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TOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL LICENSE APPLICATION
NE\I APPLICATION f]nerewrL( t 16''-"
($15.00) NAME CHANCE ONLYfI
Sqa srel^iBUSINESS NAME PH.NE# 5n-f,n-Tol
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BUSINESS ADDRESS
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TAX ID (FEN oR ssN)*4-i1q -4163Vfl n-w(ovr fl$b@ tnql L. bvnEMAIL ADDRESS
Pso.e-+ il"r -t178>rghr,iLrnq C\tvrOWNER'S NAME
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CORPORATION NAME rrr e,ppUcesler
FOOD PROTECTION MANAGER(S)
All food sewice establishments are required to have at least one (l) full-time certified FOOD PROTECTION MANAGER on staff.
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PERSON IN CHARGE
All food service establishments must have at least one (l) PERSON IN CHARGE orl site during hours ofoperation
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ALLERGEN CERTIFICATIONS
All food service establishments are required to haye at least one (l) full-time ALLERGEN CERTIFIED staffmember
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All food service establishments with nrenty-five (25) seats or more are required to have at least one (l ) employee trained in the
HEIMLICH MANEUVER on site during hours of operation.l'Hrivt"q clef\
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PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS TO THIS APPLICATION.
RESTAURANT SEATING TOTAL NO. :
TOTAL SQ. FOOTAGE :
A WORKER'S COMPENSATION AFI.'IDAVI T 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 agpropriately paid:
YESd Notr
NOTICE:
LICENSES RUN ANNUALLY FROM JANUARY I TO DECEMBER 3I. IT IS YOUR R,ESPONSIBILITY TO RETURI{ THE
COMPLETED RENEWAL APPLICATION(S) AIiD REQUIRED FEE(S). ALL RENOVATIONS TO ANY FOOD
ESTABLISHMENT (PAINTING, NEW EQI,'IPMENT, ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF
HEALIH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
SIG\ATURE l^D )\DATE I /s ?h
PRINT NAME & TITLE n Y'l
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING: All food sen'ice 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 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 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 CIOOKING: Outdoor cooking, preparation, or display olany food product by a retail or food service
establishment is prohibited.
LICENSE FEES:
Food Service:Retail S€rvice
Gr00 sEATs - Jr2s.00
>100 sEATs - s200.00
Continental - $35.00
Commotr Vic - 150.00
Non-ProIit - $30.00
Wholesale - S80.00
Residential Kit.hen - $80.00
<50 sF - $50.00
<25.000 sF - sls0.00
>25.000 sF - s2rs.00
Frozetr Dessert - S10.00
Vending Food - $25.00
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