The URL can be used to link to this page

Home My WebLink AboutApplications, WC, Licenses Prior to 2010, _- , ; � , �� ^' � TOR'N OF YARMOUTH BOARD OF HEAL '� � . � � � �9 � � ��y 9 I � APPLICATION FOR LICENSE/PE �0 <�� `�'� , � NOV 1 � 2008 * Please complete form and attach all necessary ��' e��Decem�e�r S 08. Failure to do so will result in the return of ` r applicahon pac et. TH DEPT. ! NAME OF ESTABLISHMENT: �{'i ��/�' �/VI� CMIN�S Cz (SS • TEL. #CS�� 3 �`�� LOCATIONADDRESS: qR1 !7t)U 0 Q Yl /�"I�� 5 �°2, MAILING ADDRESS: G.1t�,� C-3 aV'e OWNER NAME: TAX ID FEIN or S N : —" �' °So I� CORFORATION NAME (IF APPLICABLE): E�I S�� i1/t, �{ MANAGER'S NAME: / / TEL. # G —0�T/ MAILING ADDRESS: � C�. 1 —�'"�(�2 POOL CERTiFICATIONS: The pool supervisor must be cerrified as a Pool Operator,as required by State law. Please list the designated ' Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certificarions to this form. The Health Department wil► not use past years' records. You must provide new copies and maintain a £►le at your place of business. i j 1. 2. 3. 4. ' FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your estabfishment. — 5..=1zv SRPe Fo,e ��o YrroG c=s�v 1. �Y� 19 v (Q-f rd n/ w��n 2. Scer�"7�.;u� .=a�z 1.�08�08 PERSON IN CHARGE: r __ — ---__ __ _ --- _ Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. ' i. Y.( ��" �2�ld�t�/ [,.(C��i z. C�l�'v �°��.lc� �ld� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich Maneuver on the premises at all times. Please list your employees trained in anri-choking 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 file at your place of business. 1. �� 2. I�� ( � �t �� ; 3. 4. RESTAURANT SEATING: TOTAL # 8S (Duvcaiopy Gaxcd co /!Z� � OFFICE USE ONLY LODGItiG: LICENSE REQUIRED FEE PERA3IT# LICENSE REQUIRED F£E PERMIT# LICENSE REQU[RED FEE PERM[T� _B&B S55 CABIN �55 MOTEL 555 � _IivN S55 CAMP S55 � SWIMMINGPOOL SSOea. _LODGE S55 IRAILERPARK 5105 WHIItLPOOL 580ea. ; FOOD SERVICE: � LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQl71RED FEE PERMIT# ��. I 0-100 SEATS 585 _CON"I'[NENI'AL S35 NON-PROFIT S30 �>100 SEATS 5160 LCOMMON VIC. �60 WHOLESALE S80 ' RE'iAIL SER�7CE: —RESID.KITCHEN 580 LICENSE REQLnRED FEE PERMII'# LICENSE REQLJIItED FEE PERMIT# LICENSE REQi7QtED FEE PERMIT# � _<SOsq.ft. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25 _QS,OOOsq.ft. S80 _FROZENDESSERT S40 TOBACCO S55 � �a�E c�;rcE: sio AMOi7NT DUE _ $ �6"pa' I "•"*"PLEASE TLRN OVER AND CO,'NPLETE OTHER SIDE OF FORM"'•" ��S' D O I,' � � ' - � ... � - . ADMIlVISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensarion 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 ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence 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)momh 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 Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which haue been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool azea urnil the pool has been inspected and opened. 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 thereaRer. _ , POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Departmetrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuhs must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernvt until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooldng preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Peimits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII.TTY TO RETURN TFIE COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAIIVTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: "0 SIGNATURE: �l.La I �� PRINT NAME&TITLE: ��31 f'1" io.zt!os � , � � � �\ Thc Cominonweahh ofMassachusetAs � Department of Irtdustrial Accidentc �� i 600 Washingtoa Streey 7"'Floor j Boston,Mass. 0211I ! Workds'Com�e�aaHoa i�sarance AfSdavir Baiiding/plembiag/Ekctrical Coetractors �� Pl�e PRI(�T kelblt na�ce: address: citv � � state' zio' phme# � work site location(fvll addressl: � ❑ I�a homeownet performing all waRtc myself. Project Type: ❑New C�stn�cdm QR�odel I ❑ I�a sole�pro�aietor and have��e wo�lting in aoy�capacity. ❑Building Addition � � . . � . . : . . � ❑ I am an employer providing wotkeas'compensati�for my employees woilcing m this job. I comwev�ane• .. . � . . . .. . .. � . . .. admeas' � � � � � . . . citv: � . . . oYoe�g- inQa.ee eo. p�s S � �-�-�}��`�l 1�ppp�. .. . kk�n:. ".'-k . nSi.W�NiY.%.pA+d�.v,'' ❑ I am a sole proprietor,ge�eral eesh�actor,or 6omeow�er(eirde oweJ and have hired ihe coetracto�s lis[ed below w6o have � tl�following wartkers'comPeasa4on Pulices: � � s4mbuv me• �� . . � . . . . � � addros'. . . . . . . � ctty: � . . o�Ae!{• . . . � � . . � . iu@�au e0.� . ... ppLLv g � . . . . . . ' ..r ...- .. . , . . . . . -_. . ..:, �-_.� .:�.: . z ; ' ,�_ _,�.,,at .� R�C,'t ��!' �'W' � �9C . . . - . . - � pYY!X' . . ,_ - _ . . _..__.. __._ _—_ . __.... _._ -._ _ _—_ — ____ - _--.___-___ _ _ . . .___—______ _. . __ .-_" _-_ _ �' iA' . ..."� . # . . �� ' ):.YC. .a i�.':'.. !�{ F��:l�»y.:. 2'—P-e�� Eaive6axvec�aa6eoRqd'eduUQ3ee�n2SA�[A1GL132wkadbt4i�p�IWaKaiNWpe�NadaO�e�bf1JN.Masdh* � .�ra�*'�sv��•••�..aw�..wo w u��...r,sror wox�c onnen m.e.�.rsieue.ay.g,��. �oa�,ow u.�, � e�pgsfHhffaMaeMarybeNew�NMbHeOmecdla�dptlenettlieDlAferewe�everlBdtlsa � !Ao henby cerdfy rndn H�e pains anJpenelpks ofperjnq that Me lwferwe�ton provldal ebavr h hve aud�y � � �,��—�2�—(�� t� �Y � 1/ �(7� �� p�� i,l i,.��i✓ � p��# c � g—oi �� aBda�ose enry ao wt..rke ia ms uea w ee mmnk�d br.Wr.r�wu smdal � . � I: dyartawn: ' �p �Bo�m6�� . � � .. �BsaN i ❑cYeck V i�me�Be'eapeeee 6 rt9� � �Y Omee � .. . � QltnMkDqq�dat ' I na[�Rpen°°' PhaseB: ❑OIAa lm'saS�tmW� . . � NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law. Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our inJured employees under the above-mentioned chapter by insuring with: PUBLIC SERVICE MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY One Park Ave New York, NY 10016 ADDRESS OF INSURANCE COMPANY WC-022209-07 05/30/2007 thru 05/30l2008 POLICY NUMBER EFFECTIVE DATES RICHARD SOO HOO INSURANCE AGENCY, INC. 1148 WASHINGTON STREET BOSTON MA 02118 (617) 338-8168 NAME OF INSURANCE AGENT ADDRESS PHONE# FINE ASIAN CUISINE, INC. 981 Main St, Route 28 South Yarmouth MA ❑ EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANl� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal inJuries azising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensatlon Act. A copy of the First Report of Injury must be given to the inf ured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treaUnent is necessary and reasonably connected to the work related inJury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER , • TOW1V OF YARMOUTH BOARD OF HEALTH i PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-037 FEE: S85.00 � In accordu�ce with reeulations promul¢ated mider aud�oriR�of Chapter 94,Section 30�A and Chap[er j 111,Section�of thr�eneral Laws,a pemiit is hereby granted to: Fine Asian Cuisine, Inc., 981 Route 28, South Yarmouth, MA Whose place of business ir. China Inn Chinese Restaurant 'i Type of business: Food Service � To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BOARD OF HEALTH: .q�f�ee_e��n��S� lf�7a�Pyc7�`J2-a..ON-Q.,-� 'C� .�p� r' nqaQn-.��--- SEA7ING: 88 l.luV[GYA .7L. ./1XGC{f7YJ[� V[CC l,lllU�[/RIiK J2a6ettt s. J`3xotwi, C�e+r� i Q�ve (�'aeen6aum, `Jt.N- + F.ue�ja 5'. 3fayeo , , ?Io�ember 26.2008 ruce G.Mucphy, H, .5.,CHO Director of Health i i --�_ I THE COMMONWEALTH OF MASSACHUSETTS , TOW1V OF YARMOUTH PERMIT NUMBER: #09-023 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 Yannouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the Gcensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony vVhereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3/�EQe-le��nB-S- /��7a�R�,�71.!?��.�N��,., CRt1rc�uxnnuuQc_--�._ SEA7IAG: 88 l.lLCf3(Xo JG. ✓LC(.GiRPX VICC 1.7L[lV{Ifl(lfL ��Qaatare�,,�� Ec'ePaJa `J'- \ocember 36.3008 Bruce G. Murphy, PH, R.S.,CHO Director of Heal j ?�` ""k�s TOWN OF YARMOUTH BOARD OF HEAL� � �; �Np �NN ��= APPLICATION FOR LICENSE/PERMTI`=�p0$ �� 31��7. * Please co lete form and attach all neces , 1 � Zuii7 mp sary docume�ts bq bec ber Failure to do so will result in the return of your application packet. i NAME OF ESTABLISHMENT: Iula (l•�I`� C�((�/�v 6 S , TEL. # C b��1c��D�� ' LOCATION ADDItESS: v��( �`n 6 MAILING ADDRESS: S �t/`2 OWNER NAME:�� 19�� /ko T.�X ID (FEIN or SSNI� � (— � °� CORPORATION N E (IF PLICABLE):��_�(��7J rcd�Sf�, ��C . MANAGER'S NAME: /�'iV TEL. # C S� , f�S`I MAILING ADDRESS: (�.,�n C„�c r-� . dV`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 certification to this form. � 1. 2. � Pool operators must list a minimum of two employees currently certified in basic water safery, standard First Aid and I' Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certiScations to this form. The Health Depertment will not use past years' records. You mast previde ne� � copies and maintaiu a fde at your place of business. I 1. 2: ; 3. 4. I _ _ _ � FOOD PROTECTION MANAGERS - CERTffICATIONS: � All food service establishments are required to have at least one ful]-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certificationtothis application. 'i'he Health Department wi}I not nse past years' records. You must provide new copies and maintain a file at your establishment i. X� �la�--��lfiJ i,�,�✓� z. � i _�e��orr�r c�cE: _ _ _ _ - __ _ . -- – — - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. � �(4� _ �� W (r✓" �i 2. �� /��1 �I,�"'0 i HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-choking proceflures below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. i You must provide new copies and maintain a file at your place of business. i I��"b �Pl�"N ��v vi 2. �� " �T,,��t_ "l�� 3. 4. RESTAURANT SEATING: TOTAL # �Z OFFICE USE OhLY LODGING: LICENSE REQUIltED FEE PER'�9T# LICENSE REQDIRED FEE PER4it?= LICENSE REQL7RED FEE PER�fIT= _BBcB S50 _CAB1N S50 _MOTEL S50 _INN �550 - - _CAIvIP S50 � _SWIVLbIINGPOOLS75ea. i _LODGE S50 _I'RAILERPARK S10(1 _��'HIRLPOOL S75ra. � FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICEA;SE REQIIIRED FEE PER.4[IT R . LICEtiSE REQtiIRED FEE PER�iIT= �0.100 SEATS S75 OS�O _CON7INENTAL S30 _NON-PROFIT S25 � �>I00 SEATS 5150 1CO:bL'�SON VIC. 550 �vS–/1Q� _R7iOLESALE S75 REiAII.SERVICE: —RESID.KITCHEN S75 ' LICENSE REQ[7iRED FEE PERMIT= LICENSE REQUIItED FEE PER�tIT= LICENSE REQL7RED FEE PER�III = j I, _<SOsq.ft. S45 _>25,OOOsq.ft. S?00 _VENDING-FOOD SZO _@5,000 sq.N. S75 _FROZEN DESSERi 535 _TOBACCO S50 �iA:�,CHAYGE: SIO AMOUnT DUE _ $�ee--� """**pLEASE TL'Ry OVER.�\'D C0�1PLEiE OiHER SIDE OF FOR]t'**** �a�'O� i i � - , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any Gcense or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior o renewal or issuance of your peimits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For pwposes of the limitations of Motel or Hotel use,Transiem occupancy shall be l'united 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 ofre�dence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be wnsidered Transiem. * NOTE: Ea�1os�Motel Census must be completed and returned witn tbis aPPli�at�on. POOLS POOL OPENING:All swimming,wading and whirlpools which have bcen closed for the sea.4on must be ins ected by the Hea(th Department prior to opening. Contact the Heakh Depaztment to schedule the inspection Sve(�days pnor to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Aealth 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 revocarion of your Frozen Dessert Permit urnil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Ejutdoar caokirtg,preparation,or disptay of anq food product by a retait vr food service establishmeM is prohibited. NOTTCE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'I'E�BOARD OF HEALTfI PRIOR TO COMME�ICEMEVT. REVOVATIO?IS MAY REQUIRE A SITE PLAN. DATE: �� ` l n � °� SIGNATURE: X � �' (� � �^^" � � PRINT NAME&TITLE: ��I� �-��✓ I��'1 �^-""""6I�� 10?0 n? �\ Tht Commonweahh ofMassachusetts Departnieat of Industrial Accidents �eaN� 600 Waskutgtop SYreet, 7"'Flaor Boston,Mass. 02111 ' Worlcers'Compesaatioe I�a�ruce Affidavih Bdding/Plambiig/Eleetrical Coetraetors � � iWT 1e.Y1i. . . na�ne: i address� .. ciN �m� in� -p work site location(fiill ad�esst . . ❑ I�a]wmeowcer petforming all w�k myself. Project Type: ❑New C�ti�QRemodel . ❑ I am a sole yao�xidor aod have no one workiog in�y capacity. ❑Building Addition . . ❑ I am an employer pmviding workecs'compensation fa�my employecs wodcing on this job. .., e000aav�me: . .._ . .._- _-_ . .__. .—. - ---� -- - - __ . . _ .. . �d�s' dN- � aYeielh � S€� G�� : , :.;; . ,> ..�.,: ��.,�.._. . ❑ I am a sole proprietor,gweral contraetor,or 6omeowaer(cirde owc)aed Lave hired the contwctots lis[ad betow who have the following workas'compen4ation polices: i i eo�"..o�' I Wd'na- � I eilv �e p• � irea�oeta p�# �roe• �eu• � . sitv: � orre#• _._- -- ---- _.___. — . I, ._ .___..._ .— —. . . .----- - ---- . .-- __ - - ..._------- �- -- �ssea - _ . ___ ..------------ -- ��. . . .. . . �� . i FaYaxraeeRe�endeareq�edodQ3etlW2SAKMGLLS2eokWblYe�p�ilY�daidWpn�Meda6e�bf]T»,Ma�N�r��.. ••�r�*'�r�+��..�..dw�dn��.r.srorwowcoansRm,�.rsieaw.a.y.�en.e. ioa�.o�.amua eyry dN6 Male�eN my 6e HewaMed b He Omee atlew�d tYe DIA ter avera6e verqlatln. 1 do henby cerofy awdsr Hie p/ns owd peeehies ofPerj+eY Wrt Me iwfonw�lon provided ebar�e 6 enre anAcorrtct �� I �.r �.c'�- �?f � (�`� l o� P�°8°� Plane# o�Llmeoety MeatwrNeYWharcab6e°aoPlefM69eNYerYwn�cW dly ar tawn: �K ��t ❑eYeek if ims�le�eepeme 6 rtqa'ued �� . ❑Sds�es'a O�m ceafacl peneu: ��, �� t•masµaom� i � NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: PUBLIC SERVICE MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY One Park Ave New York, NY 10016 ADDRESS OF INSURANCE COMPANY WC-022209-07 OS/30/2007 thru 05/30/2008 POLICY NUMBER EFFECTIVE DATES RICHARD SOO HOO INSURANCE AGENCY, INC. 1148 WASHINGTON STREET BOSTON MA 02118 (617)338-8168 NAME OF INSURANCE AGENT ADDRESS PHONE# FINE ASIAN CUISINE, INC. 981 Main St, Route 28 South Yarmouth MA ❑ EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANI� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to fumish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatrnent is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees at�e hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER � TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLIS�IMENT PERMITNUMBER: #08-011 FEE: $150.00 In accordance with regu1ations promulgated under authoriry of Chapter 94,Secrion 305A and Chapter � 111,Section 5 of the�eneral Laws,a pernut is hereby ganted to: _ Fine Asian Cuisine, Ina, 981 Route 28, South Yarmouth, MA Whose place of business is: China Inn Chinese Restaurant i Type ofbusiness: Food Service i To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: .��E�e��e��np�S� R��a7�R�, J`Z..N., C��►a1vrMt/a�Qut SEATING: I IZ � l.►[G1iLC0 JC.i� VlCC l.7LQlX�/flQIL ✓2o6ent s.J�1�un, e�e,� Qrna�'ie.ere8acun, f/2..N_ November20.2007 Bruce G.Mucphy, H S., CHO Director of Health THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-009 FEE: $50.00 Tlvs is to Certify that Fine Asian Cuisine, Inc. d/b/a China Inn Chinese Restaurant 981 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMNION VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affuced their official signatures. BOARD OP HEALTH: .�fe�en S�q� `J2..NL., @l��a1Lunart SEATING: ]12 - � �QX�Cd .7G. � �fiPll VICC�Q'lXIfIML `2a8eieE.rt. `.�tixacurc, (',�e�rPi Qauc , J2.,N. November 20.2007 Bruce G. M phy,MP , .,CHO D'uector of Health !, 1 Ib� V °`e"�. TOWN OF YARMOIITH BOARD OF HEALT$ ��A � � � � ? � APPLICATION FOR LICENSE/P�R�TT-2007 U E C O 5 ZOO6 ' 3 -'c � r �S -� � �. ... � � * Please com lete form and attach all necess docu�ments b Decem r P aTY Y ��I DEPI . Failure to do so will result in the retum of your application packe . NAME OF ESTABLISFIl�4ENT:C}�fd/�d I/�I✓ [iY��/�l (s S� TEL. # �S��l� )��'�I w LOCATIONADDRESS: �� 2�� o � �du��/ , �-�a, oz66 � Mau,�rrG avvxEss: � OWNER NAME: T r � — �� CORPORATION NAME(IF APPLICABLE): � ( ,(�s� (/�/C . MANAGER'S NAME: X I� �� (ja�/Z TEL. # —o MAII,ING ADDRESS: POOL CERTIFICATIONS: , 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 certification to this form. 1. