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Home My WebLink AboutApp-License-Certifications • R-c Ct F7 y DPL v oF... TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: f c� / CAFE+-•1]t) TAX ID: ~`� LOCATION ADDRESS: • lib � �g S 04,0wf Hf#4 M6yTEL.#:SO?-ny-O 7 MAILING ADDRESS: S;4144 E-MAIL ADDRESS: �p?ed£ L Ffoocig Ao L- • CO h- i OWNER NAME: £1i1ge (Cote chAneAo(der) CORPORATION NAME (IF PPLICABLE): �p£ / I FX4S IL MANAGER'S NAME: � �r'A W/L r TEL.#: MAILING ADDRESS: Pd. iYoX VS7r)/?Ec1d � .Q• O d yy POOL CERTIFICATIONS: -77 The pool supervisor must be certified as a Pool Operator, as required by State law. Pleas list-the designated Pool Oper (s) and attach a copy of the certification to this form. 1. 2. DEC 2 2 2020 •� HEALTH DEPT. Pool operators must list a minimum of two employees currently certified in standard First Aid a,id Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. • 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. 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. Z.ck wA Q..cA ��1A(-S‘,1 2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. \71 +it t t 4 UU l-S 2. , , AkneS D1•iwipi v ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. Ed&cet fct , 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. 44 tvAcd 1(51 2. q211-7-, t a�3.L Y, � , /► , ., i/) 4. ip rr C 6 i RFTAiTRANT QFATIN(;• T(1TAi � 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: 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 of residence 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 whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, and submitted to the Health Department*three(3) days 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 SEASONAL FOOD SERVICE OPENING: All food sC!vice establishments Must be inspeOcd by the-ffealtlrBet,artmcnt--priorto-opening-Plea contact the Hkatth - Department to schedule the inspection three(3)days prior to opening. 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 the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted 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 CAFÉS: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Ilcalth. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her pen-nit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-14-0325-07 Issue Date: 1/1/2021 Mailing Address: Location Address: CAPE DELI FOODS, INC. 1 105 ROUTE 28 PICCADILLY CAFE& DELI SOUTH YARMOUTH. MA 02664 1105 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 60 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 1 B uce G. Murphy, MPH, R.S., I HO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts 2C Department of Industrial Accidents It Ems.r, fl. Office of Investigations —z 1...... --4 1 Congress Street, Suite 100 A Boston, MA 02114-2017 `4.4–& www.mass.gov/dia , Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Caf, D.Q.,( ,DJ2 –�% } ) L Address: ( ( 0 5 ffi9 City/State/Zip: 1 f r i , Mi, _,,9 Phone #: So 2- - d g 9 Are you an employer? Check the appropriate box: Business Type(required): 1.,E1 I am a employer with ib employees (full and/ 5. ❑ Retail or part-time).* 6.E Restaurant/Bar/Eating Establishment 2.E I am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 1] Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* " 11.0 Health Care 4.1 I We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: (7!j q;r"C.)_ r!.,c_)ri r Ce Co Insurer's Address: P d b6< 7 S-5-570 70 City/State/Zip: f7l I 0. 2 I. - ) 1 9 (7 --- S-5----X) Policy # or Self-ins. Lic. # eA (A 15 0 9r' Expiration Date: 7 r '— .0..'..72. I Attach a copy of the workers' compensation policy decldration page(showing the policy number and expiration date)., Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisoninent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Sist•tature /,� - w-eyL Date: /. °1-- l9 — pZ 0 Phone#: 6-40g- 371/-030 Official use only. Do not write in this arta, to be completed by city or town officiaL City or Town: Permit/License# Issuing-Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. 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' . . .. . - •_. . . . _. . • :J!c::!P! ; rse e: •" ' Address: - Security control No. Address: 783082 City,State, Zip: Course Completion Date: juN X19 Training Center Expiration Dat .---- JUN 5,2021 SA-- Y FIl2S1 1RAINING ' InstructoF-lVar�e± InstrucfsF iurr�per, su Lias .completed the" NSC CPR Course" based on the current Guidelines for CPR and ECC. F - • The National Safety Council eliminates preventable deaths at work,in homes and communities,and on the road through leadership,research,education and advocacy. For more life-saving courses from NSC please yisit"nse.or9 wining 1' THIS DOCUMENT IS VOID IF REPRODUCED _* _ - - 3 w security ControlNo. pNPI �� 7830_82 �.-,--:',71:::‘-';':',3;-_-:;,-F-2....- EDted fhe - k! -. �. .-„".. s%F 11>SC CPR Course h v�ua onto Training C TRAP4ING INC taki*Nifilittfiriaiiii4 share your opinions • ' about:# f;ourse-you. mpfeted <• ' E lrasriuctiortal Hours" 3 d y " lns�uctor - r dl�l r No. NSC. -- r,',;' `lid itaC.o ..¢t.....: ,,:: rglfatrarning Keep this card for your records.Void if reproduced. 