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HomeMy WebLinkAboutApp-License-Certifications ft.; ..... TOWN OF YARMOUTH BOARD OF HEALTH 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: JFQR' `S SEAFOOD AN IJ DA I ay TAX ID( LOCATION ADDRESS: - ' L 0 - _ TEL.#: -'71/ - 46 7 MAILING ADDRESS: 654 MAIN 4STRFF.T V\f FST 1-Ae MOUTN� M A 026'7 E-MAIL ADDRESS: ET-14E OD0Ro 0 53 ;G MAI L0 CO M OWNER NAME: EVA NG1rAX S7 - FoDo 'C Li CORPORATION NAME (IF APPLICABLE): NI/A MANAGER'S NAME: f VANGEJ.,O j T{-IFC') 5eO( TEL.#:608-36279839 MAILING ADDRESS:9'7 evETTLE Pcu E RC)-Arm ) v EST 'ceNs-TAS3),,li, NIA 02.668 POOL CERTIFICATIONS: N/A 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 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 wilLnaatjise past years' records. You must provide new copies and maintain a file at your place of business. a 1. 2. JAN 0 3 2022 3. 4. HFALTH DFPT 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. EV KG Ed,OS T - DDOeov 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. F fANSGLLOS T N EOC)C1 .0L) 2. 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. EVAN GEk_oS TI-4E0coeod 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. EVANGEt.OS Tf4FoUQP_,c)cJ 2. VI RG ) NIA T44Eonoeou 3. h- ce C T HFcDC'JEcU 4. RESTAURANT SEATING: TOTAL# (3 9 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,'0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 ,/tOMMON 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 —<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 1$5Cj.- *****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 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 J 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 thetobacco-license cap is reducefi-- --- - 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 BOA OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE/A SIT LAN. DATE: / — 3 - Z Z SIGNATURE: mit/6/77,4, 4--A---C 2 (L / PRINT NAME& TITLE: Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-1329-07 Issue Date: 1/1/2022 Mailing Address: Location Address: EVANGELOS THEODOROU 654 ROUTE 28 JERRY'S SEAFOOD AND DAIRY WEST YARMOUTH, MA 02673 654 ROUTE 28 WEST YARMOUTH,MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; 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 SEATING: 34 *RESTRICTION:Disposable service only. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G.Murph jv ,R.S., CHO Healt Director The Commonwealth onwealth °?f Massachusetts +t _,_ Department of Industrial Accidents �" =.5.)..,......(14 Office of Investigations =. = 1 1 Congress Street, Suite 100 " "' Boston, MA 02114-2017 • www.mass:gov/dia • Workers' Compensation Insurance Affidavit: General Businesses A i i licant Information Please Print Le.ibl Business/Organization Name: J Address: 65 C t ; E e G 6 73 City/State/Zip: W EST A�M GUI M Phone #: GS- pp pmate Are you an employer? Check thea appropriate box: Business Type(required): 1.❑ 1 am a employer with employees(full and/ 5. 0 Retail or part-time).* 2.0 lama sole proprietor or partnership and have noRestauranllBar/Eating Establishment 7. 0 Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. 3.❑ [No workers' comp. insurance required] 8. LNon-protit We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4), and we have r no employees. [No workers' comp. insurance required]* 10'0 Manufacturing A2,...EN.z..",_.=--; .1,Q EI4. We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other HEALTH DEPT *Any applicant that checks box#I 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 suc organization should check box#1. h an I am an employer that is providing workers'compensation insurance for my employees. Below is the policyin Insurance Company Name: formation. Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration te: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration ). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pl al i ofdaees ta fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKORDER a 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 and a fine Investigations of the DIA for insurance coverage verification. Ido hereby certify,under the pains and penalties o perjury that the Information provided above is true and correct. P .f P l y —, I Si nature: .. i al " ..- —V Date: Phone ft; ,_505 - '7 75- 9752 Official use only. Do not write in this area,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.Other Contact Person: Phone#: www.mass.gov/dia SAL F D MAMA CERTIFIED PRFESSIO DO • Designation Has Been Conferred Upon MARIO THEODOROU � .. Who has met all the ANS/ P R O M E T R I C ••••-• professional requirements for certification in •• ACCREDITED PROGRAM • • frNr,f'1 rprtttr•n '7{[?{\ .tn('f �arT'^,}i^:.. Amencan Nauonal Rfardardo Institute - - and the Conference for Food Protector #0659 Exam 6702 Recognized By Conference For Food Protection Certificate No: 2081203 {�r 1,1L,, Exam Date: 12/10/19 Test Code: 6203046702 Ryan McMillion,Client Services Manager Expires on: 12/10/24 Prometnc 17941 Corporate Drive.Nottingham,MD 21236 I 800.624.2736 MINNIENOMINK Cler,'�" Cut Here Prometric Score Report Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 80 PASS 12/10/2019 r � P R O M E T R I C ;• This is to certify that ANSI ,n, nese MARIO THEODOROU MARIO THEODOROU 35 PETER BLOSSOM LANE I FOOD MANAGER CERTIFICATION WEST BARNSTABLE, MD 02688 Exam 6702 Recognized By Conference For Food Protection 008639957 12/10/19 ID# Exam Date Greater Lowell Tech-Sarasin 2081203 12/10/24 Cert# Expires On L r �� Cut Here .. ,,. .,. _ . :: RTIFI D p • IFE II/ IL 0 / iiii ,,_ , ,,,, N M l!�- ,,- Designation Has Been Conferred Upor; • ANGELO THEODOROU Who has met all the ANSI P R 4 M E T R I C ••••.. professional requirements for certification in •• ACCREOn EO PROGRAM • •• , food service safety and sanitation. "M^ee°"et,°n°.5t°ndndsln„,tate d the C°nlerence 1°r F°°d Pr°tecbon #0659 Exam 6702 Recognized By Conference For Food Protection Certificate No: 2081206 MrIVPL__—, Exam Date: 12/10/19 Test Code: 6203046702 Ryan McMillion,Client Services Manager Expires on: 12/10/24 Prometric ( 7941 Corporate Dove,Nottingham,MD 21236 ( 800.624.2736 Cut Here Prometric Score Report Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 77 PASS 12/10/2019 PROMETRIC ; T.= . 1-,,, 414= #ossa ANGELO THEODOROU I i � necessary requirernt.-'„' ANGELO THEODOROU . h� 97 KETTLE HOLE RD l FOOD it .,.. I A' -” - ' IFICATION WEST BARNSTABLE, MA 02668 Exam 6702 Recognized By Conference For Food Protection 009058532 12110/19 I ID# Exam Date Greater Lowell Tech-Sarasin 2081206 12/10/24 Cert# Expires On L fir.. 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