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety,standazd First Aid and Community Cazdiopuimonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this forn►. The Healt6 Department will not uae past years' records. You must provide new copies and maiotain a t"de at your ptace 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 540.000. Please attach copies of certificarion to this application. T6e Health Department will not use past yea�s' records. You must provide new copies and maintain a fde at your establishmen� 1. }C(!QU 6-'fi/�'�v i,fl�� 2. PERSONINCHARCsE: __- -- _:__ _ . . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i. 5C (� (�-�(f�./ %�I l��N� a. �l� �'� i✓� �'� HEIMLICH CER'PIFICATIONS: 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-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 fde at your place of business. �. �� (I� r�.��b✓ �,f �'i✓� z. g� qr�� G /� 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIIVG: LICINSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _&@B S50 _CABIN S50 _MOTEL S50 _INN $50 _CAMP $50 _SWA�IIvIIIdGPOOL$75ea. _LODGE $50 _1'RAII,ERPARK $]00 _WHII2LPOOL E75ea. FOOD SERV[CE: LICINSE REQUIRID FEE PF.RM[T# LICENSE REQUIItID FEE PERMI'C# LICENSE REQUIRED FEE PIItMI't# Od00 SEATS $75 _CONTTNENTAI. $30 NON-PROFfL $25 L>100 SEATS E150 �0�1-OS� 1COMMON VIC. S50 �2-0�� _WHOLESALE E75 RETAQ.SERVICE: —RESID.KITCIIIEN $75 LICINSE REQUIItED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PF,RMIT# _60 sq.ft. $45 >25,000 sq.R. $200 _VENDING-FOOD S20 _Q5,000 sq.R. S75 _FROZIN DESSERT $35 _TOBACCO $50 NAME CAANGE: S10 AMOUNT DUE _ $ 'LOO.00 '•'"•PLEASE TURN OVER AIYD COMPLETE OTHER SIDE OF FORM•••"• - ` �� '#O Ch0!�i'i!� �;�+caw 3 . NO: � WQ�,y� �Nt0�.S6/ � •.;a u �f _ i e ADNIINIST'RATION , 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 AT"I'ACHED STATE WORKER'S COMPENSA'ITON INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaies and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � / YES �/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principai place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an ' aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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 Transient. POOLS POOL OPENING: All swimming,wading and whidpools which have been closed for the season must be ins ected ' by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. , 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 Fnust 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 Aeatth Departrnent by Sling the wred Temporary Food Service Application form 72 hours prior to the catered evem. These forms can be obtain�at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Staie certified tab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval&om the Board ofHealth. OUTDOOR COOHING: . . . �ookmg,_greparatron,_nr dtsglay 9f any food proslnct by a retail or fflod servis��s�ablishm�nt i�p�rohibited. N01TCE:Pemvts run annually from January i to December 31. TT IS YOUR RESPONSIBILITY TO RETURN TFIE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISffiVIENT, M07'EL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ', DATE: � 7/I ��1 � � SIGNATURE: �7C--� Cs��'Lc--� V � �� PRINT'NAME&TITLE: X I!'1 o fQ� � �( �� ) �•1,{R �o�i�roc ' I � • Public Service Mutual Insurance Company One Park Avenue - � New York,NY 10016-5807 i WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY ! INFORMATION PAGE ' NCCI Company No:16152 Prior Policy Number: WC 0222095 ! RENEWAL Policy Number: WC 022'105 "06 I1. Mailing Address: Producer and Mailing Address: I Fine Asian Cuisine, Inc. Richard Soo Hoo Insurance Agency, Inc. � 981 Main St, Route 28 1148 Washington $treet 'I South Yarmouth, MA 02664-5642 Boston, MA 0211 S Tel. (617)338-8168 The Insured:Corporation Other workplaces not shown above: Named Insured:Fi�e Asian Cuisine, Inc. 2. The policy period is from 5l30/2006 to 5/30/2007 12:01 A.M. Standard Time at your mailing address shown above. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers'Compensation Law of the 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 $ 500.000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 500.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes the following endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to ver'rfication and change by audit. Premium Basis Rate Per Estimated Loc. Code Total Estimated $100 of Annual Classifications St. No. No. Annual Remuneration Remuneration Premium See F�ctension of Information Page $464 Loss Constant: $20 Expense Constant Charge: $284 Minimum Premium $218 Deposit Premium $748 Total Estimated Annual Premium: $748 Premium Adjustment Period: Annually Servicing Office: New England Branch �� Countersigned 3/29/2006 at New York, N.Y. by . Authorized Representative THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY. . Edition 10/97 Page 1 of 5 Copyright,1987 National Council on Compensation Insurance : . . . TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-052 FEE: $150.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 11 I,Section 5 of the�eral Laws,a permit is hereby granted to: _ Fine Asian C�isine Inc. 981 Route 28 South Yarmout MA Whose place of business is: China Inn Clvnese Restaurant iType of business: Food Service f To operate a food establishmem in: Town of Yazmouth I ; Permit eacpires: December 31_ 2007 BOARD OF HEALTH: B `15. �$,, • � SEATIIJG: 112 � �� e� . I Ya�6�� i ��.�� R.n�. � i { J�,�y so.zoo� � I B�G. M�n�, Rs.,cxo Director of Health THE COMAZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-036 FEE: $50.00 This is to Certify that Fine Asian Cuisine. Inc. d/b/a China Inn Chinese Restaurant 981 Route 28 South Yarmou MA IS HF.REBY GRAN1'ED A COMIIZON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirry-first 2007 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendmerns thereto. In Testimony Whereof, the undersigned have hereunto a�ed their officiai signatures. BOARD OF HEALTH: 6 r� `>1. , M,$., . SEAITNG: l I2 ��y� ��,� N��l�NLO� A�Q� R.N. January 30_2007 Btuce G. Mwphy, RS.,CHO Directo�of Health I � GNINA thlN o�'`q.y TOWN OF YARMOUTH BOARD OF �c.'� �� s APPLICATION FOR LICENSE/P ��V�� ; � , , '� C� �'> � �� - i • Please complete form and attach all neces�c nts by Decem er�1,,2005 j Failure to do so will result in the retum our application p ket. =" ['�'05 NAME OF ESTABLISfIMENT: �, �� TEL. ' �� LOCATION ADDRESS:��"� J�� 2� d1,4 � �-�..}, rSZ��IG �,n,n�Gnnn�ss: S aw�.e c�,e a.�,,,� OWNER NAME: TAX ID r � '�6�3�`� CORPORATION NAME (IF APPLICABLE): ' � S . �lJC . ' MANAGER'S NAME: l� �� /�'d/ TEL. # MAII,ING ADDRESS: I 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. � l. 2. i 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 Health Departmeut will not use past years' records. You must provide new ; copies and maintain a file at your place of business. I i 1. 2. 3. 4. I I FOOD PROTECTION MANAGERS - CERTIFICATIONS: I All food service establishments aze 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 DepaRment will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. � I�Yo �I �1� �.f lQ/`� �T� 2. I PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �. �' i I�-o �r r�/ c.l��G z. �� Yu.�G, G�/�-o � � HEIIt�:FCH CERTIFICATIONS: All food service establishments with 25 seats or more must haue 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 attaeii eopies of employee certifications to this form. The Health Department will not use past�ears' records. You must provide new copies and maintain a file at your place of business. 1._�C SAO o�qiv (yiRl�.�- 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMIT N LICENSE REQiJII2ED FEE PERMI1'# LICENSE REQUII2ED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 � �, _INN S50 CAMP S50 _SWIIvIINA1G POOL$75ea _LODGE $50 TRAII.ER PARK S50 WHQ2LPOOL $75ee. FOOD SERVICE: LICENSE REQUIl2ED FEE PERMII'# LICINSE REQUII2ED FEE PERMI1'# LICENSE REQi7Il2F,D FEE PERMI1'# _Od00 SEATS $75 CON1"INENTAL S30 NON-PROFIT $2S I >ioosEnrs siso Ob-o�i I coNmaoxv[c. aso 06-0l6 _wiior.Es.sr,s S�s RETAIL SERVICE: LICENSE REQUIItED FEE PERMII'N LICINSE REQUIItED FEE PERMIT'# LICENSE REQUII2ED FEE PERMIT# _<SOsq.ft. $45 >25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: St0 AMOUNT DUE _ $ 2A0 .00 "•••"pLEASE TURN OVER AIYD COMPLETE OTHER SIDE OF FORM*""*^ : ADNIINISTRATION 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 STA'I'E WORKER'S COMPENSA'I'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta3ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: . / YES 'V NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 2005. SEASONAL ESTABLISF�IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENII�IG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVID BY'I�BOARD OF HEALTH PRIOR TO COMI�IENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL 6PENING: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 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 Yazmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service ApplicaUon form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen_desserts must be tested on a monthly basis by a State certified lab. Test resuh�must ba sent to-tlae�ealth 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 seati�g with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishme�rt is prohibited. DATE: � I �� ° � SIGNA'TURE: � Z�av �} � �.� � C,� PRIN'T NAME&TITLE: P 1 ��L, 09/28/05 � �� _- - —_- The Commonweatth ofMassachusttls = _ DepartMentoflndrsdiolAccidents - _ �N� - 600 Washuegmn Strrey �'Floor - � Boston,Mass. 02111 � Worlcus'Com�otio�Lseua A�vri: ' biq,/Eteehieal Co�tractors , .� ._ . .. . , M'y.. it«.Ys<. '�` ,ti�.- .� ti..ti .a _ .. -.r.. _- .— - � r. .x.: Vy}' �. �: ' 7evn. l�i�� iv ' � v�h� �G��c� 2 �� a�: 8'l �� S � Gc c�-n�- �� ;�, s.�U�, �/cvl-k.�.��h �. l�/�. a� ��F�� c s-v��.� ��—v� �( work site lacamm ftoll a�eesk ❑ I am a homoowna performiog all wak mysdf. Project Type: ❑New Cmahvcuon�Ranodel I�a sole 'dor and have��w in an Bwl ' Addition mm an emP�Y�Pro��B wadcas'aompe�atim fce my employees wo�iciog an this job. ��: � st�i- . sYre/: aYt�r! ❑ I am a sole proprietor,gaenl twtrxtor,or bomeAw�er(coalt ok)am!have ltiiod iLe can4actas lis[ed below who 6ave the followmB wo��s�comPea�ation Polices: �t� � silS: irei: A e�rv ure: �d�v: dV• o�re/: � . rr.rco.��...q.r.�a..r�seew xs�.rxc�.Lu n.waa ue�r..rerrr�e.re.r,��as�,s».»owr .�r�'��••wu ed.��ru.�..r.sTorwoaxortnrsm.me.rsieu�.a.y.�ur.�. �oan.sw u.�, apy NIW YaB�t dy 6e firw�ded 6e Ne Omta dlm�NIYe DIA Rrewaqe vnYn�. !do Aersby ce�aJ'y xwQee Bie piws a/sam/tlea ojpeyoy dYa dYe isjenw�ton proddel e&oae fa we AAcenrrt �� 2� c�.�- � ��-,� � /i 6 os— Printname�� I �'U l X �lQ�V I�J (O/V L� Phoce# \W / � C) ^OI � . �ddoseo�ly Mr�twrltelrWsambhepyiMdAYdyarYwaa�rial cKy er tewa: P�e r-�•• "' �t ❑tle�t H�le mpeae 6�'M�� Sdxmi O�e �Pd*w� pMrea; OOWv �t l�ca s.µ�oml � . �OV-16-20D5 WED 12:12 PM R S00 H� IN5 AGCY FAX N0. 617 338 1148 P. 02 � �CORD� C�RTIFICATE OF LIABILI7Y INSURANCE �HI�i "'ii"'i6 5' ! P�OD��" TIil3 CERTIFlCA7E IS ISSIlED AS A MA'fTER OF MFORMATION ONLV ANO CONFERS NO RIGHT6 UPON THE C�RTIFICpTE � RichaCd Soo Ijoo Snsuranco HOI.UER THISCER'(�F�CqTE DOES NOTAMENO,EXjENDOR i 11aB washington 9t, SuiGe 1 ALTERTHECOVEWyGEAFFORDEDBYTMEPpLICIE50ElOW. _ 8oaton t� 02110-2308 i Fhono: 617-330-9168 Fax:617-338-1148 INSURERS AFFORDINc COVERAGE NAIc A .... . .. . . . .._._ ._._......._... — .._.,_._...--'--- '---......... .... �wsunco INSURERA H6nn Amarica I dl�a China Inn ��s�c�,.�.�4na Caxta_ C.w�rpanios/P.,—... --�--- Fine A;•ian Cui�i�o Ina I 9g1 �.f�iri S}5c66t. At. 2� INGURGRP.y� � _...... —_.� � ,.__. ' soulh Yarmouth MA 026bA __,. . �. � �. INsuPEnE. '-'- -;V%�i . .`'�s_^ --'---- COVERAGES i' _ iHEPpLIC�E50f�NcuqqM1{CFlI5TED0ElOWhwVttlC�n153ueoTOTfIFMqURCONAMGDABOYEFONTHEPOII�YpP{ilOP�ryPIC�TCD,NO7Wflh151N1U / � �' M�rCRT�IN,�T11F.rIN?^VRANCEAFFDIfO��IfY�POLIC�ICSpCSCRIM1FOVpENF:IN SSUN.IE'CrtoMLTlo T[R S�fi%CLU610N6�ANOCONbITION9Fo�sUC11 `T�/� ,C/v� � ��, POI IGIES.ACCHEGAIC LIMRS 51I�WN MPY NAVE BEEN RE WCED 6Y pA10 CWMS. V,t� Insp oV�..�...."....__ '__ '_'_.. ...._..__ DCICPF"F C VE" rDLILWENpacfl0 —. .._._�, .`•A 6ni N6� 1VPEOfINBUNANCE pQ4CYNUMI9ER UaTE yll OqTF ibavr �uwiTs i epxr:nn�iMuwr Fnci+occunNewce s�0000 W �3GfOFENfkL...'_" —' A X fA6fAAkkCNLCENEMLLIA01�liV pAC 0365533 12/15/03 12/15/OQ p�iSesteeaaw�u�_e i100000 JCI,1`.IMSMME �$.IUC,C4�i MEOEI(P�MyanapN�uiU grjpQQ X Add CG 2011__ PCR�1KLbADVIWUfN 51000000'�^ � Iy2000000 I�. ._' _'___'_'._—__'._.._. ... GENkWLLwGGFteGnTE GCdvlM:ry.;Et3qtEUM�rnrrLiEsvux p(WPULTS•COMPIOP�GOj{100�0�0 ' � � pcucv�. . �a r �oc -" --_,...._ -- ' nurouooit¢uq�nu�v � ' ' —i CWApINEOSINCdE41MlT �ANY AUTU (Ee ectidunt) i �j A440WNLONI[0's .�_.. -. . . -._.— �SpIftlUl.koapToS (Pw�qn�an��RV s IIIfiFDAl/l0Y —'—..".".... ' -- NONdKNrpqIJ70S OODILYINJURY = (Pwacc�denq . .._..._—_ —'�. ..... ... ' -._.�. . ......._.'-'--' PROPEHIYUMaGE s �ror acci�r,q 6ARqGEIAppI1.fYY nU70CNI.V.EAqCCIOEtfi E �� ANvqU70 07ryERTF1AN ��CC b-" A{qD ONLV; ACO E --'_.._. . F7CES.FIUIUNRtLlAL1AWUP/ GN:HOCCURRLNCE E _._ . �.w_..............�._ QCCUR �ClA1M�NWDE ACGIiCGATE ......"____ $__'".-... ..... _ DCM1U7!IIIE ��" " '-`—' ' .. ` fiETENTION S - "'" " " --^-- .� ` S WORK[RECONVCNSA110N1111D - � a [MPLOYEp6'l1AWtlri TOPVLIMIfS lq,......."_'_ aNvrporH�romrprtrNcqq%�r,u7wF � 022209 OS/30/OS 05/30/06 e.i��acnnecioer+T t500000 orr�ecnnnu+arnezcwn�m �•- C o�.9gstrpn uMnr EL.DISCAu^E-FAEMYLAYkE SSOOODO sK�dn�rrso�sioNsn� E.�.o�sease-roucri� :500000 o7f�cp oESCRIp7K1N QF OPEItN71Cx'+S%�OGATON5/veMI�L[61 EKCLU810NS AOOEO bY FNnOrtSEYENr/srE[iA4 PRDVIS�ONS Restaurant m�th salos of alcoholic bevs, I,B99 Ehan 754 oP tatal sa1o�, no dance flr, no ant. CERTIFICAT�HOLDER CANCELI..pTION �lOSOYAR `��OANvosTxE�BOVE�[9Cq�0E0pOLIC�ESBCCANCC41EDUkFONE7H�pjcIryRN7qN bA1E7HEpEOF,7M[IssU�NCINSURERYJILLENDERVOR70Npll, ppY6WRITTEN Z�OW71 of South Yazmovth ry0710ET07HkCENTIFICAtEHOIDERNAMEo7oi}IELEFr,qyT�p�LupF7o00;O5�WLL TONI3 19311 IM�OBENpONLKanrroNORLIn91uT' YKIMDUpoN7H �Ng�1RCR,IT90.GFNT60N SOUth Ydtmouth MA REPResexrAmes. aurxon¢eo p�+aEseur�*rve Aichard Soo Hoo ACORD ZS(2Qq1f08� OAC012D C013pOF2A710N 1�98 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT _ . — - -- _ _ PERMIT NUMBER: #06-01 l FEE: $150.00 ! In accordance with reQulations pmmulgated imder authority of Chapter 94,Section 305A and Chapter ]11,Section 5 of the�eneral Laws,a peimit is hereby granted to: Fine Asian Cuisine Inc. 981 Route 28 South Yarmout MA Whose piace of business is: China Inn Chinese Restaurant Type ofbusiness: Food Service To operate a food establis}unern in: Town of Yarmouth Permit expires: December 31. 2006 BOARD OF HEALTH: B ' ' `�5. (�'afdoK,/�J,�y,, • sEn�rmrG: ��z A • Mc�`fe+�xo#y ?/ice C•'�ai�xa�c � . . Rode3t 4. Bao�wr, e%+� �S!� R.N. � ��i� R.N. , i � rra��t�ia.2oos � Bruce G. Mu�phy, S.,CHO Director of Health � _ �I I THE COMl►ZONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH PERMIT NUMBER: #06-010 FEE: $50.00 This is to Certify that Fine Asian Cuisine Inc. d/b/a China Inm Chinese Restaurant 981 Route 28 South Yarmout MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. T�iis license is issued in conformity with the authority granfed to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Tesrimony Whereof, the undersigned have hereunto affufed their official signatures. BOARD OF HEALTI3: B�c�xs� `�5. Cjrxdoiry�'J.`.�5. • SEA�� 2 n��, v�e� a��.�a�.�e� ��, a.�v. November 18.2005 Bruce G.Murph . MP .,cxo Director of Heal� i '� ; ck�'l�t 3 ° , ' I;<. r � i� ; < '� � 05�a,y TOWN OF YARMOUTH BO F Tf� µ��} � � �` �D o ,` APPLICATIONFORLI v:, �„-�L005 `Np� 3/Q ZOO4 Y '"S ...a �v+ � � * Please complete form and attach all neces `z9ocuments by Decembe �H DEPT. i Failure to do so will result in the retum of your application packet. NAME OF ESTABLISI3MENT: TEL. # S� � —0( � i LOCATION ADDRESS: - � O � MAILING ADDRESS: A..w�Q OWNER/CORPORATION NAME: 'S ril�. C• i MANA ER'S NAME: TEL. # MAILING ADDRESS: i 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. i � Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid i and Community Cardiopulmonary Resuscitation (yCPR). 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 busiuess. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certiSed 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 appGcation. The Healt6 Department will not use past years' records. You must provide new copies and roaintain a fde at your estabGshment 1. 2, PERSON INCH.4RGE: _- _ _-- - - - -- --_ _ _ _ __. Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �PM/� 10 A� 2. /Y(Cw (�-�(ewt ("l,."J HEIl�ILICH CERTIFICATIONS: AII food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �A V t� l�G�' 2. x c G.