The URL can be used to link to this page

Home My WebLink AboutFood Establishment License 5/24/23,4:03 PM about:blank o .•Ya.. 3 �o The Commonwealth of Massachusetts iii Fee o r Town of Yarmouth $165.00 Food Establishment License Number BOHF-23-1296 Issue Date: May 24,2023 Mailing Address: Location Address: 720 PITCHERS WAY HYANNIS MA 02601 125 SEAGULL BEACH IS HEREBY GRANTED A 2023 LICENSE TO OPERATE: Food Service-Seating Frozen Dessert This license is granted in conformity with the statutes and ordinances relating thereto, and expires on December 31,2023 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D., Chairman Of Mary Craig,Vice Chairman Charles T. Holway, Clerk Health Eric Weston Ja es G.Garidiner. Health Director about:blank 1/1 Li 1 Se" TOWN OF YARMOUTH BOARD OF HEALTH 12 I .,. 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: E.Fe R/11,,.ZCe eafEAMZEA -4,Le TAX ID: L/— 11'5 6/3 R LOCATION ADDRESS: / d4citI )ii .' '. 5.744,ilocrfff• TEL.#: -7? /- 7ag-J'76"�/ MAILING ADDRESS: 7 -7,vn PI /- S-(th jlP/. '3'I- = 111,14A,A4c -1.14-D26421 E-MAIL ADDRESS: `/9/'JL OWNER NAME: /1Lci M/R. . S- Ic'i° c7 V e V\'-C x.y No.ti CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: ,q4//I//A.- S. es' TEL.#: .,2e2 "l��z, MAILING ADDRESS: 72o Pic17 e,QS. •a)Ay_ if f-i.vA/(S /1r4 • �26c�t y POOL CERTIFICATIONS: -``��o�Yy77II�� vitiownwarnawmass The pool supervisor must be certified as a Pool Operator,as required by State law. Pl `e'iis'Cth�tisigr ated Pool Operator(s) and attach a copy of the certification to this form. MAY 1 1 2023 1. ,4i/A 2. HEALTH DEPT. Pool operators must list a minimum of two employees currently certified in standarc First Aid and uomm'.inity 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- >ftM//2 .- • IO6.47L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. /VC/l�l/2 • S- ./, ',- 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. Q//11 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 CAMP $55 SWIMMING POOL$110ea. BADGE $55 —TRAILER PARK $105 =WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-1 0 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: RESID.KITCHEN $80 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= $ ,(.'V] *****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 >4, 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: lst Violation a fine of$1,000.00 shall be imposed,2°d 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 uipment, ect.),Must be reported to and approved by the Board of Health to commencement. Renovation may equire a M engineer site plan. DATE:, //2Q/2P 3 /SIGNATURE: i, 1 PRINT NAME&TITLE: 7Y,.�G//1/i4 ` S. 71c9,09tS Rev. 10/11/2022 The Commonwealth of Massachusetts Print Form I Department of Industrial Accidents Office of Investigations A1 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 //CiM//2 S- ' I= t&//`2 (7 /4 e0 Address: -72, P/L/7/EA5 . (,Jet fieff- 9 E City/State/Zip: 1 4 IS _ D Phone #: 7 ' 8"//‘r Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and./ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.[ I am a sole proprietor or partnership and have no 7. [' Office and/or Sales (incl. real estate, auto, etc.) 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4.❑ 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 and/or one-year imprisonment, as well 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 ai and pena 'es of perjury that the information provided above is true and correct Signature: ,I A ,J Date: V//o2D0,2 Phone#: lam' 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 ServSa' ' fe National Restaurant Association TM ServSafe® CERTIFICATION ALCIMIR LOPES for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP). Wiii/ONNT 17885936 5443 CERTIFICATE NUMBER EXAM FORM NUMBER 5/14/2019 5/14/2024 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. ACCREDITED PROGRAM American Woolf Standonto Inertia and the Cortina*for Food Prohctlon #0655 Sherman Brown Executive Vice President, National Restaurant Association Solutions CAN 1] In accordance with Maritime Labour Convention 2006,Resolution ADM N 068-2013(Regulation 3.2,Standard A3.2). 02017 National Restaurant Association Educational Foundation(NRAEF).All rights reserved.ServSafe®and they ServSafe logo are trademarks of the NRAEF.Nationd Restaurant Association®and the arc design are trademarks of the National Restaurant Associarion. This document cannot be reproduced or altered. 171 1081 1 v.171 1 Coniad us with questions co 233 S.Wacker Drive,Suite 3600,Chicago,IL.60606-6383 or ServSafe®restaurant.org. Certificate of Completion + American Alcimir Lopes Red Cross has completed the requirements for -•� _ _ Adult First Aid/CPR/AED Online 0 r. (Eligible for Skills Session within 90 f' , days) •NI • �,TL. '•Fconducted by .eta American Red Cross O rek Date Completed:05/08/2023 ~ •- Valid Period:2 Years Scan code or visit: Certificate ID:017431R https://www.redcross.org/take-a-class/circode?certnumber=0 17431R ia 0,-/.3 r , r , r , r , r g, r , At,, r q �. .� t cam. c�/� c� r I l _ ` of vF t �•4 Ito u _ #i ..4 #i 1w P y ii �N CE RT I F I CAT E OF .` •il • t ,...„70, l'i rert.:7;;- ��. ALLERGEN AWARENESS TRAINING )'4 4.4.30: .4_. _ ;;1 i (C isici• Name of Recipient: ALCMIRLOPES .., .. ! ' Certificate Number: 5057541 1.e. U J 4. :a: I Date of Completion: 5/19/2021 • "� is rl , Date of Expiration: 5/19/2026 I <�ir :c , S.► <i.. 1:1c0 , .•tom • .) i Stk1/4 G. ' h• F -Tr r. . Issued Bv: ❑F I e • „ 11 The above-named person is hereby issued this certificate NATIONAL '� • �� ! for completing an allergen awareness training program ^�� RESTAURANT \ a recognized by the Massachusetts Department of Public Health : -,mot* "ties ASSOCIATION,, tif in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 A h• aM 333 Turnpike Road,Suite 102 wwwrestaurant.org E4C •. x Southborough,MA 01772 -' This certificate will be valid for five(5)years from date ofcompletion• 508-303-9905 • � \ ticww m are s ta u ra n ta s so c.org (��s, L. 1J �//�� ,. =_:Rasa''- . ia_C4 43 'ri. 3 .'. :. -co.,- :._ £.:.__... ?:..jOW. T 4F:v __:W., .1 -414 `� K �,,' 6. .tr `�� a. 1 .r `G�i K_ 1 .r K. .0 `G�4,�' K. 1 P `�G„V: 4. `I