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Home My WebLink AboutApp-License-Certification TOWN OF YARMOUTH BOARD OF HEALTH '► j\ ; APPLICATION FOR LICENSE/PERMIT -2022 2022 * Please complete form and attach all necessary documents by Decen ber 18, 2021. Failure to do so will result in the return of your application packet. ..TH DEPT. ESTABLISHMENT NAME: Fe-icy-500S Marke-+ TAX ID: & LOCATION ADDRESS: 9'16 1'"/�in 5 t YC rmcak r)ccJ- 11 Q ,O.67TEL.#: 3-0-3Q-ai N7 MAILING ADDRESS: 1 I k lc i� ST `la�-►�,o�,I�,��v.� � 1 d 0,1675- E-MAIL ADDRESS: Pe- crso is r- ar(c4 e a-0( . Corm OWNER NAME: Te.Vcre. 5, arc.nLer 4 CORPORATION NAME (IF APPLICABLE): 60, r /"T, !! F�i r, s /_L C. MANAGER'S NAME: Terre/ 5, (:en sTEL.#: MAILING ADDRESS: 7/8- lia-rc 5 ya.r�o ci"4 ✓J ti A/ 0)-‘75— POOL L 75TPOOL CERTIFICATIONS: 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 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. ffacC 61c,n Le70s 2. kir I a.( SA,ct 5Dr) PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PITC) on site/ during hours of operation. 1. gr �n 5(.vu,n x� 2. I I I zc A Cif 6t.�.S 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. SC- 5 1,,,0.n ccn 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 • ,iness. 1. 3. RESTAURANT SEATING: TOTAL# �n 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# X' 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 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 •<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 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 Depaitment 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. F.ROZEN 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 SITE PLAN. DATE: 3/19/). SIGNATURE: PRINT NAME & TITLE: Sc (-et S, 66,A knsI; p Octi er feto e r- Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License - Number: BOHF-22-3477 Issue Date: 03/24/2022 Mailing Address: Location Address: BOOK HILL FARM LLC 918 ROUTE 6A PETERSONS MARKET YARMOUTH PORT, MA 02675 918 ROUTE 6A YARMOUTH PORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail • 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. Board Hillard Boskey,M.D.,Chairman Mary Craig,Vice Chairman Of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston ' Bruce Gu .; ,MPH,R.S., CHO ealth Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-22-3479 Issue Date: 03/24/2022 Mailing Address: Location Address: BOOK HILL FARM LLC 918 ROUTE 6A PETERSONS MARKET YARMOUTH PORT, MA 02675 918 ROUTE 6A YARMOUTH PORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE 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. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . Bruce G. Murphy, piP .5., CHO Health Director The Commonwealth of Massachusetts *_- Executive Office of Health and Human Services (I s- Department of Public Health ; Bureau of Environmental Health Food Protection Program 305 South Street, Jamaica Plain, MA 02130-3597 617-983-6712 617-983-6770 - Fax Retail Food Permit and Health Inspection Report Request Name: Petersons Fish Market Address: 918 Main Street, Yarmouthport, MA 02675 Phone: 508-362-2147 Contact: Jeffrey S. Blankenship (petersonsmarket@aol.com) The above firm has applied to the Division of Marine Fisheries and Food Protection Program for a retail seafood dealer permit for the following products in accordance with MGL c. 130 s. 80. Please answer the following questions, sign below and fax this form to the Food Protection Program along with a copy of their current retail food permit and the most recent retail food inspection report issued by your office. Permit Type: Bait Dealer , Retail Boat/Truck , Retail Store X Products: Finfish _ Northern Shrimp Scallops Meat Shellfish X Lobster/Crabmeat Live Lobsters X Bait Other: Please check any specialized processes (seafood area only)approved at this facility that requires a variance and HACCP Plan in accordance with 105 CMR 590.003 and Food Code section 3-502.11. ▪Smoking or curing seafood as a method of preservation ❑Using food additives, acidification or a drying to render seafood non-time/temperature control for safety ❑Reduced oxygen packaging of seafood (vacuum packaging) ❑Operating a molluscan shellfish life-support system display tank (Does not apply to lobster tanks.) ❑Custom processing of seafood that is for personal use as a food and not for sale or service in a retail food establishment (ex. Private fishermen) ❑Other: Facility is currently under enforcement action by the local health department. Yes No Please sign below and fax this form along with a copy of their retail food permit and a copy of their most recent inspection report to the FOOD PROTECTION PROGRAM at 617-983-6770 (fax). If you have any questions please contact Diane Bernazzani at 617-983-6765. Completed by: Date: 5/9P-2- Telephone: °�9 /� 0 % - p �� y Fax:// 3`�;'.s �� Rev,July 2019 r'-Y+�;l�/ r�r'.Yif.�7( `` ) ex./3 c /1-,c---7, 6/5 Renaud, Philip From: Bernazzani, Diane (DPH) <diane.bernazzani@state.ma.us> Sent: Monday, May 2, 2022 12:23 PM To: Murphy, Bruce; Renaud, Philip Subject: Request inspection report, food permit and form filled out for Petersons Fish Market in Yarmouthport, MA Attachments: 05-02-2022-Retail Permit Request-Petersons Fish Market, Yarmouthport, MA.doc Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. We have received a request for a Division of Marine Fisheries Permit for a market in your town. Since local boards of health already license and inspect all retail seafood operations under Department regulations, the Food Protection Program has begun requesting copies of retail food permits and inspection reports from local boards of health when we receive MA Division of Marine Fisheries inspection requests. If the facility is conducting any specialized operations or is under enforcement by the local board of health, the Food Protection Program will conduct a joint inspection. Please find a form attached that we would like you to fill out and fax or email back to us along with a copy of your pre- operational or routine inspection report and current food establishment permit. Please fax or email back to us: -/1. An inspection report for this facility(pre-operational or routine) i/2. A current Food Establishment permit for this facility „ 3. The Retail Food Permit and Health Inspection Report Request Form signed (attached) Thank you, Diane Bernazzani, REHS, CP-FS Retail Food Safety and Training Coordinator MDPH/BEH Food Protection Program 305 South St.,Jamaica Plain, MA 02130 617-983-6765 (office); 617-719-2742 (mobile) 617-983-6770(fax) diane.bernazzani@mass.gov 1