� (�`�- IN � 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODCING: LICENSE REQUIItED FEE PERMIT# LICINSE REQIIIItED FEE PERMI'P# LICENSE REQiIIItED FEE PERMIT t� _B&B S50 _CABIN $50 _MOTEL $50 �� _INN S50 CAMP S50 _SWIIvII��IGPOOLS75ea. _LODGE $50 _TRAII,ERPARK $50 WIIlRI,POOL S75ea. FOOD SERVICE: LICENSE REQiIIItED FEE PERMIT q LICENSE REQ[JIItED FEE PERMIT# LICENSE REQUIItED FEE PERMI'C# � _0-100 SEATS E75 _CONI7NENTAL, $30 NON-PROFIT $25 �>100 SEATS 5150 �6'S�b, 1 I COMMON VICT. S50 �6$� _WHOLESALE $75 RETAQ.SERVICE: LICINSE REQiJIl2ED FEE pER[vIIT# LICENSE REQUII2ED FEE PERMI1'# LICENSE REQi7IItED FEE PERMIT# _<SOsq.ft S45 >25,IXlOsq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. �75 _FROZEN DESSERT $35 _TOBACCO $25 NAME CHANG&: $10 AMOiJNT DiJE = S QOp.00 � •"""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•^••* 1 4 ADMINIS7'RATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or perntit 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISfIMENTS ARE TO CONTACT Tf�HEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, 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 whirlpools which have been closed for the season must be inspected by the Health Department pnor to opemng. POOL WATER'I'ESTING: The water must be tested for pseudomonas,totai 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 ADVLSORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. � FROZEPF DESSER�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: Outsi e cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparatioq or display ofany food product by a retail or food service establishmem is prohibited. DATE: o o SIGNATURE: � (ln� (�} l GL'^ � �� PRINT NAME & TTTLE:_�Y�G �(�LY "�-- 10/22/04 i _—� Tke Commonwealth of Massachusetls � � D�xmtinent ojlwdustrial AccideRis h+ = _— N/aN�wab�e -- 6�Washing?on Stree� f"F/oor – Boston,Mass. 02I11 �Wor�es'C�pnsatis�I�sva�a A�ivi� .6i�glEleetrical Co�traetws ... _. .... . ._. _ ,,.._ , *�:,., , _ r �,y„ ,. ,.- .,t=�+ � s�-,.. name: address: � ��. �U. �`'�iUu �_�� i �� . ria �� ?��-6L�� i�am rrnu�9r. I am a 6omaownc perfo�ing aR wak myaclf. Projoct Type: �New Cms�rim�Rmiodel I�a sok and]mve m�e in� pdditipn I�an�PbY�'P��idinS wa�as'�m fQ my employees wmking a�this job. �.n....�: �f IV2 t etvt '�' � I��_. � � ��r �� ' s Y ��, �� I �n.: _ � � ..�.- f� �7 3 °/�� —o G�(/ � ��_P��cSen.v�c.� Mu;ua�lNs. �o � . l�C a�o� �'S'/�/os�-o�/o� ❑ I am a sole prcrprie[or,ge�a�al eatracter,or 6omeewoer(arde oweJ aed Lave hued ihe co�actois lis�ed below who have the followiog wodcas'compea4ataon polices: �u�e• �: . +�*• � or�eiT� o�tlev# �t�e: addror dtv: �. _._-�-------. . _– - — .. -------- -- _ __. _. __. ._ - - . .. __ ._---.__ . S FaYve Y aecR ervye s rqiN uAe SedW 25A�IIIGL LS2 oi kW b He i�pwMir Ka1�Ytl ps�Me�f a t�e �b31.SKM�ldla �e 7n�+'�n we1 as dM peuMb le tie br�Na 37'Ot WORIC ORDER ud�me df1M.M a dq ap4p�e. 1 odeshW Wt a ary�ttlb YNewnt dy be trwudW M Ne Omee Kl�N1�e DIA flr cwua�e sermnW�. !do hersby n�y rnder dYs pG�a m�d pen�8ea nID�Y M�t Me tafgnweNen prsddal ebnne b�re e�/csmrt s�—X ic•� e2c�.ti- c,,ra.�..,�' �,.,� I1 (3 °�°� ,/� Printnarce �(J��1 17-1 W/V I,J /�� /V � P6oce# � �t7.�� T��Y'I .�c6�.xe.ry a..at.rlrcrl�,re,beeea�WetdAreYrarM...meh1 dyerfewa: �g r� _" ❑ehalc If I�!mpea�e b�eqi�ed ❑��Bsud �'s Osm 1�� ; � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #OS-039 FEE: $150.00 In accordance with re�ulahons promu(gated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�'ieneral Laws,a pernut is hereby granted to: Fine Asian C�isine Inc. 981 Route 28 South Yarmou MA Whose place of business is: China Inn �' Type of business: Food Service � To operate a food establishment in: Town of Yazmouth Pemut e�ires: December 31, 2005 BOARD OF HEALTH: B 9!. �'osdo.c,�$,, • SEA�G: ��2 p��"�af� v�e� �� R.N.� ; A.�lf3..�, R.N. - � � i I J�,�y i i_zoos Bruce G.Murphy, RS.,CHO Director of Heal I THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH I PERMIT NUMBER: #OS-029 FEE: 50.00 This is to Certify that Fine Asian Cuisine Inc. d/b/a China Inn 981 Route 28 South Yarmou MA IS HEREBY GRANIBD A COMMON VICT[TALLER'S LICENSE In said Town of Yazrnouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commoirvvealth respecting the licensing of common victualters. This license is issued in confornrity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereumo affixed their official signatures. BOARD OF HEALTH: Be.cyo�u.s�!. (�'au/,a,g�'J.$. ' SEn'cuvG: 112 �a�ucv�/Nc.�to� 7/t�(��t Rode3t�B3orw�� - �� R.NR.N. _ January i l.2005 � Bmce G.Murphy,MP , .,CHO Director of Health � oF.y,�� SfC . o TOWN OF YARMOUTH ��,, __, `j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 ,��*�„`,,;6`�'� Telephone (508) 398-2231,Ext. 24] — Faac (508) 760-3472 ' B O A R D O F H E A L T H ,;•=-s f� � p+? � r; i fni L � To: Yarmouth Boazd of Health Permit Holders i , €y �, ;;;�j; ,,p� From: David D. Flaherty Jr., RS. H E"' E PT. � xeahn�nspector �D� _. _ _ _..._ � Town of Yar�uth � ; Re: Federal Taac ID Number i Date: March 22,2005 � � i The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of tbe details that they require we �, send to them is every es4ablishme�'s Federal Employer ldentification Number(FEIIV)otherwise I known as your"I'aa�ID Number". This is purely for administrative purposes only. ! So� businesses use the ow�r's Social Security Number (SSl� for tUis purpose. If this is the ' case for yow establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and retum this letter to i ' Yarmouth Health Department I 1146 Route 28 South Yazmouth,MA 02664 �, 'I7�ank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to call. The office hours are Monday to Friday, 830 a.m to 4:30 p.m. The 'I telephone nwnber is(508) 398-2231,ext. 241. Establishment: �I�Y1R [�'SI�wl t 1�1Q , �� , ��.,t.,�" �nv or ssrr: �;-- ti 6 S— (o � ��i��4�w„i�.:' � Location Address: �9 �1 /�'�� ?� S�(,tX�'Cti �`Cvf"1'�'t,17�'t'�L (� ��. oZ�6L� i s�g��: l3� Yi�� Guo � Print: ��Lo YfJ19 GLC�U Title: ��S(I�KM-'� �� ;,_��-• L�.SP�„� �'' � R � / \ ^ .:Y n. . . �' j .-1_,�'�� 'Y/ yq U� C.14lNf� f 0.1/J °�-"o TOWN OF YARMOUTH BOARD r�C'� H i � _� ,� _ , , s �, o�� APPLICATION FOR LIC �� -2�04 - " ry� " r S � * �� r, ¢ DEC 0 8 2003 Please complete form and attach all necesS�do�urrients by Decemb r� 2003. Failure to do so will result in the retuut�of your applicaUon pack �ALTH DEPT. C k�t ) /�� LQGATION ADDRFSS• C�,�I o � , j� ; � �-f T N � S( rS � 'S N : t,, o�.w /� M�IA .�NG ADDRFSS• R G ua.� �3 oV� POO .RTIFI ATION • The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatot(s)and attacii a copy oi ihe certificaiiun io this mrm. - 1• 2. ; Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. T6e 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. 4. FqOD PROTECTION ANA R - C RTIFI ATIONS• � All food service establishments are required to have at least one full-time employee who is certified as a Food ! Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. � You must provide new copies and maintain a file at your establishment. � �. ��.� y� 2. � '�- PERSON IN C�-LARGE: - --- - _ _ ____ ___ Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation. � i ��i�2,q G/� a. � HEIMi ICH CERTIFICATIONS: iAll food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Ma�euver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. ) You must provide new copies and maintain a file at your place of business. i i. e nY`,1 ��`'� 2. 3. �— 4. � RESTAURANT SEATING: TOTAL#�Z i wnc�xc: OFFICE USE ONLY ! LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT# UCENSE�REQUIRED FEE PERMIT# _B&B S50 � _CABIN - SSU - iN6TEi -. ___ .- -550. . . � _INN $50 _CAMP E50 _SWIMMINGPOOLS75ea _LODGE S50 _TRAILER PARK S50 WHIRLPOOL S75ea. � FOOD SERVICE: UCENSE REQUIRED FEE PERMIT 8 LICGNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT S25 I >I00 SEATS $I50 :(fQ�F-� 1COMMON VICT. S50 ��V'-0�� _WHOLESALE $75 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FBE PERMIT p LIC6NSE RFQIJIRED FEE PERMIT# _�50 sq.ft. S45 _>25,000 sq.R. 5200 _VGNDING-FOOD $20 _Q5,000 sq.ft. S75 _�RO"LEN DGSSLiR'P S35 _TOBACCO S25 NAMF GAAIVGE: �10 AMOUN'I'DUE _ $ 200•�k1 � +••••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*•" � � �. ADMINISTRATION Under Chapter 152, Secrion 25C, Subsecrion 6,the Town of Yannouth 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFP'IDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. ArFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewai or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES x NO NO'TICE:Permits run aiumally from January I to December 31. IT IS YOUR RESPONSIBILITY TO RE1'[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. ' SEASONAL ESTABLISfIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i� TO COMMENCEMENT. RENOVATtONS MAY REQUIRE A SI1'E PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENIING: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 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 are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarrnouth must notify the Yarmouth Health Department by filing the required Tempo Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the H�th Departrnent. _ �ROZF.N DF.. RTS• — , _ - - - - -- — - . � 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 wili result in the suspension or revocation of your Frozen Dessert Permit until the ' above terms have been�net. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),p�have prior appmval from the Board of Health. OUTDOOR COOKING: OuWoor cooking,preparation,or display of any food product by a retail or food service establislunent is prohibited. '; { i I / ��.� 2/ ��'�03 .*��t�: l�}o �N� �µo .��:�° I l✓ o R�S ( �si� 10/22/03 3 ,I , � � 4 � The Commonwealth of Matsachusetts = Department ajlndustrlal.-Iccidexu i ; 0/nceo/Iaresa►ysdiss , 600 Washington S1reeL � Bosron, Mass. 02111 ` �� ,` W'orkers' Campensation insurance Affidavit Aoolicant informallon: p► +.iepRiNTTrd.�ida namc�. lil't"�� (�A ��.(v 1�1 � i location� � . ut� nhone a 0 1 am a homecwner pznortning all work myselE � I am a sole propriceor_r.,'. ha�e no one��orkin_ in am capacih� �I am an employer pro�iding workers' compensacion for my emptoyees workine on this job. camnanv na�„�• �NF �s'il{�1J W 6rJ l 1UCs` C��' - ,�a��,5: �g � 2n= �fl cih" �' I��'��1..)�� phenetl . insurance co `l��iU.0 ��II�UQCL �n�� l_O nolicv q �1 Q o1�d I � "7 � I am a sole proprieroc _enerel contraetor, or homeowner(circle onel and hace hired[he coneractors listed belo� ��ho ha�e thr follo�cin_ «orkar; :ompensation policas: tomoanv nnme�� add ress: � . ��R'� nhone q• it�surancc co. _yelie�•q S9moanv name: addresr uh" � p6ee��• � insannee co. ��* . . F�ilure m stcure tovenee as required uoder Seenoe$A o(MGL IS2 n�Ind to 1�t iopailio�of eriNW padtles of�O�e ap m SI�00.00 a�d/or � ooe years'imprisonment a�xell ae eirii peodHa ie Ipt form of�STO�WORK ORDER a�d a 6�t of SIOO.M�d�q�io�t me. 1��denta�d tlat t eopy of thb etaeemen�m�y be for.nrded to 16e 011lee of Invatlg�6oet of the DIA far eovera�e verilfutlw, . 1 do�hrreby c[rtij}•under rhe pains and pma(ties ojpery'ury�hm 1ht injorrnation provid�d abovt It nut and rnrrcet ��`� o � �q � �/r�� /o� n I/�l 0 � �.l(��B) � G�— ol�f( .. olTcial use only do not r rite in�Ais arca to bt tompleted by eity or lows ollkial eity or�own: YARMOIIT$ _ .penuiNleeeu M nBuildioL Depmmeat � pLleenfie`Bo�rd 0 theck if immrdia�c response i�requirM 261 OStlettmen'e ORee (SOS ❑He�trE Departmmt . contatt penon: �Pho�p._ _� 398-2231 eat. nOther 1 , . �� YA�'�� TOWN OF YARMOUTH � 1146 ROUT'E 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 � MATTNCNCFS � �+t��ofo� Telephone(508) 398-2231, Ext. 241 — Fax(508) 398-23G5 I � BOARD OF HEALTH i December 17, 2003 i Bao Ying Gao, Pres./Fine Asian Cuisine Ina d/b/a China Inn 981 Route 28 South Yarmouth, MA 02664 � Dear Mr. Gao: Enclosed please find a copy of your check#1111 payable to the Town of Yazmouth in the amount of $200.00 which was submitted as payment for your food service and common victualler pernvts for the yeaz 2004. Please be advised that your check was returned fo insufficient funds. Please re-submit the permit �. , : _. ; fee o � �, " ,for a total of 5230.00,in the form o �' .,.. , . . ,� ,� ��. If you have any questions,please feel free to contact me at the Health Department. I can be reached at (508)398-2231, ext. 241, during the office hours of 9:00-11:00 AM on Monday through Friday. Sincer� �ruce G. Murphy, MPH Director of Health BGM/maf enc. cc: file L� ��' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1'�NT PERMIT NUMBER: #04-056 FEE: $150.00 In accordance with re atians pramulgated under authority of Chaptea-94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a peimit is hereby granted to: Fine Asian Cuisine, Inc., 981 Route 28, South Yazmouth, MA Whose place of business is: China Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31. 2004 BOARD OF HEALTH: Bn 2R. ljo+e�avs,/1 M� .$n.,' � SEATAIG: ]12 /��G�N�� OelJO3plOnt��' �V,lCi NJ4[3N[G/L . Raai�li� 6'�4lifB� lifB7R Off�fOli po�j ✓I December 16 2003 � :-c-�.�" J `^.� .a� i Bruce G.Mu�phy, S.,CHO i Director of Health i I i I II THE COMNIONWEALTH OF MASSACHUSETTS „TOWN OF YARMOUTH � PERMIT NLTMBER: #04-042 FEE: 50.00 This is to Certify that Fine Asian Cuisine. Inc. d/b/a China Inn 981 Route 28, South Yarmouth, MA IS F�R�Y GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the licensing of common victualler's. Tltis license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: BaafarrcE.s$. �'trtdo�r, M..`b. ' sEn�a: 112 �� Q/� � � Sl.�.i R./r.� f) � December 16.2003 � ��^�,,�� , ' " ' �� Bruce G.M�uphy,MP ', .,CHO D'uector of Health P.M.O •�9�357aS 5�P7J �°�A"�so TOWN OF YARMOUTH BOARD OF E p ��$ � , APPLICATION FOR LICEN 0�� `� � � � �/ I� � �"� ° ° MAY 2 9 2003 * Piease complete form and attach all necessary d e s by Decem er 31,Zpp Failure to do so wil(result in the return of your application pac e�EALT�DEPT. I�IAME OF EST I HM NT• (1 F-f � �I ou _ Z p (la u � E r S 1�IANAGER'S N MF• �l�.l �1 A-ti� TF # h��' 77S'—� rJ�`� �AILING ADDRESS: �.�9 JLl A�t l� l., .F � �r(yp�y�/jt/I S�� ()2(c t� i POO RTIFI ATION • The paoi supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy ofthe certification to this form. L 2.. ; Pool operators must list a minimum of two employees curmntly certified in basjc water safeTy, standazd First Aid and Community Cazdiopulmonary ResuscitaEion (CpR} Please list these employees below and attach copies of employee certifications to this fonn. The Heslth Departmentwill not use past years' records. You must provide new copies and maintain a t'de at your place ofbusiness. ' 1. 2 _ 3. q. FOOD PROTECTION MANA R - RTIFi ATION • All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary'Code for Food Service Establishments; 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintaip a file at your establishment. 1. HEn�i1"� Yfi-n�C�- 2. , . PERSON IN CHAR � Each food estabfishment must have at least one Person in Chazge (PIC) on site during hours of operation. , 1• �`II ^!.�x� �-s� z: K�n;�`1 �I/�nsC� I H IMT.I H RT FI ATIOI`TS• All food service estabLshments with 25 seats or more must have at least one emplQyee 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 fo►m. The Healt6 Department will not use past years' records. I You must provide new copies and maintain a file at your p(ace of business. i. � 2. �,� �f'� �A.O 3. q � _ I T A : TOTAL # I l Z j �.onc►nc: OFFIC ON Y _ ' LICENSE REQUIRED FEE PERMIT H LICENSE�REQUIRED FBE PERMIT# UCENSB REQUIRED FEE PERMIT# _B&B S50 _CABM S50 _MOTEL S50 —� 550 . ... . ._C�P� .. �...��550 � � � _SWIMMINGPOOLS75ea � . _LODGE E50 _TRAILER PARK $50 � _WHIRLPOOL $75ea. FOOD .RVI . . � � . LICENSE REQUIRED FEE PERMIT# WCENSG REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# �0.100 SEATS S95 _CQNTINF.NTAL S30 NON-PROF(T S25 ' �>I00 SEATS 5150 �3-(q � �COMMON VICT. 850 O ' # 3-!Og _WHOLESALE S75 RBTAIL_ .�� . � . .. . -� . _. . � .. . . � LICENSE RGQUIRED FEE PERMIT# LICENSE RCQUIRED F8G PERMIT# LICENSE REQUIRGD FEE PERMIT q i _<50 sq.ft. S45 _>25,000 sq.R. 5200 VENDING-FOOD 520 <25,000 sq.ft. S75 .. .. :�_PROZf�N DF.SSt�7"S9"S � :� ._ .. . . . � I _TOI�ACCO S25 NAME__ CHA�y $10 � � �: � " ' —r - AMOUNI'bUE _ $�iO.c70 I , "`""`PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"+•* % { a • . . . I , � .�.