORATION NAME: R1�N�oN �h1G. ,
A ' � • � � 5—1460.
Man.irrG annxEss: �, , n , ctit� o�o2t . i,
POOL CERTIFICATIONS:
The pool supervisor muat be certitied 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 fprm.
l. 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 of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a tile at your place of business.
1. 2.
3. 4. ,
FOOD PROTECTION MANAGERS - CERTIFICATIONS• j
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, ]OS CMR 590.000.
Please attach copies of certification to this application. The Health Depardnent wili not use past years' records.
You must provide new copies and maiotain a file at your establis6ment.
i. Yoon� l-o�J ` a.
PERSON IN CHARGE:
- - _ _-- -- __ _- - - -- --- - ------- _ ____ _--_
Each food establislunent must have at least one Person In Charge (PIC)on site during hours of operation.
�. Ya� (-0� � 2.
HFIMLICH CERTIFICATIONS:
A11 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a(I times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Aealth Department will not use pAst yeers' rewrds.
You must provide new copies and maintain a file at your place of business.
1 2 �
3. 4.
RRSTAURANT SEATING: TOTAL#�_
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT N L[CENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '�,
_B&B � 550 _CABIN S50 � _MOTEL S50 �
INN S50 CAMP E50 _SWIMMING POOL$75ea !
_LODGE S50 _TRAILERPARK �50 _WH[RLPOOL S75ea
FOOD SERVICE: ''�,
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PGRMIT# LICENSE REQU[RED FEE PERMIT#
�0-100 SEATS S75 �I-6 _CONTMENTAL E30 NON-PROFIT S25 �.
>IOOSEATS SI30 � �COMMONVICT. SSO �8 _WHOLESALE� S75 � � �'
RETAIL SERVICE: � . � � - . - �I
LICENSE REQUIRED FEE PERMIT# LtCENSE REQUIRED FEE PERMIT N L(CENSE REQUIRED FEE PERMiT# '
_<50 sq.ft. S45 >25,000 sq.R. E200 _VENDING-FOOD S20 �
_Q5,000 sq.ft S75 _FROZEN DESSERT,S35 _TOBACCO S25 �
NAMECHANGE: $10 AMOUNT DUE = S I 2S .00
"•"•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*•"• ��
ADMINISTRATION
Under Chapter 152, Sec6on 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 dces not have a Certificate of Worker's
Compensa6on Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
28
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taaces and (iens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annual[y from January 1 to December 31. [T IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATtON(S)AND REQUIRED FEE(S) BY DECEMBER 31,2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE I�ALTH DEPARTMENT FOR INSPECITON 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.
AADITION I F U ATION
- - POOLS
POOL OPEPiING:All swimming,wading and whirlpools which have been closed for the season must be inspected '
by the Health Department pnor to opening. li
POOL WATER TE5TING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, arid quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
�ONSUI�LR ADVI ORY•
I Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
� CAT�R1_N_C�POLICY:
� Anyone w o ca�i— ters within the Town of Yarmouth must notity 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 Department.
FR� .F.1V .eSERT . _ - - _ . _ - - _
Frozen desserts must be tested on a monthly basis by a State ceRified 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.
OUTSIDF Ffi •
Outside cafes(i.e.,outdoor seating with waitedwait�ess service),�u have prior approval from the Boazd of Health.
OUTDOOR GOOKIN •
Outdoor cooking,preparation,or disptay of any food ptoduct by a retail or food service establishment is proltibited.
DATE: � � 1 D3 . __SIGNATURE: �.
PRINT NAME& TITLE: Yeon �-ov� �� g I
I
10/22/03 I
I
�
: � �
The Commonwealth ojMassachusetls
: Deparlmenl of Industrial.-Iccidenu
; amceel�er�sUasa�
600 Washington Street
Boston. Mass. 01111
_ , .• ,
W'orkers' Compensation Insuraace Atfidavit
Aoolicant information• PfeesePRi1V7'Trs.'idt `
namc �(0.h�0v1 �G C�4 f�O�C - {�- ��(-1- • :
���,�,�� ���� , �+ a� ,
cii� c7� l��'IB�AA"V� ` � '�� . L�o�-O�OQ- .. ehan p �" V � Ik�� aVUC7 .
0 I am a homecwner penorming all work mysdf.
� I am a sole propriecor �r.� ha�e no one «orkin_ in am capatiry
'�. I am an employer pro�iding wo7rkers' compensation for myemplo}ees working on this job.
. .. eom�an�• name: Y1l(��'�.... .y[� -..1� IC�Z..0 c�/U�� ��-....�.SI�Q.�C� __ JQ.'�V l�Q � �✓�L' .�--�__ , _.. .
U
aJdress: �b � c��✓�0�� � ��
��»: `�k,�+�l�u�� �� ���-� yno��a. �`1�00 -- ����c
insunnceco. ��QhI�C� �`f�Q. �'S'IQ�.l.��1.✓1�'�. LO .. eolicvp ��' a-��1� �
� I �m a sole proprietor. general contractor, or homeowner(circ(e oneJ and ha�e hired the contractors listed below «ho ha�e
thz follu�cin_�corkzrs: .ompensation policrs: ,
companv name• � � � � � �
addresr
c�y: . .. � . . QAone p:
insuranee co, oelier#
eomnanv namr � � �
_ .eams: .
-----------_. —. .
t�: � � � ehoee M: �
insuraneeee. � � eelinM � � �
Failure to aeeure eorenee�s reqmred uader See000 ZSA of MGL!S2 w Ind to�Ye i�paitio�o(eri�iW peultles of���e op ro 51,500.00 a�d/or
�ooe yean'fmpriwnment u w�dl��eivil penalHn io the[orm o!�STOI WORK ORDER a�d�If�e dit0/.Ma d�y mimt mn 1��denu�d Wt a
eopy of tAy saument mw be fonv�rded to the 011fee of Investlpuom of Me DIA tw eovera�e vMlfatlo�. � ; . � �
�. /do�6rreby ce i}•' ndtr rhe paint and penaltiet ojp�rjnryYhalYhtinjormation prorided abore is trne and corrcd
Signaturc I � 1 I Ifl``�.3 :
Print name ���� � one K l '�� '� I S �I��D
, oRcial use only do not..rite in�his�rea to be rompleted by eity a lowo ollltial
city or mwn: Y�DT$ _ � � .peneiNinex M nBuildioQ Depirtmmt
- . pLieeosies Board
�eAeek if immediue respoase ie required �6� QSdeefinen'a Ofiee . .
. _. . . .- - - �HnIt6Dep�rtmmt .
connctperson: phoaeM:_ �508� 398-2231 eEt. nOther
M�v^�„ VCR I INVN 1 C Vr LINOILI I i 11\JtJR/'iP/VC 12/03/2003 '
�� (SOS)540-2400 FAX (SOS)760-198E TFBS CERTIRCATE IS IS�IED AS A AIATTER OF iNFORMATION �'.
Mur�dy & MacDonald Insurance Services ONLYANDCONFERSNORIGHTSUPONTHECERTIFlCATE
906 7w�es Road HOLDER.TFqS CERT�ICATE DOE&NOT AMEND,D(TEND OR .
ALTER THE COVERAGE AFFORD D BY THE POUpES BELOW.
Falmouth, MA 02540
Douglas MacDonald INSURERSAFFORaNGCOYERAGE NA�# '
�o B , INC. , ►��T+A Travelers Irol. Co. OF CT 25682 �,
1319 ROIffE 2E �g Granite State Insurance CO ARP
SOUiH YAIWqIiN, MA 02664 �G '�
� NSLf�RD �
lb7R�RE '�,
THE POLICIES OF INSURANCE USTED BELOW FWVE BEEN I391E�TO THE INSURED NAMEO ABOYE FOR lHE POIICY PERIOD INDICATED.N07YNTHSTANOMIG �,��
AN1'REQNRENENT,TERM OR COpD{/lON OF ANY CONIRACT OR OIHER DOfXMAB1TMRili RESPECTTO NHICH 7HHISS CERTIFICATE MAY BE IS�IED at I
IAAY PERTAMI.TF�INSUNANCE A�FORDED BY TF#POLNYES DESCRIBED HEREIN IS SIJBJECTTO ALL 7}E TERMS,DCCLUSIONS M1D CONOITIONS OF SU(Yi ',.
POLIqES.AGGREGATE LIMRS SFpYVN AIAY HAVE BEEN REDUCED BY PAID CW MS. '�.
� �vrE�H�n�wc� voucvw�eet valcvsF� raucv�mrt�iiu+ �� .
ce�w�uaexm I6808745A509 09/03/2003 09/03/2004 �u+oca� S 1 000.
