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Home My WebLink AboutApp-LicensesTOWN OF YARMOUTH HEALTH DEPARTMENT FOOD ESTABLISHMENT ANNUAL LICENSE APPLICATION T 3 JAN Z|JU NEw APPLICATIOr\*O RENEWALD ($r5.00) NAiUE cHANCE ONLYD t ivitazt nA oti Ic(IL TAX ID rr l\o ?T)sq,t PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLO\I'ING CERTIFICATIONS AND ATTACH COPII S OF CERTIFICATIONS TO THIS i{PPLICATION. PERSON IN CHARGE All food service establishments must have at least one ( I ) PERSON IN CHARGE on site during hours ofoperation vt t,v 1 ALLERGEN CERTIFICATIONS All food service establishments arc required to have at least one ( l) full-time ALLERCEN CERTIFIED staff member .''l ay' a HEIMLICH CERTIFICATIONS All food service establishments with twenty-five (25) seats or more are required to have at least one ( I ) emplo)'ee bained in the HEIMLICH MANEUVER on site durin hours of o11 RESTAURANT SEATING TOTAL NO' : TOTAL SQ. FOOTAGE: BUSINESS NAME 4 I nI lt', t, J ).'5tr , rTtt PHONE # 21-+- LrZ . Ltll- BUSINESS ADD IN /tr|itt9,t) ltt)\t ylorDRESS (!differenttr4,1 f1sl, tta, I _ Cc,n EM /A "t; I tiL ADDRESS OWNERS NAI4E.9 nl fltt,'tlar bcl - ztttPF{ONE # 21t*- MANAGERYCONTACT PERSON CORPORATION NAME (rF APPLTCABLE) PHONE 4 lar,1 2 FOOD PROTECT]ON MANAGER(S) All food service establishments are required to have at least one (1) full-time cenified FOOD PROTECTION MANAGER on staff. 1. l. t. I I l. 1 I I A WORI<ER'S COMPEN SATION AFTIDAVIT IlITIST BE ATTACHED THIS APPLICATION The Town of Yarmouth taxes and liens must be paid prior to rcnewal or the issuance ofyour licenses. Please check if approprietely paid: YEsq/ Notr \OTIC E: LICENSES RUN ANNUALLY FROM 'ANUARY I TO DECEMBER ] I. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S). AI-L RENOVATIONS TO ANY FOOD ESTABLISHMENT (PAINTING. NEW EQUIPMENT, E]'C.) MUST BE REPOKTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE MA ENCINEER SITE PLAN. PRINT NAME & TITLE Xi A /7i1 t ,,1 ,. . 4t )ulSIGNATURDATE I FOOD SERVICE SEASONAI- FOOD SERVICE OPENING:All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depanment to schedule the inspection three (3) dal's prior to openirrg. CAIERINC POLICY: Anyone who caters rvithin the Toun of Yarmouth rnust notifo the Yarmouth Health Department b1 filing the required Temporary Food Service Application fomr sevent)ln\o (72) hours prior to the catered event. These forms can be obtained at the Health Department, or from the Town's website al \\\\.w.yarrnouth.ma.us under l'lealth Department, Downloadable Forms. FROZEN DESSERTS: Frozen dessens nrust be tested by a State certified lab prior to opening and monthly thereafter, rvith sample results submitted to the Health Department. Failure to do so rvill result in the suspension or revocalion of your Frozen Dessert License until the above terms have been met. OL:TSIDE CAFES: Outside cafes (i.e.. outdoor seatirrg rvith sen'er sen'ice). musr have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking. preparation. or displal ofany food product by' a retail or food service establishment is prohibited. LI('E\SE FEES Ies!-Ssll!: 0-100 sEATs - st25.00 >t00 sEATs - s200.00 Contin.nt.l - 335.00 Common Vic - 560.00 Non-Protil - SJ0.00 $holesalc - SE0.00 Rcsidentirl Kitchen - S&).fi) Retail rr tce: <s0 sF - 550.00 <25.000 sF - s 150.00 >25.000 st'- $2E5.00 Frozen Dessert - t10.00 Vcnding Food - 525.00 I ffi It! TI I i -tI't t tJ I .! 4 -!I{ T! I r -tfI:i !I! : l. . i t & t ;t iII II o -l ! o Ia <! o_q aqt (r 55 (, zx zoIF t -lL -1-&EI(J orl ola L.otn 3I a I {I ffi [.kAF${ #$r.,$116 TIAININC CERTIFICATE (lF C(I}IPLETI(I}I This certifies that rin aguilar is awarded this certificate for Learn2Serve Food Allergy Training Course ANSI-FA.00580t200 Sarru.rtlr! ltolt elbeno C tltl U. onrl Ac.r..ltitioh BEt C€FTIFICITE ISSUER "! oflicst ra t-at r r-a ra.! Ir-t Crr tllr 2-.>t-za--*..*-^(-o-** 6 -!lt"g- Thir is yolr poclcl card whict fiB! b€ used at Oroot ot trlini.q co.npl€tio.r lhis is not Oe acn alFood Handler Licensa so you must akars ih€cr ,(i yoll local Hearth D?trrnait d nt6 t,r Fr tufrl at $e I!