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HomeMy WebLinkAbout15-011 Englewood Baking Co.r � ' � l5—al ( � F � 2015 Vendor Application a� .�p��D ; {Processed & Potentially Hazardous Foo s) MAY '� 4 2�)15 Bass River Farm Market H��TH �EPT ; 311 Old Main Street, Bass River, MA 02664 � a 2015 Market Dates: Thursdays, June 11—Sept. 17 9 AM — 1:30 PM Saturdays,June 13—Sept. 19 9 AM — 1:30 PM ,��� ��.x &,�� � � Rain or Shine � �. � Name: �1 ���I�T�� Farm/Vendor Name K�' / Farm/Business Address �f �'l��✓�� ' W� K���O�� � ���� Farm Website: WU�1Ul•�YI41���'��kIV�,C.��'Vi Telephone (Work) (Home) �ag"�"�� (Cell)��3�� Email: ���(�� ��.U�Q��I,N�i ��Obli1 Best way to contact you ,��� Narnes of Designated Person{s) in charge selling at the BRFM* *Person in charge is responsible for all operations and must be on site from 8:30 AM -1:30 PM and be a liaison for all correspondence between town officials(health, police,fire) and the Market Manager. �l i Z����.���Qw1G(,V'�. Phone ,ci08�G53~53�`� Phone Produce/Product you will be selling: (List all. Use separate page if needed. Packaged food items must have potential allergens listed as well as ingredients). Labels should have vendors name and address. FreSl��-f'rozev� C�'o tissu��, bi�.ik-S,��ac�.i�., �i z�Gi-, t,c�t�(ak�S � � � Samples Provided? (Explain methods of serving sampies: sizes, covered, iced?) ; Y�5-u�i►��.Sv�le �.u,�s _ _ � '' Where wiil fQod be prepared? ' IZes���"�a� (Gi�QY�� C4� M�SS ���W ��O�.�uDV�-h. � ; ; Check &attach copies with application: i � Copy of most recent inspection report of facility where food is prepared , �w- Product Liability Insurance ; V ServSafe Certification I � Food Ailergy Awareness Training Certification _ G.A.P.Training Certificate (Required as of 2011) _ Complete and attaeh Workers Compensation Affidavit. Attach State Shellfish Certificate, if applicable Any additionai items must be approved by tMe Health Director prior to being so{d at the BRFM. Please notify Market Manager at least one week in advance or by 10 AM on Monday preceding the Thursday Market and she will get clearance for you. Full Season Fees ,_._— Thursdays — $200.00 ays - $375 Saturdays — $200.00 A 50%non-refundable deposit is due by April 30, 2015. Final payment is due by May 2Q, 2Q15. All full-season vendors are expected to attend weekfy. If a seasonal vendar does not show up at a Market and has not given notice to the Market Manager,that vendor will receive notice from the Market Manager that his/her space is forfeited for the remaining season.There are no refunds. Educators, Master Gardeners, No charge NON PROFIT and Authors and Sustainable Living EDUCATIONAL GRQUPS advocates to share and display their knowledge and work. Must be approved by the Market Manager ' _ 1. Please make your check payable to the Bass River Farmers Market 2. Your 50% deposit+ Board of Health Fee of $50.00 * must be received by April 30�" to reserve your space. * Separate check made out to the Yarmouth Board of Health 3. All full season vendors must be paid in full by May 20th. ,;. By signing this form the vendor acknowiedges that he /�he has read and will comply with the guidelines for the 2015 BRFM which are available on our website: rwH�w.bassriverfarmersmarket.org (hard copies on request) Applicants Signature � 1�.