HomeMy WebLinkAboutApplication and WC • Towx oF YaRrro[rra BoaRn oF�ai.�ra [�(��ff�P'G D
APPLICATION FOR LICENSE/PERNIIT-20 0 �1,(gl` �EC O��
d'�' �
*Please completc form and attach all necessazy document{: y ecember 5
Failure to do so will resuk in the return of your;appltcahon pac et �1 H Utr��� •
NAME OF ESTABLISHMENT: /✓N /C � ^ TEL. # CS�)3 '���
LOCATION ADDRESS: q gI M,[�,�/✓ , t'{� D �(K–/�r �
MAILING ADDRESS:
OWNER NAME: D FE r S — –/�
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL. # ���
MAILING ADDRESS: �e.,�,�
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 certificarion to tl�is form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certiScarions 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
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this applicarion. The Health Department will not use past years'records.
You must provide new copies and maintain a t'ile at your establishment.
�.�y�c� �i� 2. �,r� �✓ ��✓�
PERSON IN_C_HARGE: _ __ _ _
� Each food establishment must have at least one Person In Charge (PIC) on sife during hours of operation.
�. �G� yf/� �i l� 2. ,X�(/b�i✓ t,./�✓�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your enployees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. ,�,^��� UIG� 2. �( � t3�t/Q�V V��°ivvl
3. 4.
RESTAURANT SEATING: TOTAL# O�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENS£REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
� INN $55 CAM3 $55 - �SWII�IMINGPOOL S80ea.
_LODGE S55 _TRAII,ERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS$REQiJIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
' �0.100 SEATS $85�6� Q—(7 S _CONTINENTAL 535� �NON-PROFIT $30
.. �>I00 SEATS $160 J_COMMON VIC. $60 _�(�—�Sr _WHOLESAL£ $80
RETAII.SERVICE: —RESID.KITCHEN S80
� LICENSE REQUIRED FEE PERMIT# LICENSE R6QUIRED FEE P£RMIT# LTCENSE REQUIRED FEE PERMIT i�
_a50sq.R. S50 >25,OOOsq.R. $225 _VENDING-FOOD S25
� �<25,000 sq.ft. $80 _FROZEN DESSERT S40 TTOBACCO S55
� xaME ctrnivsE: sis AMOUNT DUE = S ��� �`�s `'i'
I ••""`YLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'""*
NCV-09-2009 MON U1�51 Nh H. Sou Noa !ns Hgency' rnn �vv. oira«++�+� ' •
.. . � . � TEIM� • .
C .n�R 7�' CERTIFICAT� OF IIABiLITY INSURANCE ��P�s � � ii c9 0+
c
� o"n�v�rio corFx�.as ro awti�s� Trn»ce�t� Ar�
MOLDER.THIS ClIH1FlCATG OCF..3 NQT AM���� ��
ielwx'$ 00o Aoo Ino+u'a�ce ALTlRTHECOVERAG6A�FO��E�aYTHpPO� S��•
.149 kashin4ton at. Suite i �I ��Y ..^
�.oetou �A 02118-2 10 8 IiN9URERs�FFOR�����'�' �.
�hona: 617-338-8168 Fa%c617-33A-1'48
---Tsuaenn ...EIoop�Cal^ ltY DWtnc_� _,��.-.�—,`--'-'—
�SUH6D — , �' �aU0.fiRP: D7s Carta C ania� .P871 .
�{A �1NaUPERC. '�
�a�E��g�a�p Q{f18�A tIfiCB I�INBURERC. .•--� '-T'
ISl M�3II BCYO�EYA�026�� tNd41R�RE. '.I
80'q�tl Yasawut
:OVERI�OES ��E°GR THE PCUCY PEt�D INGIWiCG.MOTMITIIOTANOMJ6 .
�r{EPr�uGIESCF'.M3t7RPN�EIIBToCBELOWItA`1E0EfNE5S�OT0?MElNBJflfiP�:�b� Y' 8E%CIUSqM8AM1C4tW�T1�N{�P9UCM .