Mn�2cw.t�rsm�tu�nv ou.a�em s 300, '�.
ctn�smnoE a ocan n�oowpuymsre�I t S. '��,.
p �anovn�m s 1 000, I
sa€aa�w� s 2.000. I
con.Acc�cn�uer�ve�escac vaadicrs-carrovacc s 2.ppp, �..
vaucr � �oc �'�
ulIOMOB�ELINBILI7Y OOA8lED5NGlElM �i
�e�yy) t
ImAVf� I
MLQ�I�EDMROS 600lYiUR'! t I
Stl�IAEDM1f05 ��)
I�DAVf� 600lYNJl61Y
f
I!0!!9MlEUAUlOS �� i
PROPFRTYD�lIhCaE f I
��
I
G�RM.ELY&IIIY AUfOOKY-E��CCDEM S �
MIYAUfO �RnyW EI�ACC f 1
AUfOOKY. AGC+ S
ENCE�UIVBLT' EACMOf:CLR�NCE f
OCCU1 �QM6MIIDE AGf�f1EGRlE t
s
nmucrete - . s
aE�r+noro s s
xaom�ecoiremnra�xo 1MC 2170791 09/03/2003 09/03/2004 "
�����'m E1.EM]1ACCUENf f jQQ
6 /�HfPRUPf�'TORlPARINERD�QJlP+E
�OyF�Fl,CEP�RIXQIAEO4 ELp5EA5E-EA@.PLQlEE f IOO�
SPEqK�PAWB�OfSOabw E1.045EASE-POIIGYIIdT f S�
Of1ER
O�RP710NOFOP6GiMlY/LDCAl10NS/VH�Cl.E81E%Clt18qNBA00�BYB�OO�/OECMI.PR01fl&ON8 ��'I
ation - 1319 Route 28 Sar[h Yanaouth, M 02664 !�
li
CERTI T NO i
4110U.OMlYOFTlEIIBOYE�POLIC�BECMW�La+BffORE7XE '
j
�u�or�o���oF.n�eauw�au�nwu eo�vartrow�. '
_wvsvrane�NorecEmnE�serFxwrexa.oeerMe��nn�i.�r, ,
Tavn of Ya�ma+th aurruu�mwiesun�r+m�aww.�rosEraoai.wnnowdeu�m '�
1146 Route 28 �µ+'��'�����+�a+��� �
South Yara�autF�, MA 02664 �^����'^'� �,.`_, ��
Daxin Du LD �' � "�"" I
ACORD 25(20D1PoBj �/1CORD CORPORATIOIi 7888 ,
I
TOWN OF YARMOUTH
BOARD OF HEALTH '
PERMI'P TO OPERATE A FOOD ESTABLISHM�NT j
PERMIT NUMBER: #04-049 FEE: 75.00 II
In accordance wit6 reaulstions promulgated under au[hotity of Chapter 94,Section 305A and Chapter
111,secflon s of we Z`ieneral I.aws,a pe�mit is bereby granted to:
Brandon Inc., 1319 Route 28, South Yarmouth, MA
Whose place of business is: Wok-N-Roll
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pernrit expire4: December 31_ 2004 BOARD OF HEAt.TH: B�$. Qo+rds�,�l/.$. �
sraruv�: 19 aa�/�o�, vioa C��iaL�a� :
Qa�s3t�B�lotwg �
___ e�e�e�s e�ia�ir IQ./�._ ___
December 4.2003
Bnu�e G.Mucphy, H, .,CHO
Dir�of Health
THE COMMONWEALTH OF MASSACHUSETTS ;
TOWN OF YARMOIITH
;
PIItMIT NUMBER: #04-038 FEE: 50.00 �
I
Tlvs is to Certify that Brandon Inc. d!b/a Wok-N-Roll �
;
1319 Route 28, South Yarmouth, MA II
LS HQ2EBY CRANTID A '
COMMON VICTUALLER'S LICENSE '
In said Town of Yarmouth and at that place only and �p ires December thirty-first 2004 unless '
sooner suspea�or revoked for violation of the laws of the Commouwealth respecting the
. . ��ee . . . . . . .
to the licensing authorities by Genetal Laws, Chapter 140, and amendments thereto. !
In Testimoiry Whereo� the undersigned have hereunto affnced their official signatures.
BOARD OF HEALTH: B�oart�s$. C'Joyderc,M.�.
sEn�ruac: t9 Rd�+rw4Alo$�a��iosC�ia�.taraw
R�t4 B� ;
d�eff.� R.N. i
L�Cember 4_2003
Bnxe G. u�phy, S. HO
Director of Health
� Y �Qs�8/'�'$c� i�;s f� '� � J V � U I
'= TOWN OF YARMOUTH BOARD OF H ��'H I
� � � -�s APPLICATIONFORLICENSE/P i 2�D3.. �EP 0 2 2003 ',
' * Please compiete form and attach all necessa y ecember 1�@gTH DEPT. '
_ Failure to do so will result in:the return o ,�ur pplicarion packet. � I
. WD�C- -R01{ ¢3 Qclr7.[rtt TEL. 5 -7 -20
itl(`ATTnNADDRF4S• /3/9 ffN�2 �� sout ya.n+�u �'Iifl 0�66� �
naarr rN� annuFss• same . '
o n . LOW '`
, Lo T #.fo�-7 D-�o a
lvran.rN_r,aDD�ss: i3 i �?ocrt� �8, oufl� .ya��r0u� . �i7� 0�6 r� !
-- _ ------- I
.�� �
i
POOL C,ER�,`j�ATIONS: ��!
The pool supervisor must be cerkified as a Pool Operatoc,as required by State law. Please list the designated I
Pool OperatoKs)and attach a copy of the certification to this form.
1. 2. i
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid ,
and Community Cardiopulmonary Resuscitation (CPR). Ptease list these employees below and attach copies of
employee certifications to this form. The Health bepartment will not use past years' records. You must
provide new copies and maintain p 61e at your piace of 6usiness.
1 � ,
3. 4, !�
A E I TI I
F��) rR�T CTT� -
All food service establishments are required to have at least one full-dme employee who is certified as a Food
Protecfion 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.
Xou must provide new copies and maintain a 51e at your establishment. i
�. `foonq Lariv 2. . Fo C�o., L� �
�
PERSON IN CHARGE: _
Each food establishment must have at leasf one Person In Charge (PIC)on site during hours of operation. I
1. 7FDnq LO�iV 2. �
HFI i:i -H .ERTIFICA'P10NS: `
All food service establishments with25'seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11.6mes. Please list your emp}oyees ttained in anti-choking procedures below and ',
attach copies of employee certificaGons to this form. The Health Department wilt not use past years' records. i
You must provide new copiea-aad maietain a file at your place of business.
1 2.
3. 4- �
RF; TA TR A EATING: TOTAL# �
___ -
OFFICE USE ONLY
I.CTDGING: .
LICENSEREQUIRED FEE PERMIT N LICENSE REQU(RGD FC:E PERMIT li LICENSE REQUIRED PEE PERMIT k
BBcB S50 CABIN S50 �40TEL S50
1NN S50 CAMP $S0 _SWIMMING POOL$75ea
_LODGE S50 � �_TRAILER�PARK �550 _WHfRLPOOL S75ea
FOODSERViCE: � � � � � '�"�� � �� � � � � � � . �
LICENSE REQUIRED FEE P�RMIT# �� �� LICENSG REQUIRED FEE� PERMiT�# . . GICENSE REQUIRED FEE PERMIT#
�0-100 SEATS S75 , a�- .48 _WNTINENTAL S30 � � � � :NON-PROFIT S25
_>100 SEATS� 5150� LCOMMON VICT. S50 CI3_ �I� _WHOLESALE $75
RETAIL SERVICE: - � � � � � �
LtCENSE REQUIRHD FEE PERMIT# LICENSE RGQUIRED FGB PERMI'f N LICENSE REQUIR6D FEE PERMIT#
_<SO�sq.ft. � �545-� � � � �_>25,OOO�sq.R . : $200 ��_ . VENDING-FOOD 520 I
<2$,000 sq.ft: �..$75 � �_�RO'LfN�DESSERT S35 � _TOI3ACC0 S25
' rrnntE cxnnrcE: aie AMOUNT DUE = Ti
"*•"•PLEASE TURN OVER AND COMPLETE OTWER SIDE OF FORM""**" l��'�
I
,
' ° ' ADMINTSTKATION �
�
Under Chaptec IS�,S�etion,'�Se,'Sabsectidn 6,the Town ofYazmtiutA is now required to hoid issuance or renewai
of any license or perinit to tzpetat� a"businesff if a persorc or campany dces not have a Certificate of Worker's
Compensatiop Itss�rance. THE A�'�'ACHED STATE WORKER'S COMPENSATION INSURANCE
AFF`IDA'VYT MIJS1`�E��OMPLE'I'EH AND sIGPTED,OR .
{
: ' `�ERT.OF INSURANCE ATTACHED
�
�VO1�T�EIL'S COMP.AFFIDEkVITA SIGNED AND ATTACHED�
Town of Yarfnouth t�es and liens must be paid prior renewal or issuance af your permits. FLEAS�CHECK
APPROPRIATEI,Y IF PAID:
YES NO "
NOTICE:Pecmits nm'ant�vally from:3anuary 1 to December 31. IT IS YOIIR RESPONSIBILITY TO RETURN
THE COMPLETED APPLI�ATION(S) AND REQUIRED FEE(S) BY DECEMBER 31,2002.
� ;
SEASONAL EST.4BI:JSHNiEENTS ARE'TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECI'ION 7-]0
DAYS PRIOR TO OPENING-EOR THE SEASON. .. ,
ALL RENOYATIOI�IS TO ANY,.FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUTPIvI�NT;`$TC.),ML� BE It�PORTED TO ttND APPROVED BY THE BOARD OF HEALTH PRIOR
TO'CbMM�1VCEM�N1'. `�r1�5VA'I`IONS MAY REQUIRE A SITE PLAN.
\
; ',,
, a .
� ` ADDITION L REGULATIONS
_y .
�,\ POOLS
POOL OPEAtING:All swimming, ading and whirlpools which have been closed for the season must be inspected
by,the Health Department prior to o�ning.
POOL WATCR TEST[NG: "'ii�e w�tcr must be tested for pseudomonas,total coliform and standazd plate count
by'a State certified lab,prior to openi ,g, and quarterly thereafter.
PpOL C�,(?5IN�7 Every outdoor in�{ound swimming pool must be drained or covered within seven(7)days of
i
clo�sing. '
f FOOD SERVICE r
i
Eac�h f�oodmesta�m�t�wlu'�ch serves or sells ready-to-eat,raw or undercooked animal products are required to post i
Consumer Advisories: '
CATERING�dl,s�CY: `
�inyotre whb-�aters withi�-.3��'erm-cf Yarn�eath must no?�Ty (hg ]'armeuth Health De an rtmentb�flin� the _
required Temporary Food ;jervice Application form 72 hours prior to the catered event. Thses forms can be
obtamed at the Health Depa�tment. (
FROZF.N DF .RT : ,
Frozen desser3s must be test�d on a monthly basis by a State certified lab. Test results must be sent to the I-Fealth
DepArtrnent. Fai2ure w do so will resuit in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met. . ,
OUTSIDE CAFES: �
Ontside eafes�i e.,crt�tdcwr s�ting with uvaiter/waitress service),i?ALISS have prior appmval from the Board of Health. �
OUTDOOR C�OKII�IG: .
