HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH
>E APPLICATION FOR LICENSE/PERMIT -2022
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: ' T(. (c[T( E ' TAX ID:
LOCATION ADDRESS: L� tZ P FJ 12411oUj(i- TEL.#: 51Si- 77('41335
MAILING ADDRESS: J/J (L &i W 42mo µ(k- cg-6”
E-MAIL ADDRESS: fl k jCj4 t Q COW% Sto N�
OWNER NAME: `\1(Q DelVASE7
CORPORATION NAME (IF APPLICABLE): _
MANAGER'S NAME: I 1I(O 9.Qu, t- gl(k -'` AMPS TEL.#: / —499-'1 6174
MAILING ADDRESS: MP fNK IJ (LD �\ V7 1 0.06
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POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list�the,dc&jj 3ted
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
HErLTH GI-ET.
Pool operators must list a minimum of two employees currently certified in standard First Aid and 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. (kl 1() oeptn -( 2. @q,( ( MPS 1
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC)on site during hoursrsof operation.
1. \' O OeM PSN 2. &G�f Je' 1
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. Ofk\)1O W-1 2.
HEIMLICH CERTIFICATIONS:
All food service establishments.-with 25 seats or more must have at least one employee trained in the Heimlieh-- --
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. ,(r1J 1 O Del\AC5E 1 2. N vepWsei
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
_INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
�LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80
RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
7<25,000 sq.ft. $150 _FROZEN DESSERT $40 _ TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ ;
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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 t/
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of_Yarmo.uth 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 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 CAFÉS:
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 S E PLAN.
DATE: l SIGNATURE: Q
PRINT NAME & TITLE: OAViQ OMMP N�—�.
( COK
Rev. 10/15/19 1
The Commonwealth of Massachusetts Fee
Town of Yarmouth $335.00
Food Establishment License
Number: BOHF-15-1833-06 Issue Date: 1/1/2022
Mailing Address: Location Address:
DAVID DEMPSEY 415 ROUTE 28
KELTIC KITCHEN- KELTIC KOTTAGE WEST YARMOUTH, MA 02673
415 ROUTE 28
WEST YARMOUTH, MA 02673
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Food Service; Retail; Common Victualler
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
*RESTRICTION: 75 seats total(32 inside;43 outside).
RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET.
Board Hillard Boskey,M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T.Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce G. Murphy PH . ., CHO
Health Director
NOTICE =TM= NOTICE
TO (TiltioL,E3 TO
{
EMPLOYEES A vms.
EMPLOYEES
NJJ
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/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:
NorGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
DAWC321881 01/01/2022 01/01/2023
POLICY NUMBER 150 Sawgrass Drive EFFECTIVE DATES
PAYCHEX INSURANCE AGENCY Rochester, NY 14620 877-266-6850
NAME OF INSURANCE AGENT ADDRESS PHONE#
David Valentine 415 Main Street West Yarmouth, MA 02673
EMPLOYER ADDRESS
12/02/2021
O
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
Q0
MEDICAL TREATMENT
m
The above named insurer is required in cases of personal injuries arising 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' 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 treatment 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
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FoodSafetyState ..
Food Safety Training&Certification
• o Training Certificate•
Awarded to
David Dempsey
For successfully completing the
Food Handler Essentials Course
i5k3d-ifg874h Dec 17, 2020
Certificate Verification Number
Issue Date(valid for 3 years)
Verify at www.statefoodsafety.com/Verify Elr` o .. �
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Bryan Chapman,CCFS,CP-FSra
CEO,StateFoodSafety • }a�V 1 •�
711 Timpanogos Pkwy;Orem,UT
Scan with a smart device to verify.
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StateFoodSafety Food Handlers Card
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