�F� � ' . � �e °. ADMI.NI�AA'FION Under Chapter 152, Section 25C, Subsection b,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 � Compensarion Insurance. THE ATTACHED STATE WO�tKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR - - - - - CERT. OF INSURANCE ATTACHED �� IE �x� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE C�HECK APPROPRIATELY IF PA1D: YES� NO , NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBiLITI'TO RETURN TF�COMPLETED APPLICATION(S)AND REQUII�LED FEE(S)BYDECEMBER 31s 2002. SEASONAL ESTABLISHM�'ITiTS A�RE T�CONTACT TF�I3EAL"I'I-I DEPART[vIENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE>SEASON. � . _ r „ .. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEI�IT, MQTEL OR PQOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TH�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.� � < ADDITIONA[. RF:GUi;ATIONS • POOLS ;, POOL OPEN[NG:All swimming,wading and whirlpools which have been closed for the season inust be inspected by the Health Department prior to ppening. � POOL WATER TESTiNG: The water must be tested for pseudomonas,total coliform and standan�late count by a State certified lab,prior to opening, and quarterly`thereafter. POOL CLOSING: Every outdoor in ground swimming pool rriust be drained trr;�ov�red w'sthin seven;(7)�ays of closing. �R , FOOD SERVIGE � �nxcrr ER A1�VISORY• Each food establishment wluch serves or sells ready-to-eat,raw or undercooked,animal products are required to post Consumer Advisories. , , CATERiNG PO .ii CY• Anyone who caters wrthin the Town of Yartnouth must notify the Yarmouth Health DepaRment by filing the required'Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtame�at the Health Department: �ROZFN D�SSERTS• Fmzen de;sserts 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 tevocation of your.Frqzen Dessert P.eemit until the above terms have been met. � ,, _ �. (lIi'1'SIDE CAE�'S: i �',. �,`•�� Outside cafes(i.e.,a}itdcr9x s�e,at�.p,��"�1h N!� t � „ , � - . ,: _. � . - � >a�,. ,�.. , �r„=�a ,� � Er , ., "� ' "'t� � � , MAY-30-2003 FRI 08�47 AM R S00 H00 INS AGCY FAX N0, 617 338 1148 P. O1 � RICHARD SOO HOO INSURANCE ACyENCY, INC. 1148 Washington Street, Suilo 1 May 30 , 2003 Boston, Massachusetts02118-2108 Tel. (617) 338-8168 Fax(617) 338•1148 Mr llavid D . 1�'7.aherey Jr R,S. Lax �l 1 5U8 398 0836 'fawrt uf Yarmouth Hcall•h Offite 1 1/+6 �t 2 8 � � (`, z V� �\v1 f= (� Sauch Yarmoi4ch, M� RC, : I�'i.ne Asian Cvisinc Inc MAY 3 0 20�3 9S1 M1Xn strcEc � ��T tDEFT• South Yarmoueki, Ma ��"'"'""" DeAx Mr Flaherty ; 'Che owners tiave requested us to fsx you this cozrespondcnce to wLL : placemnnL of workars compensati.on lnsurance . t�ffec�ive this dfly, coverage has been bound writh Public Serv3cc Mutal In:.urance Cwmpany, policy to be is�ued. Ki.ndly ca.l1 it thcre are any quest3.ons. Si.nceral.y, 1 � Richazd &oo Iloo , CIC ,T.7:A ' TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBBR: #03-191 FEE: $150.00 In accordance wit6 regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter ; 111,Section 5 oftlie General laws,a permrt is hereby granted to: 1 Fine Asian C�isine Inc., 981 Route 28, South Yazmouth, MA i, Whose place of business is: China Inn IType ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth � Pennit expires: December 31. 2003 BOARD OF HEALTH: �(razlte'r�, i�i!luEcs. ��a�uxs� i SEATING .I 12 .._._.._._._. �f�c�L/A�K�. �OS�O/K/�.�� .. �1C1 � �0-�`�,-L��.y��ROfIK. L� � �4�uC�z /IiGf/GL/AtOtS � r� s S R�. �� i � May 29.2003 � G. hy, R.S.,CHO Director of Aeal I I � � � � THE COMMONWEALTH OF MASSACHU5ETTS TOR'N OF YARMOUTH PERMIT NUMBER #03-108 FEE: $50.00 � This is to Certify that Fine Asian Cuisine_ Inc. d/b/a China Inn 981 Route 28, South Yarmouth, MA i IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE I � In said Town of Yarmouth and at that place only and expues December thirty-first 2003 unless i sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of conmon victualler's. This license is issued in confornuty with the authority granted to � the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo�the undersigned haue hereunto affixed their official signatures. , BOARD OF HEALTH: �aalia sf� x�. � � sEnn'rixG: 112 Gu•fa.xl,c D. � �K.a.. `1/G:e ,�aB�t�. �war.�, elark � �atrti�'�Dexerotl � S�4 .�t. � May 29.2003 ' � Y� •� Director of Health � ,�___ , �E Y^R TOWN OF YARMOUTH BOARD O TH € �� ''J � s 1� 3 � APPLICATION FOR LICENS�E 03` I , � j f',^i � rC�s - � � ��rj��r'� � .. . i * Please complete form and attach all necega$r�,dpc��by ec�in ert3 E",29U2 "_ =:. i Failure to do so will result in the reti�of�+o'ur application packet. � -"��"" � T IS O 0/ / �- c. I, G�✓ - ' OWNER/COIZPORATIQNNAMF.: Cfint.� 7h�lPc-T�..��Al'r' �Nti-2P�/�SL ; -- - - .�9 � MAiT.INGE�nnRFSS� R$ 1 1�Ir�rJ Ci. �a. a✓i�noa� . I � POOL CERTIFICATIONS: iT6e pool supervisor mnst be certified as a Pool Operator,as required by State law. Please list the designated Pool Opeiator(s)and attach a copy of the certification to this form. i 1. 2. ' Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscita6on(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deparlment will not use past years' recorda. You must ! provide new copies and maintain a file at your place of business. ' 1. 2. i 3. 4. I� I i FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. ��N IJ� �-El� 2. ___ P�RSOAI II��F�ARCs�:_ - - Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1, �IJ1�� 'f�dlil� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions 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. �A! (�F16�n1 2. � V `� ��Ti (�a�w 3. 4. RESTAURANT SEATIlVG: TOTAL# tt � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# _BBcB $50 _CABIN . S50 _MOTEL $50 _INN $SO _CAMP S50 _SWA4bqNG POOL�SOea _LODGE $50 _TRAILER PARK S50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _Od00 SEATS S75 _CONTINENTAI, $30 NON-PROFIT $25 1 >100 SEATS 5150 ��✓"'OrI 1 COMMON VICT. S50 D# 3—(}S� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUQLED FEE PERMIT# _TOBACCO� S20 _<25,000 sq.ft. $75 _TOBACCO $20 <50 sq.ft. S45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 xn�cxnxcE: $�o AMOUNTDUE _ $ 200.00 **••*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** � i i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit ta operate a business if a person ar 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 ATTACHEL� � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 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 OPENING:All swimming,wading and whirlpools which have been closed for ttte 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 wunt by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSLJMER 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 Yazmouth 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: 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 appmval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a tail or food service establishment is prohibited. � DATE: � �` � t ` � `� SIGNATURE: @M'�/ �V � PRINT NAME & TITLE: I�A-N rJ U �d-tm tn� �d,l.<�t e�� --�� 10/18/02 : � The Commonwea/!h ojMassachusetts = Depar�ment ojlndustria/,-iccidents ; 0/JICe01//rCStl�ftl/If 600 Washington Slreet Bosron.Mass. 02111 ` '� '` N'orkers' Compensation Insunnce Affidavit Aoolicant information: PI AseYRINTier.'ida nam�� 'E'� rf� {� �9J � . locati�n -I � I NI�I N S f . ��, So, �arvv�oU �, oho��a �o8-3R8o��l � I am a homeowner pertorming all work myself. � I am a solz proprietor �r.,'. ha�e no one norkine in an} capacin� � I am an employer pro�idin� workers' compensacion for my employees workine on this job. comnanyname• �f'FOW tNUFS7M�AIT �7�I7��P (�l?fC� adAress• R��`�l� � ( S1S.}': �D. ,�(�/1�W101�1 ,�/l� r'6O�S aa�6� ehoneN• �O6 " 3(g ��Q�� { insurancrco. O . �7GlC�/� C�o. policv# �"L'a��6�� '�F9Q�oZ�i / � I am a solz proprietor. generai controctor. or homeowner(circ(e one) and hace hired the contractors listed below �.ho ha�e the follu�cing �corkcr :ompensa[ion polices: comoanv name: � address• ciR�: phone k: insurance eo. pelie�•# tomoanv name: tddress• [12Y: phoee M: � insuraneeco. � eellevM � � � F�ilure co seeure corente n required ueder See6os 25A of MGL 152 n�ind to qe i�paido�oteri�iW peWtln of�O�e ap m SI�00.00 aW/or oee ynn'imprisoameot u w�di a�tiril peoalHa io tht form o(�SiOP WORK ORDER�ed a flee of 5100.00�dar K�i�st m� [��denn�d Hat a eopy of tAy satemem mir br for.v�rded to the ORee of lavotig�uom of IEe DIA ta eoven�e verilfutle�. � - � 1 do�hneby ctrtij}• nder e ains and pmalties ojperjury thal�he injormation providtd a6avt is lnte wd rnrrceY Signaturc /�2 '�J'0 a Printname �i¢/1/�� /,�f,BGt/ PhoneM ��d 77Q �� ., olTicial use onl�� do no�r rite in Ihis arta to be completed by eity or town o111Na1 city or town: Y��DT$ _ � .peneiNiteex M nBuildiog Departmmt � � �Liecnsioe Bo�rd � cheek if immcdiatc response i�required 261 OSeleetmen'e ORee (508} 398�2231 p,at, ❑HnItE Dep�rtmeat - con�act person: phoae M•_ � _ nOlher . � . � 9fORK8RS C0�8NSATION AND SISL07CSR8 LIABILITY �[MMtIe�tGqWd POLICY INFORMATION PAaB Argoaaut Inauraace Compaay MSMLO PARR.CA Carrier Code : 14095 POLICY NOd�BBR: 7PC-2 9-643-600269 RffiiSNAL OF: N86i 1. Name of Iaeured CHOoi INVBSTl�1T SNTSRPRISB INC. DSA CSINA INN Mailiag Addreas 981 MAIN STR88T 809T8 YARMODT8,1lA 02664 Tyge of 8atity: Corporation Interstate/Iatrastate 81sk I.D.No. : Federal 8mgloyer I.D. No. : 042973607 8tate I.D. No. : Other identificatioa N�ber Locatioaa - Other vrorkplacea not ahovm aboves S88 SC�DIILB OF LOCATIONS Producer:� S 8 S1QT8 8 CO�AIQY, INC 661 SIG�ffi,AND AVSNUS NS�AAM �IGHTS,MA,02494 Producer Code: 8648 2. Policy Period: From 02/03/2002 to 02/03/2003 12:01 A.M., staadard time at tha iasured's mailina a8dreaa 3. Coverage A. oPorkers Ca�peaeatioa Insuraace: Part One of thia policy applies to the �Pozkere Compensation Lav of the followiag statna: � 8. 8mployera Liability Iaauraace: Part Tvro of this policy applies to rrork ia each atate liated in Item 3A. The limita of our liability uader Part Tvro are: Bodily iajury by accideat each accideat $500,000 Hodily iajury by diaease each employee $500,000 Hodily injury by diaease policy limit $500,000 C. Other Statea Iasurance: Part Three of thia policy appliea to ALL 3TATES 88C8PT any atate liated in It� 3A.aad the atatea of AK. ND. OH. 9PA. NV. 1iY D. Thia policy iacludea theae endoraementa ead echedulee: S88 SCSEDDLS O8 B�TDOR$8!�'1TS 4. The premium for this policy will be determined by our Maauals o£ Rules, Claesificatioaa, Ratea aad Ratiag Plans. Al1 iafornatioa rsquired in tha echedules attached to thia iaiormation page ia subject to verificatioa aad change by audit. CLASBIFIGTIONB AI� RATBS: S88 SCFIBD9L8 OF PR�IDM IN8'ORMATIOIQ TOTAL 88TIelA'P8D ANNUAL PRBMIDId PLIIS SIIRCHAR(i83: $1,387 laliIMO1S PR�[I41[: $500 DSPOSIT PRSISIDI(: $0 Aaaiversasy Dat • � Premium Adjuetaant Period: Noae Couatersiqn by: Date IsaueB: 1/31/OZ 1PC 00 00 01 A (6-90) j . . , , � TOR'N OF YARMOUTH ! BOARD OF HEALTH ! PERMTT TO OPERATE A FOOD ESTABLISHMENT PERM[T NUMBER #03-077 FEE: $150.00 In accordance wifL re�u1at�ons promulgated under anthority of Chapter 94,Section 305A and Chapter j I 11,Section 5 ofthe�'renerxl Laws,a permrt is hereyy granted to: IChow Investment Emerprise, 981 Route 28, South Yarmouth,MA i ! Whose place of business is: China Inn t � Type of business: Food Service I To operate a food establishment in: Town of Yarmouth ; Permit expires: December 31. 2003 BOARD OF HEALTH: �ka�a:� Zilfi.4a. �iGaar�,aa sEnn�raac: 112 �o '�«rGc D. Cjmides. 711.D.. `Ulee I ,� `�. �warw. �k � �a�rtu6'1X.cDmr.rrott i � K Sk� �7� Decemberl9 ,2002 ruce G. hy, S.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN 0F YARMOUTH PERMIT NUMBER: #03-051 FEE: $50.00 This is to Certify that Chow Investme�Enterorises. Inc. d/b/a China Iffi 981 Route 28;South Yarmouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE I In said Town of Yarmouth and at tUat place only andexpires December thirty-first 2003 unless J. _ .- soonersusp nefied or revok�for vialatiaaof the hws ofth��ommonwealthiespectingth� — licensing of com�n victualler's. This license is issued 'm conformity with the authority granted to, the liaensing authorit�s by General Laws, Chapter 1�0, aod amenda�nts thereto. In Testimony Whereo� the u�ersigned have hereunto affixed their official signahues. BOARD OF HEALTH: �� xdUkai, � senn,�rc: �12 � D. Cjmdak 9ll.D.. 9/tee �?��. 'breaMe, Qlark �aDuek 9R'dDora�atl Sk .�Z. Decemberl9 ,2002 1 y, Director of Health ''+' -� �r ^-✓ '.`�� C#FtIJA tNN �10F '� TOWN OF YARMOUTH BOARD OF HEALTH •��3/ �a6a,c� APPLICATION FOR LICENSE/PERMIT-2002 " _ '_: � ; • Please complete form and attach all necessary documents by December 31, 2001. Failur�'feEda�s�Fv��l��esul�in the return of your application packet. , - i OF ESTABLISHMENT: H I n�A N,�! TEL. # 39,P o�� / LOCATIONADDRFSS: I 1�lA�nl 5 i Sn. arvr�e!�n . MAILIN ADDRESS: � `f?.l �tiG . MANA ' AME: T # / / LING ADD 9 l�'! � ^ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 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 aad maintain a£le at your establishment. i. `7�n�tit Cl�m�� a. PERSON IN CIIARGE: -- ` Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. L �GC»h� �.��1� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. `,�, av�c�ie �.��m 1,� 2. �lX1(3'✓ �n in� 3. 4. RESTAURANTSEATING: TOTAL# [/� OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&.B � $50 CABIN $50 _MOTEL � S50 INN $50 CAMP � $50 _SWIMMING POOL SSOea _LODGE $50 _'['RAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE. PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _0.t00 SEATS $75 _CONTINENTAL S30 _NON-PROFIT $25 �>I00 SEATS $150 �03-b�1 I COMMON VIGT. $50 ��$ _WHOLESALE E75 RETAIL SERVICE: LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 <25,000 sq.ft. $75 _TOBACCO $20 <50 sq.ft. $45 � _>25,000 sq.ft. 5200 _FROZEN DESSERT S35 NAME CHANGE: $l0 AMOUNT DUE _ $ 200•O� ••:**pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•'*" � ��1 �� b�.. . ��.. . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMtiN'1'FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�tING 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 OPENING:All swimmiug,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 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 are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yannouth 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 Depaztment. _ - -- -- FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepaza6on,or display of any food product by a retail or food service establishment is prohibited. DATE: l I' a�-�O / SIGNATURE: GlX�1d '�i �'!/ :/" � PRINT NAME&TITLE: Z�y (_,l��,i/ '��/�?�2KJ 09/11/L�1 i _ 4 w . - `�\ The Commonwen[lh ojMassachusetls : Deparrment ojlndustrial.-iccidents ; 011/ce ol/ar�estlOs!liis 600 Washington Streel ' Bnston. Mass. OZIII " W'orkers' Compensation Insurance Affidavit Aoolicant infarmallon: PI *�ePRiNT7.s.'t.fp � eam4�. (_.�f/ /V� _L X� � loc�tinn� �I� I !l�//l� c�� / � .,a, �D, Y/.L,,��-(OG(Tff ono��a SOc� �`�� 0/�/ � I am a homeoµner pzrt�rming all work myself. � I am a solz propriemr r..d ha�e no one ��orkin_ in am capacity [uf I am an emplo}e/r*pro�iding uorkerz' compensation for my employees workine on this job. comnant name: (�L�///UP� �N✓V aJdress: �2C , /�C�}//1 L��. titv: J�. /GC{� 1�V1�l/t�i/�} �honep• S�� J�� a ��(" I insuranceco. � � C�I ✓h� oolicyN ��6�6783 Q I am a sole proprietor. _eneral contractor. or homeowner(circfe onU and hace hired the contractors listed below �iho ha�e the follo��in_ �corkzrs .ompensation polices: companv name: address• cin�: �hone M: insur�nce co pelie�•# eomnanv name: . _. . -- -_ _ _ . ._-- - -- -- - -_. __._. _ . _------ -- -- --- - -� ---- addrees: . . . �y: phoee M• � insuranee co. � �Rev M � � Pailun ro secure covenee u«qmrcd uuder Setnon 25A of MGL 132 e��Ind to the i�po�idoa o(eri�iW pndtle oh O�e�p to SI¢00.00��d/or ooe ye�n'imprisoomrnt u w�dl a civil pendtla io the form ot�STOP WORK ORDER�ed�Ifee of SI00.00�d�r q�ion m� 1 ndmta�d tLat• eopy of thia shtemrnt m�y be lor.v�rded to the Olfiee of Inratlquom of the DIA for eoven�e veriflatlw. /da hereby cenijp und r-the ai and pe alties ojperj thal!ht injonnalinn provid�d abovt is due and corre� Signaturc l�-��S�� Printname �/�(�� /,��✓1� PhoneB � /!T ��-l�� .. olTicial use onh do no�rrite in this arn to be compleud by cih ot fow�o oflleial eiry or town: Y�M�DTQ _ permit/liceroe N nBuiidioq Dep�nmcot � ❑Lieensio6 Bovd Q check if immedia�e response ie requirrd 261 �Sdectmen'e Oflice �HedtA Depanment � con�ac� person: phoneN:_ �508) 398�2231 eat. �Other I , soe4s�ea TIG s P � C � A � T ~ WOfiKERS' COMPENSATION AND EMPLOYERS� LIABILITY INSURANCE POLICY s.- RENBVHAL CERTIFICATE _.�,,..