HomeMy WebLinkAboutApp-CertsNEW APPLICATIONtr
RENE\!ALM
($15.00) NA,UE cHANCE ONLYtr
Bo*r-e\'-a-+
G z, LLC )L I b ?;,BUSINESS NAME lo ?
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BUSrNESSorrffio p*+e aJaqtl,{t 6qLn{4,(
MAILING ADDRESS (if different)
J"l'IEMAIL ADDRESS
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OWNER'S NAME
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MANAGER/CON'IA (WEo/
ONE PHO 5&-
CORPORATION NAME Lt)F
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIf,S OF CERTIFICATIONS TO THIS APPLICATION.
FOOD PROTECTION MANAGER(S)
All food service establishments are required Io have at least one (l) full-rime certified FOOD pROTECTION MANACER on stau.
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All food service establishments must have at least one (l) PERSON IN CHARGE on site during hours ofoperation
PERSON IN CHARGE
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ALLERGEN CER
All food service esta ents are required to have at least one ( l) full-time ALLERGEN CERTIFIED staff member
ICATIONS
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HEIMLICH MANEU
HEIMLICH CERT
All food service esta cnn1ts th c fi e 5 oSEATS IT]r orentv e LIired(2 ho vca at ea st noe cqtll e h-aC Clnd tht'l epov
on s te LId h uo orSI on
CATION S
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RESTAURANT SEATING TOTAL NO, :TOTAL SQ. FOOTAGE :?
TOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL i""T:" APPLrcArroN
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A WORKER'S COMPENSATION AFFIDAVIT MUST BE ATTACHED WITH THIS APPLICATION
The Town of Yarmouth taxes and liens must be paid prior to renewal or the issuance ofyour licenses
Please check if appropriately paid:
YESI Notr
NOTICE:
LICENSES RLIN ANNUALLY FROM JANUARY I TO DECEMBER 3I. IT IS YOUR RESPONSIBILITY TO RETURN THE
COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S), ALL RENOVATIONS TOANY 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 SITI] PI-AN.
SIGNATURE DATE
I I ea@u - aiDe
OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service
establishment is prohibited.
LICENST FEES
Food Service:
0-100 sEATs - $125.00
>r 00 SEATS - 5200.00
Continental - $35.00
Com mon Vic - 560.00
Non-Profit - S30.00
lVholesale - S80.00
R€sidential Kitchen - S80.00
Retail Servic€:
<50 sF - s50.00
<25.000 sF - $150.00
>25,000 sF - $285.00
Frozen Dessert - S,10.00
Vending Food - $25,00
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PRTNT NAME & TITLE
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING: AII 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.
CATENNG POLICY: Anyone who caters within the Town of Yarmouth must notit/ 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 Iab 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 License 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.
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CTRTIFICATE oF
ATLERGEN AwaREN ESS TnruN ING
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Name of Recipient: RoZALTYA rRAKovA
Certificate Number. 6062084
I)ate of ComPletion' t2t1st2o22
Date of Expira\ioa' 12h8no27
Ixucd By,
Ibe alove-namul person is hoeby is*ed this trrti/iate
Jbr eomplaitg an allergen uuarenus trai ng ?rogrdm
recognizrl lry the Mcssacbutetts DcPdrtnent oJ Puhlk He tb
in afforda,tce uitb 105 CMR 590.009(C)(3)(a).
lnflfl NATIONAL .
RESTAURANTASSOCtAT|ONo
8W.765.2122
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llis rtrt{ra* uill fu valid"/bt.live (5) yutsJrom date o} comphtiotr
Massachusetts Rcsrrurant Assoriation
333 Turnpikc Road, Suitc 102
Southborou6h, MA 01772
5 08-303 -9905
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ServSafe
National Restaurant Association
SerYSqfe'
CERTIFICATION
ASPARUH TRAKOV
br successfrrlly completing the stondords sa 6ah br the ServSobo Food Protection Monoger Certificotion Exominolion,
vrhich is ocrredited by the Americon Notionol Stondords lnrin ie (ANsI)-€onhrence br Food protection lCFp).
