The URL can be used to link to this page

Home My WebLink AboutApp-CertsarrrFn .i,l,,.Ef, TOWN O NEw A-PPLICATIONtr - -.zr R.Er{EwArF , /8b "' ($15.00) NAME CEANGE ONLYEI F YARMOUTH HEALTH DEPAR FOOD ESTABLISHMENT ANNUAL LICENSE APPLICATION 6 o 'z<c BoHr-Jq-\ bk TMENT Wwr t7 rEe"ae0 BUSINESS NAME s PH 110# BUSINESS SS TAX OREMAILRESSs PHONE #MAn'AGER'CONTACT PE CORPO ONN (I AT]LE) FOOD PROTECTION MANAGER(S) All food service establishments are required to have at least one (1) full-time certif,red FOOD PROTECTION MANACER on staff. t'J\ur\.,rr.l r( PERSON rN Cuen-cY "-- r!\.r'- ) All food service establishments must have at least one (l) PERSON IN CHARGE on site during hours ofoperation. Oq./'\1 2 All food service establishments are required to have at least one (l) full+ime ALLERGEN CERTIFIED staffmember All food service establishments with twenry-five (25) seats or more are required to have at least one (l ) employee trained in the ) ER FICATIONS HEIMLICH CERTIFICATI S AI-LERG I troDhours oftIEIMLICH NIANEUVL-R on siteI\ /.A1 2 PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTITICATIONS AND ATTACH COPIES OF CERTIFICATIONS TO THIS APPLICATION. RESTAURANT SEATING TOTAL NO. : TOTAL SQ. FOOTAGE : lloo lcr I MAILING ADDRESS (ilbiferent)- I I M owNER'sNAN* it\,dL-,{ ClAr,Y IPH.NE#5og 3bqqrnb L 2.1 f l. A WORKER'S COMPENS.A.TION AFF'IDAVIT XT UST BE A'I'TACHED WI'tH 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: YESF Notr .r-OTICE: LICENSES RI.,N ANNUAILY FROM JANUARY 1 TO DECEMBER 3I. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S), ALL RENOVAIIONS TO ANY 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 SITE PLAN. S IGNATU RE DATE PzuNT NAME & TITLE 0rr FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All 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 Yamrouth must noti$/ 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 musl 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 of any food product by a retail or food service establishment is prohibited. LICENSE FEESI Food Service: 0-100 sEATs - $125.00 >100 sEATs - s200.00 Continental - $35.00 Retail Service: <s0 sF - $50.00 <25,000 sF - $150.00 >25,000 sF - $285.00 Frozeo Dess€rt - $40,00 Vending Food - $25.00 y'co;mon vic - $60.00 Non-Profit - $30.00 Wholesale - Sto.00 R€sid€ntirl Kitchen - S80.00 0 f cof^b TOWN OF YARMOUTH HEALTH DEPARTMENT FOOD ESTABLISHMENT ANNUAL LICENSE APPLICATION &o'zQ NEvr,rPPLl(.\I|o\EJ _,d RENEWAI.E , /b\b a- (Jt5.00) \AMU CHAN(;E ONLI rl tt i+, Wuvr !)rEdaO q)t. lsW.uunilBLr-SINESS NAME "Slx:?oKsnrt BUSTNESS AP{ltss 0+L g.vlp*-Llam.adl, A'l,q r-\1Jn1'\ \J MAILTNC ADDRESS (if Aifferenr)- EMAIL AtrDRESSIla-s4:.cL $ a\ua,l. oovY\'o*'Y{**431sQb Ni,d/'-i Oz4\i,S owNEn's uali6 -U PH.IIE*.5cA 3t 4gl1h MANAGEfuCONTACT PERSON . /.\i\\rrtnrrrl 0)-n,.;,< PI IONE # coRPoR+{toN NA]ME,rfirirr-Ycirft r, \^ rLa-f \ < t-A{-^trn^.4 C(Lll FOOD PROTECTION MANAGER(S) All food sen ice establishments are rcquirel to have at least one ( I ) full-time certified FOOD PROTECIION MANAGER on starl U^ 2 All food senicc establishmetrts must ha!e at least one ( l ) PERSON IN C}IARGE on site during hours ofoperation PERSON IN CH 2 All food sewice establishments are required to have at least one (l ) full-time ALLERGEN CERTIFIED staffmember ALLI.-RG ERTIFICATIONS I ,t I HETMLTcH cERTnrcartdxs All food s€rvice establishments wirh twenry-five (25) sea6 or more are required to have at least one (l ) employce trained in thc HEIMLICH MANEUVER on site during hours ofoperation. I\\, /.AI-/ r, PLE-{SE LIST SIAFF IIEIIBERS \l'Ho HOLD THE FOLLO1I I\(; CERTIFTCATIO\S A\D.{TTA('H COPIES oF CER'tIUC.{TIo\S TO THIS ..TPPLICTTIOI. RESTAURANT SEATING TOTAL NO. : TOTALSQ.FOOTAGE: /(C. lL' I I I I 4 t. 2. I 2. The Town of Yarmouth taxes and liens must be paid prior to renewal or the issuance ofyour licenses Plcrse check lf rpproprlrtcly prid: YESE NOB r-OTICE: LICENSES RLN ANNUALLY TROM JANUARY I TO DECEMBER 3I. IT IS YOUR RESPONSIBILITY TO RITUR\ TIIE COMPLETED RENEWAL APPLICATIO\(S) AT'D REQUIRED FEE(S), ALL RENOVATIONS TO ANY }'OOD ESTABLISHMENT (PAINTING. NEW EQUTPMENT, ETC,) MIJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT, RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN. SIGn.ATURE DATE PRINT NAME & TITLE FOOD SERVICE SEASONAL FOOD SERMCE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schcdule the inspection three (3) days pnor to opening. CATERING POLICY: Anyone who caters within thc Town ofYarmouth must notiry the Yarmouth Health Department by filing the required Temporary Food Servicc Application form scventy-two {72) hours prior to the calered evenl. These forms can be obtained at the Health Depanmenl. or from the Town's uebsite at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts nlust be testcd 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 cafcs (i.e., ourdoor searing with scner sen'ice). musr 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. 