�� N¢�—••��• FAIRMONT INSURANCE CAMPANY #19518 P�I�T�IVE�72,FT�31-5000NG, TX 75039 � IN CONSIDB3ATION of the payment .of ice pn o�cy ym o �r�niu», it is agreed that the expauig policy s� wcs �s renewed for tF� period stated below. THIS o icy er RENEWAL is s�bject to aH the t�ms of the go646783 expiring policy as of its date of expiration, Previous roi�ey: except as otherwise specifi� tlerein RENEwAL AGREIDtBNT: RA2 i. Insured's Name and Ad�ess CFiOW INVESTHENT SNTERPRISES, INC. produeer Code 62Y760 DBA CHINA INN Producar S.H. SMITH & COMPAN'/, INC. 981 MAIN STRSET S. YARMOUTH, MA. 02664 EIN: 042973607 IIN: The It1Sur8d IS CARPORATION _ Other workplaces not showm abov� sES SCHEDULE W40353 2. The policy period is from o2-03-2001 to 02-03-2002t2.01am Stendard Time at the insured's mailing address. 3. 0. Workers' Corr�ensation insurance: Part One of the policy applies to the Workers' Compensation Law of the states hsted below. SEE SCHfiDULE W40446 B. Empioyers' Li�ility Insurance: Part Two of the policy applies to work in each state listed m 3.A. above. The limits of our liabi6ty under Part Two �e: Bodily Inj�xy by Acciderit $500,000.00 �ch accident Bodily Injury by Disease $500,000.00 Policy limit, 5500,000.00 each employee C. Ott�er State Insurence: Part Three of Uie poliCy applies to the states, if ar�y, listed below. ALL STATE9 EXCEPT NORTfi DAKOTA, OHIO� WA38INGTON, WEST VTRGINIA, WYOHING, MAINS, AND STATE3 DESIGNATED IN ITElI 3A OF THE DECLARATIONS. D. This policy includes these endorsements and schedules: SEE SCHEDUT,E W40179 4. CLASSIFICATION OF OPERATION PREMIUM BASIS RATE SEE EXTENSION OF INFORMATION PAGE MP, INDU3TRIAL ACCIDSNT A38ESS1ffiNT-PRIVATS: ( 0,867 % .044 = $38) Minimum Deposk Total Estimated Premium S2oo.00 Premium S1,o8i.00 Annual Premium S1,o81.00 Direct Hill If indicated, interim adjustments of premium shall be made: t ) Semi-Annual ( 1 Querterly 1 1 Month�y IMPORTANT NOTICE ��-+�` PLEASE READ YOUR POLICY CABEFULLY. M euwmoe Po6dm m�tdn wduaae and/or Inddeas rM1ii� m m�r:�:w.u��rn�s�a a,«e.an m,r«.aa�'P°�ma CounterSign6d by� �roaw.�aae. 7ms w�.r�r+�w mwm�n.na�n mwme�.xu�a�ed'n,p�w wrot h°rdrm'Mm"°M`mdm"Myon'°rrw`a"wa°e.'Ye'ec'm'rahe'"'"°m O1-15-2001 10-94 eesarorapoGry. ODI181A.T YOIA1 A�EM PoN ANY ASSIbTANCE YOU INN'� I TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-011 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,SecHon 305A and Chapter 111,Section 5 of the General I.aws,a permit is hereby granted to: Chow investment F.ntemrise5, Tnc_ 981 Main StreP /Ro � R South Yarmn�th_ MA Whose place of business is: China Inn Type of business: Food Service To operate a food establislunent in: Town of Yannouth Permit expires: December 31_2002 BOARD OF HEALTH: �rk. ZeUikos, �ei,uKaK senrwc: t tz . • D. Cfmido.r �'ll.D., �/1ee � 3 �. �fezk � �7 ;sapeYl January 24 ,2002 ce G.Murphy, .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-008 FEE: $50.00 This is to Certify that Chow Investment Enterprises. Inc. d/b/a China Inn 9R1 Main Street/Route 2R South Yarmnuth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thiriy-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 confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendtnents thereto. In Testimony Whereof,the undersigned have hereunto affixed their official sigiatures. BOARD OF HEALTH: �a�les� i�dkkec, �n�aK sEnrcm�rc: 11 z �ar/aaii.s D. Cjmrdaec 7K.D.. 2/iee �adeat`3. �, elark te�9i euxotl Januarv 24 ,2002 Bruce G. rphy, .5.,CHO Director of Health � , - : ��3s - C� D TOWN OF YARMOUTH B� ' DEC 2 O YOOO APPLICATION FOR LICE�/P - 001 ��A�.�� , ' Please complete form and attach all necessary documents by December 31, 2000. Failure to do so will result in the retum of your application packet. -------------------------------------------- ------------------------------------------------------------------------------ NAME OF ESTABLIS MFNT• �.1-1 ! IJ� S iJ 1� T�,I,. # 398 0 ��-1 LOCATIQNADDRESS: � R I M.1�(�� _�A�,�(�IAT(-F , N -------------------------------------------------------------------------------------------------------------------------- POO . R1TFI ATION : The pool aupervisor must be certitied as a Poot Operator, as rec�uired by new State Isw. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitalion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintain a file at your place of buaiuesa. 1. 2, 3. 4. HEiMi.ICH RTIFI ATION�: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintaiu a fde at your ptace of business. 1. ��cl�l N�� ( �01A� 2. � i X'UTY✓ �1� 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# _ ----------------------_____--------_----------------�--------------------------------=--r------------------------------_ OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MO'TEL $50 _SWIlv1MING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: — NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food pmtection manager certification is OMober 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 CONTINENTAI, $30 I >100 SEATS $150 �Ol -675 _NON-PROFIT $25 f COMMON VICT. $50 �01-D�$ _WHOLESALE $75 RFT� SERVICE: LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<15,000 sq.R. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NA11�iF [_'HANGF.e $jQ AMOiINT DUE _ � 200 .00 `•'"*PLEASE TURN OVER AND WMPLETE OTHER SIDE OF FORM••"** ' ADMINISTRATION iInder.CiiaptCr 152, Seetion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yarmouth taaces and liens mus be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2000. SEASONAL ESTABLISfIIv1ENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING 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. AnnITIONAL RFGULATIONS 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 testecl for pseudomonas,total colifonn and standard plate count by a State cemfied lab,pnor 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 �w eTs�rF certrTeuv rnnF F(lR FnOD ESTABLISHMENTS• The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establishments must have at least one person-in-chazge who is a certified food protection manager. �s pmvision is effective one year from the date of promulgaUon of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMK 590.000(K), enforcement of Consumer advisory,Food Code 3-603.11,will be unplemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CA iNG 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 obtained at the Health Department. _ _ -- FROZ.F.N DESSERTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit unUl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e,outdoor seating with waiter/waitress service),ir I have prior approval from the Board of Health. OU'I'DOOR COOI�NNG: �- Outdoor cookiig,prepararion,or display of any food product by a retail or food service establishment is prohibited. � �/ DATE: 1 a- (D� t1a SIGNATURE: �,(5�� PRINT NAME & TITLE: n nu (' (na�trt) �Y��n OA � 11/16/00 _� / • ' � The Commonwealth ojMassachusetts 3 Depar�ment ojlndustria/,-lcciden�s o O/nceo/%restl�st/iis 600 Washington Street Boslon, Mass. 01111 " W'orkers' Compensation Insurance Affidavit Apnlicant informaHon: PfeatePR� /1 � (� mm� 1�/WY�D� �.J Vl'VL — 14��tion� "I 75 � I�'`(!UM c7�. �. � �l� . I 11L.ir'lM 0 L(.Rn� uhone q 5�� l D � l 1�.1 � 1 am a homeowner pzrtorming all work myself. � I am a solz proprieror�cd hacz no one��orking in any capaciq � I am an employer pro�idinsµorkers' compensation for my employees workin¢on this job. compan�� name• l W�-�1.6+ � �/L-Vl ,..��Iress• ��/� l"�QMn ��. �:e.�• �� l GlY VY1 0 IA.7L..- phone M: .�o O } /6 � �4' � insur�nceco 1 � � ✓ h�Uil'QM1'lCO policyk `>S��E�CIb I 6 � � I am a solz proprietor. _eneral contractor,or homeowner(circle onel and hace hired the eontractors listed below �cho ha�e the follu�sin= �corkzr> ,ompensation polices: compgnv name• �- ^�dress• ��• phone q• insur�ncc co Dolicv# an a addrc�•• �• nhoee#• _ incuron�w rn � porte.N . Failure to secure covenge as required ueder Seerioo 25A of MGL ISS n�lad to ibe iopaitlo�o(erisiul pe�dtla of a��e ap to 51�00.00�W/or one yean'imprisonment u w�ell as eivil pendHea io the form of�SI'OP WORK ORDER�od�Iloe of f100.00�d�y apiort sa 1 odenta�d H�t a eopy of thb sntemmt may br fonvarded to the ORce ot lovestigatlonf of the DG for eovm�e veriRt�tlw. !do hrreby certij}•un r rh uins and penaUies ojpery'ury thm�he injormalion providtd abovt is d�t and correcC Signa[urc � �Ti � Date �r� '/a�d1� Printname PhoneB so8 3�8 8 �� I > oRci�l use only do not wri�t in�his arta to be completed by city or town oflieial � eiry or town: YA��DTQ _ permitAieenu k nBuildiag Departmeut �Licensiog Bo�rd �thetk if immediate responst is required � 261 �Stleetmen'�ORee �H�alth Departmmt conroct person: phaoe M;_ �508} 398�2231 eat. nOther oe.�,.d;;vy vui � � � ' WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCEaPOLICY RENEWAL CERTIFICATE �INSURANCEo FAIRMONT INSIIRANCE COMPANY #19518 '�� PhonelNumberV,J7"L)FF337, 5U(yONG, TX 75039 � �� IN CONSIDERATION of the payment of ice ocat on o icy ym o premium, it is agreed that the expiring � policy is renewed for the period stated below. THIS RENEWAL is o icy um er go646783 Subj2Ct t0 ell th2 te�mS Of the Previous Policy: 80646783 expiring policy as of its date of expiration, except aS OthBrwiSe RENEWAL AGREEMENT: RAl I � specified herein. 1. Insured's Name and Address '� . CHOW INVESTMENT ENTERPRISES, INC. Producer Code fi29790 ;� � DBA CHINA INN Producer S.H. SMITH 8 COMPANY, INC. � 981 MAIN STREET . S. YARMOUTH, MA. 02664 EIN: 042973607 i � IIN: I The Insured is CORPORATION I� Othe� wo�kplaCeS Itot Shown ebov2: SEE SCHEDULE W40353 , 2. The policy period is from o2-03-200o to 02-03-2001 12:Ota.m. Standard Time at the Insured's mailing address. I� 3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed below. SEE SCHEDULE W40446 . I� 8. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in 3.A. above. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000.0o each accident � Bodily Injury by Disease 5500,000.0o policy limit, $500,000.0o each employee C. Other State Insurance: Part Three of the policy applies to the states, if any, listed below: � ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WEST VIRGINIA, WYOMING, . MAINE, AND STATES DESIGNATED IN ITEM 3A OF THE DECLARATIONS. D. This policy includes these endorsements and schedules: SEE SCHEDULE W40179 � � 4. CLASSIFICATION OF OPERATION PREMIUM BASIS RATE SEE EXTENSION OF INFORMATION PAGE MA INDUSTRIAL ACCIDENT ASSESSMENT-PRIVATE: � � 0,893 X .053 = $q�) Minimum Deposit Total Estimated Premium $200.00 Premium $1,107.00 Annual Premium $1,107.00 � Direct Bill If indicated, interim adjustments of premium shall be made: ( 1 Semi-Annual ( ) Quarterly ( ) Monthly � � ` -� ��_- / �-.::�..��`"�y�;� � Countersigned 6y � W 18820 12-16-1999 INSURED'S COPY � .70-94 � THE COMMONWEALTH OF MASSACAUSETTS TOWN OF YARMOUTH PERMITNUMBER: #01-048 FEE: $50.00 This is to Certify that Chow's Investment Enterprises d/b/a Chin Inn 9R1 Main 4tr /Rnnta �R S�Lth Yarmnnth 1��A 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. This 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 have hereunto�xed their official signatures. BOARD OF HEALTH: $d�1L. �e�. �avuxa�c s�„�G: �,2 ��. x�, v� �� , � �1Zielael d :� �JZ.D. Februarv 14 ,2001 � � ruce G.Murphy, H, , CHO Director of Health -- ---- I TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-075 FEE: $I50.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General I.aws,a permit is hereby granted to: (`hnw'c inv ctm nt Fnt �n�ce5, 9R1 Main 4treP 4nnth Yarmo�h 1��A Whose place of business is: China Inn Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expues: December 31. 2001 BOARD OF HEALTH: Ed'I1t �etYed, ��ct� S�,�G: ��z ��.� z�, v� �� , � ��e o :� Februarv 14 ,2001 I Bruce G.Murphy,MPH,R ., Director of Health • � .�'lir�X�i I�) I.� �. f � ` TOWN OF YARMOUTH BOr1RD OF HEALTH �� g �• APPLICATION FOR LICENSE/PERMTT-2000 N QV 2 �F � ,_, , . � -� ' Please complete form and attach all necessary documents by DecembeY 31; 1999.� Fail e��A{,s�*�06�Tilt i the retum of your application packet. � , ..a � ;aa ------------------------------------------------- ---------------------- �- �----------_—_ __—__--_. Tasr.is�-m�rrr� �"�iNA �,��J ��,a°6��L. # 39,�ntc�i LOCATION t�nDRF_SS: a 62 R' �J �.1 # IN D � ____��_-------------------------_�_____________-------------------_..��_____�_------��__��_. POOL CERTIFICATI�NS: The poot supervisor must be certified as a Pool Operator, as required by new State law. Please Gst the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Poo( 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 certiScations to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your ptace of business. 1. 2. 3. 4. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of empioyee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. �-,�1�1� �� a. ��,tsm�l �ul 3. 4. ', RESTAURANT SEATING: TOTAL# 1 I NON-SMOKiNG S�ATS: TOTAL# �'- --- - - - - --------_------------------------ --------------�-------_________-------------------------_— OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _B&B $50 _CABIN $50 _INN $50 _CAMP $50 LODGE $50 _TRAILER PARK $50 MOTEL $50 SWIl�IlbfING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 � >I00 SEATS $150 ZK'(3 NON-PROFIT $25 I COMMON VICT. $50 YZK' (o _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<Z5,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ 'ZCX�— "'""PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM•••"• . 3 ADMINISTRATION LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW I�QUIltED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS•IF A PERSOIV OR?C0�?IP'�1NY 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 ATTACI�D � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK PROPRIATELY IF PAID: YES `� NO NOTICE: PERMITS RUN ANNiJALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBII.IT'Y TO RETURN Tf� COMI'LETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT TE�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvviEENT', MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENl',ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COI�IMENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMNIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIlvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI-IE CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMEN'I'. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII.URE TO DO SO WII.L RESULT IN Tf IE SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEA'TING WITH WAITER/'WAITRESS SERVICE),�.T HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. gu�voox coo�rrG: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF FOOD PRODUCT BY A RETAII, OR FOOD SERVICE ESTABLISI-IMENT IS PROHIBITED. � DATE: 1(�a -� � 9 SIGNATURE: GL�! PRINT NAME& TITLE: ��p� e 11/12/99 + � The Commonwealth ojMassachusens = Department ojlndustrial.-iccidexls ; OlAceol/aresl/Osdiis 600 Washington Street ' Bosron.Mass. OZII! ` °� '` Workers' Compensation Insurance Aflidavit ARnlicant information: p► ns�pR(p7`Tes.'i�g namc �� 't � 1�) Pv $.�� 1`� an: � � , S' oa „ g � � � I � 1 am a homeowner pznortning all work myself. � I am a sole propriator r..,', ha�z no one norkin� in am capaciR� �I am an employer pro�iding workers' compensa[ion for my employees workine on[his job. comnan� name: l /� �'� A � �1� aJArccs• �13 � 1-l �" � N J� �t,: Ya.r �m��A phon p• � 6� �'T � insurance co. l'��t S`� eolicy# � I� C�J H l 1 ��S S� � I am a sole proprietor. qeneral contractor. or homeowner(circle onU and hace hired the contracrors listed below ��ho ha�e the follu�cin_ ��orkar; ,ompensation polices: cumoanv name: - ad d ress: citv': nhon e' insurnncc co oeliev# eomoanv name: tddrcss• �►�'� phoee N• insurance eo. ��p • F�ilure ro secure corenet a�«quircd uoder Seenon ZSA of MGL 153 n�ind[o tht ioporiUw of eridW pndtln oh O�e ap m fl¢00.00��d/or ane yean'imprisonment aa w�ell a�ci IHa io the form ot�SI'OP WORK ORDER nd�lix o(5100.00�d�y q�iost a� 1��denta�d t!n a rnpy of tAy statement mw bt fonv ed to[lu 00ice of Inve�ug�tiom otMe DIA tor eovera�e ved6atlw. /do hrreby certif}•u r rhe parns penalties oj e ury rhat the injor on provided above is trne and rorrra � � � � \� Signamre � � Ic �` � Print name � one k �� .. Q � � I . olTicial use onh do no��rite in Mis area to be completed by cily or tmvs ollltial cin or rown: Y�H�DT$ _ � permiNiteeee M n8uildine Departmeai � �Licensioe Board �cheek if immrdiate response i�required 261 �Seiettmen'f Oflite (508) 398--2231 p,Et, �Hu1tADep�nment conuc�person: phone N:_ ____, _ nOther THE COMMONWEALTH OF MASSACHUSETTS . � TOWN OF YARMOUTH PERMIT NUMBER: Y2K-6 FEE: $50.00 This is to Certify that Chow's Investment Enterprise d/b/a China Inn 9R1 Main Street, Snnth Yarmonth, MA IS HEREBY GRAIVTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirry-first 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 confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �d Y�In• �•tba, C�a.,,�ry�, � / /� SEA'CING: 112 oan G. �u�ann� �//.