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CERTIFICATION
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r3l Thpit lEd s.i! tor
JENNIFER BURKHARDT
5651)
€rra Forr. NU^taEr
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Details
lnternal Only
License Restrictions/Conditions
Expiratron Datet
1213112026
Business lnformation
Business Namet
Family Table Collabrotive
Business Mailing Address (if different)
Business E-Mail-
jeni@fami lytablecollaborative.org
Business Legal EntitY
lndividual
Business Address in Yarmouth *
261 Whites Path Unit 5, South Yarmouth, MA
02664
Business Phone #*
7812485753
Business Type*
Food Service
Corporation Name (if applicable)
Tax lD (FEIN or SSN)*
FEIN
ls this a i'IAME CHAI'IGE?
No
Owner / Manager lnformation
Owner's Name*
Jenni Wheeler
ManageriContact Person Name*
Cape Cod Collaborative
FEIN
Owner's Phone Number
Manager i Contact Person Phone Number*
508420-6950
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
Name and Title Address
Telephone Number Email
Emergency Telephone Number
Please attach copies of certifications for all listed below:
List all Certified Food Protection Managers*
UNKNOWN
List all employees with Allergen Certification'
UNKNOWN
Establishment Operations
Length of Permit
Annual
Establishment Type
Continental Breakfast
Non.Profit
Location is Permanent Structure?
Yes
Common Victualler
I
Wholesale
II
n
II
Residential Kitchen for Retail Sale Food Service
Frozen Dessert Mobile
Retail Service Vending Food
I
0ther Name Change Only
I
Affidavit
New construction, remodel or conversion requires an Occupancy Permit from the Building
Department in order to receive a valid Food Permit.
Submitted by Staff
I
Worker's Compensation lnsurance Affidavit
!
I
Type of Business*
We are a non-profit organization, staffed by
volunteers, with no employees. [No workers'
comp. insurance requiredl
Business
Non-Profit
Food / Retail Service
fttr
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 wwwyarmouth.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.*
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'
Notice
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