�.����hY.TBRM 0�CONOtT�N OF H7Y C W1fNCT OR 0`NFP oOCUNEN'�YITN Iii�PCC'f TO W14CH'M�S ClNTIFlCATC NJ�Y i613511EP TJ .
'rO�ICEi.AGGPEfi�16L�MR�6'NOWND+AnY4A QEENRPCUCED�NOClR�4M5 6U6dCCTi9PG.7FIE F�M 4M�.
, --� � -- rpuer vuw�+ � ...ancn xcuarer�ce ..�s_ip00000
3R�' Pe pµ ,. . "
� L�Q0�0
�F�exvw�uo�m Ql/Ol�G9 i 01/41/1� 'p.¢Mu��oaw.nn: , '_;�.__
� � �mEossrtMror•a.nm�l ; '�SOUO .
A �, i 7(�COMM6RCIN.GENNM��IF00.fTY �� C;7+OBOOOOZ»� i m
� ��c�.vrnsnwos �,%� �ccuA; � aenscw�anuvov�uxv s 100�000 —
.. ; � �,�r�rc_eoA�_�3 20000¢0 .
� '- i �'-- ...--. .� � I I PRW�T6�COMP�6rAGG lOOO_QCQ _
�� �'� _- -- I � I
; I GQ,.�pGpqEC�p78 LiAFT APPLIts PGR� ^
, -. r"�PR�t ' 'lof. I . COIAO�NEU5INGLF IIAM �
Pu
^? i a�tfoMOMtf LUeam �I �, �l2�ax�t�+Mi �, .
` ~�1 ANY AUTO �! I� I BD�ILY NLlUP'�
L' ntLOWNEOAUTDd ; � I '����� � I{:
� �� �aEHE�J180/u70fi 1�� I, I 9pp14Y P�.��R'1 1�'f
I I.IPwaQitlaN1 �
� rl Ht4E0 Ru�OG ;, i I �'-i. - ..
�NCN�OWN@P M1TC0 , . '1 PR�Pr'��e '.'.0
�� '� ' �(P.r.c�liaMl
. !�"i� ' . ��. AY� T_OOYLY�EIA�CIOlNT !�,i
� �t ,t
� �G�WWit1AiWT' I I I,A�YTOD�Y* , '"'�4G t
� ',. ��11NY FUTO � '� t
W�'11�'CWMRNCE 3
����1 UMRFGLiA lINB�UYY '. � ' FOGPE�re : ` .
I. �J OCCUR �GtTIM3 4ADE ,� ��I �I 's .
�� �'��RPUCT9L8 I . I �� �� ..
I ".
'RGTFMION � '"—"� ".� .SOPY:1MiLE-r--J-� � .
�� " i�in v�N' ' 051301p9 ! 05/30/10 I�� Fwtnr�ccio Nr. s,T 50U000
�NORu�a+'�r r ' sSOOOOD
g �wrwovnx �p/r�eTue�EcunvEr-,i OPC 023209 � (, �,�.maR�se-v,ranv�o e
�Off'IC6�1lM�6RF%:WOP^ ,_..Ji . � EL.D;@RNeE-pOLICrLIMM� 4 $00000
� . �;Mmdsfery I
� tya.awm�wwas { .J__—. , '
�SP£Gi MP_�� -"'��-- �. '�
oT i , �
i � �
' i
' x� iPT� fdu i W�+nar r vcmr_�ea uaicn �DO�9Y 6MOORs i�v�cw�F vRovn�s , .
, �1� r��tanrtaC with ealee o! alaoholic bwPr l�a■ r�� �5b
Raute�28.•Bou[h Yar.aonEA.tMA C2669_66 2rta�mnCat, lacatad at 981 Kaia Str, y
CIW:EI.1-ATION �:
CE(iTIFICA7!NOLDBR eh�y�p ANy pp TNP V�E oGiCRMF-0 W�ICf�9E CNICRIIH�K�ON�TM!FXPRPTIUM
� yva wa'riw
T080Y71x wttrx{t�cF,YHi�asux+owsuaearm�enorwvo�YorAtI.�,Q--
nm�eN ro r�+e:E111W1C1TH NOLQiN NW�TO 7M!LlFT.BUT rNLY11Y'ro 00 506XA4L
Tovm oE &outh Yazmouth iwoeewooa�w.�t�ow�u�fwmcr�urrwwouvwrHer�a�ar�n,rtaAcerrcaort
Tawn HAll pe►a�RM'►rnee. ' .
