HomeMy WebLinkAboutApplication and WC ¢ c,���" N.�
� TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENS . }. �t{; �� q j�15
..-- * �
Please complete form and attach all nece�� e �s, � m r 1 S ZOl S.
Failure to do so will xesult in the re�of�r�r appli ai`t'pa� t. tTH DEPT.
ESTABLISHMENT NAME: CAMP WINGATE*KIRKL�AND TAX ID:
LOCATION ADDRESS�'9 WHITE ROCK ROAD YARMpUTH PORT,..��Q„02675 TEL.#: 508.362.3798
MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT�.MA 02675
E-MAIL ADDRESS: WEYSANDYC�CAMPWK.COM
QWNER NAME: SANDY & WILL RUBENSTEIN
CORPORATION NAME (IF APPLICABLE): 1�INCATE KIRKLAND OPERATINC ��C
MANAGER'S NAME: SANDY & WILL RUBENSTEIN TEL.#: 508.362.3798
MAILING ADDRESS:� 79 WHITE ROCK ROAD YARMOUTH PORT. MA 02675
POOL CERTIFICATI�NS:
The poot supervisor must be certified as a Poot 4perator,as xeqnired by State law. Ple�se list the designated
Pool Operator(s)and attach a copy of the certification to this form.
1. �•
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR),having ane certified employee on premises at �11 times. PIease list the
employees below and attach copies af their certifications to'this form.The Health Department wilt not use past
years' records. You must provide new copies and maiatain a file at your place of business.
1. 2•
3. 4•
, .,. ;
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
All food service establishments are required ta have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the 5ta.te Sanifaty Code for Foad Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health llepartme�nt witl not use past ye�rs'reeords.
You must provide new copies and maintain a fiie at your establishment.
1. THOMAS STARK 2, SANDY RUBENSTEIN
PERSON IN CHARGE: '
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operatian.
�. THOMAS STARK 2. SANDY RUBENSTEIN
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 far Food Service Establishments, 105 CMR S90.Q09(Gj(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new cogies and maintain a file at your establishment.
l. THOMAS STARK 2. SANDY RUBENSTEIN
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-chaking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new co}�ies and maintain a file at yaur place of business.
1. THOMAS STARK 2. SANDY RUBENSTEIN
3. CYNTHIA CLIFFORD 4. WILL R,�IBENSTEIN
RESTAURANT SEATING: TOTAL# 1 T5
OFFICE USE ONLY
�a�c��vc:
LICGNSE REQUIRED FEk: PERMIT# LICENSE REQLIIR�D FFE PERMIT# LICENSE REQUtRGD FGG PERMI'1'#
B&B x55 CAB[N $SS MOTBL $110
�INN �55 �CAMP $55 .��( SWIMMING POQL$1 f0ea. ,
=LODGE $55 _TRAILBR PAR1C $105 _WFIIRLPOOL S1 lQea.
FOOD SERVICE:
LICENSE REQUIRED FGE PFRMIT# LlGENSE REQUIRED FEE PERMt'1'# LICENSE REQUIRED FEE PERMiT#
�-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $3�
�>100 SEATS $200 �� TGOMMON VIC. $60 ��� —WHOLESAf�E $$4
—RESID.KITCNEN �RO
RETAlL SERVICE:
LICENSE REQUIRED FEE PERMfT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUlRED �EE PERMIT#
<50.�q ft. $54 >25,000 sq.ft. $285 VENDING-:FOOD $25
=<Z5,000sq.fi. $I50 =FROZENDESSERT $40 TOBACCO SIlO
NAME CHANGE: S�s AMOUNT DUE = $ 315.ot�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
f
� - . . � � . • . {
ADMINISTRATION `
Under Ch�pter 2 52,Section 25C,Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal '
` of any license ar per�nit to operate a business if a person or company dces not have a Certificate of Warker's
Compensation Insur�ce. THE AT"TACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF 1NSURANCE ATTACHED X !
