HomeMy WebLinkAboutApp-Certs-R..r+r-A\-SL-L'\\ r
TOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL LICENSE APPLICATTON Wuvr gt
luaur!pdao qtFe,Nf N APPLICA.IIo\ f] r .;;*"*^;E nrr-pohf gU'
($t s.00) NA!!E cHAricE oNl-Yfl
PHONE #-?03&y
TAX ID (FEIN oR ssN)Nz tq qtr't
BUSINESS NAME
BUSINESS ADDRESS
2o
MAILING ADDRESS (if different)
EMAIL ADDRESS
6Z ,(
lryJ;-l +-
W /*d
PHoNE}p-va- (atofio* a nl Ltl e 4{,*4rtlOWNER'S NAME
'^o*'bo Fi i a '//cLMANAGER/CONTACT PERSON .,rtuly D, f Ae./
COnpOnef tOU NA.Utp ru ,lppLrcagLe) /
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS TO THIS APPLICATION.
FOOD PROTECT]ON MANAGER(S)
All food service establishments are required to have at least one ( 1) full-time certified FOOD PROTECTION MANAGER on staff.
rlA eu-2
PERSON IN CHARGE
All food service establishments must have at least one (l) PERSON lN CHARGE on site during hous ofoperation.
t'Edu,arc) /lzau
2
ALLERGEN CERTIFICATIONS
AII food service establisbments are required to haye at least one (l) full-time ALLERGEN CERTIFIED staff member
E
HEIMLICH CERTIFICATIONS
All food service establishments with twenty-five (25) seats or more are required to have at least one (l) employee trained in the
HEIMLICH MANEUVER on site hours of
2
RESTAURANT SEATING TOTAL NO. :
TOTAI SQ. FOOTAGE :
7/"4'-'&
t.
2.
2.
L 4"- a
41,,-,n,e) /.r,ril lc
The Town of Yarmouth taxes and liens must be paid prior to renewal or the issuance of your licenses.
Please check if appropriately paid:
YEStr NOE]
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 TO ANY FOOD
ESTABLISHMENT (PAINTING, NEW EQUIPMENI ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF
HEALIH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
SIGNATURE DATE
PRINT NAME & TITI,E
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.
CATERING POLICY: Anyone who caters within the Town of Yarmouth must notiq/ 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 llom 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. Failr,ue 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 fiom the Board of
Health.
OUTDOOR COOKING: Outdoor cooking, preparation, or display ofany food product by a retail or food service
establishment is prohibited.
LICENSE FEES
Retail Service
<50 sF - s50.00
<25,000 sF - $150.00
>25.000 sF - $285.00
Frozen Dessert - S40.00
Vending Food - $25.00
Egsd&slss,
0-r00 SEATs - $r2s.00
>100 sE_{Ts - s200.00
Continental - 535.00
Commoo Vic - $60.00
- Noo-Profit - S30.00
rit holesale - S80.00
Residential Kitchetr - $80.00
A WORKER'S COMPENSATION AFFIDAVIT MUST Bf, ATTACHED WITH THIS APPLICATION
ServSofe
CERTIFICATION
CHRISTINE GREENE
h rx<orur odrtp ttr ocdqdr s lrtfi ld l* Scr&9 Fed httoion ^rdEs- C'ifidk E&niErb.,rhA n c.Edr.d 6y i. Al$ lA i@ iroddd slEJd* hl!.lr{d6.El Aa-drdi6 3dd (A tA5l-Cqkt6 k r@d P6rdo tcf?r.
5864
EXAM fORM NUMIEI
6117n024
DATT Of E
a17PO29
DATt Of E)(PttAlON
L, 'Eii[€{6,qitdi
ER
6t*--red.-rda
cld,*{-!cas ha' h,b3a@,6q, r !0.0.6L3!!n5&!.d4
{0655 ffi
-et,
,",,,Q
IICATE
ServSqfe'
CERTIFICATION
William Greene
k giGS,t @nddiio *l !b.do'& t r 16l' fo. *. s-,sd i..J ri*chn tildEs6 cstiffdlo. Esix.t ,*id\ i. do.di.d l, *r ^ 61lAEt- Notid sladrd h.&r.l NdnEl A..Edildidr Bdd lArusl-c6&re b Food A...ri.. icf?l.
5€64
EIAM TOiM N UMIE RER
611712024
DATE Of E
d17no29
DATE OT EXPI'AIIONk difidi6 iqdtd
10655 ffi
r.+d*5F@d(@r ed bd r.d!i ldna u( 6d&.t
@dqq.@i$r'.*64
EW
S"rrS"Q
n)ru,,/-O\J