Qutdoor cookin�,preparation,or display of any food product by a retail or.food service establishment is prohibited.
DATE: � �� SICxNATURE; ��"
PRINT NAIvIE&TITLE; � � ��1�
10/18/02 ��` .�i . " `.� _
� � ' � ,�y � � ��y,. } � .a . '� �
� .
� Murray & MacDonald
(nsurance Services, Inc.
ICCBT Fnancial Companies
August 26, 2003
Town of Yarmouth
Health Depaztment
1146 Route 28
South Yarmouth,MA 02664
RE: Brandon,Inc. dba Wok-N-Roll
1319 Route 28 South Yarmouth,MA 02664
To whom it may concem,
Please be advised that effective today,August 26,2003,the above business,Brandon,
Inc.DBA Wok-N-Roll has applied for Workers Compensation coverage through he
Massachusetts Workers Compensation and Inspection Bureau. The Workers
Compensation Bureau will assign an insurance company to Brandon,Inc. and we will
forwazd a Certificate of Insurance to you as that information becomes auailable.
If you have any questions regazding this matter,please feel free to contact me. I�i
With Kindest Regazds, I
�/�����, � �'�w,_
Mark R. Adams, CPCU,AAI
I
I
I
_.__._ �
,
CCBT Rnaricial Canpanies 4W Iones Road TEL:SOO.S00.8990 �
Fa�manh,MA 02540 FAX:508.760.1985
� www.ccbLmm
�
' . , �
The Commonwea/th ojMassachusem '
"s = Departmen�ojlndustria/.-lccidents '
; omceoll�suysWis
600 Washington S�reu
Baslon. Mass. 01111
` W'orkers' Compensation Insuraace AHid�vit
ARnlicant information: Pf ++.c� ,
aamc� � VV�—�{'(— ROL(� (.l�(/�e �Gs/QGlI�/'!il� � .
locmian: �3� / l�f�t2 -G6 . . . � I
cm �l� dQY�'!/l0(,�� , /"/!�{ ��6tS� ehon p �g'�60'�060 ��
� I am a homeoµner pertorming all work myself. '
� I am a sole propriemr�r.,�, ha�z no one��orkin� in am capaein� ;
� I am an emplo�er pro�idine uorkers' compensation for my employees workin¢on this job. j
romnanv name:
!/UIu/'�ac1 � /�'IQ����'/d .lr�su�'An�e �c�syrce 1�c . C
address: �flJ(� ��/(Q� /I�aG� � . . . � iI
tih�: �/{'Ii18U/vL � ////f �02 JT7'� yhene a. 6OO•6UO •0 9<� �
iesurance ea. oolicv M j
� I am a sole proprietoc generai contractor. or homeowner(circle onU and have hired the conhacrors lisced below ��ho ha�e 'I
the follu�cing �corktr :ompensation polices: �
tompanv namr � � � � � � � - i
addresr
cin�: � � � nhone p• . . . .
�unncc ro. neliev#
comoanv namr. �
addres�:
[itv: � . . . . .. phoee M• � . . . ..
insaroneeee. � � �p�yM � � �
F�ilun ro seeure coven`e as required uoder Sa000 25A o(MGL 152 n�Ind to be i�po�iuo�oterid�l pwltles M�Ne ap w 51,500.00 a�d/or
� ooe ywn'imprisonment u w�ell u civil peeNBa is t6e form o(�STOP WORK ORDpt a�d a 6s dS100.M�dry q�iost sa (a�denta�d Wt•
eopy of thN sntement m�r be for.v�►ded to the 011fee of fovnNpuom of Me DIA for eoven{e rerilkatlo�. � I
�. /do�hrreby cenijy ander thr paint and ptnaf�res ojperjury thm the injornmtinn provided abovt is bne awd rontd ';
Signaturc /1��'�J �� p� � ��27�l�3 I
/ ",, � T !
Print name �K L�(i(/ �K ���7�jQ—2060
�
.• oRci�l use onl. do no�.rite in this area to be coiopleted by eiry oe tow�o ollleial
ci�y or town: Y�DT$ _ � .permiNieeox M nBuildin`Department
� �Lieemio�Bo�rd
�cheek if immediate response if required 261 �Sdetlmen'e 011iee
(508} 39g��31 �t, ❑HnItO Departmm�
aonure penon: pboae M:_ __ _ nOtAer �i
�
._ .� .. � .. �i
. � . i
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-198 FEE: $75.00 '
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I
ll 1,Section 5 of the General Laws,a permit is hereby granted to: '
Yoong Low, 1319 Route 28, South Yarmouth, MA
Whose place of business is: Wok-N-Roll Chinese Restaurant
Type ofbusiness: Food Service I
To operate a food establishinent in: Town of Yarmouth �
Permit expues: December 31. 2003 soaix�oF HEru,TH: ekwilea�f, zo[ft�oa, �Fat�a,c �
sEnn�ru.rc: 19 D. Cjas�e,c 7X.�.. `Utce ekaGuxaK
�. ��. �
�attiek 7Xeaar�x�e7stl '
� � . .. 'r�i�Gc$ .,L. � � . .� ��.
. � . � � ) ,/� � � � �
� � � . ,
September 3.2003 7��`..
.Murphy,MPH . CHO I
Director of Health
I
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #03-114 FEE: $50.00
This is to Certify that Yoong Low d/b/a Wok-N-Roll Chinese Res[aurant
1319 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thitty-first 2003 unless
sooner suspended or revoked for violation of the laws of the Commonweahh respecting the
licensing of common victualler's. This license is issued in confortnity with the authority granted to .
the licensing suthorities by Generat Laws, Chapter 140, and amendments thereto.
In Testimony Whereo�the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �,kailu'�f. :Ce!ltiFec, �
SEATING: 19 � '�p�D, ��p�y �`D. �/�
�OBa�Z 3. S"aeaas. �k
�a�iek'IXcD�
S�Fa , yl. �,
r'
Seutember 3.2003 �
ruce .Murp y, H
Director of Health
�
� I
: l- �}c{'��
i
,F=YAR TOWN OF YARMOUTH BOARD D '
Z � ^r�
� �� � � �
3 �= APPLICATION FOR LICENS
'`��'' NOV 2 1 2002 '
* Please complete forcn and attach all nece o ts by Dece ber 31, 2002. j
Failure to do so will result in the reture�f y applicahon p k�j�qLTE�I DEp�'
`U - o �o r7
,
,
�
MANAGER'S NAME: 70� y �t� TEL. #�0�-7�� -d-o6�o '
MAILING ADDRESS: '
I
POOL CERTIF'ICATIONS: �
The pool supervisor mnst be certified as a Pool Operator,as required by State law. Please list the designated I
. .__P1101.nnr�stnr(cl an�l attarh_�ppy.g�tlle CCIk1�tC8LtoI1 to thLS forin_ ...-- .---.- - --.. . . i
1. 2. I
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid i
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 fde at your place of business.
L 2.
3. 4. �
FOOD PROTECTION MANAGERS -CERTIFICATIONS: '
All food service establishments are required to have at least one full-time emgloyee who is certified as a Food !
Pmtection Manager, as defined in the State Sanitary Code for Food Service�stablishments, 105 CMR 590.000. i
Please attach copies of certification to this application The Aealth Deparhnent will not use past years' records. �
You must provide new copies snd maiutain a file at your establishment i
1. 2.
.___.PFR C(17�T IAiI`N A R(:F•
------. �. -----' --- -_... - -- ---- ---- -- - ._ -� ___ . ___ .
Each food establislunent must have at least one Person In Chazge (PIC)on site during hours of opera6on. �
I
1. 2. �
��II,ICH 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-chokwg procedures below and j
attach copies of employee certifications to tlus form. The Health Department will uot use past years' records. j
You must provide new copies and maintain a fde at your place of business. ;
I
1. 2.
3. 4.
�
RESTAURANT SEATING: TOTAL# j
I��Gnvs:
OFFICE USE ONLY ',
LICENSE REQU[RED FEE PERMIT# LICENSE REQIIQtED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
_BBcB S50 _CABIN S50 _MOTEL $50
_INN $50 _CAMP� SSO _SWA4A9NG POOL SSOea I
_LODGE $SO _TRAILER PARK $50 _WFIIRI,POOL $25ea
� FOOD SERVICE:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $75 �o3-(k37 _CONTINENTAL $30 _NON-PROFIT �25� ';
>100 SEATS $150 1 COMMON VICT. S50 #63-02� _WHOLESALE $75 �
AF.TAn .AV[ .
LICENSE REQIJII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIILED FEE PERMIT#
_TOBACCO $20 _Q5,000 sq.ft. $75 _TOBACCO S20
<50 sq.ft. $45 _>25,000 sq.ft 5200 _FROZEN DESSERT a35
NAME CHANGE: S10 AMOUNT DUE _ $ t 2S.00 i
****'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••:'*
' ` , �
�
ADMINISTRATION '
Under Chapter 152, Section 25C, Subsecrion 6,the Town of Yazmouth 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 Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO I2ETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECE1viBER 31,2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TE�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.
ADDITIONAL REGULATIONS
POOLS
POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Depaztment prior to opemng.
POOL WATER TESTING: T'he 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 witlun 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 Yannouth 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 Department.
FROZEN DESSERTS:
Fmzen desserts must b�test��on a monthly basis by a Stata certified Iab. 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 CAF�`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),niust have prior approval from the Boazd of Health.