OR
WORKEI�'S COMP,AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewai or issuance of your perrnits. PLEASE CHECK ,
APPROPRIATELY IF�'AID:
YES X NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRAIVSIENT OCCUPANCY: For purpc�ses of the limitations of Matel or Hatel use,Transient occupancy shall be
limited to the tempvxary az►d short terin occupancy,ordinarily and custamarily associated with matel and hatel use.
Transient oceupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Trar�sient occupancy shall generally refer to continuous accupancy of not more tt�ari thirty(34)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 �t be corisidered transient. Occupancy that is snhject to the collection of Room Occupancy
Excise,as defined in M.G.L.c. 64G'or 83U CMR 64G,as amended, shall generally be considered Transient.
POOLS I
PO�L 4PENING:All swimming,wading and whidpools which have be�n closed for the season must be inspected
by the Health Department 'or to o 'ng. Contact the Health Department to sc6edule the inspection three(3)
days prior to apeAiu�. P E OT : People are NOT allowed to sit in the pool area untit the pool has been
inspected and open�d.
�
POOL WATER TESTING: The water must be tested for pseudomonas,total cotiform arid standard plate count
by a State certifted lab, and subrnitted 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 j
closing. I
FOOD SERVICE �
f
SEASONAL FOOD SERVICE 4PENING: '
Ali food service establishrnents must be inspected by the Health Department prior to opening. Please contact the
Health Department to scheduls the inspection three(3)days prior to opening. .
CATERING POLICY:
Anyone who caters wittlin the Town of Yarmouth must notify the Yarmouth Health I.�partment by filing the
required Tem Faod 5ervice Application form '72 hours prior to the catered event. These forms can be �
obtained at the H�th Department,or from the Town's website at www.varmouth.ma.us under Health Department,
Downloadable Forms. �
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening arxi monthly thereafter,with sample results
submitted to tt►e Health Departmeat Failure ta do so will result in the suspension or revocation of your Frozen "
Dessert Permit until€he above terms have been rnet.
OUTSIDE CAF�S:
Qutside eafes(i.e.,outdoar seating with waiterlwaitress serviee),mast have prior approval from the Board of Health. �
OUTDOOR COOHING: ,
Outdoor cooking,preparation,or di�play ofany favd product by a retail or food service establishment is prohibited. I
NOTICE:Permits run annually from January l to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMFLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2015.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC,),MUST BE REPORTED TO APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. REN4VATIONS MA REQ � �T" AN.
DATE: 11/20/15 SIGNATURE: �
PRINT NAME&TITLE: DY RUBENSTEIN OWNER/DIRECTOR
�r�.�oioans � � � � �
; The Commonweolth of Massachirseus
� �
� Department of Indusirial Accidents
Office of Investigations
1 Congress Street,Suite I00
; BOston,MA �2114-2017
www.mass gov/dia
Workers' Compensation Insurance A�davit; General Businesses
Aunlicant Information Please Print Le 'b�iv
Business/Organization Name: CAMP WINGATE*KIRKLAND
Address: T9 WHITE ROCK ROAD
City/State/Zip:YARMOUTH PORT Mq 026T5 Phone#:�•�2.3'T98
Are yan an emploper?Check the appropriate boz: Bnsiness Type(required):
1.0 1 am a employer with 80 employees(full and! 5. ❑Retail
or part,time).* 6. ❑RestaurantlBar/Eating Establishment '
2.❑ I am;a sole progrietor or gartner�hip�nd have na `:
employees working for me in any capacity. ?• ❑ Of�ce and/or Sal�,s(incl.r�al cstate,auto,ctc.) ;
, [No workers' comp.insurance r�uired] �. ❑Non-profit
3.❑ We are a corporstion and its officers have ex�rcised 9. [�£ntertainment '
their right of exemption per c. 152, §1(4),and we have 14.Q Manufacturing
no employees. [Na workers' comp. insurance required]'� 11.[�Health Care �
4.❑ We are a nan:profit organization,sta.ffed by volunteers,
wi#h no employees. [Na workers' comg.insurance req.] 12.[] Qther Childrens Summer Csmp
'�Y aPPlicant th��box#1 must alsa fill out the seaioa below showing thdr wockers'compa►sati�policy mformation.
