HomeMy WebLinkAboutApp-Certsi30ur-)q-)oo
TOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL LICENSE APPLICATION3.o26.
NEW APPLICATIONtr
naxrrv,rl[y'
(s15.00) NAIIo cHANGE ONLYfI
o
t'l *Pprooru horr" oe PrzzoBUSINESS NAME PHONE #
3oY . .3 ?1,7z o
2
7pau'rr? tl A Ot
13t €ourr Zg 9. ''l
3'[ eouorre* ftu
,./o u /// I't n'
14,
q n FHOt'Yfr r{OP @ 6r.4/L . (oH TAX lD (peru on ssN)
82 -L69 //qCqEMAIL ADDRESS
f, vft-tt Kouhctt<,tOWNER'S NAMI--PHONE #\ot zq4 zzoo
MANAGER/CONTACT PERSONIvAaz (ouq-cteu PHON h #5o-r jq? 72oo
CORPORA'I ION NAME lrr,a,rrrrc,rsrrl B& I coep
PLEASE LIST STAFF Mf,MBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATTONS TO THIS APPLICATION.
-Luftv (torlfr(HeuI
Kov C.(C t/PT
')
PERSON IN CHARGE
All food service establishments must have at least one (l) PERSON IN CHARGE on site during hours ofoperation
ALLERGEN CERTIFICATIONS
All food service establishments are required to have at least one (l) full-tirne ALLE,RGEN CERTIFIED staff member
HEIMLICH CERTIFICATIONS
All food service establishments with twenfy-five (25) seats or more are required to have at least one ( I ) employee trained in thc
HEIMLICH MANEUVER on site durtn hours of ratlon
RESTAURANT SEATING TOTAL NO. :
TOTAL SQ, FOOTAGE:
frn u Kot,+ct((/I
I Koynt/(euIufi t)
2
BT]SI\I.-SS.\DDIIISS
MAILING ADDRESS (if different)
I
I FOOD PROTECTTON MANACER(S)
I All food service establishments are required to have at least one (l) full-time certified FOOD PROTECTION MANACER on stafi
L
I
I
I
A WORKER'S COMPENSATION AFFIDAVIT MTIST I}E ATTACHED WITH THIS APPLIC.{TION
The Town of Yarmouth taxes and liens must be paid prior to renewal or the issuance ofyour licenses
Please check if appropriately paid:
YESA Notr
NOTICE:
LICENSES RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 3 I. IT IS YOUR RESPONSIBILITY TO RETURN THE
COMPLETED RENEWAL APPLICATION(S) AND REQU I RED FEE(S). At,L RENOVATIONS TO ANY F OOD
ESTABLISHMENT (PAINTING, NEW EQUIPMENT, ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF
HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQIJIRE MA ENGINEER SITE PLAN.
SIGNATURE D^rE /. q .2I
PRINT NAME, & TITLE V ?u F
FOOD SEITVICE
SEASOI T-AI- FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Deparlmenl
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 Yannouth must notiry the Yarmouth Health Department by
filing the required Temporary Food Service Application form seventy-two (72) hoLrrs prior to the catered event. These
forms can be obtained at the Health Deparlment, or from the Town's website at www.yarmouth.ma.us under Health
Department, Downloadable Forms.
I,I('ENSE FEES:
Retail Ser\ ice:
<50 sF - $50.00
<25.000 sF - $t50.00
>25.000 sF - s285.00
Frozen Dessert - $,10.00
Vending Food - $25.00
Food Service:
0-t00 sEATs - sl2s.00
>t 00 sEATs - s200.00
Contin€ntal - S35.00
Com mon Vic - $60.00
Non-Profit - 330.00
wholesale - $80.00
Residential Kitchen - $80.00
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 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.
OUTDOOR COOKING: Outdoor cooking, preparation, or display ofany food product by a retail or food service
establishment is prohibited.
,A(:OFIt>"CERTIFICATE OF LIABILITY INSURANCE 01t05t2a26
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AIVEND, EXTENO OR ALTER THE COVERAGE AFFORDEO BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIV€ OR PRODUCER, ANO THE CERTIFICATE HOLDER,
IMPORTANT: lf the ffithepblicy(ies)musthaveAoDlTloNALlNSUREoprovisionsorbeendo6ed
It SUBROGATION lS WAIVEO, subject to the terms and condations of the policy, certain policies may @qulre an ondoEement A statement on
this certaficate does not confer rights to the cenificate holder in lieu of such endorsement(s).