1156 xoute 28 R�°��d 80o ISoo� :
gp�ytp Yarmouth MA 026E4
� �16W-2009 AG RO C � � TIDN. il�I • ��.
ACakD 25 f�a��) �
7he nCORD same and lopu aro toyis»r�d ma�s oi�CORD
i
THE NA7IONAL REGISTRY QF
p�c�O°�s�, FOOD SAFETY PROFESSIONAL3�
a� 'a,�
CERTIFlEB
XIAO QIAN WANG
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR
THE FOOD SAFETY MANAGER
CERTIFICATION EXAMINATION
� �s j y +�
PiCSidatt:� � .'s
�,��c
�
�""� � ISSUE DATE:JULY 5,2009
`(� CERTIFlCATE NO:ZC'ZO394144
TEST FORM: ZCA
N0656 IL�urttllute u cW W W far oorc
I _. . . . . ... ._... . . � . ... ._ . .IWW-vvMnRMJMnNIlVI.�.._._.......a
��i . . ._. .. . . . . . . . .
. a�� National Registry of Food Safery Professionals�
NoHfication of Test Result CERTIFIED FOOD SAFETY MANAGER
ID#: xxx-�c-5206 XIAO QIAN WANG
Scaled Test Score: 90
II Candidate Status: Pass
� Test Date: July 5, 2009
CMificace No:ZC20394144
[ssue Dace:July 5,2009
i
� Congratulations!Attached is your certifica[e and wallet card.Please notify XIAO QIAN WANG
� the National Registry of name or address changes at the address below. 981 1�AIN ST
SO YARMOUTH, MA 02664
Ensure Food Protection(You scored 100°h corred).Mastered
' Purchase and Receive Food(You scored 73°h correct).Competent
Food and Supplies Storage(You scored 73°k cortec[).Competent �
Foods Preparation,Service&Display(You scored 89°h correet).Mastered
�i Equipment&Facilities Maintenance and Cleanliness(You scored 75%coned).Competent
Personnel Hygiene,Training and Behavare Related to Food Safety(You scored 700°h corredl.Mastered
Legal Comp�iance(You scored 100%corred).Mastered
� Nadonal Registry of Food Safety Professionels� I 5728 Major Blvd Ste 750 � Oriando,FL 32819-0000 � Phone:407.352.3830 � Fax:407.352.3603
7't�E NA77oNAL R$4i18T12Y O!'
�gooD FOOD �AP'E,7'Y PROFESSIONAL.B�
' Ceim�s :
� � @�C�.YINC GAC?' �
� HAS SUCC6SSP'ULLY SATISR76D'�FIE Rgqp�REMgMg FOR �
THE FOOD Sw!°'E7'Y MpNpG6R
CERTIFICATION EXAMINATION
. .�. . . � � ���fi����. .
�fCSI(�Clll:
� I.aw+e�r.[I,�mch: .. ..
� � IseuE De'1'�DeCEMeE[t 8,2008
CeRrfftcw�No:ZC20326942
'i�sr Fo�:ZCB
p06%
. . . 1W artlhah Ywl vYW Wr more
r. . . .�r�..�-..-e. � .�.�. � � . ` ::........ . . . . . . .._.... .. �.�....�i.P `:...�P_'. .:�J.MR'l'Ji3iYf04Yir8S �...�:'�__--
- �
� s� National Regishy of Food Safety Professionals�
NotificaHon of Test Result cER��n Foo�sa.r��NtntvnceR
ID#: xxx-xx-4070
Scaled Test Score: 88 BAO YING GAO
Candidate Status: Pass
Test Date: December 8, 2008
Certificate No:ZC20326942
Iwve Dete:Decemyu 8,2008
Congratulations!Attached is your certificate and wallet card.Please notify BAO YING GAO
the National Registry of name or address changes a[the address below. 9$1 1Kl�IN $T
S YARMOUTH, MA 02664
Ensirre Foad Protectlon{You acoretl 91%cortect):Mas�red
Purchase and Recefve Foqd(Ypl scared 91%correcq.Mastered .