> Date �I'��l� Please return completed application to: Bass River Farmers Market PO Box 1374 South Yarmouth, MA 02664 Market Manager: Carlene Veara (774) 217-1067 � ' � ; � � The Commonwealth of Massachusetts Fee Town of Yarmouth �g�•� � Food Establishment License � Issue Date. 04/22/ZO15 Number: BUHF-15-1830 Mailing Address• Location Address: ELIZABETH MCNAMARA 64 MASSACHUSETTS AVE ENGLEWOOD BAKING COMPANY WEST YARMOUTH.MA 02673 64 MASSACHUSETTS AVENUE WEST YARMOUTH,MA 02673 `'� IS gEREB�GRANTED A,2015 LYCENSE TO OPERATE: Residential Kitchen for Retail Sale � This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31,2015 unless sooner suspended or revoked �nd is not transferable. Con_ diti°ns *RESTRICTION: Non-potentiatly hazarrlous fioods only. Board Tanya Daigneault,Chairman Hillard Boskey,M.D.,Vice Chairman Of Mary Craig,Clerk Evelyn P.Hayes Health Charles T.Holway ruce G.Murphy,MPH,R.S.,CHO/A .von Hone,R.S.,CHO Health Director/Assistant Nealth Director < ! . � . gN �.� c a � o o� a 2 J� �� � h n � H � � � - o � w � � aN � � , 9 � � o �o , c �y� ��'� � e •�� � , ;'o �� � � N� � 0 o� g V = o J r� � Pf�+ �:y ^T _ C% � O . � � � �: :� � � � n N � o.� '=� � y �' m �' n � � p � r.l in � O � �F `� � � �d � n O T O �. � �.. � n � v � Rt �n�r m �h� �. 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E�.1�ABE'€M C,�itc`�F�1�iIf��41�A 1 aa n�asskcMus�rs a�tvu� 55$ V11�5T YIIFfMUUTi^l,MA 026i� 53-13/110 MA 1 _ �`_l�r.�f� 26582 - 1 �n�k � `�f-��-r�� $�arr� t�{�-��1� 1 � � �. � ��,�� . . 11.�i��__dE2�l��"�G� N�%00 � s „ .»� ��i�,.., ' �.�ti„ BankofAmerica''''� � acH n[ror�aooiae ' ���p� C .�. 1���'-�Y�t N�C�� __ :- __ _ �-_�-:-_�� � ? 0 5 58 � , iHaflentl Clerke � � � ����. , i i . \ �1 I I • � ELI�ABETH C.McNAMARA ! 64 MSSSACHUSETTS AV£M1IUE ��L� WEST YARMOl/TH,MA 02673 53-13/�to',MA ' �1 l ���1� 2856? i �m.,.. �t., Zn 7�� ' �,;�,� V�'��rm�r� N��}"�._-------_._I � I��,,��, , ������' -�` —�i�'��1 -�v�I_____ �� . , � s . � ��,; � ��,.i,.� � °. BankofAmerica�� ���:�_� ���:ACHp/r013000i36��.�. � . � . � . �/�_ ���t►11 ��1C�' C'�'�ttl .�D � .�,_..�.��, ,_ , � :� 0559 . i Harle(q GlSrke � ..._..._.� .. . . . . . _._ . "��W...:._ . �� � � ' ` THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH BOARD OF HEALTH ; PERMIT NLJMBER: #15-011 : FEE: $50.00 � ; This is to Certify that F.li�abeth McN m r /a nglewood B king Comn�nv j _ 64 Ma � Av n�e, We�t Y rmot�th, MA � I IS HEREBY GRANTED A LICENSE � � For NAME OF EVENT: Bass River Farmers Market { ATE OF EVENT• Th�r days �nd S���rda�� hr�i g n � PmhP ,�n�5 , LOCATION: 311 Old Main Street, South Yarmouth MA � FOOD SERVED: Fresh& frozen croissants biscuits foraccia, pizza cupcakes 1 i � This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and � expires September 20.2015 unless sooner suspended or revoked. i Mav 15,2015 BOARD OF HEALTH: J[uuf.a 1�p,i�.�Ze�cuet, C�i[rvltrtaft ; �53cr.o��.l1Z..`1�., `?Iice C!Pcavuruut �J.. Bruce G. Murphy,MP , . ., CHO Director of Health � .�.........._.,..____..,._..._...__..._..�...._._ ,�..�..�..,..._.�__...__.���..___..__............__..... . ...._........_..._. ... ... ...... _ _ _ _ __ _ _ .._._............._____...._...�:,......�,,.,...�._..._..