� Vice l.�irman oce,�� t��,�, c�.� ��6,�f��G,Gy_.g�1�� kl ae�O be lin December 1 , 19� Bruce G. Murphy, MP R.S. O Director of Health TOWN OF YARMOUTFI BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NUMBER: Y2K-13 FEE: $150.00 In accordance with regulazions promulgated under authority of Chapta 94,Secrion 305A and Chapter 11 l, Section 5 of the General Laws,a permit is hereby granted to: Chnw's Tnvestment F.ntemrise_9R1 Main Street.�outh Yarmouth_ MA Whose place of business is: China Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31. 2000 BOARD OF HEALTH:��n/. �Btt�, C�yt�.,q.u//.n n/ SEATIIJG: l iz �oan G. �u�wa3 K.//•, veca l�ha�.ma �2o6�.t g.�cf3ro1w/�, C�,� a6.da[la J'ak/olle�y'-B._/�oopw ic�a eCo h[in . December 1 , 19� Bruce G. Murphy,MPH, .S., O Director of Health , �21�e� Gl�i na 1 n n TOWN OF YARMOUTH BOARD OF HEALTH [� � �,�` . � APPLICATION FOR LIC��TSE/PE3iMIT=1499 �A N 2 1 1999 � * Please complete form and attach all �ecessary document�by December 31, 1998. F u{q�q�q�p�A�SuI in the retum of your application packet. ---------------------------------------------;-------------------- -------------------------------------------------------- oF E T r.i �rr : (r-�i�r i a 1�� T�,. # 3 9�d/�/ I.(1CATION Ai>DRESS ST �N M S OWNER/CORPORATION NAME� CNovt�5 �Al!/f-STM��I-T N7 P /S ER' N L L # 0 7�f MATT.INGAi)DRFSS lC� l'�uf. ,cNdo�✓ ,E�d Se. arry,ou i -------------------------------------------------_____—_------- -- - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. 1. 2. Pool operators must list a minimum of two employees cvrrently certified in basic water safery, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificat�ons to t}us form. The Health Department wiil not use past years' records. You must provide new copies and maintain a£ile at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the pcemises at all times. Please list your employees trained in anti-cholung 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 t"�e at your place of busiuess. 1. lYN�t/Y (,f»V✓ 2. ��"0�i/ C�141�✓ 3. �-L 4. RESTAURANT SEATING: TOTAL# l/� NON-SMOKING SEATS: TOTAL# �� —____�_—_----- _____�_� Y�----------------------------------------------------------- - - - - _ _ — OFFIf.`E i�3E ONLY _ _ _ LODGING: LICENSE REQUIltED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 MOTEL $50 SWIl�Il�IING POOL $SOea. _WHIRI,POOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 I >100 SEATS $150 •I NON-PROFTT $25 1 CONIMON VICT. $50 9�-q0 _WHOLESALE $75 RETAIL SE�iVICE: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $'75 _FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAMF AN E: $10 AMOUNT DUE _ $ ZLL" `- """•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•»" ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQtJIRED 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 INSiJRANCE. 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 ANIVUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILII'Y TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�vvfEE1VTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMNIING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENT,AND THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TI�REAFTER. �_ POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMR�IING 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 DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TF� CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DESSERTS: 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 DES5ERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET. _ -- -- OUTSIDE CAFES: OLITSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),MLTST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�iENT IS PROHIBTI'ED. � DATE: , � SIGNATURE: �'�1�� PR1NT NAME & TITLE:�,9,t/� � L (�F/�iir� �i�ae�<r�vC� . - ,_ . � The Commonwealth ojMassachusetts � = Depar�ment ojlnduslrral,-I ccidenfs ; O/llcsol/irestlyslNis 600 Washington Streef Boston, Mass. 02111 W'orkers' Compensation ►nsurance Affidavit Anolican[informaHon: PleeuPRlRI'T�dGi.F: oamc: �L/i/U'� 1A1A� � location: 7 6 I . !"ClLZYI ��. � � ut�- 7FLTt�/N1g��TGi� /�/} ��b�/� � ehonep �LO ��'[� l � i am a homeoµner ptrtorming all work myself. � I am a sole proprietor�rd hacz no one �corkin_ in am capacih• 0' I am an employer pro�idino workers' compensation for my employees working on this job. company name: `2ylA/A �J(//1� _ _ tf�d CS : [ V WV•li � � • � tity�: ✓o. Yar�o�� `�'(�� G'�� nhoneq: � !v �l� / ipsurnnceco. HLLICD �N�R(CAAI ��iF_�l/GV policy# � -�0- 6�8-o�a9 � � I am a sole proprietor. aeneral contractor. or homeowner(circle onel and have hired the contractors listed below ��ho ha�e thz follo��in_ ��orkzr compensation polices: nv n address• cirv: phone p: insurancc co. poliev# eom a�ny namr. � addresa: _ _.__ ...._. __ _. . . . � e�: Qhoee M• insuranee eo. eeRev M F�ilure to seeure covenge as required uoder Seedoo 25A of MGL IS2 n�lad to the iepo�itfos oferisiul pndtla oh O�e ap ro SI�00.00 a�d/or oae yean'imprisonment a�w�Nl a eivii pee��Hee io thc form ot�STOP WORK ORDER aed a Oee of SIOO.M�dq qaiert�e 1��denfa�d N�t a eopy of tAH sntemrnt m�y be for.varded to�he ORce of lova�ie�8om ottAe DIA for eoven{e veri6utlw. /do�hrreby certijp un r rhe ins and prn llits ojperju tha�!ht injormatinn provided above it trut md cor►tct Signaturc L �atc /' �a � ( / Print name � /v 7 � � PhoneM �!d"��Y—� . oRcial use only do not wri�e in�his area to be tomple�ed by ciry or to�vn ollleial city or rown: Y�H�DTQ _ permiMiteme M nBuildioe Departmeut � �Lietosiog Bo�rd p cheek if immediate response ie required Z61 QSelectmen'�ORite (508} 398-2231 p�t, �Healt6 Dep�rtment rontact person: phone M:_ _ _ nOlher Ira nM i,05 pIM / 11i20 '98 15�28 ID�AI.L.IED AMER AGY FAx�15087601667 PAGE 1 !OR_q� CERTIFICATE OF LIABILITY ;INSU�RANCE °ATEi"N"roonv� ii�zo�i9yd PROpUGEIF (508�39A-GU33 FAX (SU8)7G0-1fi67 THISCERTIFICATEISISSUEOA9AMATTEROFINFORMATION �Ilied AmefiCan lnsurdn[e AgrnCy, InC.. ONLYANDCONFERSNORI(iHTSUPON7MECERTIFICATE )ne Atl anti c Avc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAQE AfFORDEO BY THE POLICIES BELOW. /armoUth, MA 026f4 COMPANIES AFFORDING COVERAGE ,�n. W Aµ� public Service Mutual EXt: nL "� � � V 2 � N9UXE0 COYpqNY �n� LS Chow Tnvcstmeni Enterprisc Inc B China inn �0� 2 Q 199$ 981 Mein St COMP�NY So Yarmouth, Mn o2t,6� � HEALTH DEPT. Cf�NqNY 0 � ' �� THIS IS TO CERTIFV 1 M�� TI IE POLICIL'S UF INSURANCE LISTFU kiELOW HAVL BEEN ISSUED TO THE INSURCD NAME�AUUVE FOR THF POLICY PERIOp INDICATEO,NUTWITHSTANUIN(i ANV REQUIREMENT,'1 LRM OR CONDI f ION pF ANY CONTRAC'I'UFi OTHER pOCUMENT WITH RF.SPECT TO WHICtI TI IIS CNRTIFICATE M�Y f3E ISSUE�QR MAY PERTqIN,THE INSUI2ANCE AFFQItL7E�BV TML"POLICIES OESCIiIBED HEREIN IS SUBJECT Tp p�L TI1E TERMS. EXCLUSIONS AND CnNI)I I IONS OF SU(:11 POLICIF.S LIMITS SHQWN MAY HAVI:DEEN REDUCCO OY PAI�CLAIMS. � TYYEOfINGUkANCE POLICYNUMBER POUCYEFFEC7�yE POLICYE%PIpq71pN ��M�� OA7F.�MM�W/YY) uqTE�MMIO�M') ,GENENnI.LIRBILITY ... . QtNEflALAGGNFf�qfE S COMMEHCInIGI.NLf1ALLNlllll�y PryUUUCTS-COMV/OPAGG 6 � CI.A�MS MAUC OC(:Uli YEHSUNAL 3 Af W INJURV S nNMF.H'98CU!lfRAC7�jH'yNfiUT U4HOCCUNRCNCE S . hINEOAAIACF�MyanaOieJ f . � � �, MEo ExP(AnY�pxlw�) f �FIffONOBILE LU1&UiY ANVAUIU GOMBINfASINGItLIM1T S AI.L UWNCDAUTIIF BODII Y INJUItV E SGNCWLCD All l U5 IM1�r ppRO�l i1WCDAllill) � rxm-owrv�unuiox oounvn�dum s (Perecciaentl pRUYtRTVOAMAGF. S ; 011RI10ElY&LITY A�lTOOfiLV-UACCIOtNi S ANY A�170 U711Eq THAN aUTO Orll Y: � ' . � � F.ACH aCCIOENT f . .., ACpNt4pTC S EYCESS LIABILI'fY EACII OCCUNNFliC[ 5 UMOR411AFUIiM AGGRE('MIF f OTI IGk'I qpN UMORCI l A PpNN s YYORIfEPSGOIMENSAI'N)NqND x IUXYLIMRS ER EMPIOYERS'LI4tl11.T' .. . U3 251fi6B 98 02/U3/199B 02/03/19y9 ELfq(;MpCCIDEN� a 500,000 rHr.NrwrnicToa� X iN�:i 500,000 OARTNER$ItXhCUTNF F�.UISCASF Pp�ICy L�MIT S OPFIC[RSARE: L'Kt:l EL�ISF.A6t-G4MPLOYEE i SOO OOO OTHER iGWPTON OF OVER/1TIDNSII cH;qTIDNSN6HICLESISPECIAL ITEMS � TR�R �ANCEI.LAT�pN SHOULp pHY OF TI IE q9pyE pEg�q�BE�VOLICIF.9 9E GAryCELLFD BEFOPE 7XE EIfPIR4TION DATE TMFJlEOF,TI�ISSllINO CONPANY yy�LL ENOEAVOfl TO 1/A�� Town of Yarmouth 3�._a�SWlil'I7ENNOTICETOiHECfRTIFICA7EHpLpENNAMEOTo7HELEFT, Board of Health BIITFAILURETOMqIL9UCHNO110E9HRLLIMP0.9EN00BL10P710NOflLIABILI7Y Rte 28 Mal n 5�.reet allo uroH me coMPanv.irs ENT3 ON qEPRESENTqTVE9. So Yarmouih, MA 02664 RERiE9ENTATIV �RD 263(1/88) � .. �ernnn nnon.....�....�... TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-153 F'EE: $I50.00 In accordance with regula[ions promulga[ed under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of[he General Laws,a permit is hereby granted to: i _ Chnw's investment Fnt .rnri�e� 981 Main Street, So � h Y rmo � h MA ! Whose place of business is: China Inn � Type of business: Food Service To operate a food establishment in: Town of Yarmouth i Permit expires: December 31_ 1999 BOARD OF HEALTH:�d�nf .�eltopee, �'�a[�t.././+/a�� / /J/ t SEA7TNG: 112 oa/n C��. '�/ ullivan�/KJp.//l.� Vice (_,hairman � oberE ,1.[��rowan� C,(erk , adrie�Ja�r/o1l��aooPed � ic� oCou��lin � Februazv 12 . 19 99 �- � ruce G.Mwphy,MP ,R .,CHO � D'uector of Health � i r------------ � � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH i i PERMIT NUMBER: 98-27 FEE: $50.00 I ! This is to Certify that Chow Investment Enterpri e /a C1Lna I 9R 1 Main 4 r e* 40 � h Yarmo �th 1��A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and eacpires 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 amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BoaxD oF�at,�: �d??'/. ��e7up�0�, e�/�;,�,��/�Rn / /J SEAI7NG: 112 ' �[�oa/n.��'J/ /u�l[ivan�/KJA.//.� Vice (_.�i,rma2 Kobort,}. /,rowart� C,(e/r/� - a�.ie�e.�a�oU�y�/dnopee aL ou� Febmerv 12 , 19 99 ruce G. Murphy,MPH S., O Director of Health y . .. �� _'"'^,, �"� l �/�J(� �f`� , . � �, .� � � � . . ;� �nf � � L� � ��i �, L TOWN OF YARMOUI'H�OA�Q�;��,TH APPLICATION FOR LICENSE / PERMIT - 1998 DEC 0 2 1997 � HE�LI�F� �_;;��i'T. " Please Complete form and attach all necessary documents by December 31, 1997. Failure to do so will resuk in the return of your application packet. -----------5-------------------------- -------------------------------------------------------------- N F ,U I� -----�------- � # 3 � Dl � l G D _ a , q,� � O I GN hDT N' ��S'� ------------------------------------------ ----------------------------------------------------------------------- POOT CERTIFI ATIONS: Pool Operators must list a minunum of two employees currently certified in basic water safety, standard first aid and Community Ca;diopulmonary Resuscitat3on(CPR).Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintaiu a file at your place of business. 1. 2 3. 4. �' 1�I H .RTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti- choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintain a � file at yoar place of business. � i. `i�n.�N�� to�„� ! � ��t-JvNI 3. 2. � I Xn n\ 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAT, #� --------------------------------------------------------------------�------------------ OFFIC � T � ON� _ LODGIIv : LIC. REQUII2ED FEE PERNIIT# LIC. REQUIRED FEE PERMIT# _B&B $50 _,CABIN $50 —� aso .�ca� $so _LODGE $50 _TRAILER PARK $50 ._.MOTEL $50 _ S WIM POOL $gpea. _WHIRLPOOL $25ea. FOO_ D_ S .�RVICF; LIC. R,EQUIItED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# _aioo sEATs sas _corr�rrrai, $30 � >100SEATS $150� q8-V2 _NON-PROFIT $25 � COM. VICT. $5 qB'�..1 _WHOLESALE $75 BET�IL SERVIC�: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _45,000 sq, ft. $75 _FROZ. DESSERT $35 _>25,000 sq. ft. $20� - - -__ Separate payment is needed for AMOUNT DUE — �. liquor or emertainment licenses ' f 9J 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 COMI'ENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSUI2ANCE AFFIDAVIT MUST BE COMPLE7'ED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PY.EASE CHECK APPROPRIATELY IF PAID: YES V 1W0 NOTICE: PERMITS RUN ANNUAI-I-Y FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQtJIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL ESTABLISHIvIENTS ARE TO CONTACT'I'I� HEAL'i'H T)EPARTMENT FOR II3SPECTION 7-10 DAXS PRIOR TO OPEI�TING FOR'THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLI5HMENT,MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MiJST BE REPORTED TQ AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COrRvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. Ai�DITION i. F ITI ATIONS POOLS POOL OPENRIG: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH I)EPARTMENT, pND TI� WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPENING. -- - -� ORAINEDQR-COVERERII�THIN SEVEN(71DAYS OE��SINGOL MUST BE FOOD SERVICE �a�RtNc'.POL.ICY: ANypNE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NOTIFY TI� yARMOUTH HEALTH DEPARTMENT BY FILING'PI�REQUIRED TEMP�RARY TI�SE FORMS CAN BE OBT�AINED ATaTI�HEALTH D PARTMENA'T�RED EVENT. cun�FN DESS�RTS_: FROZEN DESSERTS MUST BE TESTEA ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEAL'TH DEPARTMENT- FROZEN DESS R PE�RMIT EUIdTIL THE ABOVE TER1�� VE BEEN MET. OF YOUR OLTTSIDE CAEE�: ��HpVE PRIOR APPR01V AL FROM THE BOARD F HEALTH.�SS SERVICE), OU'i'15�OR COOI�tAfG: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�vv1ENT IS PROHIBTTED. .� � DATE: I l �9� g _ SIGNATiJRE: �1 � � —�— PRINT NAME &TTl'LE: �9�yr�,�c•� _ 10/97 page 2 of 2 � ____� _ � —,_ —�-,�. M�kKERS GDKP£�SATIQN AND EMPlOYER'S LIABILITY' INSURANCE PQLICY ' ' PUBLIC S�RVICE nU7UAL INSURANCE CDltPANTsNEM YORKsN.T. VGCI 6S3fiPANT NtJ: 15152 MC UG '!G 'J1A It�ORlIATION PA6E POUCY NUMBER� . FnoM � ��"PERioo .o pREVIOUS POLICY OTHER COVEPAGE PRODUCER NUMBER �3-25166H-9� ±J2 C3 .7 +�2 [f 9 J3 25 66ti 9 4— i�-5_5—b 1. TH� I4+iSURfD MAILING ADOit�SS: PRt1DUGtR NAME AND AD�R� 5 LH[DN INVESTNENT cl7TL-RP3tISF MAHtHdEYSMRI6H7 INSURANCE AGENtY ITIL BDSTQN 4b iiASHINGT[SN ST PDB 746 981 MAIN ST NATIGK RA �3I�6� 50 7ARlSCTUTH !!A i�26fi4 THE iNSt1RE0: GORPORATION FED ID Ntl, 44-7_973607 E'THER !At]RKPLAG£5 NDT SH�SiN A�OYEx SANE 2. THE Pt�IGY PERI�D IS FRaM 42JU3/1997 TQ �2/�3/1998 12:fli AH STANDARD TIffE AT TNE I�iStJRED•5 ±4AILING ADORE55. 3. A� MiNtitLRS fA?1PENSA7I�lN INSU�tAt�ICEs YART Qt� {� Til� P13LICY APPLI�S TD TH� iit3RKEiZS CQ!lP�AiSATION LAilS !� THE STATES LISTED HEi2E: ?4A55 ALHUSf TT S 3. �kFL+�YE�S ltAeILITY INSURANCE. S'ART TWO OF TNE PUIIGY. APPtIES TC� bi�RK IN EACH STA7E LIS7ED IN [TFA 3.A. T}HE lIMI75 �F �t7R IIASiLIT7 UNUER i'ART 7ilU ARE: BUdiLY Iti.1URT SY ACGID�NT �100s��1 EACH ACCiDEAJT BI,DilY INJUKT AY OISEASE �5t?Os4tTi3 Pt�IGY I.IMIT SDDtLY INJUi2Y ST DISEASE S10t2�tftHG EAGH Et�PLOYEE C. �ITNER 57AiES INSURANCE: PART Tt�R€E D� THE P�.ItY APPtIfS TO TNE 57Ai�S• IF ANYs LiS�ED HfRE= D. TiiIS P'QtICT IS�iCLUDES THESE cN13DRSEMEMIS ANEI SLHE➢lDLES : 5iG242 NL332 i�C�G�41i HC2�fU3(a3A MG20flb�1 4. i}!E PREMIUM FQFt THIS P't)IICY MItL BE DETERMINED $Y`[3tiR MA1�R3AL OF RULES• GLASSIFItA7i�NSs RA7ES AND RATINb ALANS. ALL I�ORNpTION REpUIREII B�LL'iit IS StIBJECT TU VERiFIGATYflN AMD CtIAHGE BT`AUDIT. PRE�! BASIS Rd3E E5T GLdSSIFICA7ION5 lDC COOF" TQ7A1 PER ;1Jt3 ANN41Al ST N� NO ANN REMUA! II� RE�UN PRE?1IL1:1 ( S'cE SCtIEDUL� ) E%P£T1SE. Ci7N57ANT $19� �19�: � AIAJ i';tE�! $229 ��t3Si7 Pt2E�i $1�39'? ES7 APIA3UAL PR[�1 �is39et � PstF:itUM EIDJU57"!ENT P�R�(SD:ANN�iALLY � Ct;Ut�iT��2SIGVETJ i2J=�3/1997 AT N'tli Yt7RK� N.Y. 8Y � •' ��'T'"�`� r �.'.:PY�`?IriiiTs 1�87 NAT�CFJJNCIL �H CG'?iP.INS� � UT:� �E�RESEPiTd7IY� .�::,; �i � � �..c�� : �.�� -. . ..��: e 7-- r7 . 7,.... -`.1 -�. !':-If?'d f*1V�CT�°dF;.�T � • Og�Y`�R �� '�o TOWN OF YARMOUTH 0 H L6�6 NOC�TL 28 SOl�CH l":AItVIOI�TII 11AStiACH[��Ii"1-I'ti 17366-i--��SI � MATtqCHEES � j�� •�'ko+.a.na�t* /,a' Tclep�lone Ii0£il $9N-nal. P.