OUTDOOR COOKING:
OuWoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: l� !3 0 �' SIGNATURE:
PRINT NAME &TITLE: S'
10/18/02
• ` Pub{ic Service Mutual Insurance Company
one Park nvenue
New Yak NY 10018-5807 'i
WORKERS COMPENSATION AND EMPLOYER'S LIABtUTY INSURANCE POLICY I
INFORMATION PAQE
NCCI Gompany No:16152
Pdor Policy Number. i
NEW LINE Poi'wy Number: WC 018281 02
1. Named Insured and Mailing Address:
Producer and kAailing Addreas: �
Wok'N Aoll Inc. Richard Soo Hoo tnsurance Agency, inc.
1319 Main Street 1148 Washington Street
Rt 28 Boston, MA 02118 ;
South Yarmouth,MA 02664 Tel. (817)338-8168 ;
I
The Insured:Carporation Fed. Employ. ID No.042988395 ,
; OU��r„wc�c�s not shown above: '
2. The poticy period is from 4/1l2002 to 4/1/2003 12:01 A.M. Standard Time at your mailing address shown ebove. I
3, q. Workers Compe�saticn Insurance: Part One of the policy applies to the Workers'Compensation Law of the I
states listed here: Massachusetts �
i
B. Empioyers Liability Insurance: Part Two oi the policy applies to work in each state listed in Item 3.A. The(imfts
I
of our liability under Part Two are: Bodf�y Injury by Accident $ �Q •p 000 each accident I
Bodily Injury by Disease $ 59Q.PA� Po�icy limit �
Bodily Injury by Disease $ - ��0.00o each emptoyee ,
C. Other 5tates Insurance: Part Three of the poilcy applfes to the states, if any,listed here:
D. This policy includes the folbwing endorsements and schedules: �
See Eutension of Intormation Page �
4: The premium for this po{icy will be determined by our Manuais of Rules, Ctassifications, Rates and Rating Pfans. !
9 Y � -
AI!information required below is subject to verffication and chan e b audit. i
Premi�mB�,sis___. _ _ AatePer- �stimateo ,,
-ta�- -"�ode Tota{ Estimated $100 of Annual i
Classifications St. No• I�g Annual Remuneration Remuneration Premium
... ..�,_ _ . _ _ _ $1�144
See Extension o!Mlormation Page
Loss Constant: $0 Expense Constant Charge: $244
Minimum Premium $219 Deposit Premium $1,388 Total Estimated Annual Premium: $t,388
i
Premium Adjustment Period: Annually 4
Servicing Office: New Engiand Branch I
Countersigned 3!1?J2002 at New York, N.Y. by � �---�
i
AuMorized Representadve
;
�
THIS INFORMATION PAGH WRH THE WORKEfl3 COMPENSA170N AND EMPLOYERS LUBILITY INSURANCE POLICY AND
EN�ORSEMENTS,IF ANY,ISSUED TO FORM A PART TMEREOF,COMPLET@S THE ABOVE NUMBERED POLICY. '�
EdWon 10/87 Pege 1 of 3 i
CopyrigM,7987 Natlanal Counclt on Compensatlon Ireurance �,
�
i
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLJMBER: #03-037 FEE: $75.00
In accordance with re�u1ations promulgated under authority of Chepter 94,Section 305A and Chapter
111,Section 5 ofihe Z'ieneral Laws,a permrt is hereby granted to:
Wok-N-Roll I�., 1319 Route 28, South Yarmouth, MA '
Whose place of business is: Wok-N-Roll I�.
Type of business: Food Service '
To operate a food establishment m: Town of Yarmouth '
Permit expires: December 31.2003 so.�Rn oF HEni.'r�i: �fa�fia:i�. ze,l�oc, �k�ra�c
__
sEnru�rG: 19 . D. yerde�,oj.Y�hL'.D.. ?/ru�fa�r«rs.c ,
A . . � . � fE�. �i. {�c� .
Pat��a«r� ;
:i�de«Slrsk. ,�.�1. ,
December 5 ,2002
Bn�ce G. hy, S.,CHO
Director of Heal '
THE COMMONWEALTH OF MASSACHUSETTS �
TOWN O�YARMOUTH
PERMIT NUMBER: #03-024 FEE: $50.00
This is to Certify that Wok-N-Roll I�.
1319 Route 28, South Yazxnouth, MA
IS HEREBY GRANTED A
� COMMONVTCTUALLER'S LICENSE
In said Town of Yarmouth and at ttiat pJace only and e ires December thirty-Srst 2003 unless �
a j
sooner sus�or��vak ' ' �►m�v�lth resp�ctiltgthe-- —j
licensmg o common victualler's. This license is issued in conformity with the authority gratrted to �
,- the licensing suthorities by General Laws,`Chapter 140,and amendments thereto. �
In Testimo�Whereo� the uudersigned have hereunto affixed their official signatures. j
BOARD OF HEALTH: �s'!�, x�a. � I
sEnnnNc: i9 D. � 7/C.D.; 'fi�ee �
�. �. � �
�aD�ie�'I�aaaa i
� K Ska�E. .?t,
i
December5 ,2002
ruce . urP Y •,
Director of H
I
� �i „ � K-N-Ro�, �
� OWN OF YARMOUTH BOARD OF HEALTH Q �' = ` I
;;� �� � � ' PLICATION FOR LICENSE/PERMIT-2002 ��� 1 9 2001 - �
I /� �- ) '
' Please com'pfe'te form an�att�ach all necessary documents by December 31, 2001. Fa�l �q�lp�sqa��sytlt i I
tke return of your application packet. �
i
i
AME F ES LI HMENT: 0 - TEL. # S� - o� o �
� � i
DRESS: '
;
i
MANA ER' NAME• To nf U � c1 T'EL. # Sa�-7 Go-a-o��
raen ING DRESS• .4n�M,.e f�-s �-�nan2 i
i
POOL CERTiFICATIONS: �
T6e 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 certifica6on to this form.
1. 2• i
Pool operators must list a minimum of two employees cunently 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. Yon must I
provide new copies and maintain a file at your place of bnsiness.
1. 2. � �
3. 4•
�
I�
FOOD PROTECTION MANAGERS - CERTIFICATIONS• �
All food service establishments are required to have at least one fuil-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 application. The Health Department will not use past years' records.
You must pmvide new copies and maintain a£de at your establishment.
1.'0� � S D 2. S'fp�nrnin� F�-� �fZ I
_ _�'ER.�'563��CI•�fiE: _——_ -- -- _ --- ------ -- - - �
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2. �
HFiMi ICH CERTLFICATIONS:
All food service estabiishments with 25 seats or more must have at least one employee h�ained in the Heimlich �
Maneuver on the premises at a116mes. Please list your employees trained in anti-chokuig 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£de at your place of business.
L 2. j
3. 4. i
RESTAURANT SEATING: TOTAL#�� i
OFFICE USE ONLY '
c: '
LICENSE IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# '�
'
B&B 50 CABIN S50 _MOTEL S50 � I
_ — j
1NN $5 _CAMP S50 SWIMMINGPOOL$SOea '',
— i
LODGE S50 _T2AILER PARK $50 _WHIRLPOOL $25ea 'I
FOOD SERVICE: �I
LICENSE REQUIRED FEE PERMIT# ' CENSE REQUIRED FEE PERMIT# UCENSE REQiJIRED FEE PERMIT#
10-100 SEATS E75 �QfQO — TINENTAL S30 _NON-PROFIT $25
>100 SEATS $150 �CO N VICT. $50 Da'� .a' _WNOLESALE S75 ,
FT ►I. ERVICE: ��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# �
TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO S20
<50 sq.ft. $45 _>25,000 sq.R. $200 _FROZEN DESSERT$35 �I
— AMOUNT DUE _ $ r 2S. O� �
NAME CHANGE: $10
**••*PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•**"• �''�,
_ _
a '
•v 1.r
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
Compensa6on Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSIJRANCE ATTACHED
�
WORKER'S COMP. AFFIDAVTT 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: i
YES ti' NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISF�4,NTS 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.
ADDITIONAL REGULATIONS
-- POOLS
POOL OPEPTING:All swimniing,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 are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Department by filing the '
required Temporary Food Service Application form '72 hours prior to the catered event. Thses forms can be
obtamed 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
Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit unril the
above terms have been met.
OUTSIDE CAFES: �
dutside cafes(i.e.,outdoor seating with waiter/waitress service),mus have prior approval from the Board of Health.
QUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food pmduct by a retail or food service establishment is prohibited.
DATE: a. 0 SIGNATURE:
PRINT NAME& TITLE: ��/ �{ � , inr n/�j?.
i
09/11/O1
I
' - WORKERS COMPENSATION AND EMPLOYERS LIABILITY INStiRANCE POLICY
J— INFORMATION PaGE
� ti����� No L E G 1 O N Po�,� Nw�b-oo24ss,
109D1
1. 1!VS(.'RED: WOK'N ROLL, INC. Renewal of Polic No.
�WC500248918
The InsureJ/Mailing address:
1335 MAIN STREET ROUTE 28 �Individual �Partnership
SOUTH YARMOUTH, MA 02664 '�
X�Corporation or
Othet workplaces not shown above: lnsured's I.D.No(s).(if applicable)
See WC 00 00 Ol F.E.I.N.#042989395
Risk]D# 320794-
2. POLICY"PERIOD: The policy period is from 04/0I/2001 to 04/D1/2002 1?:01 A.M. Stanat the 1 sured's mailin address Ii
3. COVERAGE: I
q. Workers Compensation Insurance: Part Ona of the po4icy applies to the Workers Compensation Law of the states
listed here: Massachusetts
B. Employers Liability insurance: Part Two of the policy appl'res to work in each state listed in item 3.A.The limits of our
liabiliry under PaA Two are: Bodily Injury by Accident$100,000 each accident
! Sodily Injury by Disease 5500,000 policy limir
Bodily Injury by Disease $100,000 each employee
C. Other States]nsurance:Part Three of the policy applies to the states,if any,listed here: SEE GU20�E
D:This poficy includes these endorsements snc�schedules:see ouzo�n
� 4. PREMIUM: The premium for this policy will be de�ermined by our Manuals oFRules,Classifications, Rates and Rating
Plans. All Information re uited below is sub'ect to veritication and chan e b audit.