Food and Supplies Storage(You scored 90%correcl),Cbrt�etent
FooOs PrepaVation,Service&Display(You scored 94%corred).Mastered
Equipment&Fatilities Mainte�ance and Cleanliness(You scored 56%correct).Competent
Personnel Hygiene,Training and Behaviws Related to Food Safety(You scored 69%conedj.Competent
Legal Compliance(Yau scored 100%cortect).Mastered
Nallonal Registry of Food Safery Professionals� � 5728 Major D)vd Ste 750 � Orlando,FL 32819-0000 � Phone:407352.3R30 � Fax:4W.3523603
� F .
I ^ •
ADMIlVISTRATION
Uteder Ghapter 152, Section 25C, Subsecrion 6,the Town of Yarmouth is now required to hold issuance or renewal
i af any license or pernrit 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
I CERT. OF INSURANCE ATTACHED
OR
iWORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
i Town o£Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CI�CK
APPROPRIATELY IF PAID:
YES�� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIEIVT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use.
' Transient occupants must have and be able to demonstrate that they maintain a prinapal place ofresideace elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dweliing unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as deStted in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transieirt.
� POOLS
I POOL OPENING: All swimming,wading and whirlpools wlrich have been closed for the season must be insp��
by the Health Departmernpnor to opening. Contact the Health Departmem to schedule the inspection fl�e(3)days
pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area wrtil the pool has baen inspected
and opened.
' POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Deparhnent three (3) days prior 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
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by Sling the required
Temporary Food Service App&cation form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified Iab. Test results must be sant to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pennit until the
above tetms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waittess service),must have prior approval from the Boazd ofHeahh.
OUTDOOR COOHING:
Outdoor cookin�,pr�aration,_or display of any_food product by a retail or food service establishm�nt is pr91u�'bi�i. ___
NOTICE:Pernuts run annually from Januazy 1 to December 31. IT IS YOUR RESPONSIBIGITY TO RETURN
TI� COMPLETED RENEWAL APPLICATION(S)AND REQLTIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PA.INTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BpARD pF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN.
DATE: L s SIGNATURE: ���° ` �� �^"'
RINT NAME&TITLE: C� C� Y� /�/ �`,F�r(�o
09f25/09
I
-t.�s.-r � �.��cz
i
; TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #10-085 FEE: 585.00
In accordance with regulations promulgated undei authoriry of Chapter 94,Section 305A and Chapter
j 1 I l,Secrion 5 of the Grneral Laws,a pe:mit is hereby granted[o:
I
� Fine Asian Cuisine Inc. 981 Route 28 South Yarmouth MA
Whose place of business is: China Inn Chinese Restaurant
�
j Type of business: Food Service
ITo operate a food establishment in: Town of Yannouth
i
i Pernut expires: December 31 2010 BOARD OF HEALTH: �Kian `.$Ka�nton-Sm�i1t�l�, C'llainutcan
ISEA7ING: H4 ✓ l�p(�f12QU�� V(CC �"Q�Illf/LQIL
I ?IIu�C.SHA[(t[�2it I�� CeP![�
�� �
✓�04 � .M.1�.
February 17.2010 1�
Bruce G.Murphy,MP ,R. .,CHb
D'uector of Health
�
---------------------------- --------___�-- ------ --___ --
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #10-055 FEE: 560.00
This is to Certify that Fine Asian Cuisine. Inc. d/b/a China Inn Chinese Restaurant
981 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and exp'ves December thirty-fust 2010 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornuty with the authority eranted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: `.�3Kiarc `.il3aa�inta�-Sm!�i�tll, C'lfaixntaa
SEAIING: 84 J �a. �Q[gt!¢pU�� VICC �%XffUYK
2Uu�icun C. SnOltld?!l IQ, C'IPnP
�� �
.`,(3ae , .M.`�.
Febn�ary 17,ZO10
Bruce G. Mwphy, H, R.S.,CHO
Director of Health