501.41051t72015..1015 90000e130'52016 Natjona4 Safety Count /0174 0000 L. rt; _O. S9, NSA PR I. cr CourseT Ad Biby& Child couNc, Name: Address: - --_ Security Control No. Address: - 783076 City, State,Zip: Course.Completion Date: 5,1g19 Training Center: SAFETY FIItST TRAINING E €fi,Date JUN 5s Zf121 las [cVa€ Ir istructor Number, KRIS E (7BRIEN 3&M82 S USA - E , Y has completed the'NSC CPR Course based on the current`' i -... Gtadelrnes for CPR and ECC. I • The National Safety Council eliminates preventable deaths at work, in homes and communities,and on the road through ' ' leadership,research,education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED oHP�S _ j Ao a. a i Secur ty Control No 0„..„. 783076 • ascom NSC CPR Course We want,your feedback! Please visitinsc.Orgfi'restaidevaloation to Traunwg IElf.:l INC take a brief survey a share your opinions Completion f e 9. about the NSC course you completed. •' instructonal Hours lnstru2104.47,''' 3teu • mature• instructor No. "`#n it life- nsc•org/fatrainir cg Keep this card for your records.Void if reproduced. SO r ' ki a s_<' g501.405102018 1015 900008730�:ZOl6Nafional '% `' f�yz v-„ ` - _ :web Council 79174`0000 [ y " %pvc� JAMES D3'OLUMPIO Name: Address: Security Control No: Address: - 783081 Gity,'tate Course Completion Date: JiJN 5,2019 Training Center: Expiration Date: JUN S,2021 S TS T NIl�IG, Instructor{Va€ne • Instructor �!I:O'BRiEN Number. .- 3i1�2 XikIVIE. ' - -S,„<bl'1 ' •,:: i '''',, 4. ) ' 0 has the NSC CPA Course based err-tt r> R and ECC. • _ - `\ The Nation'Safety Council eliminates preventable deaths at work, in homes and communities,and on the road through leadership,research,education and advocacy.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED Q` Security Control No. 783081 hascompteted'the We want your feedback! NSC CPR Course Please vrsrisc,Dctstaidevahre#ion to Tfs,Ce IKiYi Instruc take a brief strr�af�� opinions.- comptehon about the NSGsburse you ed_ fF tional Hours: gg. Instru a �� urs. 1� !/ Y i.. Instructor o. �+� r nsc.org/fatraining Keep this card for your records.Void if reproduced. 50M05102018 1015 900008130 02016 National Safety Co u cd 79172-0000 }aL -,..,,,,,..0,....:"0.-_..; ., s -:;,...,%:.5&-“:.,''- ',';.-.',.:' -„,4.'7, �uNc = Security C,orrtrol No: Address: ------i------- 783077 Address: City. . Course•Completion Date: „KN5,2019 Training Center. f attoet Date: SUN 5,2021 S2�F QST RAf1�11vG. Instructa�-tcur€iDer:_ f)'BRl is •+ 36Q48L " Lk R Q. �� " 4K h fas ^co pie. ,CPR bated-sari - The National Safety Council eliminates preventable deaths at work,in homes and communities,and on the road through _t leadership,research,education and advocacy. For more life-saving courses from NSC please visit rnsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED `,„"` , - Security Control No ;.�s^ z � 78 2 0 f 77 � : = NSC CPR Course We'wants feedback! Please vtst devaWation to Trairxng cer,te .r- G INC take a • s 'ys >ic opinions Comptetor t �, _ 1 about�tllel•I$ . COri <• ` • r _ Instructional Hous 3 you feted. , = � z _ instructor rf,_- 0 . — ins No.. �+� rtgi g Keepthis card�7L"'* ��-� ::��` nsc.o fatrainin � for your records.Void if reproduced. : - -. 5o,N;m51o2ots..lola 9000081,33 02016 Natona}Safety Counal 79174-0000 1,7.747,-;,',,,„..4.„-;,',,,,;.,,-,f,... ,,,.`:,„,..' s -- AL a *c5� s a t - zk a. , Name: Securty Control No. mess: -. 783083 co,state,Z-�..__: Course Completion Date: juN 5,2019 Training CeNnter- eS-_ FIRST Expiration iRSTExpiration Hate: JUN5,2021 1 struct _ apr Sl_pBi�intrct€��s "TRAIATfNG C �. has the NSC CPR Coursthe R, 4based an y , y e F* C�!R'mid:ECC. The National Safety Council el ina#es.preXentable deaths at work.,in homes and communities,and on the mad through leadership, research,education and advocacy. For more Iffe-saving from NSC please visit nsc,org/fatraJning THIS DOCUMENT IS VOID IF REPRODUCED • ~ Pl Fa Security Cout Nor ,NP _ 7303 r ted the 10, r(� r fd NSC'C� Course - ° «• aluation to Training° ctiC tafce a - Opinions Completion t about ftte itir5 you ed. ' Inst.„,.,:al Hass: 3 _ Instructor ..n { �� %% ` #�. nsc-ort fatrafrtrtt9 Keep this and for your records.Void if reproduced. « - 4 Z , 50M05&O 2Oi5 X00008130®2016 National Safety Coro cf 791 74 000 • ....y ,,,. k.,J llAMM peiwu. use ui 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 '640, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the I lealth Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People arc NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas, total colilbrm and standard plate count by a State certified lab, and submitted to the Health Department'three(3) days 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 SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the health Department prior to opening. Please contact the-Health Department to schedule the inspection three(3)days prior to opening. 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 the catered event. 'These forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.ma.uS under Health Department, Downloadable Forms. FROZEN DESSERTS: - Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted 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 COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. • TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date IS considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020. • 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. DATE: 14 ao-6 SIGNATURE: nn CL PRINT NAME & TITLE: icper � - / Lti Rcv. 10,15;19