'*If die ooxpe»ata offieers have cx�npted thearsdves,'b�the c�xpaation has other employces,a wodcers'co��policy is ce.quusd mnd such aa '
rn'gac��"sh�uld d�ack bmt�1.
-��
I am an employer that�sproviding workers'compcnsation tnsurance for my employees Below�s the pvlicy�xformation.
Izis�tnce Campany Name: THE PMA INSURANCE GROUP
Insurer's Address: 380 SENTRY PARKWAY P.O. BOX 3031 '
CityJStatelZip: BLUE BELL, PA 19422-0754
Policy#or Self-ins.Lic. # 201401-02-91-40-1 Y Expira#ion Date: 02101/15
Attsch a copy of the workers' compensation policy declaration page(showing t6e policy number and ezpiration date�
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up tA$1,500.00 and/ar 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
Investigations of the DIA for insurance coverage verification.
I do hereby certt ,un e a�ns and penaltiGs of perJury that the information pravided abave ifs true and correc�
�
�
' ate• NOVEMBER 20, 2015
Phone#: 508.3 2 3798 �
Officiat use only. Do not write in this area,to be completed by ctty or towre offcial '
City or Town: Permit/I.icense#
Issuing Authority(circIe one):
1.Board of Health 2. Building Department 3. CitylTown Clerk 4.Licensing Board 5.Setectmen's Office
6.Other
i
Contact Person: Phone#: '
www.mass.gov/dia �
�
1 ��-� �� _
I �ICORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY)
'; 3/11/2015
� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
i
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
i
; BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
� REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
', IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
icerti�cate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Nnnne: AMSkierAgency,Inc.
j A.M.Skier Agency �a�NNo,EM�: 570-226-4571;800-245-2666 jac,No►: 570-226-1105
; 209 Main Avenue E-n�ai�
� Hawley,PA 18428 aooRess: amskier@amskier.com
� INSURER(S)AFFORDING COVERAGE NAIC#
� iNSURER A:Markei Insurance Company
� INSURED INSURER B:ThB COtt1�Ile�C2 InBUrdOC2
Wingate Kirkland Operating LLC
� 79 White Rock Road INSURER C:pMA Insurance Group
Yarmouth Port,MA 02675 INSURER D:Evanston
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUB POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE �NSR VWD POLICY NUMBER (MM/DD/YYYY� (MM/DD/YYYY)
GENERAL LIABILITY EACH OCCURRENCE
$ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
$ 100,000
A �CLAIMS MADE �OCCUR ❑ ❑ 8502CY4078711 2/1/2015 2/1/2016 MED EXP(My one person) $ 10,000
PERSONALANDADVINJURY $ �,OOO,OOO
GENERALAGGREGATE $ 5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ �,OOO,OOO
POLICY �E�a LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a 1,000,000
X ANY AUTO BODILY INURY(Per person) �
ALL OWNED � SCHEDULED $
/\ AUTOS AUTOS ❑ ❑ BODILY INURY(Per accident)
X HIREDAUTOS � NON-OWNED 1021CY0074070 3/1/2015 2/1/2016
❑ AUTOS PROPERTY DAMAGE
Deductible:Comp.;Coll. $ 1000; 1000
UMBRELLA LIAB OCCUR EACH OCCURRENCE
p EXCESS LIAB CLAIMS-MADE � � XONJ566214 11/1/2014 11/1/2015 � 70,000,000
AGGREGATE
DED RETENTION$
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
C ANY PROPRIETORIPARTNERIIXECUTIVE Y�N N�A 2015010291401Y 2/1/2015 2/1/2016 E.L EACH ACCIDENT $ 500,000
�FICHMEMBER EXCLUDED? � ❑
(Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE
If yes,describe under $ 500,000
DESCRIPTION OF OPERATIONS belav E.L.DISEASE-POLICY LIMIT $ SOO,OOO
❑ ❑
DESCRIPTION OF OPERAT70NS/LOCATIONSNEHILCES(Altach ACORD 101,Addifional Remarks Schedule,ff more space is required)
Certificate is confirmation of coverage
CERTIFICATE HOLDER CANCELLATION
Wingate Kirkland Operating LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
79 White Rock Road I
Yarmouth Port,MA 02675 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE6
r
HENRY M.SKIER 4
r
President
� 1988-2010 ACORD CORPORATION.All rights reserved
ACORD 25 2010/05 I
( ) The ACORD name and logo are registered marks of ACORD
i
i
!
