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Home My WebLink About2022 App-License-Certifications a ►, TOWN OF YARMOUTH BOARD OF HEALTH MAY 1 ! 2022 - r\ APPLICATION FOR LICENSE/PERMIT -2022 "''{ HEALTH E T. * Please complete form and attach all necessary documents by Dec, , ., / 1. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: r "" �t7 TAX ID: _ - ,�/ _ LOCATION ADDRESS( i„.1, 4 / I i/ . 3 i �//j I l TI i i- " 33 MAILING ADDRESS: Pi G/ _I i /11//�J i _# - - ii ' a E-MAIL . ADDRESS: GCl � _ D` ‘ / cO ni OWNER NAME: /Gd-riC-/Q Xf J/e/-e•{iali CORPORATION NAME(IF�1jPIJCABLE): C 41,6s 71- /iv SCD 0/3 LCA MANAGER'S MANAGERS NAME: / Y/G! p/�¢ I El_.#: R-_ y(v-j,7lS MAILING ADDRESS: 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 yearsrecords. 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 copies and maintain a Qleat your establishment. 1. Ptd /i`c/Ct. fie( -Fei /edMar) 2. a Mt ' PERSON IN CHARGE: Each foo establishment must have at least one Person In Charge (PI on site during hours of operation. 1. /, ��l$Ort rtv cd 1-na-n 2. dna ct 11 1i— —ci1___ 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. , [.� ici".11Sa F�I ec/n -e� n --� /� e'� 1. lit. / L! a l�/1•f:-Fel l � 2. �/(�/t Gc.�'1 (i. oZCc h HEIMLICH 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. — --}.- 2. 3. 4. - -- --_� RESTAURANT SEATING: TOTAL# f me OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 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 4 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _ =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ c7 aS. 6 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 5 ery ,gJ' 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 REST' E A SITE PLAN/ DATE:T)t j TQ,_2._SIGNATURE: I ` ?-7LL-12—e,e-4/1—e"--) PRINT NAME&TITLE: &/ri CLQ Keil 4-- 671 ed` ta/1 aorta Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $225.00 Food Establishment License Number: BOHF-15-1471-07 Issue Date: 1/1/2022 Mailing Address: Location Address: PENGUINS GOT THE SCOOP LLC 517 ROUTE 28 (-5371 PENGUINS ICE CREAM IGLOO WEST YARMOUTH. MA 02673 15 BLACK WATCH WAY MASHPEE, MA 02649 IS HEREBY GRANTED A 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, 2022 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 ---,..---)A—• ..` jai Bruce G. Murphy,MPH, . , COO/James G.Gardiner Health Director/Assistant Health Director INNS VP,..--.1111111111L.g.'401 1 r,,:::_, , .chilli :rs CERTIFICATE ,, �q of COMPLETION ANSI s, ... _ ACCREDITED sd #1203 Patricia Kent-Friedman ►t Ei has successfully completed the required Allergen Awareness program for RIA Allergen Awareness Certification Date Completed: 7/21/2021 Valid through: 7/21/2024 A m2 Certificate#; 861748 Course Reference FH Always f FoodSafe° compony G,.A{i*U r`'r The Always Food Safe Company Nick Eastwood s. 899 Montreal Circle,St.Paul,55102 President wwv+.a!waysfeodsafe corn 1844312.2011 The Always Food Safe Company 4 ,............... FAILURE TO DO SU CAN RESULT IN SEVERE PERSONAL INJURY QFROM ELECTRICAL SHOCK. CUIDADO TESTA MAQUINA DEBE SER DEBIDAMENTE CONECTADA A TIERRA! NEHERAD A.A PLACA DE[NFDRMACXON A AL DIASRAMA DE ALAMBRADO PARA UNCAIONES De MCA APROP ADAS EL NO IACERLO PUEDE PROVOCAR EN IESIONES PERSONALES GRAVES POR ELECTROCH000E 417+0.eV 7 3 ServSafet ® _ . , . _ ___, . :.. . .... __ ServSafe s . .., . .,__:,_---, CERTIFICATION Y PATRICIA KENT-FRIEDMAN :....p..,., for successfully coerpletinc the standards set forth for the ServSafe'"Food Protection M.aroyr Ce,ricalan Examiraton r ' 5 which is acredited by the.Arneri con Notionol Standards Institute(ANSI}-Conference,:or Fod prarecr on(CFP/ J ER • ,a; 10748 ERS • :Es EXAM FORM NUMBER 3 4/6/2021 DA I f '',i AN,IN ), 416/2026 Auc' dwen DATE OF EXPIRATION MI�J , sur recerfifionm m rogwments ): r T Vitt Nte,eenf,roley. 0 The 6,44,,p, ,,,,,, 899 WWN -. •.u+�•,a•�.�*b.a.-,>v� 4,SA eec amsga A_*v., NOTICE = NOTICE TO TO MIME IMMIS•Sr =No= EMPLOYEES MUM. r EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900- http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Farm Family Casualty Ins. Co. NAME OF INSURANCE COMPANY P.O. Box 656,Albany, New York 12201-0656 ADDRESS OF INSURANCE COMPANY 2001W7976 12-01-2021 POLICY NUMBER EFFECTIVE DATES MARK SYLVIA INSURANCE AGENCY LL(404 MAIN ST, CENTERVILLE MA, 02632-2916 508-428-0440 NAME OF INSURANCE AGENT ADDRESS PHONE# PENGUINS GOT THE SCOOP LLC 15 BLACK WATCH WAY, MASHPEE, MA 02649-2215 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 2001W7976