�L 2 FL — P:IY f5081 j94-L_ 6i' B O A R D O F H E A L T H NOTICE To: Chow Investment Enterprise From: Colleen E. Pelley Heakh Inspector Date: December 19, 1997 Subject: 1998 Permit Application The Heakh Department has received your 1998 Pernut Application. Unfortunately, we are unable to mail your permits for the following reason: 1. Heunlich certification card copies were not provided as required by MGL 97-305.D As a reminder, The Health Department will not use past years records in order to process applications. You must provide new copies and maintain a file at your place of business. Businesses which aze unable to produce such documents are encouraged to contact Health Inspector, Colleen E. Pelley at (508) 398-2231 ext. 241, or stop by the Heath Department between the hours of 830 a.m. to 4:30 p.m., and I will assist you in any way possible. Please be advised that your establishment can not legally open until the required information is obtained by this Department and a permit has been issued. Thank you for your time and anticipated cooperation in this matter. CEP/jmp cc: File � Printed on L � Hecyded Paper TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-42 FEE: $150.00 In accordance with re�ations promulgated under authorily of Chapter 94,Section 395A and Chapter 111,Section of the General Laws,a pemrit is hereby granted to: Chow Tnvestment F.ntPmrise� 981 Main Street�,Son h Y nnon h� MA Whose place ofbusiness is: China Inn Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31 1998 BOARD OF HEALTH:��f.+,�ettee��, C�[+�M.q.+�an � / /�/ SEATING: 112 �[�oan C�c. 7�nullivan� K.//.� Vice l,hairman RESTRiCT10NS IF ANY: NOIIC /�o�rt�,g}. O,rowert // a�r/ielle �a�r/o1l��iy-A.JdooPee . ichae oCou��[i.n December 18 . 19 97 Bruce G. Murphy,MPH, .5.,C Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-27 FEE: $50.00 This is to Certify that Chow Investment Enterprise d/b/a China Inn __ 9A1 Main StrePt Snnth Y rmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and eap ires December thirty-first 1998 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 amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �� `��o7ttpeee� C'�(�irm�/a�nn ' /� SEAI7NG: 112 �(�oa/rt � Ju/�L[i.van� K.�1.� Vica C,�irman RESTRICTIONS IFANY: Noue . /�obert a�B 9>rowan '/ . o�.wCle�a�rola�ry-.htoopae '��' u��_ December 18 , 19 97 ' r Vl�. nxce G. Miuphy,MPH,R.S., - 0 Director of Health . _ ,��qtq � ;: ; � __ , • : ; `° _ �, - r F , _.�._ � ,;'i ; ; TOWN OF YARMOUTH B 1 DEC 0 2 1996 � APPLICATION FOR LICENSE / PERMIT - 1997 ( `,_. l � ai.7.:: � * Please Complete form and attach all necessary documents by December 31, 199fs Faii[ffe to-d� -- --' so will result in the return of your application packet. ------------------------------------------------------------------------------------------------------------------ I�AME OF ESTABLISHR�NT: �f-t i Nu� !/�%nJ TEL. # �`Jc�� ADDRESS: 4A I f 1o%H , i. .S'n. ��- MAILING ADDRESS �au� OWNER ORPO MANAGE 'S NAME• TE .# Ul / �LirrG AnD�SS: lu �'�o ' �. Y Y ------------------------------------------------- ---------------------------------------------------------------- POOL CERTIFICATIONS: Pool Operators must list a minimwn of two employees currently certified in basic water safety, standazd first aid and Community Cazdiopulmonary Resuscitation(CPR).Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. HEIMLICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti- choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintain a file at your place of business. l. L�/,lJ� (,E1�dfiP/ 2. ///,Y41d/ (1.€�L� 3. 4 , RESAiJRANT SEATING: TOTAL# OQ NON SMOKING SEATS: TOTAL # �G ----------------------------------------------------------------------------------------------------------------- OFFICE USE ONLY LODGING: e w LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _ SWIM POOL $SOea. _WfIIRI,POOL $25ea. FOOD SERVICE: LIC. REQLTIRED FEE PERNIIT # LIC. REQUIRED FEE PERMIT # _0-100 SEATS $75 _CONTINENTAL $30 � >100 SEATS $15 � �_Iq _NON-PROFIT $25 ! COM. VICT. 50� °17'l�j _WHOLESALE $75 RETAIL SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq. ft. $75 _FROZ. DESSERT $35 ' —>25,000 sq. ft. _ $200 _ .- — � j DOI�i(71'INCLUDE PAYMIIQT' AMOUNT DUE _ ��'�� Ft?R LIQLTOR fHt i ENTERTARVMENT� � _ � ADMINISTRATION " � _ � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENE WAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSONOR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSLJRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. P,LEASE CHECK APPROPRIATELY IF PAID: YES �� NO NOTICE: PERMITS RUN ANNiJALLY FROM JANiJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1996. SEASONAL ESTABLISFIl�fENTS ARE TO CONTACT THE HEALTA DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY "I'HE BOARD OF HEALTH PRIOR TO CODR�fENCEMENT. RENOVATIONS MAY REQLIIRE A SITE PLAN. AnDITIONAL REGULATIONS POOLS POOL OPEIVING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND TF� WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPENR�IG. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN('7) DAYS OF CLOSING. , � _ _ - - FOOD SERVICE ('ATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �ST. HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A _ _ _ �ETAfL-OR FOOITSE�IC�ESTABLISHME3�'f' IS PROI�IBITED. -_____ __ ---- -_ --- — q q/ � IATE: �`�� a l ' C(o SIGNA'I'URE: a�s� • r PRIN'I'NAME &TITLE: �V��1n/.�/ �e,vs/�u� 9 /96 page 2 of 2 , _ \ 12l02l1996 13:08 5087601667 NIAHONEY & WRIGHT S Y PAGE 01 i � � U6�E DATE IM�MNDP�YI A@�1�. ��'�'E � 12/2/96 rRODYCIII TMIB f�NTIFICASE�S�9$UFD AS A MATfER OF INFOA�710N ONLY AND CONPENS Mahona BcWCl llt Insurance C.O NORIGNTSUPONTMECFATIfICATE�LDER.TMISCFRT�FICAlE00E9NOTAME�. Y g EX7EN0 OR AL7ER THE COVEMOE AFf�i060 er i nt rU�iCt89 ee�ow Allied American One Atiantic Ave COMPAIWES AFFORDIN4 COYERAQE S Yarmouth Ma 02664 �� Public 5ervice lnsurance . �p. ws.ceoe . , oour� B LE'rt!A MNMN Ghow investments Encerprise �� China Inn 981 Main St �` D S Ysrmouth Ma 02664 �� rrovr�uaEs i TMIS IS TO CERTIFY TFIAT THE POI�GES OF IN6UMNCE LISTED 6RlOW NAVE BEEN ISSUED TO TME INSUpED NAME�ABOVE FOR THE POLICY PERIOD INOICATCa,NOTw�THOTANDINO ANV AiOU�NFYFN�.TFRM OR CONDfT�ON Oi ANV CONTRACT OR 01HER DOCUMENT WITH qEBPECT TO WMICN THIS EXC USICONS ANp CONDIST ON9 O SUCH POLICIE�MITS SNOWN Ml1r IIAVEBBEEN p OU EID 9Y P�OICU11M5 tl(V IS OUbI�GT TO NLl TME TElIM9, � TY�E OF iNB4N��MCE PWx'f NIIYFI �) �7(M1NDO�YY� ALL L1MIf91� tn � pGuiNAI bOPEO�ii f I a�uu�uawrr � 'WMM(RCIAL OENEML UN�IIY . PROOUC73COMNOPB��n { p�iMS MAOE OCC.Ufl. PCYEOM�L l MVE�T�S�Mfi NLIINIY t ' OWNEN'9�CON7RACia1'8PR0'T. iACMOCCURIENCE � . PInE ONJMi Ulnyarw Wq � wlEwcri E%ro�s[(MY on�n�^I f �urarw�a u�liurr oouauao BNqLE i IINY N1T0 uexr ' DODILv �l1 OWNED�UTO! INJURV i �N6WLFD PUTOS ��) eooav MIREO A�OS INJUNY f NON�OWNEO AUi09 ��,IPu�ecweix� yRWEL1�8QI7V ��qry { �O^AMAfiE [RCEf�UAWIT' � Ty.•_.. EnGH �oanEOAT£ OCCuqRENCE � :;: i i x � ' OTXER TMAN U!�lREtLA idNM � 9TATUTOp� �.e�suw►wM,wN � lOQ,UUO 1�cxnccioEern XX "ND 03- 251b69-96 ?/.�36 1/�� $00�D0� �o�cuu_raucr uw�r� ��TM , � lOO�OOO ro��E�EACH EMPtO�'EI OTIIBI OffGtlP710N OF OPl1M110N8M10CATIdiflYE111CLE8�eT�REO cr.nTlflc�TE Ma oEn CANctLLAT10M Town af Yarmouch ��O AN� OF THE ABOVE OEgCRIBED POLICMS 6E CANCELLED BEFOAE THE Route Lb EXPINATIMJ n�TE THEIIEOF. THE ISSUING CONIPANY WILL EIIDFJIVOA TO S Yarmouth Ma 02664 MAIL—,.-OAYS WR1TfEN NOTICE?0 THE CEHTIRICATE HOLDEA NAMED TO THE LEFf, BUT F�u URF 7p W11L SUCM NOTICE BHAIL IMVpSE NO OBLIGATION OR WIBILITY OFANY IUNU UPON TME GOMpANY TS AGEN R SENTATIVES. •tnw�o�ewr��rve ACDAD�S-8 /t/ � �ACORD t�M1ICR�TION 19t1 NUMBER FEE 97-19 THECOMMONWEALTH OFMASSACHUSETTS $150.00 ! .........�.Q'�.... aF..YA[dvDlA'H...................... � Board of Heal[h of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. ..� #97-19 D�R�ffiFR 11 96 ..............r... 19..... In accordance with Regulations promulga[ed under au[hority of Chapter 94, Section 305A and Chapter i I1,Section 5 0!the Genewl Laws a Permit is hereby granted to: ..�v?.?Hv,Fsn�rr,II?r,Ea2x;SEs..?I`I�:,.9$1.�1(N.�',(R4U!'E..zS..S,.YARn�C�71 Whou place o(business is .....��.J�y....... ....................................... Type of business and any restrictians F:OOD.SF,[2y,j(�',,��g q� �D.Q.�.LS.......... To operare a food establishmrnt in .. �..............................�. ............ D�� 31 (City or To�) �Permit Expires .................r....19.9�. � � • j .. . . . . .. ... . .. .. .�... .... .... ...... .. 6o3fd ..... . . O� � � �.. �.. �d_... . ... �y Health .... . . �-'�/ FOPMYJ9 q.N.BULR�u COMPwN� ••• •• • •• /•A ' �•�V .......N��i, /�!J �� NUMBER FEE q7-iq THECAMMONWEALTHOFMASSACHUSETTS �SO.00 ....T�_.___.oL._YA�rfli7fH.__........ This is to Certify tAat �._I��r_Fldi'FRPRISES INC.__DlB/A_CF1.�PLA__IP$V.......... ._.....___981 M4IN STREEP/ROITPE 28 SOI7PH YAHIv10I7TH� MA ...____... IS HEREBV GRANTED A COMMON VICTUALLER'S LICENSE in said ...____YARtdO[7PH_____........._.._...._..........__..___........................................ and at that place onir and expires December thirty-tirst 19__q7..._unleas sooMr suspendcd or revoked [or violatlon of tLe laws of the Commonwnith rapecNng [he lia�reiog o(common victudlers. T6is Gcense e isued in conformily with the suthority granted ro [he licensn6 auNodNea by Cenenl Laws, Clupter 140, md ammd- men6 tAnNo. � in 7estimony Whereof,Ne mMersip�ed hrve�ceunto a6xed Ner � ' ' tures. ...... . . • . ^ . __.�..... __ ........ � _... ._ �_ . . _ �nti ... Licmang . .. �/ � AuMoritis � �..../... ��(/N._ • . � . DEGFMBFR 11,_.. t9 _96_ � R"��r � � �/ ;/ �3 vonM s ve wu.suiKw m..aosror+,ue (OVER) �,1�i� CT TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMIT - 1996 - � s ,� , L # ly91 00 '++�.�------------------------------ K �'2oa. ----------------------------------------------- -- , NAME Ol� EST�BLISHMENT: L I� i N c� �L n� TEL. NO. : �9�Q �� I �I AnnxEss: �� ! li'fQ �c �f So. �a vmoviTl.�_ (�R . 0�� o �,/ C� DD MAILING ADDRESS (IF DIFFERENT) : �9p5 OWNER/CORPORATION NAME: �,�,^�D �N U�S i'- M��f-1----. ��U—"" l5« EPT. MANAGER'S NAME: ��I/(I �I�� C.�f'/41(/✓ TEL. NO. �UO �02� - MAILING ADDRESS: RFSTAURANT SEATING: TCYfAL # � ' � NON SMOKING SEATS TOTAL # __ -2� Jnder Chspter 152, Sec. 25C, subsscti�n 5, �;�a Towr. af Yarr�c�th �s ccv re�uirz3 to hold issuance or renewal of any license or permit to operate a business if a person or Co. does not have a certificate of worker's compensation insurance. The attached State Workers' Co¢Qensation I��ce Affidavit �ust be campleted and signed . Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes no ------------------------------------------------------------------------^------------- All food service establishments with 25 seats or more must have at lease 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 their certifications. �. ��N,�y �-�� z. �� A, �.�� 3• �i�fl/ll C-Hv32✓ 4. Pool Operators must list a minimum of two employees currently certified in basic water safecy, standard L1CSL dla d71O l:(M�Ullli.y CaY(�iuFiui(f10Y'iaiy ReSiJbi:li.fli.Yt�i1 �Ccnj. Please list these employees below and attach copies of employee certifications to this form. 1. 2- 3. 4- ------------------------------------------------------=------------------------------ OFFICE USE ONLY ' LICENSE REQUIRED: FEE: PERMIT # LICENSE REQUIRED: FEE: PERMIT EYIOD SERVICE MOTEL $50.00 0-100 SEATS $ 75.00 CABIN $50.00 �_OVER 100 SEATS $150.00 � TRAILER PARK $50.00 NON-PROFIT $ 25.00 INN $50.00 COPPPINENTAL BREAKFAST$ 30.00 LODGE $50.00 �_CONA70N VICT[IALLER $ 50.00 � CAMP $50.00 SWINIlNING POOL ( ) $50.00ea. VAPOR BATH/ ( ) $25.00ea. WHIRLPOOL RF.'�'DT� �_:'()Qli gFRyTr� Less Than 50 sq.ft. ,prepackaged candy,gwn,soda,chips LESS THAN 25,000 sq. ft. $ 75.00 MORE THAN 25,000 sq. ft. $200.00 EROZEN DESSEFtT � �� pd SOFT-SERVE ICE CREAM $ 35.00 TOTAL DUE $ TURN OVER TURN OVER TURN OVER TURN OVER \ Page 1 of 2 f � ., _ _ -. ' w \ , 1T�^ G � ADDITIONAL REGULATIONS: CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST N(7fIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEIILTH DEPARTMEPTi'. FROZEN DESSERTS MUST BE TESTED ON A MOPPPHLY 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 YWR FROZEN DESSERT PERMIT UNPIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE) MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. FAILURE TO OBTAIN PRIOR APPROVAL FROM THE BOARD OF HEALTH WILL RESOLT IN THE SUSPENSION OR REVOCATION OF YOUR FOOD SERVICE AND COMMON ViCTUALLER PF.&2MITS. OUTDOOR COOKING� PREPARATION, OR DISPLAY OF ANY EOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMEPPP IS PROHIBITED. EVERY OUTDOOR IN GRO[7ND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. RESOLTS FROM POOL WATER TESTS BY A STATE CERTIFIED LAB MUST BE RECEIVED BY THE HEALTH DEPAR44�1EAPr PRIOR TO OPENING. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e. , PAINTING� NEW EQ[IIPMENT� ETC. ) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. NOTICE: PERMITS 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, 1995. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPT. FOR INSPECTION 7-10 DAYS PRIOR TO OPINZNG FOR THE SEASON. , APPLICATIONS MUST BE COMPLETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR FSTABLISHMENT UNTIL THE ABOVE TE12f7S HAVE BEEN MET. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. � DATE ��`� d '�� SIGNATURE �Z9h ��2�d`� `� PRINT NAME & Title ��NN� �G �l'�w (r/ O(�es�� I1�ORTAL�TP: 7ffi�SE APPLICATIONS NALST BE �LElED IN EVLL AI�ID SUBMITTED ON O�It PRI�2 RO DHCffi� 31� 1995 Q2 YOU WILL BE SOBJHLT 7�D AN ADMINISTRATIVE E�ARING, 11/95 Page 2 of 2 , _ � r The Commonwealth ojMassachusetts - � � Department ojlndustria/.-lccidents ; Olf/eeollsres�oslhis 600 Washington Street ,.� Boston,Mass. OZlll W'orkers' Compensation Insunnce Affidavit Ag�licant information: PTeae�`� �� /, namc: l �H�i�G{ .�JV�/ . . location: 7 �� l e�/i1/ �% cin �D. / ��f�L/�l� /"!A . �o2�i�� ohone+� �!Q dl`�" / � I am a homeowner pertortning all work myseif. ' � I am a sote propriecor ar.d hacz no one ��orkinc in an} capacin• �am an employer pro�idine workers' compensation for my employees workine on chis job. � comnanvnamr [�l/UR 1-N/✓ � �� ,Vd��55: �C, � L'I(T�A/- S'� � � sj(v: ��D, 7 f1�'/��G7�� /��F, f/c2 FXo� yhone q• ��t� �/�� insur�nce co. �olicy# � I am a sole proprietor. qeneral contractor. or homeowner(circ%onel and ha�e hired the contractors listed belou ��ho ha�z the follo�cin_ ��orker ,ompensa[ion polices: comoanv name: ' address: c'Si }': yhone p: insurance co. � ooliev# eomoany name: addresr � - tiri• nhoee M• insuranee co. neBev M Failure to seeure coverage as required under Seeaoo ZSA of MGL 152 eaa lud to the iopoeitioo of erimiW pea�ltln of a�ae ep to 51,500.00 a�dlor ooe yean'imprisonment as w�tll af eivii penaltla in the form of�STOP WORK ORDER tnd�6ut of 5100.00�d�y atfimt ma I a�denu�d thu a eopy of thn satement may br fo �ded to tde 0lfiee of leveatiguioee ott6e DtA for eovenge veri6utio�. � � /do�hrreby certij}• nder e 'ns and p npl�ies ojperjury(haf the injornmtion provided abovt ir trat and eorrcd / Signaturc 21t1�� Print name �/f}iV�� ( �m//1� Phone M 7 L o � l/ / .. o(Gcial use onh� do not.rite in this area to be completed by city or tmve ollleial - � ciry ar town: Y�M�DTQ _ permiNiceau N nBuildiag Department . �Lieensiag Bovd 0 cheak if immediate response ie required 261 QSdectmeds ORee � � pHnitC Dep�rtmen� conmct person: phonc p;_ �508� 398=2231 eat. �Other o<.nm J a�Fl�i � . 7/U1[I�CR.] l.:J/lfut.snsaan. .....� �... �_" __ _ _-. PUBLIC SERVICE MUTUAL INSURANGE CDMPANY�NEN Y�RK�N.Y. : NGCI COlfPANY NO: 1b152 HC �fl OC �lA ', , , . INFORMA7t�N PAGE '� � � POLICY NUMBER Faou � �C PERb°�. . �o� „ �-�_�pREVIOUS POUCY:,��`�.a =�OTHER COVERAGE =�'P_ ODUCER NUM6ER �'� 03-251ob8--96 G2/�3/96 �32/03/97 Q3 25ibb8 95 4-2G-555-6216 1. TNE INSURED/HAILING ADDRESS: PRODUCER NAME AND ADDR£SS LHON INY�STMENT ENTERPRISE MAHONEYSWRIGHT INSURANCE AGENGY INC ` BDSTaN 46 MASHINGTON 5T POB 746 - 981 NAIN ST NATICK 11A �1760 SD YARMOUTN HA �126b4 ZHE It75URED : GORYORATIDN FED ID tdfl :�74-29736�7 OTHER NDlLKPLaCES NOT SNOiiN ASOVEs SAME 2. �THE PQLICY PERIOD IS FROH 021fl3/1996 7D fl2/43/1497 22:01 AH STANDARD 7IHE AT= THE INSURED�S MAILING AD�RESS. 3. A. • WORKERS CDHPENSATIDN INSURANCE: ` PART '{3NE OF THE . POLICY APPLIES TII THE NIIRKERS COPlPENSATION LANS OF THE 57ATES LISTEO HERE: MASSAGHUSElTS 3. EriPLOYERS LIA�ILI7Y INSURdNGE: PART TSiO OF THE POLICY APPLIES T� HC�RK IN EACH STATE LiSTED IN ITEH 3.A. THE LINITS aF ' OUR LIABILITY UNDER PART 7ND ARE: 80DILY INJURY BY ACGIDENT �100��s� EAGH ACLIDENT BOOILY INJURY BY` DISEASE �5053•DO+J Pt�LICY ' LIMIT 8IIDitY INJURY OY - DISEASE $1S3fls+�fl� EACH EMPLOYEE G. DTHER STAT�S INSURANCE: PART TNREE DF THE PDLICY ' APPCIES TO THE STAT�S� tF ANYs LI57ED HFRE: " il. THIS POLICY IyCLUDES TltESE EAIt70RSEMENTS AND SCHEDtlLES : }iC242 WC332 NCi7�ii�4i4 NC20e�3t�3A 1iC2�S�SS�1 4. THE PRE?1IUt! FOR TNIS PC3�ICY #iILL SE DETERMINED 8Y �UR AiANUAL 0� RULES• GLASSIFICATIDNSs RATES AND RATING PLANS. ALt INFORMATIDN REQUIRED BELON IS SU8JECT 7D YERIFICAT3t3Y AND tHAP1GE BY AUDIT. PREM OASIS RATE EST GLASSIFICATIOt�S L�C CODE TOTAL PER S1Q0 ANNUAI ST ND NO ANN RENUN OF RFMUN PRENIU�� ( SEE SCHEDULE ) [XPcNSE CL�NSTANT $1bJ i � HIN P2EM $22J DEPOSIT PREH �i�8G5 ES7 ANNUAL Pf�� S1r8II5 ; PREMIUti AOJUST"tENT PERFODtANNUAL�Y �,,,,y�' ^�� =�j• �� ,T� �. `. Gt3UNTEttSIGNED �lJZb13996 AT N�Y1 YDRK, N.Y. BY � ,.. �.:.