Benson Young & Downs
Po Box 158
565A Route 28
HaMich Porl l\.iA 02646
Elarne Donoghue
(508)432 1256 (508) 430,1532
Edonoghue@byandd mm
IN SIJ RER(S) AFFOROING COVERAGE
rNsuRERA. Norfolk & Dedham 23965
B&l Corp
dba Yarmouth House of Pizza
1311 Route 28
South Yarmouth l\lA 02664
tNsuRER a. Dorchester 137C6
COVERAGES CERT|FICATE NUMBER 25 26 MasterCOl REVISION NUMBER
THIS IS TO CERTIFY IHATTHE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUEO IO THE INSUREO NAMEOABOVE FOR TI']E POLICY PERIOO
INOICATED NOM4THSTANDING ANY REOUIREMENI TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUIVENT WTH RESPECTTO V',tiICH THIS
CERTIF]CATE MAY BE ISSUEO OR MAY PERTAIN THE INSURANCE AFFORDEO AY THE POLICIES OESCRIEEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES LIMITS SHOVIN I$AY HAVE AEEN REOUCEO BY PAIO CLAIIVTS
COMMERCIAL CENERAL LIABILITY
CLATMS-MAOE E OCCuR
:.:::4..
JECT Loc
R1779536A a9t1512425 49t15t2026
EACH OCCURRENCE $ 2,000,000
FREMTSES (Ea ccure.@)$ 50.000
M€O ExP lAny one peMn)s 5 000
PERSONAL AAOV ]NJI]RY s 2.000 000
GENERALACGREGATE $ 4.000 000
PRODUC'TS. COMP/OPAGG $ 4,000 000
B OWI"IED
AUTOSONLY X SCHEOULED
AI]TOS 923882r44
COMBNEDSINGLELMT s
s 250 000BOO LY NJLJRY (PeT peTson)
BODILY NJURY (PeT a@de.I)s 500,000
s 250.000
9
EXCESSIIAE
OCCUR
CLAMS.MADE
5
AG6REGATE s
WORKERS COMPENSANON
ANO EIIPLOYERS' LIABII IiY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFF CER/MEMBER EXCLT]OEO'
R PTION OF OP€RATTONS bdw
wcc50082464452025A 09/15/2025 09t15t2026
STATI]TE
EL EACH ACC DENI s 100 000
E L OISE,ASE- EA EMPLOYEE s 100,000
EL DISEASE POLCY LIMIT ! 500.000
oEscRtPTtoN oF oPERAIIONS I LOCATIONS / VEHICLES (ACORO i 01, Additional R.m.rr. S.h.d!re, m.y b. rttlch.d i' noc .pa6 B .eq!icd)
dba Yarmouth Hous€ ot Pzza
CERTIFICATE HOLDER CANCELLATION
Soulh Yarmout,l MA 02664
SHOULDANY OF IHEABOVE DESCRIBED POLICIES BE CANCELLEO AEFORE
THE EXPIRATION OATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTI]ORIZEI] REPRESENTATIVE ,*r)
ACORD 2s (20 t6i 03)
O 1988-2015ACORO CORPORATIOI{. All rights reserved
The ACORO name and logo are registered marks of ACORD
|
,,,0,,,0,u
I
,,,,,-
tl
1146 Rle 28
ServSofe
CERTIFICATION
IVAN KOVACHEV
o
[or. successfully co-pleting the siondords set lorth for the ServSob@ Food Probc on Monoger Cerlifico]ion Exominofion,
which is occredited by the Americon Notionol Stondords lnstitute (ANSI){onfe.ence lor Food Prolection (CFP).
