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Home My WebLink AboutApplication and WC �► TOWN OF YARMOUTH BOARD OF HEALTH �C��MG� oDI � � APPLICATION FOR LICENS .ElP,��T-� 1 T ,,,,. � �_� ��1��- DEC 13 2012 * Please camplete farm and attach all necess�y'd � ��;b � �:ber 1S 2012. Failure to do so will result in the ret�of��'a�`ic ion ac L�IEALTH DEPT. ESTABLISHMENT NAME: CAN�P WINGATE*KIRKLAND TAX ID: LOCATION ADDRESS:79 WHITE ROCK ROAD YARMOUTH PORT, MA 02fl�..#: 508.362.3798 MAILING ADDRESS:79 WHITE ROCK ROAD YARMOUTH PORT,�IAA 02675 OWNER NAME:SANDY�WILL RUBENSTEIN CORPORATION NAME(IF APPLICABLE):WINGATE KIRKLAND OPERATING LLC MANAGER'S NAMESANDY$WILL RUBENSTEIN �L,#; 508.362.3798 MAILING ADDRESS�9 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 POOL CERTIFICATIONS: X 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. l. �• Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmanary Resuscitation (CPR). Please list these employees below and atta.ch copies of employee csrtifications to this form. The Health Department will not use past years' records. You mast provide new copies and maintain a file at your place of business. l. 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 Pratection 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'rccords. You must provide new copies and maintain a file 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 operation. 1_ THOMAS STARK �, 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-cholcmg 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 busincss. l, eeunv Q��cicwcTE1N 2�1ANET MCGILL 3.�TH�MAS STARK 4• RESTAURANT SEATING: TOTAL# 175 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM]T# B&B $55 �CABLN $55 +MOTEL S55 1NN $55 � CAMP �55 �'�.Q�a" _SWIMM[NG POOL $80ea LODGE $55 TRAILER PARK $105 _.WHIRLPOOL $80ea �OE3D SER�fE�: - _- _ , --- - LICENSE REQUIRED FEE PEI2MIT# LICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� 0-100 SEATS $85 iCONTINENTAL �35 NON-PROFIT S30 �>]00 SEATS $1G0 ��S I COMMON VIC. S60 �13�� _WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN $$0 ' LIGENSE RE(�UIRED F6E PERMIT# LICENSE REQUlRED FEF. PERMiT# GICENSE R�QUIRED FEE PERMYT# _<50 sq.ft. $SO >25,000 sq.ft. 5 _,VENDING-POOD $25 �<25,OOd ft. $80 —FROZEN DE BRT � _TOBACCO S95 AM T DUE _ $ 2?S,a6 NAME C�0�/11 �l5 d�� _ *�***PLEASE TURN OVER AN� � ��i�a�Q��RECTOR � � € ADMINISTRATION � , I Under Chapter I52,Sectian 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal j of any Iicense or permit to operate a businiess if a person or company does not have a Certificate of Worker's ` Compensadon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. 4F INSURANCE ATTACHED�_ OR [ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X 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 thirky(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 OPE1vING:All swimming,wading and whirlpools which have beer�closed for the season must be insp�ted by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection th�ree(3)days pnar to openi.ng.PLEASE NOTE:People are NOT allowed to srt m the poql area until the pool has been inspected and opened. � F P40L WATER TESTINGr The water must be tested for pseudomonas,total colifo�n 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 SEIZVICE � - ' SEASONAL F04D SERVICE OPElvING: All food service establishments must be inspected by the Health Department priar to opening. Please contact the Heaith Department to schedule the inspection three (3}days prior to opening. CATERING POLICY: . Anyone who caters within the Town of Yanmouth must notify the Yarmouth Heaith 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 CAFES: � I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. � OUTDOOR COOKING: 4utdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. `' ; E , � 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 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL �R POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.), MUST BE REPORTED TO AND A.PPROVED BY THE BOAR.D OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE A TE PLAN. j DATE: 12/07/12 SIGNATURE: �� PRINT NAME&TITLE: SA Y R BENSTEIN OWNER/DIRECTOR Rev,10/09/12 ` n � r TO � N OF YARMOUTH Boardof � Health l l46 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-2445I Health "'�i° Telephone(508)398-2231, ext. 1241 Fax(508)76Q-3472 Division APPLICATION FOR A LICENSE TC)CONDUCT A RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) .