HomeMy WebLinkAboutApp-CertsTOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL LICENSE APPLICATION
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a-CORPORATION NAME (IF APP
PLEASE LIST STAFT MEMBERS WHO HOLD THf, FOLLOWING CERTIFTCATIONS AND ATTACH
COPIES OF CERTIFICATIONS TO THIS APPLICATTON.
FOOD PROTECTION MANAGER(S)
All food service establishments are required to have at least one (l) full-time certified FOOD PROTECTION MANAGER on stafi
All food serr,'icc cstablishments must have at least one (l) PERSON IN CHARGE on site during hours ofoperation
PERSO HARGE
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ALLERGEN
All food servic to have at least one (l) full-time ALLERGEN CERTIFIED staff member
TIFICATI
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All food service establishments with twenty-five (25) seats or more are required to have at least one (l ) employee trained in the
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HEIMLICH MANEUVER on site d hours of ()n
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A \I'ORKER'S COMPENSATION AFFIDA\'TT NIUST BE ATTACHED \\'ITH 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:
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NOTICE:
LTCENSES RUN ANNUALLY FROM JANUARY I TO DECEMBER 3I. IT IS YOUR RESPONSIBILITY TO RETURN THE
COMPLETED RENEWAL APPLICATION(S) AND Rf,QUIRED FEE(S). ALL RENOVATIONS TO ANY FOOD
ESTABLISHMENT (PAINTTNG, NEW EQUIPMENT, ETC,) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF
HEAITH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
SIGNATURE
PRINT NAME & TITLE /re4, iltus-, o/t//, t77aoe.e.€r-v -:T/
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING: All food service establishments must bc 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 notifu 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 fiom 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 CAFI1S: 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.
I,ICENSO FEES:
Retail Service:fggClgslse:
0-t00 sEATs - $125.00
>100 sEATS - s200.00
continetrtal - $35.00
ComDotr vic -$60,00
Non-Prolit - $30.00
lVholesale - $80.00
Rcsidential Kitchen - $t0.00
<s0 sF - $50.00
<25,000 sF - $150.00
>25.000 sF - $285.00
Frozen Dess€rt - S.10.00
Vending Food - $25.00
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Ac()Ri/-CERT!FICATE OF LIABILITY !NSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER.
IiIPORTANT: It the certificate holdor is an AOOITIONAL INSURED, tho policy(ios) must have AODITIONAL INSUREO provisions or be endorsed
lf SUBROGATION lS WAIVED, subjsct to the terms and conditions of the policy, certain policies may require an endo6ement. A statemenl on
lhis cerlificate does not confer rights to the certilicate holder in lieu of such endoBement(s).
Robert M. Zagami lnsurance
Agoncy
555 Bridgo Stre€t
Weymouth, ilA 02191
PHONE 781-337-4033 781-3374103
tnsurance.com
INSURER(S] AFFOROING COVERAGE
rNsuRER A: Travelers
INSURED
One Hope, lnc., dba
Heavenly Restaurant
194 Main Street
W. Yarmouth, MA 02673
rNsuRER B: safety lnsuEnce
INSURER C
INSURER O
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD
INDICATED- NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 8E ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDEO 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THETERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY I"IAVE AEEN REDUCED BY PAID CLAIMS
INSR TYPE OF INSURANCE POLICY NUMBER
B
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GEN'T AGGREGA-TE LfiIT APPTIES PER]x JECT
OThER
v v 8MA0028670 02127 t26
EACH OCCURRENCE s 1,000,000
DAMAGE TO RENIEO
PREMISES (Eao6o.6.ce)s 500,000
MED EXP (lny one mr$n)s 10,000
PERSONAL & ADV INJURY $
GENERAL AGGREGAIE s 2,000,000
PRODUCTS , COMP]OP AGG s
s
AUTOIIOBILE LIABILITY
OWNED
HIREO
AUTOS ONIY
SCHEOULED
NON.OWNEO
COMBINED SINGLE LIMI-T s
BOoILY INJURY (Per FMn)s
BODtfY TNJURY (P6r a@idst)s
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UISRELLA LIAE OCCUR EACH OCCURRENCE s
AGGREGATE S
DED RETENTION$s
woRxERs cotaPE{saTioN
ANO E PLOYERS'LIABIIrY
ANY PROPRIFTOR/PARTNFR/EXECUTIVF
OFFICERATEMBER EXCLUDED?