Code Premium Basis Rate Per Estimated Annuai
Classifications No. TotalEstimated $IOOof Premium
Annual Remuneration Remuneration
SIC Code:5812
See WC 00 60 Ol
Ifindicated below,interm adjustments oFpremium Premium for lncreased Limits part Two, IFapplicable
shall be made- otal Premium SubjeM to the Experience Modification
Premium Modified to Reflect Experience Mod.of
�Semiannually; � Quarterly; �Monthly � �
otal Estimated Standard Premium
Premium Discount,if applica6le
MA-DIA Assessment $42 Expense Constant Charge $
otal Estimated Annual Premium
Minimum Premium $200 De osit Premium $1 254 Total Estimated Annual Premium $1,254
NameofProducer. LOVELETTEINSURANCEAGENCY _,��_� �_ ����2,z���
Servicing Office: Small Business Underwriters Countersigned By � -
TWO PARAGON W AY,FREEHOLD, NJ.07728 Authoriud Representative Dnte
TH1S INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITV INSURANCE POLICY AND
ENDORSEMENTS,IF ANV.ISSUED TO FORI11 A PART THEREOF.CONPLETES THE ABOVE NUMBERB�POLICY.
COPYRICHT 79R7,NATfONAL COUNCIL ON COMPENSATION INSURANCE wc0000m e,
N�OWIIED.i-931 p
(Ma-DEC�10;98
. �
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMI1'NUMBER: #02-060 FEE: $75.00
In accordance with re ationspromulg�under autl�ority of Chapter 94,Sec[ion 305A and
Chapter 111,Sec[ion�f the General Laws,a permit is hereby granted to:
Wnk-N-Rnll inc 1319 Route 2R South Yarmouth_ MA
Whose place of business is: Wok-N-Roll Restaurant
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth '
Pernut expires: December 31_2002 BOARD OF HEALTH: (!ka�dea:l�, xefltkos, �ifa�ur�aw
SEATAIG: 19 �a«�r.�D. �aadac �D.. 'Ur.ee (�FaK«�a.� �.
,�oBert� �taa�. !,l��k
�aAra��oroarot�
`r�deae S� �� �.
Fe�26 ,2002 �
ruce G.Murphy, .S.,CHO
Director of Health
THE CObIMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH I
PERMIT NUMBER: #02-043 FEE: $50.00
I
This is to Certify that ` Wok-N-Roll Inc. d/b/a Wok-N-Roll Restaurant I
1319 Main Street/Route 2R_ Snuth Yarmnnth� MA '
IS HEREBY GRANTED A '
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at tUat place only and expires December thirty-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 confomuty 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 signahues.
BOARD OF HEALTH: �fa�fea� zdll�Fat, �ksdaxa.s i
senn�nr�c: 19 D. Cjmtdas. �K D.. `Utee '�
�a� S��raaaMc. L�ferk � I
Pa�ek�e�e� !
Slra .?Z, i
I
Februarv 26 ,2002 I
ruce G. Murphy,MPI� R. HO
Director of Health i
I
.; ; GJo�r.-N-2ncc Q�s�r
�v � � � � d � �
TOWN OF YARMOUTH BOARD OF HE L
APPLICATION FOR LICENSE �j, ,��, •�Q� O ? YOOO
jA�~' '�'y HEALTH DEPT.
• Please complete form and attach all necessary documents by Dec , 000. Failure o o so w► re
the retum of your application packet. �3(�
-- — -- --_---_- - - -------------------------------- -o^--- --
' o ,'
� i
QWNER/CORPORATION NAME: Lt�0 U. -/,j� e LL J'
' -3d
MAILING ADDR SS: .C' A,�_J} D Y'L i
------______M__�_.____--------------------------------- --------------------________�____ i
pOOr.GERTIFICATIONS:
The pool aupervisor must be certified as a Pool Operator, as reyuired by new State law. Please list the
designated Pool Operator(s)and attach a copy of the certification to ttus form. i
I. 2. '
Pool operators must list a minimum of two employees currenUy 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 Heslth Department will not use paet years' records. Yoa mast '
provide new copies and maintein a Cde at yonr place of buainess. i
1. 2.
3. 4.
HEIIv1I.ICH CERTIFICATIONS:
AIi food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the prcmises at all times. Please list yoiu employees trained in anti-choking procedures below and
attach copies of employee certificafions to this form. The Healt6�artment will not use paat years' recorde. ,
Yoa must provide new copies and maintsin a file at your place o business.
1. 2. I
3. 4. I
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# i
-.________ W.�-----�---------_---- ---------- -"�--���_______- f
_ _ _
OFFICE USE ONLY �
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
_INN $50 _CAMP $50 �
_LODGE $50 _TRAILER PARK $50 j
MOTEL $50 SWIMMING POOL $SOea. �
_WHIItLPOOL $25ea. i
FOOD SERVICE:
NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Eatablishments,the effeMive date for '
food protectlon manager certificallon is OMober 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
/ 0-100 SEATS $75 �01-1Z _CONTINENTAL $30
>100 SEATS $150 NON-PROFTT $25
�COMMON VICT. $50 �Ol 079 _WHOLESALE $75
RETAIL SERVICE: ;
�
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 TFROZEN DESSERT $35
>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE = S �25•0 0
*•'•*PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM*•*••
�_,_..__.__.---_--.._ , - _
� ! ADMINISTRATION
� '�
ndeF G�t� };�?a� ' on 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
�_:�
atty'tl�ert��6�'�t 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
�
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: /
YES ✓ NO
NOTICE:Permits run annually ftom January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLISHIv1ENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENTNG FOR'TI-IE SEASON.
ALL RENOVAITON5 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
AI?DITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department,and the water tested for pseudomonas,totai coliform and standard plate count by a�tate
certified lab,pnor to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
NF W STATF S.�NiT�RY CODF FOR FOOD ESTABLISHMENTS•
The effective date for food protection manager certification is OMober 1, 2001. As stated in 105 CMR
590.003(A) 2), food establishments must haue at least one person-in-charge who is a certified food protection
manager. �s pmvision is effective one year from the date of promulga6on of 105 CMR 590.000.
The effective dste for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement
of Consumer advisory,Food Code 3-603.11,will be imnplemented January 1,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. ,
�
.A .IZiNG 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 Thses forms can be
obtau►ed at the Health Department. . .
___ _
FROZ.F.N DESSERTS:
Fmzen desserts must be tested on a montlily basis by a State certified lab. Test results must be sent to the Health
Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the
above terms have been met.
O T F.C FM`•S: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mnst have prior approval from the Board of Health. �
OUTnnc>R COOHING: �
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: �.¢.r nZ�,7�U SIGNATURE:
,
PRINT NAME&TITLE: � � S o
11/16/00
I _ _� - -- �
_
_ � � I
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY �
INFORMATION PAGE I
NCCI Co.No Polic No.
�o�o, L E G 1 O N W�5-0oZ489,
1. INSURED: WOK'N ROLL,INC. Renewal of Poli No.
WC40024891
'fhe Insured/Mailing address:
1335 MAIN STREET ROUTE 28 �Individual �Pa�fiership
SOUTH YARMOUTH,MA 02664 I
�X Corpora6on or ��
�
Other workplaces not shown above: Insured's I.D.No(s).(if applicable) '',
See WC 00 00 Ol F.E.I.N.#042989395 �i
Risk ID# 320794 '
2. POLICY PERIOD: The policy period is from 04/Ol/2000 to 04/Ol/2001 12:Ot A.M. Standard Time, �
� at the Insured's mailin address �i
3. COVERAGE:
A. W orkers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of ihe states '
listed here: Massachusetts �
;
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.The limits of our ;
liability under Part Two are: Bodily Injury by Accident$100,000 each accident '
Bodily Injury by Disease $500,000 policy limit �
Bodily Injury by Disease $100,000 each empioyee �
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: SEE GU207E
I
D:This policy includes these endo�ements and schedules:SEE GU2o7A I
4. PREMIUM: The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans.All Information ired below is sub'ect to verification and chan e b audit.
Code Premium Basis Rate Per Estimated Annual
Classificatians No. Total Estimated $100 of Premium
Annual Remuneration Remuneration
See WC 00 00 Ol
If indicated below,intemi adjustments of premium remium for Increased Limits part Two,If applicable
shall be made— otal Premi�un Subject to the Experience Modification
remium Modified to Reflect E�cperience Mod.of
�Semianaually; � Quartedy; �Monthly
otal Estimated Standard Premium �
'umDiscount,ifapplicable ' I
MA—DIA Assessment $42 xpense Constant Charge
obl Estimated Annual Premium �
i
i
Minimum Premium 5200 osit Premium $1,254 Total Estimated Annual Premium 51,254
Name of Producer: LOVELE7TE INSURANCE AGENCY �']i n� �
Servicing Offi�ce: Small Business Undenvriters Couotersigned By � n't/n�/2nnn
TWOPARAGON WAY FREEHOLD NJ.07728 AuthoriadRepresentative Date
THIS IIYFORMATION PAC.F.WITH THR WORKF.RS COMPF.NBATION AND F.MPIAY6RS I.tARII.ITY INSIIRANlIF.PM.If.Y AND ���
ENDORSEMENTS IR ANY.ISSUED TO FORM A PART THEREOF.COMPLE7E5 THE ABOVE NUMBERED POW CY. '
COPYRIGHT 1987.NATIONAL COUNCIL ON COMPENSATION INSURANCE
8IOOUIfED.]-97N11 WC M M 011
(MA-DEq10/98
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #O1-079 FEE: $50.00
Tlus is to Certify that Wok-N-Roll Inc. d/b/a Wok-N-Roll Restaurant
1319 Main Street/RrnitP 2$, So � h Y rmo � h„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 victualler's. Tlus license is issued in conformity wrth the authority granted
to the licensing authorities by General Laws, Chapter 140,and amendments thereto.
In Testimony Whereof,the undersigned haue hereunto affixed their officiai signatures.
