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Home My WebLink AboutApp-License-CertsDocusign Envelope lD: 7 D5 ABE34 -7 AB7 47 27'885A-9049DAEF8699 T.,THUST BE POSTED ON PREIIISES** This License affirms that the specified premises, structure, or portion thereof ha6 met the necessarycondltions including any inspcctions required at the tame of issuance.It must be framed or laminated and prominently displayed in a clearly visible location within the approvedpremises. Interim Health Director James Gardlner Signature of Interim Health Director ewk"tt A The Commonwealth of Massachusetts Town of Yarmouth Health Department FOOD ESTABLISHMENT LICENSE ISSUED TO: 528 Euck Island Rd W Yarmouth, MA 02673 Bucky's Certificate No. BOHF-23-2272 The purpose of 105 CMR 500.000 is to establish business of preparing, processing, or minimum standards for those persons engaged in the distributing food for sale in Massachusetts. 1 N40L5 R 005 00 sh0a be rbea ncostru de na ad d to ro om et ht Ue dn e nrl U r os fpppeo ro cttesp n theppIbhcaeth License Expiration: December 3L, 2026 Fee: $150.OO Restrlctlons / Conditlonr: Retail Food <25,OOO Sq. Ft. I I Eo.rd of He.lth: Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Charles T. Holway, Clerk Laurance V€nezia, DVM Eric Weston tcG! I Details Expiration Permit Expiration Date* 12t31t2026 Business lnformation Establishment Name (listed on DOR Business License)- Bucky's 1 Establishment Phone #* 5085349061 DBA ("Doing Business As" Name) / Store Front Name" Bucky's Business Street Address in Yarmouth (City, State and ZIP)- 528 Buck lsland Road West Yarmouth, MA02673 Manager/AgenUOperator Name* Aleem Khurram owner/Corporation Name AKMU Owner Phone Number* 5085349061 Email Address* AKMU66@yahoo.com Mailing Skeet Address (if different than Business Street Address) Mailing Address City, State, ZIP Details lnternal Only License Restrictions/Condilions Retail Food <25,000 Sq. Ft. Expiration Dale- 1213112026 Business lnformation Business Name* Bucky's Business Mailing Address (if different) Business E-Mail* AKMU66@yahoo.com Business Legal Entity Corporation Business Address in Yarmouth . 528 Buck lsland Rd, W Yarmouth, MA 02673 Business Phone #* 5085349061 Business Type* Retail Service Corporation Name (if applicable) Akha inc Tax lD (FEIN or SSN)' FEIN ls this a NAME CHANGE? Owner / Manager lnformation Owner's Name* Aleem Khurram Manager/Contact Person Name* Aleem Khurram FEIN *-*-3856 Owner's Phone Number 508-534-9061 Manager / Contact Person Phone Number' 508-360-3237 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 Emergency Telephone Number 508-360-3237 Please attach copies of certifications for all listed below: List all Certified Food Protection Managers' Aleem Khurram List all employees with Allergen Certification* N/A Establishment Operations Address S28-Bucklsland Road west Yarmouth MA 02673 Email Akmu66@Yahoo.com Location is Permanent Structure? Yes Name and Title Aleem Khurram Telephone Number 508-360-3237 Length of Permit Annual Establishment Type I I I I I r I I I Continental Breakfast Common Victualler Non-Profit Wholesale Residential Kitchen for Retail Sale Food Service Frozen Dessert Mobile Retail Service Retail Square Footage* Less than 25,000 sq. ft. Vending Food 0ther I 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. I I l, the undersigned, attest to the accuracy of the information provided in this application and laffirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Heallh on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. Pursuant to MGL Ch. 62C, Sec. 49A, I certify under lhe penalties of perjury that l, to the best of my knowledge and belief, have filed all state tax returns and paid taxes required under law.* Worker's Compensation lnsurance Affidavit Type of Business* We are a corporation and its officers have exercised their right of exemption per c. 152, S 1(4), and we have no employees. [No workers' comp. insurance required]*t Submitted by Staff I Business Aleem Khurram Dec 26, 2025 I do hereby certify, under the pains and penalties of perjury, that the information provided above is true and correct.* Aleem Khurram Dec 26, 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.* ! 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 information above*