ER
10795
EXAM FORM NUMBER
2t19t2023 2t19t2028
DAT E OT EXPIRATION
for recedificolion requiremeni5
DATE OF EX
Locol lows opply Ch
rion Solurions
$::'"\
\.y/
trefrrE
B&ffiblfiw
lcaiEDfa-! aaolilx
lnaL..! tblbl| $crxr,na MAdr,lraqiutE hh.dha.i
s0655 5her
S. S.l L€o or. no&61! ol dc NRAE Norb.ol R6roldhr a'Boticl@ oad Ae o,c dc,gn
Conb.r 6 vrfi qett@, oi 233 S wftIr ttia, Su'E 36(D, Ch@eo, lL 60606{383 d ssvSoLOE Er6r'o€
th your locol r99
Notiono Resio
1 :oald, RclolJidi atM N 068-2013
r.irooddra3ddid Ederffil Fodddis lNRAffl. All nghts e.o.d
d,e ko.JeNrlr .t il,c |loliEl r.!!ru,onl AsuError
il-.. &!ed @aEr b. Gp.odsed or dt.d.
l / !8l l
Allsl Naho n al Ac c te d lalt on 8o ar d
Complrtion Date
$ uanxzsenw
Str LEARN e sERVE
CERTIFICATE tlF C(l]'IPLETIllN
This certif ies that
lvan K OVAChEV
is awarded this certificate for
ANAB-Accredited Food Allergy Training
r['l Expkalion Dat€Certiticrte t
ACCREDITEDIEIEIEE
CERTIFICATE ISSUER
f0975\
Ihisis you. Dock.r c.rd,hi.i m4 De u*d ar
prootort.aininAcohol.r,on lh'sG@r rhe
0eparrmenrand make sureyo! lu( anlhe
requrcme s bfi.,r.npry ^qr0, rmproyrunr
o
AnAB-Accrodited Food Allsrgy Training
ar,ra8
ffi
TRAINING
LEARNzSERVE
Disclaimer
Dear lvan Kovachev
Congratulations on successfully completing this course.
Your certif icate of completion will enable you to show proof of training
to obtain f urther licensing if necessary.
This certif icate does not provide any associated designation. Please check
with your Local Health Authorities with regards to any additional
requirements for employment or liability purposes.
Thank you for choosing 360trainingl
I
I
a
The Educati*r: Center, balow, verifies that
lvan Kovachev
has successfully completed the knowledge and skill evaluations for the
Emergency Care & Safety lnstitute Course.
Couria Namo
1i* Co., CPR
Ed!<ation Cantar
l1L,'.jr.3r'.ctr.t'n
Nov.mb.r ?5, ?o?n
Racornrtrnded ienaral Datc
J-al tudlarncr lro.t t
Stud.nt AutlFrbt€on t{urrb.r
JCtl2ft€O[
€ds<atron Cent.. gEBil
Edu(at;on Center Phon6 Numbot lnrtru<tor Name lnrtruct.r lD Nlmh€r
Thts qertificate does fiol qrsr antee s.!y luture perlorrnance or slgg6st any {qrn. (r{ Ii{eos{rre Slills d*teriqrate ratr,idy when not
uled. Periodic rerrarn,nq rs strongly recommended
5nd.6r a!rrt4t*b. ,: NucvcYu(att
E&<.tto.r C.dtc C.r. Cod CPR
€&dir. C.ft* Elr.at nioo..t.(!( ceB
tas...Lc crr{.r rioi. a: gO$3G4-r7iO
lmt rxid lllFc J.!*l R&,'riirt Mctr,
llrirs.ao. lo a: JC9t?fHOOxtA
Tlr Ede<.don C.'n.r !trii.. rh.r d!..la. h.. .s...i.G&
<.n{r.t d ttr k.-{.dff, ed .ldt .v*drod t!.t,l.
Em.r.n , C... t 3$rty lartttr& Cd!..
Novenbai 21 20?,a ttotlnto .25 m?6
Cour.. Co&di{rr4 O.r.R,..ri,r$r*ndnd R.n6&,1 }nls
t
NCY
Certificate of. Com pl etion
Ecs-Ll AdQ$t,.)
ccurl.: adrrr. c,llid, lrarr cPR & AEo , s4na d Flrrr rr,o
l{tmr3 ,rrn x0?a6rv
,Llct.rr,rar!.anbrrE.oftieariaixdqr66gu*-sardq.x*r,txld.! frt..i !r rTt.xr.r..<.e CaO