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°` ` TO WN OF YARMOUTH ��of
� Health
1146 UTH YARMOUTH,MASSACHLJSETTS 02664-24451 �
� ��(���d[�� Telephone(508)398-2231,ext.241 Health
Fax(508)760-3472 n'�gi`m
MAR 1 � �fJ��i� .
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HtNL i rr t.�+�::�-' ��. �* �� � ;. �'` FEE: $80.00 per year �
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COMMISSARYJCATERING TEMPORARY FOOD SERVICE APPLICATION -2010
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Name of Business:"'\..��Q� ���� TaJc ID (FEIN or SSN)O�T��-��0 0�
Contact Person���°�-- 0 ��►�R<<� Phone Number:�O$;�gt.��3��
Mailing Address:���(�17��h12 �IA' " �--�'b• �i�. 1►�n , '{U��S S� C�3���U�- ,^
Address where food is prepared: f 71V -5 f"�
Method of food transportation:��l'�l
List all food suppliers: r r ._� ,
t'C�bti �- � ,r��s
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Ice obtained from:
Procedure for keeping potentially hazardous foods below 45E F or above 140E F:
Describe hand washing facilities/procedures and methods for washing and sanitizing cooking utensils:
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Signature of Applicant: c Date: �— l� ` /G
NOTE: 'The Yarmouth B of Health must be notified 72 hours prior to service of catered event.
Caterers located outside of the Town of Yarmouth must also submit a copy of their current local faod service
permit and last inspection repart.
All app6cable items must be completed in order for your appGcallon to be processed.
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. ' `�\ The eommonwealth of Massachusetts
Deparbnent of Industrial Accidents
I�C'I N�ll�s
6110 Washington Street, f�'Floor
Boston,Mass. 02111
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�I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workeas'compensation for my employees wodcing on this job.
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