-��E�--�i55:9(i� Name of Camp: CAMP WINGATE*KIRKLAND Site Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 Site Address: Tax ID Number(FEIN or SSN): Type of C$mp: Day(less than 24 hrs.) Residential(24 hrs.) X Hours of Operation: Dates of Operation: Opening:APRIL 1, 2012 Closing: NOVEMBER 15, 2012 Name of Camp 4wner• SANDY&WILL RUBENSTEIN Office Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 4ffice Telephone Number:508.362.3798 Name of Camp Operator(if different): Address: Telephone Number: Camp Director• SANDY & WILL RUBENSTEIN 20 LINNELL LANE YARMOUTH PORT, MA 02675 Address: 39 508.362.3798 Age: Telephone Number: Coursework in Camping Administraxion: Previous Camp Administration experience: Health Care Consultant:SHEILA KANE Type of Medical License: RN/NP MA License number:115260 Address�1 KINGSBURY WAY YARMOUTH PORT, MA 0267�,elephone:508.375.0419 . os,�o��0 1 of 2 f � � Hospital for Emergency Services: CAPE COD HOSPTIAL � r Health Supervisor: SUSAN ROACH � C � Age: 50 Type of Medical License, Registration or Training: RN/ MA#169125 Swimming Area: Yes X No If Yes: Presh Water X Ocean Pool CPO ; Specific Onsite Locations: BEACHFRONT LOCATED ON ELISHA'S POND ` Water Quality Testing Performed By:BARNSTABLE COUNTY HEALTH LABRATORY Aquatics Director:TO BE DETERMINED PRIOR TO WATERFRONT OPENING JUNE 1ST Submit Certifications: CPR First Aid Water Safety Other Lifeguards and Credentials: Watercraft/Boating Activities: Yes X No Describe:SMALL CRAFT BOATING: , K, Food Service: CANOE AND SUNFISH SAILING. 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 No Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and volunteer who may have contact with a camper? YesX No IMPORTANT: CONTACT THE YARMOUTIi HEALTH DEPARTMENT 48 HOURS PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. � �, SIGNED: ` pRTNTED; NDY RUBENSTEIN DATED: DECEMBER 7, 2012 See the next page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in aclvance. This will expedite the process. osr_ono 2 of 2 � The Commonwealth oJMassachusetts Depar•tment of Industrial Accidents � Office of Investigations ' 1 Congress Street,Suite IOU Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aoalicant Information Please Print LeQiblv Business/Organization Name:CAMP WINGATE*KI RKLAN D Address: 79 WHITE ROCK ROAD CitylStaxe/Zip:YARMOUTH PORT MA �2675phone#: 508.362.3798 Are you an employer?Check the appropriate box: Business Tyge(required): 1.0 I am a employer with 70_,__employees(fall and/ 5. ❑Retail or part-time).* 6. ❑RestaurantlBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. � [No workers' comp.insurance required] g• ❑Non-profit 3.� We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. l 52, §1(4),and we have 10.�Manufacturing no employees.[No workers'comp.insurance required]'� 11,[�Health Care 4.❑ We are a non-profit organization,staffed by valunteers, with no employees. [No workers'comp.insurance req.] 12.�Other Childrens Summer Camp *Any applicant that checks box#i must also fill out the section below showing their workars'wmpensarion policy information. *"If the corporate officers have exempted themselves,but the cotporation has other employees,a workers'compensation policy is required and such an organization should check box lil. 1 am an employer that is provlding workers'compensation insurance jor my employees. Below is the policy inforn�ativn. Insurance Company Name: THE PMA 1NSURANCE GROUP Insurer's Address: 380 SENTRY PARKWAY P.O. BOX 3031 City/State/Zip: BLUE BELL, PA 19422-0754 Policy#or Self-ins.Lic.