HomeMy WebLinkAboutLONG DELL INN-FOOD - FOOD c --De-L Mon-
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Town of Barnstable
tF�T BOARD OF HEALTH
fl John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
oar4d3rxa�e• F.P.(Thomas)Lee
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16:)g Daniel Luczkow, M.D. Alt.
. . .® 200 Main Street, Hyannis, MA 02601
��� A. Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 455 Issue Date: 01/01/2022
DBA: LONG DELL INN
OWNER: HAPPY TAILS HOSPITALITY LLC
Location of Establishment: 436 S. MAIN STREET CENTERVILLE MA 02632
Type of Business Permit: BED AND BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 10 OutdoorSeating: 0 Total Seating: 10
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST: $55.00
CONTINENTAL BREAKFAST:
MOBILE- FOOD:
MOBILE- ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
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• ~ -��r For- Initials:
�• �.� Town of Barnstable
Date Paid $W
MENSTABU.; Inspectional-Services
y MASB.
`b i6;� Public Health Division cheek#
CFO MA'S�
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE ZOtiv NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: ANY 'f po l,5 H 0 S P k-rh l.I X1--t dh Lo N 1FL r N N
ADDRESS OF FOOD ESTABLISHMENT: �j(o 5 N M AI � .,>e
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: V1 A. . C01t4
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
f TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: y //.I'/ZZ.TO 12-
NUMBER-OF SEATS: INSIDE: 10 OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE_DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
_7BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
-CATERING...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
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bVVNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: YES/ T�O D.O.B OWNER PHONE# V)SO
ADDRESS 'I Vo 5 MAW S { C t< V/tC C /' A V 24 3 Z,
CORPORATE OWNER: 7,-*6S HdM17,-¢Ll7y� "LC-
CORPORATE ADDRESS: 7.;�
PERSON IN CHARGE OF DAILY OPERATIONS: 141A4c JA-W06S4^j $ D ONN 4 Gt1 Q�N/lJ ` x
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have-1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records.You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
I. HA&(, 4Tko8501'.3 L7 I. ARC- 860/3 s o/J G y/ 0 7 / 7.0 7-1
1
Z-Z.—
SIGNATURE 4:A)PLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior-to.opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/bealthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc