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Home My WebLink AboutApp, WC, License & Certs The Commonwealth of Massachusetts Fee Town of Yarmouth $225.00 Food Establishment License Number: BOHF-15-1471-06 Issue Date: 1/1/2021 Mailing Address: Location Address: PENGUINS GOT THE SCOOP LLC 517 ROUTE 28 (-537) PENGUINS ICE CREAM IGLOO WEST YARMOUTH. MA 02673 15 BLACK WATCH WAY MASHPEE, MA 02649 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Frozen Dessert Manfucturer; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 8 *RESTRICTIONS: Paper service only. Menu: Hot dogs, ice cream (soft serve & hard), pretzels, candy, cookies, brownies, pizza slices (pre-cooked), soda, coffee, water. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric'Weston 41 Bruce G. Murphy, MPH, R.S., HO/Mallory R. Langley, R.S. Health Director/Assistant Health Director /0 a TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2021 *Please complete form and attach all necessary documents by December 18,2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: r`* I Ilia CQ leL�A AX ID: LOCATION ADDRESS: Al 0/2 ,41,, r, TEL. : < )(a 95–,(p G (-1 MAILING ADDRESS: a.)., 7'11.6i%1�I f/- EMAIL ADDRESS: ) I-F e C 1 C3 OWNER NAME: f–'tz ',GI 4i/ K.f-rcr- CORPORATION NAME 1 APPLICABLE):_ ' A !,, i Ar,' fk; CO 0 , MANAGER'S NAME: i 1,S-011 Cof 1 % _� TEL.#: -graa�j s, — E� MAILING ADDRESS: (a ��' t /43C i� al "AMY' A A"y aft e3j z/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new co ie and maintain a file at your establis! •;ent. 1. liar(inn r/ed 2. , J(4 eartiF\- Pee PERSON IN CHARGE: /11P ihenr 1411 . cm ' Each food stablishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 4 i ri ri`s e it_ (-1 ,c,64,Louliu 2. 04rj(1 a-- 16erktk Pili•e_ilint. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide ew copies and maintain a file at your establishment. l. 1. Q.rrI son t--7 { PN-0-- ---2. i 6-1A__ feedAr ` /l i '� 1�1 HEIMEICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FEB 0 2 2021 RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _ MOTEL $110 INN $55 _CAMP $55 _—SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 — —WHOLESALE $80 —REM).KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 _<25,000 sq.fl. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** F . ice - 1411 ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED c/ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. 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 Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 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 CAFÉS: Outside cafes(i.e.,outdoor seating with waiter/waitress 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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 18,2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' .• fit' A SITE PL ,,, DATE: /J �l 17t) 7'/SIGNATURE: ar PRINT NAME&TITLE: MilritmMIEMBLE A Rev. 15/19 The Carrnruealth ofMid Print Form 1 Det of Industrial Accents M of I Investigations y IR 1 0/ Suite 100 Boston,MA 02114-2017 '• ' vuuturass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly ,....._ Business/Organization Name: %l U)/'1 ;-1"u. Cuedty /Oi) J 0,„cs UUP y7 l Address: /s ac4 �1 p- City/State/Zip: Y Phone#: 5b0 (1 111'417 ` Are you an employer? Chec///- appropriate box Business Type(required): 1.1=1 lam a employer with/ /�j% employees(full and/ 5. ❑ Retail or part-time).* 6. restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp.insurance required]** 4.ElWe are a non-lrofit organization,staffed by volunteers, 1 11•El Health Care with no employees. [No workers' comp.insurance req.] ' 12.❑ Other *Any applicant that checks box#1 mist also fill out the section below showing their workers'compensation policy information **If the corporate offices have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I an an employer that is prvvidir workers'kers'caaripe► rtionfor my erployees. Below is the inform tion., Insurance Company Name: / ar'm ram 1 ) �. 0/ 'l �i ` 7 .3y///1 L ) '�C Insurer's Address: c �7 to S. , i City/State/Zip:__ 6401 tn Or 7-) /VW) YOIC i(2b 7-Ai 6 Policy#or Self-ins.Lic.# i O01 K) )LO ' Equation Date: O/ - i — 00:D--, Attacha copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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 fowl 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 Investigations of the DIA for insurance coverage verification. I do ha-aby .. ;k, r r; thep u ns and penalties of pajwy that the mfom tion provided above is true and connect Sia .lure: r ./,A.1 . _ _ ` orA 1 Date: , 3 / 20 "0 Phone#: -Dr---) V-179 Official use only. Do not write in this area,to be completed by city or touxr officiaL City or Town: Permit/License# Issuing Authority(circle acne): 1.Board of Health 2.Building Department 3.City/Town Clerk 4 Licensing Board 5.Selectmen's Office 6.Other Contact Person: __ — Phone#: www.mass.gov/dia `n VIA Farm Family Casualty Insurances Company AMERICAN An American National Company NATIONAL 344 ROUTE 9W1 GLENMONT, NEW YORK 12207-2910 SELECT BUSINESS PACKAGE DECLARATION PAGE Policy Number: 2001X1162 Portfolio Number: Account Number: Name and Mailing Address of First Named Insured: PENGUINS GOT THE SCOOP LLC 15 BLACK WATCH WAY MASHPEE, MA, 02649-2215 Agent: 3020 MARK SYLVIA INSURANCE AGENCY LLC 404 MAIN ST CENTERVILLE MA, 02632-2916 Agent Phone: 508-428-0440 Business Description: SELLS ICE CREAM & FORZEN YOGURT Form of Business: Limited Liability Corporation Transaction Type: Renew Policy Period: From 01-26-2021 To 01-26-2022 12:01 A.M. Standard Time at your mailing address shown above IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THE POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY PROPERTY COVERAGE Buildings TOTAL LIMITS OF INSURANCE Business Personal Property $0 Business Income & Extra Expense $60,000 Actual Loss Sustained Not Exceeding 12 Months Other Endorsements See Schedules LIABILITY COVERAGE General Aggregate Limit (Other than Products-Completed Ops.) Products-Completed Operations Aggregate Limit $2,000,000 Personal &Advertising Injury $2,000,000 $1,000,000 EACH PERSON/ORGANIZATION Each Occurrence Limit Medical Expenses $1,000,000 Other Endorsements $ 5,000 EACH PERSON See Schedules PREMIUM Premium shown is payable at inception POLICY SUBJECT TO ANNUAL AUDIT: Yes Total Premium $1,712.00 The Declarations, Schedules and Forms and Endorsements Make Up Your Complete Policy. Refer to Schedule Of Forms and Endorsements. Process Date: 12-07-2020 w W X-3842 0319 Page 1 of 5