# 201201-02 91-40-1 Y Expiration Date: 11/1/13 Attach a 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 fi.ne up to�1,50U:00 andior oue-year imprisocunent,as wetl as civil penaities in the form of a STOP WUftK OItllER and a fine of up to$250A0 a day against the violator. Be advised that a copy of this statement may be forwazded to tlte Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cer ntler thepains andpenalties ofperjury that the tnformation provided above is true and correct. D te:DECEMBER 7, 2011 f Phone#: ' 50 .362. 8 Official us !y. Do not write in this area,to be completed by city or town officia� City or Town: ��10 '� ________ Permit/License# Is ' circle one): .Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Ot�er Contact Person: Phone#: �0 S-�;��-aa3 iy x I Z�( www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY-INFORMATION PAGE INSURER: POLtCY NO: 201201-02-91-40-1Y PENNSYLVANIA MANUFACTURERS' ASSOCIATION INSURANCE RENEWAL OF: 201101-02-91-40-1Y NCCI Company No: 11916 Account No: 0291401 RISK ID #0475487 ITEM 1.NAMED INSURED ANp MAILING ADDRESS: PRODUCER NAME AND ADDRESS: WINGATE KIRKLAND OPERATING, A M SKIER AGENCY INC. LLC 209 MAIN AVENUE 79 WHITE ROCK RD HAWLEY PA 18428 YARMOUTH PORT MA 02675-2314 PRODUCER NO: 1258 LEGAL ENTITY: LIMITED LIABILITY COMPANY OTHER WORKPLACES IVOT SHOWN ABOVE: (See Extension Of Information Page) ITEM 2. POLICY PER10D:From: 11-01-2012 To: 11-01-2013 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3.COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 500,000 each accident Bodily injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 500, 000 each employee C. Other States lnsurance: Part Three of the policy applies to the states, if any,listed here: All states except North Dakota, Ohio,Washington and Wyoming. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuais of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verifica- tion and change by audit. Total Estimated Minimum Premium: $ Annual Premium: $ Audit Period: ANNUAL Issued At: 75 NEW YORK Da#e: 11—Z1-12 Countersigned by WC 00 00 01 A CopyrigM 1987 Natlor�al Council on Comper�satton Insurance tNSURED COPY f � � F PENNSYLVANIA MANUFACTURERS' Policy Nu mber .; ASSOCIATION INSURANCE COMPANY 201201-02-91-40-1Y � EXTENSION OF INFORMATION PAGE ' WORKERS COMPENSATIOW CLASSIFICATION SCHEDULE G State of: MASSACHUSETTS O475487 k Named Insured WINGATE KIRKLAND OPERATING, Effective Date: 11-01-2012 i 12:01 A.M., Standard Time ' Agent Name A M SKIER AGENCY INC. Agent No. 1258 Total Estimated Estimated Classification ot Operation Code Annual Per$100 of Annual No. Remuneration Remuneration Premium 0001-01 WINGATE KIRKLAND OPERATING, LLC FEIN # 52-2943840 SIC CODE 7032 NAIC CODE 721219 MA ERN # 82576311 WINGA,TE KIRKLAND REAL ESTATE LLC FEIN # 52-2443825 SIC CODE 7032 NAIC CODE 721219 MA ERN # 82576311 79 WHITE ROCK RD YARMOUTH PORT MA 02675-2314 20 LINNELL LN YARMOUTH PORT MA 02675-2305 CI,ERICAL OFFICE ENIPLOYEES NOC 8810 ; . .� CAMP OPERATION NOC 9015 � _ _ s .. , f k F ' i WC890415 INSURED COF�1' � NOTICE � � NOTICE � TO ' ° TO ., EMPLOYEES ,= EMPLOYEES • � �O V 'IM Sy♦ The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts OZ 1 1 1 617-727-4900 - 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: THE PMA INSURANCE GROUP NAME OF INSURANCE COMPANY 380 SENTRY PARKWAY PO BOX 3031 BLUE BELL, PA 19422-0754 ADDRESS OF INSURANCE COMPANY 201201-02-91-40-1Y ` 11/01/12 - 11/01/13 POLICY NUMBER EFFECTIVE DATES A M SKIER AGENCY INC 209 MAIN AVENUE HAWLEY PA 18428 NAME OF INSURANCE AGENT ADDRESS PHONE # WINGATE KIRKLAND OPERATING LLC 79 WHITE ROCK RD YARMOUTH PORT MA 02675 EIVIPLOYER ADDRESS ��1��L ��s�� 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 Worker's 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 services 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, e ployees are hereby notified that the insurer has arranged for such attention at the C`�rn� �'c�� 5 � � :� �� S�`: �- �r�7 is M, �c►� I�AME OF HOSPITAL � ADDR SS � TD BE POSTED BY EMPLOYER WC 7506f (7-01)