BOARD OF HEALTH: �d� �etlea. �aur.xak
s�,��: �9 e�.�. z�. ti� ���
�� �. e�
�� �. .D.
M�n� ,zooi
ruce G.Murp y, R. HO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NiJMBER:_#O1-126 FEE: $75.00
In accordance with regulations promui�ated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General I.aws,a permit is hereby ganted to:
Wok-N-Rnll Tn . 1319 Ro� P R 4nLth Yarmnitth h�A
Whose place of business is: Wok-N-Roll Restaurant
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31.2001 BOARD OF HEALTH: �d� 3etlea, (�aK
S�,�G: �9 ��. z�. ti� ��
��� �, �
�eo� D. C1mrd,o�c. .D.
March 7 ,2001
ruce G.Murphy, R .,CHO
Director of Health
iA�.�.ry.
` ; l�J�l� V�- �DI �
� - � `� �' ' ���;L� � � � � oen � �
TOWN OF YARMOUTH_
,- APPI.ICAITON FOR i.i � -2000� D E C 0 6 1999
� ,�,��� �l�3977 � �v5
* Please complete form and attach all necessary documents'6y December 31, 1999. Failu
the return of your application packet.
NAME OF EST a� I�r�FrvT � �Ne�.� —N� �fZ.�—R6� +------- .�'F',L # 7�i 6 b�6�l c�
L I
D S'
' # 0 '—�
POO . .RTIFI ATION . Ar�------�_____�_�_��_____�_______ .
The pool supervisor muat be certified as a Pool Operator, as r_eguired_by new Stats la�r._ Pl�se list the
designated Pool Operator(s) and attach a copy of the certiScation to this form.
1. 2.
Pool operators must list a minimum of two employees currendy certiSed in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attsch 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 plsce of business.
1. 2.
3. 4.
HFii�ICH . .RTIFI ATIONC�
All food service establishme�rts with 25 seats or more must have at ►east one employee trained in the Heimlich
Maneuver on the premises at a1!times. Please list your employees uained in anti-choking procedures below and
, attach copies of employee ceRifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fiie at your place of business.
1. 2.
3. 4.
REST.4UR�tNT S�ATING: 'FO'Ft�L-# —— —N�N-&MOKING SEA�3:-'FO'FAL# ---- --- --- _ _
��� -__._------- OFFICE U3E ONL•Y _____—��__�_ ����.
LODGING•
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_B&B $50 CABIN $50 '
_INN $50 CAMP $50
_LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMR�IIIVG POOL $SOea.
— I
WHIItLPOOL $25ea. �
FOOD C .RVICF.� '
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I
I 0-100 SEATS $75 Y2K-�9 �CONTINENTAL $30 ,
_>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 2K� I _WHOLESALE $75 '
RF.Z' II. . ERVI E• . !
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35 �
_>25,000 sq.ft. $200 �
NAME CNA �• $10 i
AMOUNT DUE _ $ � �
•'"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••••• I
V"'
1
�
t � A I
�--- ' �-- � -��� I ADMLINI3TItATION
� t, IN
IJNDER CHAPTER 1�, SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOUTH IS NOW REQUIRED
�TO HOLD ISSUANC� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
P.F,�SQT�I'-'bR:�'�'bh�Il#ANY 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 YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK AP,PROPRIATELY IF PAID:
YES �� NO
NOTICE: PERMITS RUN ANNUALLY FROM JANLJARY 1 TO DECEMBER 31. TT IS YOUR �
RESPONSIBII.ITY TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIItED FEE(S) BY (
DECEMBER 31, 1998. �
SEASONAL ESTABLISFIMENTS ARE TO CONTACT Tf-IE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR Tf� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVTING, NEW
EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO
COMNNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLt#N.
ADDITIONAi REGL7I,ATIONS
POOLS
POOL OPENING: ALL SWA�IlvIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR ,
PSEUDOMONAS, TQTPd,COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CER'TIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY Tf�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIlvIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
('ATERiNG POLICY:
ANYONE WHO CATERS WITFIIN Tf�TOWN OF YARMOUTH MUST NO'I'IFY THE YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 �
HOURS PRIOR TO TI� CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT TI� HEALTH �
DEPARTMENT. �
i
FROZEN DFSSERTS• �
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN Tf�
SUSPINSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTILTf�ABOVE TERMS HAVE
BEEN M�T.- - . _ _ _ - - -
__. __ - -
Oi1TSIDE C�F'FS:
OiTTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),�$T HAVE PRIOR
APPROVAL FROM TI-IE BOARD OF HEALTH.
Oi17'D OR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISfIMENT IS PROHIBTfED.
II DATE��� ��_SIGNATURE:
�
PRINT NAME&TITLE:
11/12/99
I
�
V�bRKERS CONII'ENSATION AND E:VIPLOYERS LLABILITY INSURANCE POLICY �
,
INFORMATION PAGE
� NCCf Co.No L E G 1 O N C` `�w�-oo�Z4$91
10401
1. INSURED: WOK'Id ROLL,INC. Renewat of Policy No.
RENEWAL �
The Insured'Mailing address:
1335 MAti3 STREET ROUTE 28 �Individual �PactneishiP i
SOUTH YARMOUTH,MA 02664 '
I�X Corporation or
Orher workplaces not shown above: Insnred's I.D.No(s).(if applicable
See WC 00 00 Ol F.E.I.N.#042989395 i
Risk ID# 320794- �
2. POLICY PERIOD: The policy period is from 04lO1/1999 to 04/01/Z000 12:01 A.M. Stsnat th Insured's mailing address
;
3. COVERAGE: (
A. Workers Compensation Insurance:Part One of the policy applies to the Workers CompensaHon Law of the states �
listed here: Massachusetts �
B. Employers Liability Insurance:Part 1'wo of the policy applies to work in each state listed in item 3.A.The limits of ow '
liability under Part Two are: Bodi1Y Iqjury by Accident S 100,000 each accident i
Bodily Injury by Disease 550Q000 policy:'vnit
Bodily Injury by Disease $100,000 each employee '
C. Other States Insurance:Part T'hree of the policy applies to the states,if any,listed here: �I
D: This policy includes these endonements and schedules:wCoO0000n,wC0000at,wce��s,WC0004la,V1'C200301,WC200302,WC200303A,
WC200601,GiR07E,890046
4. PRENIIUM: The prcmium for this policy will be deurmm�by our Manuals af Rules,Clsssificarions,Rates and Rating
Plans.All Information required below is subject to verification and change by audit.
Code Premium Basis Rate Per Estimated Annual
1 Class�cations No. Tocal Estimated S100 of Premium j
Annual Remuneration Remuneration �
�I
I
See W C 00 00 Ol
If indicated below, interm ad,justments of premium mium for Inaeased Limits part'ftvo,If applicable
s�����_ otal Premium Subject w the Experience Modification
mium Modified to Reflect Experience Mod.of I
�Semiannually; � Quarterly; �Monthly
otai Estimated Standard Premium
ium Discount,if applicuble
MA—DIA Assessment S67 pense Constant Charge
otal Estimated Annual Premium
$
Minimum Premium 5210 Deposit Premium $1,503 To:al Estimated Annual Premium $1,436 i
Name of Producer: LOVELET'CE INSLTRANCE AGENCY �
Servicing Office� Small Business Underwriters Cauntersigned By '
TWO PARAGON WAY,FREEHOLD,N.J.07728 Authorized Represantative Date
TF[[S INF014NAT101V PAGE WTTK WO AS COMPENSATION AND EMPLOYERS LLlBII1TY INSURANCE POLICY AND
E�����N�'�QpY[lIGHT B7 NA O1VAI.AC WTCIL ON COMPFIVM3A110N IIVSL�RAIY E NUMBERED POLiCY.
. WCOOU001A, �.
lIOU01(ED.].97811 � �I
. . > . .... �� �.� I
TOWN OF YARMOUTH
' � BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT �
PERMIT NUMBER: Y2K-49 FEE: $75.00 �i
�
In accordance with regulations promulgated under authority of Chapter 94, Sec[ion 305A and Chapter j
11 l, Section 5 of the Geceral Laws,a permit is hereby granted to:
Wok-N-Rnll ina 1319 Rnute 2R South Yarmouth MA
Whose place of business is: Wok-N-Roll Restaurant
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31_2000 BOARD OF HEALTH:��P/. �attRg/,, C'�{�.,g.�//zn / /�/ �
SEATAIG: 19 �oan G. �uUivart� K.//.� Vite C�hairma �
�o�� a,��, c�,�
a6.;alG��l�&y-JJ��
��. ,�1� ;
December 16 , 19 99
Bruce G.Murphy,MP .5., O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-31 FEE: $50.00 i
i
This is to Certify that Wok-N-Roll Inc. d/b/a Wok-N-Roll Restaurant ,
1319 Main StreeURoute 2R�4nuth Yarmnuth_ MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-fust 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the �
licensing of common victualler's. This license is issued in conformity with the authonty ganted '
to the licensing authorities by General Laws, Chapter 140,and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatutes.
BOARD OF HEALTH: �l�J�.+.�,ttay,, C�(�.,,q�//.. � / /�
SEATQdG: 19 oan G. �u[livan� K.//.� Vica l,�n �'
�06�.�� /3,�„�, C�.� ;
�a6,�1�.��G�y-�l�
��.lO�o�
December 16 , 19�
Bruce G. Murphy,MPH,RS.,CHO
Director of Health
�,���-N-�11
. TOWN OF YARMOUTH BO�1;B�F HEALTH p � 6 � � � � �
� APPLICATION FOR LICEN�E'/�'`F;}}�IIT- 1999 DEC 1 5 1g98
, ��;�__.,
* Please complete form and attach all necessazy documents by December 31, 1998. Failu
the return of your application packet.
�' / l -----------------------------------------/--------/----•---
RtAL,fi'., (1F FCTART TCNAAFNT� �AI1�1 IC� -III� �(JLL �Yl C� � T�"i # 7BUa06 �
I D S: S
N - LL
, - # fl_
S
POOL CERTIFICATIONS: � ��
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tivs form.
