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°� TOWN OF YARMOUTI-�_ _ Baaz
� ��c�
1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664- 4451 -
�� Telephone(508)398-2231,ext. 1241 ��,�, ������
Fax(508)76Q-3472 ision
HE�1#.�N C�EPT•
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is necessary) �3�:99--
Name of Camp; CAMP WINGATE*KIRKLAND
Site Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Site Address:
T�ID Number(FEIN ar SSI�:
Type of Camp: Day(less tt►an 24 hrs.) Residential(24 hrs.) X
Hours of Operation:
DatesofOperatian: Opening: APRIL 1, 2012 Closing: NOVEMBER 15, 2012
Name of Camp Owner: SANDY�WILL RUBENSTEIN
Office 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
Address: 20 LINNELL LANE YARMOUTH PORT, MA 02675
Age: 40 Telephone Number: 508.362.3798
Coursework in Camping Administration:
Previous Camp Administration experience:
Health Care Consaltant:
Type of Medical License: MA License number:
Address: Telephone:
osnaio l Of 2
r
Hospital for Emergency Services: CAPE COD HOSPTIAL '
,�-����- Health Supervisor: '
Age: t Type of Medical License,Registration or Training:
Swimming Area: Yes X No
IfYes: "" Fresh Water_� 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 Descrihe:SMALL CRAFT BOATING:
ROW BOAT, KAYAK,
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 whorn?
Is refrigeration available for perishable foods? Yes X No f
Background Checks: I
Ha.s 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
IlIZPORTANT! CONTACT THE YARMOU'I'FI HEALTH DEPARTMENT 48 HUURS PRIOR
TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNTGHT
CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUII.DING AND FIRE
DEPARTMENTS.
SIGNED: �
p��D; � NDY RUBENSTEIN DATED: DECEMBER 7, 2013 f
i
See the negt page attached for a list of documents that must be completed and submitted before 'I
your application can be fully processed. You are stroagly encouraged to complete these documents
as soon as possible and submit them in advance. This will ezpedite the process. i
�,�„��„a 2 of 2 ',
� The Commonwealth of Massachusetts
Department of Industriat Accidents
Office of Investigatiorts
' 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Anplicant Inforniation Please Print Legiblv
Business/Organization Name: CAMP WINGATE*KIRKUND
Address: 79 WHITE ROCK ROAD
City/State/Zip: YARMOUTH PORT MA 02675 Phone#: 508.362.3798
Are you an employer?C6eck the appropriate bog: Business Type(required):
1.� I am a employer with 70 employees(full and/ 5. ❑ Reta.il
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2.❑ [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] 8• ❑Non-profit
3.❑ We are a corporation and its officers have exereised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.Q Manufacturing
no employees. [No workers'comp. insurance required]* t 1.�Health Care
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.�Other Childrens Summer Camp
'A.ny applicant that checics box#I must also fill out the section below showing their workers'compensation policy information.
"If the coiporate officers have excmpted themsetves,but the corporation has other emgloyees,a workers'�mpensation policy is requirai and such an
oiganization should chedc box#L
I a»e an employer that is providing worhers'compensation insurance for my employees. Below�ts the policy information.
Insurance Company Name:THE PMA INSURANCE GROUP
Insurer's Address: 380 SENTRY PARKWAY P.O. BOX 3031
City/StatelZip: 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' compensallon policy declaration page(showing the policy number�nd eapirarion date). '
Failitre to secure coverage as required under Section 25A of MGL c. 152 can tead 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 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 covera.ge verification.
I do hereby certi und enalties of perjury that the information provided above is true and correct.
Si ature: Date: DECEMBER 1, 2013
Phone#: 508.3� 3798
Official use only. Do not write in this area,to be completed by city or tawn officia�
City or Town: Y�MOU7'1� Permif/Liceuse#
I (circte one):
1. Board of Heatth� .Building Department 3. City/Town Clerk 4.Licensing Board S.Selectmen's Office '
6.O
Cantact Person: Phone#: 5738—�348 0�0�3! ,�/Zy'/
wivw.mass.gov/dia
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