$rrtnE tt belore apprin! ky employm€nl ou€sric.!s? supgorteJ60trCdl!.com l_t)h I +r l LE/AFIN eSERVE' TRAININ(.' Disclaimer Dear xin aguilar 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 f or employment or liability purposes. Ihank you for choosing S60trainingl n. I x l360tr;(]IT] L/t TOWN OF YARMOUTH HEALTH DEPARTMENT FOOD ESTABLISHMENT ANNUAL LICENSE APPLICATION oqtarrDent 13 JANWI NOW APPLICATIONf] RENEWALf] ($15.00) NAt\IE CHANCE ONLYD Bo+1tr-as aaut BUSINESSNAME At," r,'t 5*yln; Pxr,PHONE # 211+- boz . ztlh {trrlrorm fu Prrt tY| ozb ; BI]SINESS ADD nnYi'r,f'ry"ttW'"%o,tLa,i n4i//t, /afl e l+8 e,vAir- RonRr,ssItr',, fr4,t;l aqq fiuL,lrt, l- Ccm TAX I Di+'T,i"Tltg owNersNAfue-ia/ tlor^ila, pFroNE *2'It-t.. bc) - art ueNAcr,n-rcoNr,rtr ppnsoN PHONE # CORPORATION NAMF- (1r, AppLTcABLE) PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING Cf,RTIFICATIONS AND ATTACH COPIS OF CERTIFICATIONS TO THIS APPLICATION. lar,'l I PERSON IN CHARGE AII food service establishments must have al Ieast one (l) PERSON IN CHARGE on site during hours ofoperation Yi"t n v't C"/ 2 ALLERGEN CERTIFICATIONS All food service establishments are required to have at least one (l) full-time ALLERGEN CERTIFIED staff member. vil cvt 1 HEIMLICH CERTIFICATIONS All lood service establishments with twenty-five (25) seats or more are required to have at least one ( I ) employee trained in the llEIMl-lCH MANEUVER on site durin houm of eration RESTAURANT SEATING TOTAL NO. : TOTAL SQ. FOOTAGE : I I FOOD PROTECTION MANAGER(S) AII food service establishments are required to have at least one (l) full-time certified FOOD PROTECTION MANAGER on staff. I l. l. l. 2. t. I A WORKIR'S COMPENSATION AFFIDAVIT MUST BE ATTACHt,D WITH THIS APPLICATI ON The Town of Yarmouth taxes and liens must be paid prior to renewal or the issuance ofyour Iicenses. Please check if apFropriately paid: YESv NoD NOTICE: LICENSES RUN ANNUALLY FROM JANUARY I TO DECEMBER 31, IT IS YOUR RESPONSIBTLITY TO RETTJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S). ALT, RENOVATIONS TO ANY FOOD ESTABLISHMENT (PAINTING, NEW EQUIPMENT, ETC.) MUST BE REPORTED TO AND APPROVED BY TI,IE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN, SIGN ..4'l ',t,DATE /).rl / PRINTNAME & TITI,E ur,l ar FOOD SEIIVICE SEASONAL FOOD SIlt{VICE OPENING:All fbod service establishments must be inspected by the Health Depaftment prior to opening. Please contact the Health Deparment to schedule the inspection three (3) days prior to opening CATERING POLICY: Anyone who caters within the Torvn of Yarmouth must notiry the Yarmouth Health Department by filing the required Temporary Food Service Application foml 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 wu,w.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 tenns have been met. OUTSIDE CAFES: Outside cafes (i.e., outdoor seating with server service), must have prior approval from the Board of Health. OUTDOOR COOKINC: Outdoor cooking, preparation, or display ofany food product by a retail or food service establishment is prohibited. I,ICENSE FEES: Rctail Servicei <50 sF - s50.00 <25,000 sF - $t50.00 >25.000 sF - s28s.00 Frozen Dessert - 540.00 vending Food - $25.00 Food Servicel 0-100 sEATS - sl2s.00 >100 sEATS - $200.00 Continental- $35.00 Common Vic - s60.00 Non-Profit - 330.00 Wholesale - $80.00 Residential Kitchen - $80.00 ao.l ao{ro s t E e UIoa tao+o ? 11IrtF { --tIn { -oz xz og Ff, il I!9-F 0 + "5r Eq F$Iil+ {'r ;I { E B Iiq I+; !&I.rr IxIzn t. l' IL I,i -lilo in AJco o o Ft- It {f {t Il I aIiIitIIrl:. I iri, IIt- LiI : a ! { I, t Ii i-lot>!;loi*t6 f : o $ 9 e L =Ut ffi m.,r-o;t 3 o t z CIo III 5 I ) I I I ffi LEARTasERvE' TRAINING' CERTIFICATE OF CO}IPLETIO}I This certifies that is awarded this certif icate for Learn2Serye Food Allergy Training Gourse 2.00 i,g Compl.tlonoat. u08/mu Erplrrilon Oat. w@nml Corliticale * ANSI-rA-005mI Altsl NatloDel Acctodibtlott Eodrd ACCREDITED==E- CERTIFICATE ISSUER H4915\ Samsntha l,lontalb€no-0tficer THIS CERTIF'CAIE IS NON-TRANSFEFABLE For employer verificetion of carlificaro validity please send yo ur request r o FoodU andlerProgra mAd min @ 3 :3 rA trilt,i;rafkllrrlltCE Comphnon&n: trprrrronorb B ed.d rri. enrrki!. rd -J-zt:Za--3m6.tion&ft ,Crrl6..ii!am ^rlag:-:-! 6 This is yoor pocl€t card v/hich may be used as proof of tra iniag cmdetion. This is not the actual Food Hardler Llcens€, so you must always check withyour localHealth DeFatmart rnd nnaro nrB tou fumtr eI the requlrernents before appting fDr emdo)4nent. 0ue6liorE? BUpporteS80trainirB.com g8d'.kh-'.bd6luin@l*.r!4 rin aguila trt u) h t{.k l LEARNzSERVE' TRAIN IN G' Disclaimer Dear xin aguilar Congratulations on successfully completing this course. Your certificate of completion will enable you to show proof of training to obtain further licensing if necessary. This certificate 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 360training! 6504 Brid(e Point Parkway, Suite 100 | Austin, TX78730 | 360training.com