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Home My WebLink About2023 Licensing • The Commonwealth of Massachusetts Fee Town of Yarmouth $30.00 Food Establishment License Number: BOHF-15-1345-08 Issue Date: 1/1/2023 Mailing Address: Location Address: HOWARD LODGE MASONIC TRUST 20 DAVIS RD HOWARD LODGE A.F. &A.M. SOUTH YARMOUTH, MA 02664 P.O. BOX 303 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2023 LICENSE TO OPERATE: Non-Profit; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2023 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 tlf/25 Bruce G.Murphy,MPH,R. ;CH() ames G. Gardiner Health Director/Assistant Health Director • r � , fETOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2023 * Please complete form and attach all necessary documents by December 18, 2022. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: kid W.4 RJ L.da G 1 ,4-f a4-4/14 TAX ID: LOCATION ADDRESS: lo 1704 d13 4MI go,frino v71,Md 0V.66* TEL.#:3.."O —3q1 g?,?tom MAILING ADDRESS: , Q' rile E-MAIL ADDRESS: /1/o N e OWNER NAME: ilea/0 4/ t,]f e ,Fa4A-/L CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: rcn ' The pool supervisor must be certified as a Pool Operator,as required by State law. Dew list the designated Pool Operator(s) p erator s and attach a copyof the certification to this form. DEC ZUZZ 1. 2. I ICALTH DP PT 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. 2. —PERSON IN AROE: - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. d wara/ fioe /✓ cy 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. 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. 2. 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC NSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 ON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICE NSE R QUIRED $50 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# sq >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 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 & VIOLATION ASSESSMENT 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. Violations of 105 CMR 665.000, State minimum standards for retail sale tobacco,shall be assessed as follows: 1st Violation a fine of$1,000.00 shall be imposed,2nd Violation within 36 months of 1st violation,a fine of$2,000.00 shall be imposed and a prohibition on sale of tobacco products may be imposed for at least 1 day and up to 7 days, 3rd Violation within 36 months of 1st violation or additional violations during that time period,a fine of$5,000.00 shall be imposed, and a prohibition on the sale of tobacco products may be imposed for at least 7 consecutive business days and up to 30 consecutive business days. 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, 2022. All renovations to any food establishment,motel or pool(i.e.,painting,new equipment,ect.),Must be reported to and approved by the Board of Health to commencement. Renovations may require a MA engineer site plan. DATE: 1 tip SIGNATURE: PRINT NAME&TITLE: Rev. 10/11/2022 The Commonwealth of Massachusetts f Print Form Department of Industrial Accidents Office of Investigations 4 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / Please Print Legibly �Business/Organization Name: lbu'aC Ld�j e , F ///W( Address: 2O D i¢ C//5 Re (.d_ City/State/Zip:, ,Y,4 t7iC v IP Phone #: ,5o o' 4je5 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no rl nff P a,iorc..l:,(incl. real estate. a lu, ctl..) employees working for me in any capacity. [No workers' comp. insurance required] 8. 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.11 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: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration 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 arid/of one-year imprisonment, as welt 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. , .Signature: �7 /'�/ J >`�Cf Date: d'.-----C. ,;2 ;4-- Phone#: SGa-5)-3/�"��/�c 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 Report - Town of Yarmouth Yarmouth Board of Health Food Establishment Inspection P 1146 Route.28,South Yarmouth,MA 02664 Establishment: _fcs..4,0Icr-, l 0%.4(C,5 )tC ' Date: / ,,,,rrp ',.yt,'7 Page 1 of Address: R�, c;7* Time in: 'f Time out: Telephone: Permit No.: Number of Violated Provisions Related to Foodborne Illness Risk Factors Owner: and Interventions(Items 1 through 29): Person-in-charge: Number of Repeat Violations Related Ins ector: �J to Foodborne Illness Risk Factors P ( j -'-) ;-j and Interventions(Items 1 through 29): Type of Operations): Type of Inspection: Other Information: BY Food Service Establishment Routine 0-Retail Food Store 0 Re-inspection 0 Residential:Cottage Foods 0 Pre-operational 0 Residential:Bed& 0 Illness investigation Breakfast 0 General complaint 0 Mobile/Pushcart 0 HACCP 0 Temporary Food Estab. 