•.<�:.�,::. -',. = CDPYRIGHT� 19t37 NAT.G3U13CIL ON COriP.INS. AUTHORIZED REPRESENT ,7,jME .'Sil� Y OI 1�745 .�80 31261995 2G 94 9U79 21s)r CNO'rl INVESTMENT . _ _ . _ ��A��HICIIe .�.•. . , . . . � O•DATE�MWUU/YY) . �112/96 rnooucex THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION { i'i2 �?le`:%'F: i'..�.��lt i T:iLat�: �+ t+,}(:p�L'y 1t7C. ONLY AND CONFERS NO RIGHTS UPON TiE CERTIFICATE � ime. ,">L12?tt3.0 .�VPrnze . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR So7�th Ya�r,icut;i, :°;a. �:�2664 � ALTER THE COVERAGE AFFORDED BY THE�POLIqES BELOW. � � . COMPANIES AFFORDING COVERAGE COMPANV A Fi2biic ServicP rh�t,�al InG. Cc. � COMPANV C.icc� invest�nL Lnterori.^>� B � � � �, ll��f. (.;'1Jilld i2n RPSt^t:1'3'.:?.0 COMPnNv . 9II't� P?ain S�reet � � ,Sout'2 Ya.��!nt�C'�, ?�a. :)2.664 ca.wnriv D .,. — THIS IS TO CERTiFV�THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWRHSTANDING ANV REQUIREMENT,TEqM OFi CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS . � � CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SU&IECT TO ALl THE TERMS, � EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: � � L7�X iYPE OF I113UR11NCE POl1CY NUMBEN PoIICY EFFEC7IVE POUCY E7�IMiqN �,� D�iE(IiWW/YY) DA7E(I�VDDIYY) GENEPAI W�BKm . . � BODILV IWURV OCC $ COMPREHENSIVE FORM � � BODIIV INJUflV AGG $ � PREMISE$/OPEMTIONS . PROPERT/OAMAGE OCC S EXPLO�S RN 8NC APSE HAZARD PROPEflTV DAMAGE AGG S PflODUCTS�COMPI ETED OPER � . BI 8 PD COMBINED OCC $ �CT�� 818 PD COMBINED AGG E � INDEPENDEN�CANTqqCTORS PERSONALIWUflVAGG S � .BqOAD FORM PROPER7V DAMAGE � PERSONALINJURV . . I1UfO110BRE lU1BRlfY � BODILVIWURV s ANY AUTO (Per person) ALLOWNEDAfJ�OS(PrivatePass) . ALLOWNEDAIf�0.S � BODILYINJURV $ . � (OUiertlianPeivalePassenger) . (PeraccideM) . HIRED AUT0.5 � . � PROPEFTVDAMAGE . § NON-OWNED AUTQS � GARAGE LIABILITY BODILV IWURYS � PROPERTY DAMAGE y COMBMEO EI[CESS LJABILT' � EACH OCCURRENCE $ UMBRELLAFORM '� ACaGREGA7E � $ 07HEfl THAN UMBRELLA FORM S W011KEH5 CqAPENSA7IW!qND STATUTORV LIMITS ENPLOVEfiS'LIqBRRY EACHACCIDENT $ �/ n?:�.;��. y.M1 � THEPROPqiEfOR/ INCL ��-2-r'L��Sv—�C�`� Z��9FJ ��,�i�j/ � DISEASE-POLICYLIMIT $ �j�Jv' [�} PqR7NERS/EXECUTNE � , OFFICERSARE: EXCL � DISEASE-EACHEMPLOVEE § IUL �i} � O7NEX .�. � . . .�.. ..�UESCNPiqN OF OVEIU710NS/LOCA7qNSNEHICLES5PEC4LL REYS � I� i x` �..h� � .,.r.t . _ . . _ . . ...._ .. 1"�.,,� ��?'«'R's[ ....._, t'�59G� i7Hi'1 Oi` YH'T�;7LICIi � �� TME p�� m ��S BE CANCELLED BEFONE THE T�3.CA'ISC� �.}E'T_;�, . EXNMIqN DA7E 7HFAEOF� 7!E 55UINB C01PI1NY�WILL ENDERVON TO WUL i��`.2 �C�� . . I.l) DAYS WHR7EN N0710E R)iHE CERIIF�A7E XOLDER NIUm TO 7HE IEFf, J:';: �. �c^.Y`',.�i Y.�.:� ?,9f} �'�{Jt�7{ . BUT FAILUNE TO MI1Y.SUCH NO710E SHALL IINOSE NO OBl1C.�710N OH LJRBIL1fY .. OF ANV IN8/ UPON 7HE pGEM3 qi REPflESEMA71VE3. . AI/IIIONQ A71VE � . �� .._�;.� . � . :.. . _ .. �>.:..,...».. _ „y . . . ....�. . «... _ . fr ._.. m3�,.'a� t'X�t'.<;.._. . . � e > - NUMBER FEE THECOMMONWEALTH OF MASSACHUSETTS 96-33 $150.00 . . . . . . . . . .T.�� . . . of .. .YARMOUTH . .. .... .. . . ...... . .... . . Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Pcrmit No. . 96-33. . . . . . .JAN[JARY 3 19g6. . In accordance with Regulations promulgated under au[hority of Chap[er 94, Sec[ion 305A I and Chapter I I I, Section 5 of the General Laws a Permit is hereby granted to: , , ,CHOW, INVESTMENT ENTERPRISES�, INC,, , d(b/a., CHINA INN . . . . .. . . . . . .. . . .. . . .... .. . Whose place o(business is . . 9$�.ROUTE„�8�, SOUTH. .�A�OUTH Type of business and any restrictions ..�QQ.� .�Y��i. . . . . ...... . . . ... . . . . .... .. . . . . ..... To operate a food establishment in ..YSRMQUTt'1 .. ........... . ....... . .... .... ... . .. . . . . . .. (City or Town) Permit Expires .. DECEMBER 31 �g 96 ..... .. .!�. . .. • . . � YHl� ... . .... . . . ./� . - . . Board .. .... . . .. .. .�. . . . . ._ of . .ta ..., , , , , Health FORM]3B �� '\� A.M. 9l1LKIN COMFnNv v� 1 � NUMBER � � � FEE 96-23 THE COMMONWEALTH OFMASSACHUSETTS $50_00 _........Ta''�N......of...._YARMOUTH...._...._..............._........... This is to Certi(y that ...CHOW _Ipjt(ggq+�p �p�ISES.,....INC_...... d/!a/a......CH INA...Z NN..... -....__...._98.1._R9UTE....2.��_..SQSJTH...XARMQUTH_...._._........__._.....__...._._...._........._........._._......_......... IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE in said _....___.YARhK?UTH_....____......____....._...._....._..........._..........__........._...... and at that place only and expires December thirty-frst 19._96......unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing ot common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by Genenl Laws, Chapter 140, and amend- ments thereto. In Testimony Whereof,the undersigned have hereunto atfixed their ofl 1 si �ures. _..:.. ..... .�� . • _ _... _. ri . _...._. .�.. Licensing _.... _ __ . � _ uthonties `' . M. . �.. A . . JANUARY 3 �� y/ _.___...._. ..___. _..._..__. 1996._. ft� IFORM53CBA.M.SUIKINCO.-BOSTON.MA // �OVF,R� - (/ � . i� k + ` � '1'UWN OE' YARMOUI'H BOA2D OF HEALTH �� APPLICATION FOR LICENSE/PERMIT - 1995 � ��( (33 `� 200 , --------------------------------------------------------------------------------------- NAME OF ESTABLISHMENT: ��/�/fJ ��^� TEL NO • 39�- ��C�/ aon�ss: ��/ ��Fin/ .�� RM,oi.�� A MAILING ADDRESS (IF DIFFERENT): OWNER/CORPORATION NAME• ��JQ//1/ �/U�-�7 �ff-iV� L 0/� /��q(��S MANAGER'S NAME: �,�/I/A/ �/ HQ�/� TEL NO ,jl� �l�(L� MAILING ADDRESS: 9R� � �'� �D ��G/%H RFSTAURANT SEATING: 7.CYPAL # /�a NpD7SMpKING SEATS TOTAL #� Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarnrouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or Co. does not have a certificate of worker's canpensation insurance. As part of renewal or issuance of your permits, you must attach a copy of your certificate. If not applicable, please explain: �..�—..�e...�.� Town of Yarrtrouth taxes and liens must be paid prior to enewal or issuance of your permits. Please check appropriately if paid: yes� no ---------------------------------------------------------------------------------------- All food service establishments with 25 seats or more must have at lease 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 their certifications. 1• ��tN�l/ � �-HDI�i�/ a. 3._ /�/X�3/✓ C�'�21/ 4. Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and CoRenunity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. — 1 2 3. 4. ------------------------------------------------------------------------------- OFFICE USE ONLY LICENSE REQUIRED: FEE: PERMIT # LICENSE REQUIRED: FEE: PERMIT F'OOD SERVICE MOTEL $50.00 0-100 SEATS $ 75.00 CABIN $50.00 �OVER 100 SEATS $150.00 q S-33 �ir.�t ppa�c $5a.00 NON-PROFIT $ 25.00 INN $50.00 CONTINENTAL BREAKFAST$ 30.00 LODGE $50:00 �(_COMMON VICTUALLER $ 50.00 �� CAMP $50.00 SWININIING POOL ( ) $50.00ea. VAPOR BATH/ ( ) $25.00ea. WHIRLPOOL RETAIL EY)OD SERVICE LESS THAN 25,000 sq. ft. $ 75.00 iHORE THAN 25,000 sq. ft. $200.00 FROZEN DESSERT SOFT-SERVE ICE CREAM $ 35.00 TOTAL DOE $,�D �� PURN OVER T[7RN OVER TURN OVER TURN OVER - Page 1 of 2 I"� � � _ _/ -..� . ` 4.� � ' .� � � �< = x , ADDITIONAL REGULATIONS: CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HFAT.TH DEPARTMENT BY FILING THE R�UIRED TEMPORARY FOOD SERVICE APPLICATION FORM � 72 HOURS PRIOR TO TI� CATERID EVENT. THESE FY)RMS CAN BE OBTAINED AT T[� HEALTH DEPARTMENT. EROZEN DESSERTS MUST BE TFSTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TFST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION �2 REVOCATION OF YOUR FROZETI DESSERT PERP7IT UNTIL THE ABOVE TIItMS HAVE BEEN MET. WTSIDE CAFES: OUTSIDE CAFES (i.e. r OUTDOOR SEATING WITH WAITER/WAITRFSS SERVICE) MUST HAVE PRIOR APPROVAL FROM THE BOARD OF FIEALTH. FAILURE TO OBTAIN PRIOR APPROVAL FROM TE� HOARD OF HEALTH WILL RESOLT IN THE SUSPENSION OR REVOCATION OF YOi1R E'OOD SERVICE AND ' C:OFPION VICT[JALLFdt PERMITS. OUTDOOR COOKING� PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE FSTABLISHMENT IS PROHIBITED. EVERY WTDOOR IN Q20UND SWIPP7ING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. RESULTS FROM POOL WATER TESTS BY A STATE CERTIFIID LAB MUST BE RECEIVED BY THE HEALTH DEPARTMENi' PRIOR TO OPENING. ALL RENOVATIONS TO ANY FOOD FSTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQi7IPMENT, ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. NOTICE: PII2MITS RUN ANNUALLY FROM JANUARY 1 DD DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(5) BY DECEMBER 31, 1994. SEASONAL ESTABLISHMENTS ARE TO OpNTACT THE HEALTH DEPT. EYH2 INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. APPLICATIONS MUST BE G�OI�LETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLQSURE OF YOUR ESTABLISHME[�Ti [lt�PrIL THE ABOVE TERMS HAVE BEIN MET. A HEARING BEE'ORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPETIING. � DATE SIGNATURE 2- � �Z�j�� Pxrrrr Nar� e Titie �sJ-�litl y � 1 �p�U� l' �iGC��"'� n�arrt+rrr: 7ffiE APPLICATIOLZS MUSP BS dONIPLEP� IN EVLL AL�ID SUffi�IITP� Qd Q2 PRIQ2 1V DHCffi�IDffi2 31. 1994 OR YOU WILL BS SUBJHGT 7�D AN Ai�JLS�ATIVS HLARING. 11/94 � I Sil�EitS CDMPE.�Tf�t AlH3 EMPI.t1YE3t�5 LIABILITY INSilit�l�iCE P�ItY Pt��.IG. SERiREE l�Lf�C ��6dJRANEF CDMPAHYsi�it-YOWCsII�Y� NC6I Cfu1PANY iHl� 26252 tiC 00 DO OU INE�!lATION PA6E � I � POLICY NUMBER� - Fnor� ��'P�1O0� m� � � ��" ��US PO[.L(Y - fJrFiER COVERM'aE PRODUCER NUMBER 03—�SIS68-95 02l03/95 02/63/96 I 4-20-555-6226 �� 1� Tt1E INSi1R�D/AIIILIN6 ADORf55s PRmUGER NAME ANB -ADDit£SS I CFiflii IirYESi7�EttI ENTERPRISE _ . ?U1H@�EYSiiRI61iT INSi�E AS�MGY° F3iC_BIISTDli ib itASiiIN6iQN ST PUB 746 98I lIAIN ST NATICK Mll OI76d SO YARMDU7H 1!A 02664 THE INSUR£D : G RP�t ON OT?tER Sit]fdCPLAGES ARTC SiiDitW ABIIYE: SA �'� 2�-IHE POLIG7=PEitSDD I5 F 021U3/1995 7�J 02/03l2996 I2.OI A!1 STANOARD 7IME ' AF ' FFlE 'INSLRED•S lIAfLIN6 I[BDR � 3. A�••Si0R1CF3t5 GilMPEriSATIIIM INSi1RANCE. PART Ui� [3F THE Pi7f.IG7 APeEIES 7D .THE i Si0R10ERS GDl�ENS�iTIQN EaAS DF THE .:5'IATES LISTED HERE: MASSACHOSETTS ; _ . _ ,' � j � i ; B�• EMPLnTERS LIABILI77 INSURANGE. PART T'd0 OF THE POLILY APeLIES TO MORK IM EAGH STATc LISTED IN ITEN 3.A� THE LINITS OF OUR LIASILITY IINDER PART TH(2 AREs BilOILY IN.lURY BY AGCIDENT SIOOs000 EAtH ACCIDENT BUDIL7 INJURY BT DISEASE 5500•000 POIICY lItfIT BaDILY INJUR7 BY OISEAS� ;10U•OOQ EAtH EMPLOYEE G � OTHER STATES INSURAHC�. PARr THREE DF THE PCLIC7 APPLIES TJ THE STATES� IF ANT• LISTED HER�: D. TNIS PQIIGY INGWDES 7HESE ENdORSEAENTS AND SGHEDULES : MG20Q40I WG242 IiG332 iiG000414 WC200303 Mt240601 4. 7HE PREMIUM FDR THIS POLICY iiILL 8E DETE4MI4ED 8T 01)R ]IANUAL OF RULES• CCASSIFIGATIDNS• RATES ANO RATIN& PLANS. ALL INFQRRA7I�N REWIRED 3ELC:i IS Si18,iECT T� VEKIFICATIDN ANO C:�ANGc 8T AUDIT. PREM 3ASI5 RATE EST C€ASSIF2GaTI�NS LOC CODE T07,1L PEit 5100 ANNUAL ST �l] Np ANN REAfUN CF RE�YUN PREMIUII ( SEE SGHEDULE ) / �� 7 � �I � EXPENSE tIINSTANT $260 � b0 MIN ?RFM ;220 DEPQSZT PR�H 31s647 EST NNUAL PREri $1sb47 PREMIUA ADJU5T:IENT PERIDD:ANYUALLY CDUtiTERSI6NED 03/OT/I995 AT NEN 7CRK• N�7� 3Y . :„; C�PTRISHT, 1987 YAT.CGUNGIL ❑N CJMP.INS. AUTHORIZED R£PRESENTATIVE .00a Y O1 1sb0I . . '"... .... aE..: A.Si�'av'+..-e s :.t...'� r.r�e«. ...a':-. ':. ..��'.q.uy. � ' s .��r \ _ ... �:'� . �. '.:}. ..+'etT »'q. ;`ti:�,�'�K^�y„p�C=w ,��."�� ',_� � �., ' .The Conrmonwealth o"jMassachusetls � ' . -- ; .. '� Department ojtadustrialAccidems '� O/IIesN a�,�:�§ _ _ � /� �r,i.,,`'��'1�3= � 600 Was/rington Street 4.�`=..•'�°' Boston,Masx 02111 Workers' Comprnsation Insunnce Amdavit Anolicantinformafiom " "" ' "- - a ." �"'L ��: `��rN° y �-� �v' � �,y�.�i --- � - ;...._. . -_ _ -- <I I �i ai ) /�/ S= . s��'b Y f7�lLl0%f �{� � �� G!�/ ❑ i am a homeowner penormmg allµork mysdf. �h��S w ["'j f am a solr propri�tor_-d h�cz no one�rorkinc in an}•capacih• � I am an employer pro�iding workers' compensation for my empio ees workin¢on t6is job.�� . • � -. �...__ __.�_ . _ _.. . eomna_m• eamgi �HrNf� 1 N/� address: 7/1,� (%�//l� �- J �;t,., S n_ L'�,�'��'t� /��J � 99 0��/ {� / nhnn u� insurance ro /"�A6 ' A�a�� /i1/r;�v�` �Q� �� b 3 � S�� 6('� 9.C- _..�„�----�-:-n ❑ 1 am a sole proprietor. general contractor, or homeowner(cfrc%onel and ha�•e hired the contractors listed below who ha�z the follu�cin_ �corker,' .ompensation polices: �moanv namS• • . addre•s• cin• nh N insurantc eo � . . � policv# ... ..' ��_..� ' " "" " "TM' �� ... _.. . .,... _ .. .. . _.r. >"'%..�.•v:::twl��r . . _ address fits'• Rgp�"' insnranee co . �u�E6.5� OQII�v M FaNure to feturc eovenge u reqmrcd uoder Seepce 2SA o(MG6 ISS tu ind to�Ye�e - one yean'ImPrjspAOltqt ff xt1l�f lIYII ��O��W P��of�Aae op ro SI,S00.00��d/or roPY o(tAb autemeat mar be fonr�rdMP o tpe 011iee of Ieveetlp�w��O��aed a A�e af SI00.00 a dq apimt me. I indenta�d tla�a em'en;e verlepW�. , /do Aereby cerfifj•u er tha int artd peaaltla aI pery'nry that the injon�tfon prorided u6�r�g��d�� s�� .�>� . ��.�� / ' 7- ��— `�� Print name�iT'//i/Y�( f/�t� � � - m1e� . 7�?D 5 -� �� `'� ,- oRciat use only do not.�te in thb ana ro 6e eomplaed by eiry or tewo ollldd eiry or towm YASMpI1T$.,� �5 � � � � - permibllmeteM 95-33 9S- L3 �Bui�diogDepartmeet ❑eheck if immediate responx i�rcquired O�eeo�iog Bo�rd - OStIK[mtOh OIIIC! eootact penom phone a•_ �508 398� 31 261 flHealth Departmmt , � —�- _��' ,�Older : �•e•�+m;.a�Vlni � I NUMBER FEE ��-- THE COMMONWEALTH OF MASSACHUSETfS � -��00 , 10WN- ........--- ..o£. - ...X�MOU'�'H........--�•-----•------•----•-----•----- This is to Certify ihac ..C�'10W..INVFSTMENT ENTERpRISFS d/b/a CHINA INN -- ��---� ........---••-----••- -- •---...----•--••--�-----------....-_........ _981 MAIN STREET, SOUTH YpRMpUTH . ---- - -...-- - ......._..........._........................ -�---• ...- ........._...----........----�•-------....------•-•-----•-••--......--- IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE in eaid .�TH_YARNIOUTH - -. -.. ..... .....--...... ........ .------ and at that place only and ezpiree December tl�irtyfir£t 19_95....._ unless sooner auapended or revoked for violation of the lawe o[ the CommonN-calth respecting thc liccnsing of common victuallera. This license ie ieened ia conformity with the authority granted to the licensing authoritiee by General Lawe,Chapter 140, and amendments thereto. In Teatimony Whereof, the underaioned have hercunto at6xed their 9'ici eignaturp. . - ' .. .. �..A� ... . .. . ` ... .'. • X . . ...... . ........... ... *_ f�% � lY.K�� . . . ... .. . . .... --�----•-�r-�---T-=-�-..---��--. .. . .... Anthoritia -- ....------�- --��---- � -- - --�--------...... ---- ---• .._AUGUST..�i..................19._9.`�. rfn.7�" • /Z¢�f/�i'�.. O.i�.y� FORM 5 3tq q M SULNM.INC -BOSTON r` �I �0�� V I�. \` � �f NUMBER FEE �I�� 95-33 THE COMMONWEALTH OF MASSACHUSETTS �SjSO.00 ---�------------...... of ------YARMOUTH.................•----...........---�� i i Boar3 of Health of � � � PERMIT TO OPERATE A FOOD SERVICE ESTABLISHMENT j IPermit No. ----95-23..--•.--•--• AUGUST. 2-'----•------19_95_ � In accordance with Regulatiun, promulgated under authority of Chapter 94, Section 305A I and Chapter 111, Section 5 of the General Laws a Permit ia hereby granted to: . � � .CHOW INVESTMQVT ENTERPRISES�__981..MAIN STREET�...SOUTH--YARMC)UTH---.--••--------------- � ----..__....----- I Whoae plaee of businesa is _-CHSLVA_I[t1N------...._..-----------------------------------------------------.------........ j Type of bueinesa .....�D_SERVICE. i To opernte a food sercice estaLlishment in ...T�N._�F..Y��_........._................._........_..._...,. i 1 (City or Town) � Permit F.�cpires _DE�CEMBER._31�.._......-•-------lg--��- .- � .��"'�..n_ � ; ._.......- - -- ---� ---- - I ----- . . ............ . ....--- --- - � - oard ' ! -----�------- - -- -- �� of � - ---... _ . .._ I ---• ------ ------ --- ` ------- ---�..3'�.----� - /•� ----- •---" - Healt6 � ' •------------/-,//-�/.'r'b* --� I --------...--------- I-- FORM S l3B A M SULKIN �BOSTON �r � ��`� � Vlr � . ��..�..� -h �:� Y ,,;