°� TOWN OF YARMOUTH Bo�dof
� � � xea�th
1146 ROLTTE 28,SOITTH YARMOtTTH,MASSACHUSETT'S 02664-24451 "
• Telephone(508)398-2231,ext. 1241 Hcalth
Faac(508)760-3472 Division
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is nece�sary) -Fi,�E:"333;00"'
Name of Camp:CAMP WINGATE*KIRKLAND
site Aadress:79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Site Address: ;
�
Tax ID Number(FEIN or SSI�: E-mail
Type of Capnp: Day(less than 24 hrs.) Residential(24 l�s.)
Hours of Operation:
Dates of:Operation: Opening. APRIL 1, 2016 Closing:
Name of Camp Owner: SANDY & WILL RUBENSTEIN ''I
_ ;
Ot�ice Address:79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Office Telephone Number:508.362.3798 ;
Name of Camp Operator(if different):
Address:
Telephone Number:
Camp Director: SANDY & WILL RUBENSTEIN
Adclress:20 LINNELL LANE YARMOUTH PORT, MA 02675 '
Age: 43 Telephone Number: 508.362.3798
Coursework in Camping Administration:
Previous Camp Administration experience:
Health Care Coasultant: SHANE PETERS
Type of Medical Lieense: NURSE PRACTIONER Mq License number: RN252623 !
Address:P O. BOX 441 MARSTONS MILLS, MA 02648 Telephone: �
4a�ons 1 of 3 i
i
i
i
I
,
f
� , i
V
f
Hospital for Emergency Services: CAPE COD HOSPTIAL
Health Supervisor: MARY COLWELL
Age; 64 Type of Medical License,Registration or Training: R N
Swimcning Area: Yes X No �
If Yes: Fresh Water X Ocean Pool CPO
Specific Chtsite Locations: BEACHFRONT LOCATED ON ELISHA'S POND
Water Quatity Testing Performcd By: BARNSTABLE COUNTY HEALTH LABRATORY
Aquatics Director:
Namie O BE DETERMINED PRIOR TO WATERFRONT OPENIN�$e UNE 1 ST
Lifeguard Certificate issued by: Exp. Date:
American Red Cmss GP_R:Certificate: Exp. Date:
American Eirst_Aid C�rtificate: Exp.Date:
Previous aquatics sugervisory experience:
WatercraftBoating Activities: Yes X No Describe; SMALL CRAFT BOATING:
ROW BOAT, KAYAK,
Compliantwith Ghristian's Law: Yes X No CANOE AND SUNFISH
SAILING.