1. 2. _
Pool operators must list a min'unum of twoemployees aurently certifiai in basic water safety, standard First Aid and
Commumty Cazdio�ulmonary Resuscitation(CPR). Please list these employces below and attach copies of employee
certifications to this form. The Health Dep$rtment wiR not use past years' records. You must provide new
copies and maintain a fde at your place of business. �
1. 2.
3. ' 4.
HF.IIvILI H 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 anri-cholang procedures below and
attach copies of employee certi8cations 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. j
1. 2�
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
—__________—_ — _ -------- --------- ------- ------------ -
. __ _ �FFiCE i�S�fflNf,Y - _ _
LODGING:
LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# I
B&B $50 _CABIN $50 �
INN $50 _CAMP $50 '
LODGE $50 TRAII.ER PARK $50 ,
MOTEL $50 _SWIlv1A�IIIVG POOL $SOea.
WHIItLPOOL $25ea. I
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIltED FEE PERMIT#
i
� 0-100 SEATS $75 9Q-�8 CONTINENTAL $3� I
>100 SEATS $150 NON-PROFTT $25
�COMMON VICT. $50 �� WHOLESALE $75 ,
RFT li SERVICE: i
LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIItED FEE PERNIIT#
_<50 sq.ft. $45 TOBACCO $2�
<25,000 sq.R. $75 FROZEN DESSERT $25
>25,000 sq.ft. $200
NAMF.(:RANGE: $10
aMouiv�r nuE _ $�5 --
*•••"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'"'"'
� .
ADMINISTRATION �` `
LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI-IE TOWN OF YARMOUTH IS NOW REQUIRED
3'O H�SLD I3SiJANCE 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 COMPENSA ON INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTA TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK AP OPRIATELY IF PAID:
YES_s� NO
` NOTICE: PERMITS RUN ANNUALLY FROM JANUARY i TO DECEMBER 31. TT IS YOUR
RESPONSIBILTI'Y TO RETURN Tf� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISFIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR'THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIvfENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE ItEPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR
TO COMNiENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN.
A DITION� F 1i ATION
POOLS
POOL OPENING: ALL SWIl�IlvIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CL05ED FOR
Tf�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT,AND TI�WATER TESTED FOR
PSEUDOM�NUS, TOTAL COLIFORM AIVD STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, I
PRIOR TO OPENINCi, AND QUARTERLY TF�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING POOL MUST BE DRAINID OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
CATERiN PO I Y�
ANYONE WHO CATERS WITHIN TFIE TOWN OF YARMOUTH NNST NOTIFY Tf� YARMOUTH '
HEALTH DEPARTMENT BY FILING TF� REQUIItED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT Tf� `
HEALTH DEPARTMENI'. f
FROZEN DECSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.,L RESULT IN
__ Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS
- -- - - - ---- -- - _ _
HAVE BEEN MET. _ - — — -- -- - _ �
OUT IDE FR �
OUTSIDE CAFES (i.e., OiITDOOR SEATING WITH WAITER/WAITRESS SERVICE), MIlST HAVE PRIOR '
APPROVAL FROM TI�BOARD OF HEALTH.
Oi1TDOOR COO iN �
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD '
SERVICE ESTABLISfIMENT IS PROHIBII'ED. !
�
DATE: � �� SIGNATURE: �
PRINT NAME& TITLE: %/� � D f l� l�l ( �?�_
�
WORKERS COMPENSATIONAND EMPLOYERS LIABILITYINSURANCE POLICY
' INFORMATION PAGE
NCCI Co.No PolicyNo. ���
��� L E G I O N WC3-�91 '
1. INSURED: WOK N ROLL,INC. Renewato[PolkyNa ',
RENEWAL
The Insured/Mailing address: �
1335 MAIN STREET RO[TI'E 28 . �Individual �Partnership
SOUTH YARMOUTH,MA 02664
XQ Cocporation or
Other workplaces not shown above: Insured's I.D.No(s). (ifapplicable)
See WC 00 00 Ol F.E.IN.# pqz9g9395
RiskID# 320794
2. POLICY PERIOD: The policy period is from 04/Ol/1998 to 04/Ol/1999 12:OI A.M.StandardTimq
at the Insured's mailing address. �
3. COVERAGE: �' I
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compeasation Law of the states
6stedhere: Massachusetts
B. Employen Liability Insurance: Part Two ofthe policy applies to work in each state listed in item 3.A. T6e limits of our ;
liabilityunderPaRTwoare: BodilyInjurybyAccidentS ]ppppp eachaccident �
Bodily Injury by Disease S 500000 policy limit �
Bodily Injiuy by Disease S ]00000 eac6 employee �
C. Other States Inswa�yce: Part'I9rcee of the policy applies to the states,if any,listed here:
D. Triis policy includes chese endorsemenrs and schedules: wc000000n,wC00000�,wc000a�a,wC0003�tn,wczoo3o�,wczoo3m, I�
wczarsos,wczoo3o6,wczooso�,
4. PRENIIUM: The premium for this policy will be deurmined by our Manuals of Rules,Classifications,Razes and Rating
Plans. All informatian required below is subject to verification and chage by audit.
Code PremiwnBasis RatePer EstimatedAnnual �
Classifications No. TotatEst6nated $IOOof �� I
Annual Remunetation Remuneration .
See WC 00 00 Ol j
�
Ifindicatedbelow,interimadjustmentsofpremium PremiumforincreasedLimitsPartTwo,ifapplicable S
shallbemade— TotalPremiumSubjecttotheFacperienceModiScation �
PremiumModifiedtoReflectexperienceMod.of a
❑ ���Y. ❑Q°�h'> ❑ Monthly S
ToffiI EstimatedSmndardPremium a
MA-DIA Assessment S48 PremiumDiscount,ifapplicabk a
Expense Coastant Charge $
TotalEstimatedMnualPmmium a
$
MmimumPremi�E 210.00 sitPcemimnS 1753.00 Total AnnualPremimn a 1388.00
NameofPraducer. JERMONE J SULLNAN INS • !
ServicmgOfftce: MASBU Program Countersigned B 03/31/1998
TWO PARAGON WAY,FREEHOLD,N.J.07728 "��^^^���tid� o•'•
�THIS INFORMATION. PAG6 WITH THE WORKERS COMP6NSATION D PLOYERS LIABILITY INSUMNCE�POLICY�AND '
� BNDORSEM6NT3. IF ANV, ISSUED?O YORM A PART TH8RE0 , COMPLE7LS THE ABOVE NUMBERED POLICY. �-� '�.
g�ppp�������.. ' COPYRICHT 1987,N.4�ONAL:�COUNCI6 ON COMPENSATION INSURKNC6 . . � . � �WC 000001 A �
� � - � � ,. ,` .
. �y.. . c��J� . ,i.5 i[*p r ,,�I� . ; � a {,�#,
r ..��+�:�'it'�.xr .i.?�.�5�:�,.lAa�'afP�:� ` � �,3�!# d . . �s x . ��'„ ' .. �k.CL'� _,"yr».�.. i ��:��F'+��i;�z'�r�tz,�s+" .
, TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLLSHMENT
PERMIT NUMBER: 99-88 FEE: $75.00
In accordance with regulations promuigated under authority of Chapter 94,Sectian 305A and
Chapter 111,Section 5 of the General Laws,a�x,�mit is hereby ganted to:
Wnk-N-Rnll in 1'i7911�ain 4treet/Rou 2A Co rth Yannn�th A�A
Whose place of business is: Wok-N-Roll Inc
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth I
Permit expires: December 31. 1999 BOARD OF HEALTf-I:�'��n/. �ot�p�e, C'�/�;,,q„/a�,.q � /J '
SEA1'IIVG: 19 oan G. �ulLivan�K.//,� Vice l��iairman
o6a,r.� /3rowpn, C'�,.�
a�rie��a�iole��ooPe9 I
K� p'�o,��� ;
Januazv 27 , 19� � ,
i
Bruce G.Murphy,MP ,RS. HO I
� Director of Health �
-----
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH I
PERMIT NUMBER: 99-53 FEE: $50.00 �
This is to Certify that Wok-N-Roll Tnc �
-- 1319 M in Ctreet/Ront S Conth �'arn,n nh 1��A
IS F�ItEBY GRANTED A
COMNION VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only aadexpves December thirty-first 1999 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 with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendmems thereto. I
In Testimony Whereo� the undersigned have here�mto affixed their official signatures. I'
soa� oF�.�,�: �'d�/. �.e�, C�;.�
��,�: �9 ��.� s��,,,��, vKa c�:,�a
,�o�.���r�7,�/w'R, c�,� i
. . a6rio�JakoW�y-.�ooPoa i
��10' �1.�,�
Janusrv 27 , 19�
ruce G. Murphy,MP S., O
Director of Health
�I
f +
R -,_ �. BIUe.Rczk Gub Ao-sl,o�
y , TOWN OF YARMOUTH BOARI?OF��EAd�TH� ��, � � � � 0 d � � �
� APPLICATION FOR LICENSE/��,�YI�'�195� � pE� � 6 t998 �
� �,:1 fu„E:�' ;
• Please complete form and attach all necessary documents by December 31, 1998. Fai T �R�'sul in j
the return of your application packet. !
_—____---_--------------------------------- ------------------------------------------------------------ j
NAME OF ESTABLISfIMENT: RIu2 �oc.�. ��.1,�-b �ro -Sho� TEI.. # 5�K 3G6' 6?�Y- I
LOCATIONADDRESS: .ik TOl�d (?d• So. yizvmaUi'L, I
MAiT.iN('. ADnRF � n6, h'1 '✓1 Sr• Sa . )�YtYi0U1'l-� '
RA N � � �t R 'r S�
MANAGER'S NAME• �/. r #
MAII,ING ADDRESS: � 'roc(cQ R� So.- �.rmbu 1'�
--------------------------------------------------------------------------------------------------------
POOL CERTIFICATIONS: i
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Op��t�or(s) and attach a copy of the certification to tlus form.