0 Other ' AC 0 Other �<"-*�' FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS 5 POINTS l IN=in compliance OUT=out of compliance N/O=not observed N/A=not applicable COS=corrected on-site during inspection R=repeat violation Compliance Status IN OUT N/A N/O COS R Compliance Status IN OUT N/AIN/O COS R Supervision f Protection from Contamination / 1 Person-in-charge present, demonstrates 15 Food separated and protected i/ knowledge, and performs duties r 16 Food-contact surfaces; cleaned & / 2 Certified Food Protection Manager v sanitized Employee Health Proper disposition of returned, Management, food employee and % 17 previously served, reconditioned & ... A 3 conditional employee; knowledge, unsafe food responsibilities and reporting / f/ Time/Temperature Control for Safety, 4 Proper use of restriction and exclusion 18 Proper cooking time&temperatures 5 Procedures for responding to vomiting /, 19 Proper reheating procedures for hot / and diarrheal events holding / Good Hygienic Practices 20 Proper cooling time and temperature 6 Proper eating, tasting, drinking, or 21 Proper hot holding temperature ' -. tobacco use 22 Proper cold holding temperature 7 No discharge from eyes, nose, and 'bf 23 Proper date marking and disposition mouth 24 Time as a Public Health Control Preventing Contamination by Hands ,/ 8 Hands clean & properly washed Consumer Advisory J / No bare hand contact with ready-to-eat / 25 Consumer advisory provided for raw/ / . 9 food /+ undercooked food Highly Susceptible Populations 10 Adequate ha si sinks properly v Pasteurized foods used; prohibited foods supplied and accessible 26 /111 not offered Approved Source ! 11 Food obtained from approved source Food/Color Additives and Toxic Substances 12 Food received at proper temperature 27 Food additives: approved & properly used Food received in good condition, safe, & - • ,/ 13 unadulterated 28 Toxic substances properly identified, stored & used Required records available: shellstock 14 tags, parasite destruction Conformance with Approved Procedures 29 Compliance with variance/specialized I process/HACCP Plan GOOD RETAIL PRACTICES AND MASSACHUSETTS-ONLY SECTIONS 2 POINTS IN=in compliance OUT=out of compliance N/O=not observed N/A=not applicable COS=corrected on-site during inspection R=repeat violation Compliance Status I IN I OUT I N/A IN/O I COS I R Compliance Status IN OUT N/A N/O COS R Safe Food and Water i - 48 Warewashing facilities: installed, Pasteurized eggs used where < maintained, & used; test strips 30 required 49 Non-food contact surfaces clean 31 Water& ice from approved source Physical Facilities 32 Variance obtained for specialized 50 Hot& cold water available; processing methods adequate pressure Food Temperature Control 51 Plumbing installed; proper backflow Proper cooling methods used; devices 33 adequate equipment for 52 Sewage &waste water properly _temperature control disposed 34 Plant food properly cooked for hot 53 Toilet features: properly holding constructed, supplied, & cleaned 35 Approved thawing methods used 54 Garbage & refuse properly 36 Thermometers provided & accurate disposed; facilities maintained Food Identification 55 Physical facilities installed, Food properly labeled; original maintained, & clean 37 container ■ 56 Adequate ventilation & lighting; Prevention of Food Contamination designated areas used Insects, rodents, & animals not Additional Requirements listed in 105 CIIlR 590.011 38 present M1 Anti-choking procedures in food Contamination prevented during service establishment 39 food preparation, storage and M2 Food allergy awareness display Review of Retail Operations listed In 105 CMR 590.010 40 Personal cleanliness M3 Caterer 41 Wiping cloths: properly used & M4 Mobile Food Operation stored M5 Temporary Food Establishment 42 Washing fruits & vegetables M6 Public Market; Farmers Market Proper Use of Utensils Residential Kitchen; Bed-and- 43 In-use utensils properly stored M7 Breakfast Operation 44 Utensils, equipment& linens: MS Residential Kitchen: Cottage Food properly stored, dried, & handled Operation ( 45 Single-use/single-service articles: M9 School Kitchen; USDA Nutrition properly stored & used Program 46 Gloves used properly M10 Leased Commercial Kitchen Utensils,Equipment and Vending M11 Innovative Operation Food & non-food contact surfaces Local Requirements 47 cleanable, properly designed, L1 Local law or regulation constructed & used L2 Other Official Order for Correction: Based on an inspection today,the items marked"OUT" indicated violations of 105 CMR 590.000 and applicable sections of the 2013 FDA Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If you are subject to a notice of suspension, revocation, or non- renewal pursuant to 105 CMR 590.000 you may request a hearing before the board of health in accordance with 105 CMR 590.015(B). Date of Reinspection: Discussion with Person-in-Charge: Signature of Person-In-Charge: Date: Signature of InspeOorC ^ _ i ,.Date:_ o y� �: . ti L, ,,. MDPH report form-10/5/18 ve si - W F� �t Food Establishment Inspection Report - Town of Yarmouth Establishment: f OCA Date: /c3.14 Page <y of Temperature Observations Item I Location Temp(°F) Item I Location Temp(°F) Item 1 Location Temp(°F) Observations and/or Corrective Actions Violations cited in this report must be corrected within the time frames stated below or in Section 8-405.11 of the Food Code Item Section of Code Description of Violation Date to Correct By Number �t.5—, -T'ety fP 1 5-0 -- i S--Z;;"-F " 1r - " fNG S ef) cLp A Pei Ga7s I I.VC� / ti^F''�r / ' dG � l.4 S Signature of Person-in-Charge: Date: Signature of Inspector: /: 7- �. -� - / MDPH report form-10/5/18 version Date + d.J