Food Service:
Is food handles, served or prepared? Yes X No
To what extent? Snacks Cooked and Served by Staff X
If cooked onsite,Food Manager(submit copy of ServSafe) THOMAS STARK '
Catered if so,by whom? �
,
Is refrigeration available for perishable foods? Yes X No G
Fire Arms Instructor:
Name: ACTIVITIES WITH FIRE ARMS ARE NOT OFFERED AT CAMP W*K
i
National Rifle Assn. Instructor's Card(or equivalent)
' Date certified: Expira.tion Date: i
0,,,015 2 of 3
Background Checks:
Has the Camp O�wner or Director obtained and reviewed the CORI and SORI of each staff
person and volunteer who may have contact with a camper? Yes X No
IMPURTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1)
WEEK PRIOR TO OPENING TO SCHEDULE AN INSPEGTION! THIS IS
MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION
WITH THE BUILDING AND FIRE DEPARTMENTS.
•�� r
B�'�+�8�� �+F���on,I acknawledgc that I have s�bmt�ed alt na�airad docunientation ''
and I � in c�erplisrrce-r�aftJe the-Siate's ��te�nrem strendards for R�cr�t�onal Camps for ;
Chlldren,State ode Chapt�rlY, IOS CMR 43U.U40. '
SIGNED: �
PRiNTED;S Y RUBENSTEIN DATED: NOVEMBER 20, 2015 ,
S� the neat p�ge attached for a list of documeats that must be completed and submfttecl '
before your applicat3�n can be ful�y processed. You are strongly encouraged to camplete
these documents as soon as possible and submit them in advxnce. Thts will expedite the i
proce�s.
�
oa�3a�s 3 Of 3
�
�
�
�
�
I
�
Reauired.,�ocuments i
I
See the MA Regulations for Minimum Standards for Recreatianal Camps for Children, �
State Sanitary Code, Chapter IV-105 CMR 430.040 and the guidance documents issued ;
by the Department of Public Health, Division of Community Sanitation for additional ;
assistance with developing the following documents. I
Gheck '
Documcnts
Sut�nittai
*Staffinforuyarian forir►s(see attached)...................................................................
*Procedures for the background review of staff and volunteers(105 CMR 430.09Q).............
w�PY of gromotional literafure(I05 CMR 430.190(C}).............................................
'`Prdccdtt�res fcn reporting suspect$d child abuse or tteglxt{105 CMR 430.493)...........:......
*H�enith c�policy(145 CMR 430.159(B)),including imznunizat�on records...........:.......
*Discipline poficy(1QS CMR 430.191)......._..........................................................
*Fit�e evacu�tion p�an—approved by local fire department(105 CMR 430.210(A)).........,....
*Disaster plan{105 CMR 430.210(B)) ..................................... ... . ..........
*L,+�st camper ptan(lOS CMR 430.210(C}).............................................................
*Lost swi.mmer pl�n(1�S CMR 430.210(C)). .......... .............................. . ....
*Tra�c control plan(lOS CMR 430.210(D))............................. .. ... .............
*Day Camps—contingency plan(105 C'MF�430.211).................................................
*Priu�itive, Trip or Travel Camps — Written itinerary, including sources of emergex�y care
and ccui#is�g�ncy plans(105 CMR 430.212)..:..............,..,,.............:..........:...............
#G�rrent certificate af accupancy fram local buiiding inspector(105 CMR 430.451).,..........
*Writ�en statement of compliance from the local fire department(105 CMR 430.213)..,,.......
*Aquatic ptan,including Christian Law,PFD fitting tests,water testing and swim tests......
`
Attach the names, ages, applicabie cuirent certifications (if any), such as First Aid, and
the anticipated role at the camp of all supervisory staff(see below). Use as many pages
as necessary to complete this.
Please; If you are applying for an original camp license for a eamp based in Yarmouth, '
you must file a plan showing the following with the baard of health at least 90 days
before your desired opening date(See MGL Ch. 140 § 32A):
A Buildings, structures, facilities and fixtures
➢ Proposed source of water supply '
� Works for disposal or sewage and waste water
Suvervisory staff ineans those persons with the responsibility, authority and training to
provide direct supervision to camper groups. This may include counselors, junior
counselors, general activity leaders or other staff who provide supervision to campers
without assistance.
04,30115
I
�
i