1
1 _ _ -2. _ _
Pool operators must list a minimum of two employees currertly certified in basic water safety, standard First Aid and i
Communrty CazdioQulmonary Kesuscitation(CPR). Please list these employces below and attach copies of employee
certifications to ttus form. The Health Department will not use past years' rceords. You must provide new �
copies and maintain a Tile at your place of bueiness. �
1. �ffi � 2.
3. 4. '
HEIMLICH CER'I`IFICATIONS:
All £ood 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-chokuig 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 fiie at your place of business. i
1. ,p.!{� 2. I
3. 4.
i
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# I
�_�_____��____� ________�----- ---------------- -------------------
_ _ _ _. --
--�S��AFL� _ _
i
LODGING: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT #
_B&B $50 _CABIN $50 i
INN $50 CAMP $50
LODGE $50 TRAII,ER PARK $50
MOTEL $50 SWININIING POOL $SOea.
WHIltLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $75 �,� _CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
�CONIMON VICT. $50 �� _WHOLESALE $75
'
j�TAIL SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# ,
_<50 sq.ft. $45 _TOBACCO $20 I
_<25,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ � `2-S ` '
•""•"pLEA5E TURPi OVER AND COMPLETE OTHER SIDE OF FORM••""" '���'
_ _ . _,
� � f
,
. �
ADNfINISTRATION `
iJNDER CHAPTER 152,'SECTION 25C, SUBSECTION 6,TI-IE TOWN OF YARMOUTH IS NOW REQUIRED
TQ I30LD ISBUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPE1tATE 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 YARMOUTH TAXES AND LIENS M[JST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID:
YES� NO
NOTICE: PERMITS- RLTN ANI�IUALI.Y FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.TTY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMIvIENCEMENT. RENOVATIONS MAY REQUIltE A STI'E PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALI, SWIMI��IING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf�SEASON M[JST BE INSPECTED BY Tf�HEALTH DEPARTMENf,AND'THE WATER TESTED FOR
PSEUDOMONUS,'£93't4I,Cf�LIFORM AND STANDARD PLATE COUNT BY A STATE CERTIF�D LAB,
PRIOR TO OPENiNG, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMA�IING POOL MUST BE DRAINID OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MIJST NOTIFY TI� YARMOUTH
HEALTH DEPARTMENT BY FII,ING TF� REQUIItED TEMPORARY FOOD SERVICE APPLICATION
FORM ?2 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI�
HEALTH DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN
Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS
— --- -- ------- ---- -------
HAVE BEEN MET.
OUTSIDE CAFES:
OUTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WATTER/WAITRESS SERVICE),�$T HAVE PRIOR
APPROVAL FROM Tf�BOARD OF HEALTH. I
OUTDOOR COOKING: I
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD '
SERVICE ESTABLISHIvIENT IS PROHIBI'I'ED.
DATE: ��,�_SIGNATURE:
PRINT NAME& TITLE: l-�'G/jtti/crw�» �i'. �G. [�Jp
. ��o �ERT��iC�4TE C1F LI�E�ILITY 1�[��i�1�CE��-r ', 04 1`"�;"6 ', '�
vnooucErs :. -�, .... . .. .....: ... . .. ._:. ..... THIS CERTFICATE IS ISSUED AS A MATTER OF MIFORMATION �
The Addis Group, Iac. ONLY AND COWFERS NO RIGHTS�UPON THE CERT�ICATE i
3uite 200 HOLDER.THIS CERTIFICATE DOES NOT AMEI�,EXTEND OR
100 Hour Halls Corporate Ctr. ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.
9Peat CoaBhohoCkea PA 19428-2976 COMPANIESAPFORDIN6COVERAGE
G81Y SP. W8LI'eII� CPCQ� ARM CAMPNNY ..
vn�.ra. i - a-aioo F.zwo.610-825-9136 A 14merican Zurich
wsurtm wMvnnr
B
Slue Rock Club '
c/o Davenport Realty Trust �u+�' '
l�r. George 9aldain �
20 North 1Saia St. ��.
South Yarmouth, MA 02664 p
_ ._ _.__ __._ _
C�S
THIS IS TO CERTIFY THAT THE POL1pES OF MISURANCE�LISTED BELOW HAVE BEEN ISSUED TO THE MISURED PYMiED ABOVE FOR THE POLICY PERIOD
WDICATED,N07WITNSTANDING AN7 REQUIREMENT.TERM OR CONDITION OF ANY CANTRACT OR OTIiER DOCU`EM WfiH RESPECT TO WNICH THIS
CERTIFICATE MAY BE ISSUED OR M4Y PERTAIN,TFE INSURANCE AFFORDED BY THE POLK�ES DESCR�D HEREIN IS SUBJECT TO ALL THE TEF9uS,
IXQUSIONS AND COMqTIONS OF SIX:H POLICIES.LMfTS SHOWN M4V HAVE BEEN REDUCED BY PAID CLANAS.
'ro NPE OF INSURANCE POLICY NUMBBt POLICY EFFECTIVE POLICY EXPIRIITION �TS
LTR DATEIMMIDM'Y) DATE�MMIDD/YY)
OENERALLIIIBIIITY 6EI�RALAOORE6A7E E
uMMERcwLGENERALUABY.m PRooUC75-COMWOPAGG S '
CU11MS MADE �OCCUR PERSONAL S FDV INJURV f
OWNER'SBCOMRACTOR'SPR6T FACHOCCURRENCE S �
FlREDAMPGE(Myanefin) E
Mm D(P(My one persm) 5 i,
AU701/OBILE LIABB.JiV - �'�.
- Co1.�INEDSINGLELIMff 5 �.
ANVAU�o � . �
ALLOWNEDAU�W �I
BODILV WURV s
�,m����� �o..�> �
HA2E0 AVf05 BOdLV INJURV I
NOt40WNEDAUfOS . �� s
I
PROPQ27V DNMGE f
(iRRROELNBIIJTY � RUfDONLV-EAACGIOQJ! S
ANV Atf�O . 07HER THM!AVfO ONLV: I
EAC11 nCaDBIf S I,
� AGGREGATE f �,
EXGESSLUBu.RY � E�CHOCCURRENCE S ��..
UMBRELLAFORM AGGREGA7E S
OTHER iXN1 UMBRELUI FORM E
WORI�tBCOMPEN511TIONAND g T�ORVTIAMp�15 � ... .- ::
.. ..i......._._..._._�
EMPLOYERSl.111BL1iV EJ.EhCfiACGOINf L1�Q0��00�
A PE����E % � iPC81960T401 03/O7/96 03/01/99 aas�-va�cru,xr s1,000,000
o�snree Exu ao�nsE-En�.wi.or� s1,000,000
ot�rt
oEscnirrpx oF ormnrwr�ocn�srv�xaFsrsrEcuLL rre�s ''.
&Bt'E�IG4�H[�ER ClIFfG�AtCd1I '��.
Yp�p_Z sriw�oanoFn�eaeovEo�cxeEowi.�aEseecnwca�eer�nie '
�wrsntan onre rNmEOF,n�wsuwo eavnNr v�e+oenvae To� '
��DAYS YYNITTEN NOTICE TO iME CERTIFICATE HOIAER N11Mm TO THE LffT� ',.
Toavn of Yarmouth evr va�une ro�suex raT�swu�irvos¢xo oe�wnnw�ae un�utv ...'
ATTN: Permit Dept. '�,
1146 Route 28 oFu+riv+ouroxn�ecwran,rtsno�rsaixEvaEserrnmres.
S. Yarmouth, MA 02664 A���REPFtESENTATIVE
(iary 9P. Narre� �• �-�.� �.
�s9pC.S{11Ab1 ': i PJA�t?I�GG�AI�::
r �
C
TOWN OF YARMOUTH ',
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�NT
i
PERMIT NUMBER: 99-93 FEE: $75.00 I
I
In accordance with re�tions promulgated under arthority of Chapter 94,Section 305A and �
Chapter 111,Section�of the General Laws,a petmit is hereby granted to: il
(
Daven,nnrt Rea1tT Tmct,48 Todd Rnad, Snuth Yarmnuth MA I
Whose place of business is: Blue Rock Club Pro-Sho�
Type of business: Food Service
To operate a food estabGshment in: Town of Yarmouth
Permit expires: December 31 1999 BOARD OF HEALTH:�d�/I�(e�lto�aq, C�:,�q/�,.
�M1 li. JN4{LVRM1��i I•� V1CQ C�N/A[iM1
xesZ'tucrtoNs te nxr: Packaged cluPs,canaS>chewtnB Fom onl}'- Ko�rrl� �rowa� Cler�r
� �a6,a�saGo�,6yJd�Pe� i
:��. �C'u �� �
Janaarv 2s , 19 9� � j
Bruce G. Murphy,MPH, S., O '
D'uector oFHealth
-- �
THE COMMONWEALTH OF MASSACHUSETTS I
TOWN OF YARMOUTH �I
PERMIT NUMBER 99_57 FEE: $50.00 I
i
T7ris is to Certify that Davenoort R T�•^' a"��'R�""gack Club Pro-Shon
48 Tndd Road c...,*h VArmnnth MA �
�
�
IS HEREBY GdtANTID A
COMMON VICTUALLER'S LICENSE
In said Town of Yaimouth and at that place only andexpires December thirty-first 1992 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued 'u►conforroity with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereo�the undersigned have herreunto affixed their official signatures.
BoaRv oF�.�.�: L'��in9. ��.7r�@�, C�(�:,,/�/�,.q� //
. �/�oan G. Janllivaw�/KJ/.�/l•� Vicr l.�irman
Ko��� LJrown� l.leHt
ac,;.�/s����/ �aa
. ic�[O, oe h(in
�
Janaarv 28 >19 99 �G.Mutpby,MpH, S- O '
Director of Health