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10763
EX,AM FORM NUMBER
1211412026
DATE OF EXPIRATION
lor recertilicotion rEquiromenfs.
olion Soluliohs
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12114t202
DAIE OF EX
Locol lows opply
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TIFICATE N
MINATION
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Notion
'.nsc SECURITY CONTROL NO
405105c45Ei382
National Safety Council Certificotion Ccrrd
Rozoliyo Trqkovo
hos successfutty compteted the cognitive
ond skitts evotuotions for the fotlowing:
COMPLETION DATE
12le/2O2s
INSTRUCTOR
Richord Todd (*1040918)
EXPIRATION DATE TRAINING CENTER
12131/2027 Cope Cod Sofety Troining
TRAINING CENTER ID
2071551
fhis course rs eguivalent to AHA ond meeas ECC ond ILCOR guide{ines.
This credentiql con be verified ot nsc.orglFAverify
AdutL Chitd & lnfont CPR & AED
5.00 hrs
'.nsc SECURITY CONTRO L NO
105to4EA2C7E26
National Safety Council Certificotion Ccrrd
Asporuh Trqkov
hos successfutty compteted the cognitive
ond skitts evotuotions for the fottowing,
Adutt, Chitd & lnfont CPR & AED
5.00 hrs
COMPLETION DATE
12/9/2025
INSTRUCTOR
Richord Todd (#1040918)
EXPIRATION DATE TRAINING CENTER
1213112027 Cope Cod Sofety Troining
TRAINING CENTER ID
a^,-lE E /ZU / IJJq
Ih{s course rs eguivalent to AHA ond ,neefs ECCond ,ICOR guidetines.
This credentiql con be verified ot nsc.orglFAverify
WoRKERS CO PEt3ATtOt
AroE PLOYERS LIASIL]TY POLICY
TYPE AA I rcRMAION PAGE WC OO OO 01 ( A)
POLICY NUi'8ER:
nEElrrl oP ( 6HrrB - 118063 3 - { - 2 5 )
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INSURER: tHE tRAvEr.ERs
A STOCX COflPAIIY
1.
INSURED:
AC PIZZA LIJC DBA TOI,YS PIZZI.
1020 ROmE 28
sortg YtSt oum HA 02561
DATEOFTSSU€: 12-19-25 Uc
oFFlcE2 ru@ PooL 161
PRODUCER; ETLB GAOUP DBI| ENCLAf,D I.
c(re.tlrr oP ArrRrcA
PRODUCER:
III&B GROI'P XAfl ETGLAI'D L
6802 PAmCoN PLACE. SrE200
RrcEtotrD vA 23230
NCCI CO CODE: 13{ 19
InsuTed Is A LII,iITED IJIAIILITY col(PN[y
Other work places and identification numbers are shown in the schedule(s) attached
2. The policy pericd is hom 01-19-25 to 01-19-27 t2:01 A.M. at the insured's maihng address.
3, A. WORKERS COiTPENSATION INSURAIICE: Part One of the pohcy applies to the Workers
compensation Law of the state(s) listed here:
'lA
B. EIIPLOYERS LIABILITY lltlst RAXCE: Part Two of the policy applr€s to work in each state lbted in
rtem 3.A, The limits of our liability unds Part Two are:
Bodily lntlry by AccidenL $ sooooo Each Accrdent
Boddy lnirry by Disease: $ 500000 Policy Lim(
Bodity lnpry by Disease: S 5oo0oo Each Employee
C. OTH€R STATES lt{SlrFAtrlCE: Part Three of the policy apPlies to the states, rf any, hsted here:
covEnAoB nrPLtcED BY EIDORAnaEST WC 20 03 068
D. This policy rncludes thete endorsements and schedubs:
SEE LIEf,IEG OF ETDOff'IIIETTS - ETTITISION OP INPO P.A.GE
4. The premaum for Sris polky will be determined by our Mtnuals of Rules, Classificattons, Rates and Ratng
plans. All required information is subiect to yerification and change by audit to be made AItluAr,LY.
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