HomeMy WebLinkAbout2022 - App-License-Certification The Commonwealth of Massachusetts Fee
Town of Yarmouth $125.00
Food Establishment License
Number: BOHF-22-4034 Issue Date: 04/26/2022
Mailing Address: Location Address:
LOBSTER HUB LLC 938 ROUTE 6A
COUSINS MAINE LOBSTER YARMOUTH, MA 02675
6 BIRCH BARK ROAD
MEDWAY, MA 02053
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Food Service;
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022k unless sooner suspended or revoked and is not
transferable. v
Board Hillard Boskey,M.D., Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce G. Murphy, MP , R. ., CHO/James G. Gardiner
Health Director/Assistant Health Director
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: (II UJ 07I n a1/1P LO Di f er TAX ID:
LOCATION ADDRESS: 3f3 Hain S#. Yarmouri `Corr /1A TEL.#: (v17-320.7323
MAILING ADDRESS: birch Ban rd F1PdW ocf t14 0,1:8°2(.75
E-MAIL ADDRESS: ra r('OdC'ousinJmixjr rJnb.1-6r.fOrn
OWNER NAME: 'Til d iti rt./6 0
CORPORATION NAMEIF APPLICABLE):
MANAGER'S NAME: Toru Nr/Jon G Ste-930-4639 TEL.#: ,J1-9 -77
MAILING ADDRESS:
OL CERTIFICATIONS:
OOL
pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
of 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. Tara Ne/Jon 2. Todd 1UCljon
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. Tara AJe/Jon 2. TO Old k/for?
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. Taro New() 2. Todd He/J On
�IMLICH CERTIFICATIONS:
food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
11
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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#)(
tEllVCCOLU
APR 0 4 2022
HEALTH DEPT.
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.
BACCO PRODUCT PERMIT CAP
A tobacco permit holder who has ail 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, a "=L OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND AP;;..:'-i- D B '- BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE•.!'i AS -"LAN.
DATE: 3/31/22. SIGNATURE:
PRINT NAME&TITL . /OW A M/!Gt7
Rev.10/15/19
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