HomeMy WebLinkAboutApp-Certs-LicenseDocusign Envelope lD: 7 DSABE34 -7 AB7 47 27-885A-9049DAEF8699
*tMusT BE POSTED ON PREI'IISES* *
This License affirms that the spccafied premises, structure, or portlon thereof has met the necessary
conditions including any insp€ctions required at the tlmo of issuance.
It must be framed or laminated and prominently displayed in a clearly visible location within the approved
premises.
Interim Health Director James Gardiner
Signature of tnterim Health Director fin"i*r^*
A The Commonwealth of Massachusetts
Town of Yarmouth
Health Department
FOOD ESTABLISHMENT LICENSE
Bass River Rod & Gun Club
620 Route 64, Yarmouth Po4, MA 02675
ISSUED TO:Certificate No.
BOHF-25-163
The purpose of 105 CMR 500.000 is to establish minimum standards for those persons engaged in the
business of preparing. processing, or distributing food for sale in Massachusetts.
105 CMR 500.000 shall be liberally construed and applied to promote the underlying purpose of protecting the
ublic health.
License Expiration:
Dece mber 3t, 2026
Fee: f 30.OO
Restrictions / Conditions:
Borrd of Health:
Hillard Boskey, M.D., Chairman
Mary Craig, Vice Chairman
charles I Holway, Clerk
Laurance Venezia, DVM
Eric Weston
Details
lnternal Only
License Restrictions/Conditions
Expiration Date'
12t31t2026
Business lnformation
Business Name*
Bass River Rod & Gun Club
Business Mailing Address (if different)
Business E-Mail*
treasurer@bassriverrodandgun.com
Business Legal Entity
Association
Business Address in Yarmouth *
P.O. Box 29, Yarmouth Port, MA 02675
Business Phone #*
508-375-9395
Business Type*
Food Service
Corporation Name (if applicable)
Tax lD (FEIN or SSN).
FEIN
ls this a NAME CHANGE?
Owner / Manager lnformation
Owner's Name*
Bass River Rod and Gun Club
Manager/Contact Person Name'
Paul Heslinga
Name and Title
Lawrence Lyford
Telephone Number
508-2724505
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS
Name of Certified Food Protection Manage(S)
All food service establishments are required to have at least one (1) PERSON lN CHARGE on site
during hours of operation
FEIN
Owner's Phone Number
Manager /Contact Person Phone Number'
7749941949
Address
Email
Emergency Telephone Number
Please attach copies of certifications for all listed below:
List all Certified Food Protection Managers*
Lawrence Lyford
List all employees with Allergen Certification*
Lawrence Lyfo rd
Establishment Operations
Length of Permit
Annual
Establishment Type
Continental Breakfast
I
Non-Profit
Location is Permanent Structure?
Yes
Common Victualler
I
WholesaleIt
I
I
I
I
I
I
Residential Kitchen for Retail Sale Food Service
I
Frozen Dessert Mobile
Retail Service Vending Food
I
Other Name Change Only
Affidavit
New construction, remodel or conversion requires an Occupancy Permit from the Building
Department in order to receive a valid Food Permit.
l, the undersigned, attest to the accuracy of the information
provided in this application and I affirm thal the food
establishment operation will comply with 105 cMR 590.000 and
all other applicable law. I have been instructed by the Board of
Health on how to obtain copies of ,l05 CMR 590.000 and the
Federal Food Code. Pursuant to HGL Ch. 62C, Sec. 49A, I certify
under the penalties of per,lury that l, to the best of my
knowledge and belief, have filed all state tax returns and paid
taxes required under law.'
Paul
Heslinga
Nov 17,
2025
Worker's Compensation lnsurance Affidavit
Type of Business'
We are a non-profit organization, staffed by
volunteers, with no employees. [No workers'
comp. insurance required]
I
Submitted by Staff
Business
I do hereby certify, under the pains and penalties of perjury, that
the information provided above is true and correct.'
Paul
Heslinga
Nov 17,
2025
Food / Retail 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 seventy-two (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 CAFES: Outside cafes (i.e., outdoor seating with server 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.
I acknowledge that I have read and understand the information
above.*
I
Notice
PERMITS RUN ANNUALLY FROM JANUARY ,1 TO DECEMBER 31 . IT IS YOUR RESPONSIBILITY
TO COMPLETE THIS APPLICATION EACH YEAR.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT (PAINTING, NEW EQUIPMENT, ETC.) MUST
BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.
RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
I acknowledge that I have read and understand the Notice
informalion above*