0-ilJ Food S.r!icc:,Tltmsnars-srxm >t00 sEATs - s:oo-00 Continentrl . $-15.00/Cooaroo Vk - $etl \on-Profir - s-10.00 Wholesele - 38).00 Rc.ldeDthl Kllchen - lm.m Retail srnicr: <s0 sr - s50.00<:5.fir0 sF - J150.00 >25.000 sF - $2E5.00 I rozeo D!s!6rt - l{0.00 Veltdirg Food - S25.00 A \\ oRKf R'S C OltPt:\S.{]tO\ Af flDA\ ll' I t. St Bt] .\ t T.{('H}]D \\ I I lt tHlS APPLICATIO\ otf sofAb { t_t( u\sE t Et:s: Details lnternal Only License Restrictions/Conditions 1 0 Seats Restriction: Disposable service only: No stove or fryolator: No public restrooms: Hours of operation 6:30 am - 5:00 pm Expiration Date* 1213112025 Business lnformation Business Name*Business Address in Yarmouth t 311 Route 28, West Yarmouth, MA 02673Bagels & Beyond Business Mailing Address (if different)Business Phone #* s083644196 Business E.Mail- bagelsbeyondcc@gmail.com Business Legal Entity Corporation Business Type* Food Service Corporation Name (if applicable) Tax lD (FEIN or SSN)- FEIN ls this a NAME CHANGE? Owner / Manager Information owner's Name* MICHAEL DAVIS Manager/Contact Person Name* MICHAEL DAVIS FEIN ----*7596 Owner's Phone Number 508-3644196 Manager / Contact Person Phone Numbed 508-3644196 Name of Certified Food Protection Manage(S) All food service establishments are required to have at least one (1) PERSON lN CHARGE on site during hours of operation Name and Title Michael Davis Address PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH COPIES OF CERTIF]CATIONS Telephone Number Email Emergency Telephone Number Please attach copies of certifications for all listed below: List all Certified Food Protection Managers' MICHAEL DAVIS JHENELLE MILTON List all employees with Allergen Certification* MICHAEL DAVIS JHENELLE MILTON Establishment Operations Length of Permit Establishment Type Continental Breakfast Location is Permanent Structure? I Common Victualler tr I II Non-Profit Residential Kitchen for Retail Sale Number of Seats lnside' 10 Total Seats 10 Retail Service 0ther Wholesale Food Service Number of Seats Outside * U I Frozen Dessert Vending Food Name Change Only I I I I tr Affidavit New construction, remodel or conversion requires an Occupancy Permit from the Building Department in order to receive a valid Food Permit. Submitted by Staff I Worker's Compensation lnsurance Affidavit Type of Business- I am an employer with employees * Business lnsurance Policy Information Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lnvestigations of the DIA for insurance coverage verification. lnsurance Company Name lnsurer's Address Policy # or Self.ins Lic. #Expiration Date Food / Retail Service SEASONAL FOOD SERVICE OPENING: All 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 notify 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 Permit 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 of any food product by a retail or food service establishment is prohibited. I acknowledge that I have read and understand the information above.' Notice PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO COMPLETE THIS APPLICATION EACH YEAR. ALL RENOVATTONS TO ANY 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 SITE PLAN. I acknowledge that I have read and understand the Notice information above* I ServSafe Servsqfe' CERTIFICATION I\4ICHAEL DAVIS for succEssfuly conpleting l}re stqndords set b h ftr 6€ wlrich ir occredited by Ae Am€ricon Notionol slon ER 2t2812022 DATE OF E locol lcwr opply. Monoger Cerfi ft cotion Exominolion, 6r Food Procction (CFP). 2t28t2027 DATE OF EXPIRATION lor rccrrfi ficolion rcquircmenls. 5o[.rlioos EiFIE #ffi S.r6t hgo 0l. ioa,.ic d fl. rtAE frdioiJ Lh,a, a.o.Lrol. !dllt. oG 4da,r CcE,, vrl qy.rio.Ed 2ll S. lthd, &in, erib 3ae, O'tqc [- 40a06(Bf , Srr6.tC,ersr.d9. (@rd #0655 5556 EXAM TORM NUMBER CTRTIFICATE OF ATTTRGEN AwNRENE S S TnruN TNG Name of Recipient: MIoHAEL oAvls certificate Number. 64583e0 Date of ComPletion' 7/e/2023 Date of Expiration' 7/s2028 EfiEtr rffi lmucn Bv: Ihe abote-named penon is bereby issued thi: cert{rcate for completing an allergen awareness training Progrdm rerognized by the Masucbusetts Department of Publit Heahb in accordance atitb 105 cMR 590.009(c)(3)(a). If MRflffi-NATIONAL . RESTAURANT ASSOCIATTONo am.765.2122 www.rc3taunnt.or8 Marmchuccttr Rcstaurent Ar6ociatiod 333 T&npiLc Road, Suitc 102 Southborough, MA 01772 508-303-9905 www.marc6taugnta35oc.or8 Zhk ertfate will bc ulidforfoe (5) Jearsfrom date of completion t rd '+' {n {lr i.3 ! t