DESCRIPTION OF OPERATIONS b€IN
n uB2J200118 02t24t25 02124126
x SIATUTE OTH.ER
EL EACT]ACC]DENT 500,000
E I. DISEASE - EA EMPLOYEE s 500,000
E.L. DISEASE POLICY LIMIT s 500,000
B Liquor Liability added to above
policy eft 04124t2025 8MA0028670 04t24t2s 02127126 claims made form
1,000,000
DESCRIPTIO| OF OPERAnO S / LOCATIONS , VEHICLES {ACORO l0l, Additlonal ReD.rts Sctudub, my b. allachen I morc spa.e i! r.qulE.l)
Additlonal lnsurod: Andreas Evangelldls and Arlemis Evangelldis, 194 Main Stre€t, W. Yarmouth MA 02673
CERTIFICATE HOLDER CANCELLATION
SHOULD Ai{Y OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATIOI{ DATE THEREOF, NOITCE WLL BE DELIVERED INACCORDANCE wlTH THE POLICY PROVISIOXS,Yarmouth Town HallAttn: Licensing
1146 Route 28
South Yarmouth, MA 0266/t Q^
acoRD 2s (2016/03)
' o 1988-2015 ACORO
The ACORD name and logo are registered marks ofACORD
toN rights resorved
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CERTIFICATION
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wlrir:lr i: cr<r:rcrlitccl by lho Anrcricor Nrrtion<rl Slr.rndords lnstitute (ANSIf -Conlerc,rce for Food Protccliorr (CFP].
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EXAM FORM NUMBER
3125t2021
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DATE OF EXPIRATION
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which is occredited by the Americorr Nolionol Stondords lnstitute (ANSI)-Conference for Food Protection (CFP).
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ATLERGEN AwnREN E S S TRATN ING
Name of Recipient: Leeje Young
Date of Completion: December 12,2023
Date of Expiration: December 13,2028
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CTRTIFICATE OF
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Name of Recipient: Dave Headley
Date of Completion: December 13,2023
Date of Expiration: December 13,2028
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OF COMPLETION
IN RECOGNITION OF SUCCESSFUL COMPLETION IN:
Standard-CPR/AED
(Adult/Child/lnfant)
Automated External Defibrillator (AED)
LEE'E YOUNG
The student has successfully met the requirements for certification by
completing the cognitive training and skills evaluation in the
specified course in terms of NCPRF@ and in accordance with
the corresponding ILCOR, OSHA, and AHA@/ECC guidelines (2020).
Date!Jan 21,2026 Renew:Jan 21,2028 lD#: 3CCC43 lnstructor: Paul J. Scruton
Course Provided Byr
THIS CERTIFICATE IS PROUDLY PRESENTED TO
NationalCPRFoundation" sisnature:
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OF COMPLETION
IN RECOGNITION OF SUCCESSFUL COMPLETION IN:
Standard-CPR/AED
(Adult/Child/lnfant)
Automated External Defibrillator (AED)
Dave Headley
The student has successfully met the requirements for certification by
completing the cognitive training and skills evaluation in the
specified course in terms of NCPRF@ and in accordance with
the corresponding ILCOR, OSHA, and AHA@/ECC guidelines (2020).
Date: Jan 2L, 2026 Renewr Jan 2L,2028 ID#=2D13FE9 lnstructor: Paul J. Scruton
Course Provided By:
THIS CERTIFICATE IS PROUDLY PRESENTED TO
NationalCPRFoundation" sisnature:ra-(la