HomeMy WebLinkAboutApplication and WC .� �' ► TOWN OF YAItMOUTH BOARD Or H�ALTH � �S�GL��,IL� o E`i�
���� APPLICATIQN FOR LICENSE/PEItMIT - 2
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* Please complete form and altach all neces�. ' � m er 15 20I.i.
Failure to do so will result in tlle retti; o { ' a i ' i ga et. fl��T,
ESTABLISIIMENT NAME: CAMP WINGATE*KIRKLAND TAX ID•
LOCATION ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT MA OT�: 508.362.3798
R�A]LING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT MA 02675
c�WNER NAME: SANDY& WILL RUBENSTEIN
CORPORATION NAME(IF APPLICABLE): WINGATE KIRKLAND OPERATING LLC
MANAGER'S NAME:SANDY& WILL RUBENSTEIN TEL.#: 508.362.3798
MAILiNG ADDRESS:79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
POOL C�RTIFICATIONS:
Ti�e pooi 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 d�e certification to this fonn.
1. 2,
Poo! aperators must list a minimum of two emplayees cui�ently certifieci in basie water safety,standard First Aid
and Community Cardiapuimonary Resuscitation (CPR). Piease list these employees below and attach copies oF
empIoyee certifications to this form. The Health Department will not use past years' records. Yau must
provyde new copies and maiatain a file at your place of business.
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3. 4.
F�OD PR�TECTI�N 1VTANAGERS - CERTIFICATIONS:
All food service establisiunents are required ta have at least ane full-time employee who is certified as a Food
Proteceion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR S90.OQQ.
Piease attach copies of certification to diis application. The Health Department will not use past yeArs'recurds.
You must provide new copies and maintain a file at yoar establisiiment.
]. THOMAS STARK �, SANDY RUBENSTEIN
PERSQN W CHARGE:
Each faod establishment must llave at least one Persan In Charge{PIC)on site during hours af opera�ian.
1. THOMAS STARK 2, SANDY RUBENSTEIN
HEIMLICi�i CERTIFICATIONS:
All food service establishments with 25 seats or more must have at ieast one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your em�loyees trained in anti-choking procedures below anci
attach copies af employee certificaCions to rhis Fonn. Tl�e Health Dcpartment will nat use past ycars'records.
You mast provide new copies and maintain a file at your place of business.
I._$ANDY RUBENSTEIN 2,JANET MCGILL
3. THOMAS STARK �.,
RESTAURANT SEATING: TOTAL# 175
4FFICE USE 4NLY
LODGlNG:
LICENSE RBQUIRED FEE PERMIT# LICEIVS6 REQUIRED FEE PERMIT#� LICENSE REQUIRED FEE PERMIT#�
—��� �5$ ` �CABIN $SS �MQ1'EL $55
._INN $55 �CAMP :�55 _SWINLMNG POQL $SOea.
t.nnC:F �55 TRAiI.ER PARK �105 WHII2I.POOL $80ea.
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ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 5,the Town af Yarmoutl�is now required ta hold issuance or renewal
of any license or permit ta operate a business if a person or compa��y cloes not have a Certi�cate of Worker's
Compensatian Insurance. THE ATTACI�D STATE WORKER'S COMP�NSATION INSURANCE
AFI+'IDAVIT M[]ST BE COMPLETED AND SIGNED, 4R
CERT. OF INSURANCE ATTACHED X
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WORKER'S C�MP. AFFIDAVIT STGNED AND ATTACHED
Tawn of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES X NO
t�Ac.'l�'ELS � t�TI�E�t Lt��G�t�+tG EST�L�S1�vF�h]TS
TRANSI�NT UCCUPANCY: Far purposes of the limitations of Motel or Hatel use,Transient occuPancy shall be
limited to the temporary and short term occupancy,ordinariIy and customarily assaciated with moteI and hoeel use.
Transient occupants must have and be able to demonstrake that they maintain a princi�al plac� of residence
elsewllere.Transient oceupancy shall generalIy refer to continuous occupancy of not more than thirty(3Q)days,and
an aggregate of nat mare than ninery(90)days within any six(6)month period. Use of a guest unit as a residence ar
dweUing unit shaIl nat be considered transient. Occupancy that is subject to the collection ofRoom Occupancy
Excise, as defined in M.G.L. c. 64G Qr 83�CMR 64G, as amended, shall generally be considered Transient.
PO4LS
POOL OPENING:All swimming,wading And whirlpoals which have been closed far the season must be inspected
by the Health Department prior ta opening. Contact the Health De�artment ta schedule the inspectian three(3)days
prior to apening.PLEASE N4TE:People are NOT allowed ta siC in the pool area until the poal has been inspected
and opened.
POOL WATER T'ESTING: The water must be tested for pseudomanas,total coiiform and sCandard plate count
by a State certif'ied lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CI.,�SIN�:Every outdoor in ground swimming poal must be drained or covered within seven(7}days of
closing.
roon sERv�c�
S�AS�IVAL FOOD SERVICE OPENIlVG:
All foad service estabtishments 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.
CATER�NG POLICY: .
Anyone who caters within the Town of Yarmouth must natify the Yarmouih Heaith Department by filing the
requirecl Tempor��ry Faod Service Application fonn 72 hours prior to [he catered event. These farms can be
obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under HeaIth Department,
Downloadable Forms.
FRQZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monfihiy thereafter,wiCh sample results
submitted to the Health Department. Failure to do so will result in.the suspension ar revocation af your Froz�n
Dessert Permit until the above terms have been met. �
OUTSIDE CAFES:
nuCsic�e caf�.s(i.e.,outd�ar se�tin���.�ith u�ait�r/waitress�erv:c�),mu�t have priorap�i�av�l fi-oi�i t�i�Baard c�C�-Ieal�ii.
OUTD04R COOKING:
Uutdaar cooking,preparation,or disglay of any food product by a retail or faod service establislunent is prohibited.
NOTIC�:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSI$ILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S}AND REQUIRED FEE{S)BY DECEMBER 15, 201 i.
ALL REN4VATIONS TO ANY FOOD ESTABLISHM�NT, M4TEL OR POOL {i.e., PAINTIlVG, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AI�TI? PRO�IED BY THE B�ARD OF HEALTH PRIOR
TO C�MMENC�MENT. R�NOVATIONS MAY R I�. IT�PLAN.
�����.
DATE: 12/07/11 SiGNATURE: ;�
PRINT NAME&TITLE: SA Y R BENSTEIN OWNER/DIRECTOR
Rev. l0I2S/l1 �
°� y TQ �VN OF Y � R. MOUTH B��of
� � ,: — ��
; i 146 ROUTE 28,SOUTH YARMOUTH, MASSACHiJSETTS 026 244��-='`-���H���
a•••� Tele phone(508)398-223I,ext. 241 s.,r,;� :�7xvi�i n
Fax{508) 760-3472 -``° : ; ��
HEAIT�i p�pr
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIUNAL CAMP FOR CffiLDREN
(Use back of appGcation if additional space is necessary) -F-�E:-�'SSfiQ
Name af Camp: CAMP WINGATE*KIRKLAND
Site Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Site Address:
Tax ID Neunber{FEIN or SSI�:
Type of Camp: Day(less tban 24 hrs.) Residential (24 hrs.} X
Houxs af Operation:
Dates of Operation: Opening: APRIL 1, 2012 Closing: NOVEMBER 15, 2012
Name ofCamp Owner: SANDY&WILL RUBENSTEIN -
�ce Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Office Telephone Number. 508.362.3798
Name of Camp Operatar(if different):
Adrlress:
Telephone Number:
Camp Direc#or: SANDY&WILL RUBENSTEIN
Address: 20 LINNELL LANE YARMOUTH PORT, MA 02675
Age: 39 Telephone Number:508.362.3798
Coursewark in Carnping Adminish'ation:
Previous Camp Administration e�erience:
Health Care Consultant: SHEILA KANE
Type of Medical License: RN/NP MA License number: 115260
Address11 KINGSBURY WAY YARMOUTH PORT, MA 026��p}�one: 508.375.0419
oe��wne 1 Of 2
__. . _ _ _ _ _ ____ ___ _ _ _ .._
Haspitat For Emergeney Services:CAPE COD HOSPTIAL
Healtt� Supervisor: SUSAN ROACH
Age: 49 Tyge of Medical License, Registratzan or Training: RN/MA#169125
Swimming Area: Yes X No
IfYes: Fresh Water X Ocean Paol CPO
Specific Onsite Locations: BEACHFRONT LOCATED ON ELISHA'S POND
Water Quality Teskiug Perfarmed By:BARNSTABLE COUNTY HEALTH LABRATORY
Aquatics Directar. TO BE DETERMINED PRIOR TO WATERFRONT OPENING JUNE 1 ST
Submit Certifications: CPR First Aid VV'ater Safety
Other Lifeguards aud Crede�rtials:
Watercraft/Boating Activities: Yes X No Describe: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
c��a �e 50, 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 staffpersan and
volunteer who may have conta.ct with a camper? Yes X No `
IMPORTANT! CUNTACT THE YARiVIOUTH HEALTH DEPARTMENT 48 HOURS PRIOR
TO UPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVEItNIGHT
CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE
DEPARTMENTS.
SIGNED.
PRTNTED: �� DY RUBENSTEIN DATED: DECEMBER 7, 2011
,
See tke next gage attached far a list of documents that must 6e completed aud submitted before
your applieation can 6e fully pracessed. You are strangly enroaraged ta comptete t�tese documents
us soon as possible and submit them in advance. This will expedite the process.
oe�ts;aa 2 of 2
_ __ . _ __ _ _
_ _
� The Commonwealth of Massaehusetts
Departrnent of Industriu!AcciJents
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.60Q �Yasfringtvn Street, 7'h Floor . � . .. . . . : -
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Watitets'Campensation lnsurance Affidsvit:. -. .. , .� � - _ . ._ . • • -
Anulkut ixiormstfa�: Meaae P�tINT 1e�tbi� " . . - . . .. -
�: CAMP WINGATE*KIRKLAND �
,��;5: 79 WHITE ROCK ROAD
�i�v Y�►RM�UTH pORT state• MA rin• 02675 nhonr� 508.362.3798
work s;tc location rfui!addressl:
❑ I am a homeawner pecforming all wortc myseif. � -..�.,—
❑ f am a so2e proprietor and I�ve ao ane working in any capacity.
�C] I am an employer providing woricers'compensatio�For my c�nployecs working on t6is job.
CAMP W!W£A�'FE*K#R�CLA�VD �-:-- �,.- -: . _;...:..: :.... : ...•r . -
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,aan,s: 79 WHITE ROCK ROAD
�e�:YARMOUTH PORT ��a�- 508 362 3798
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❑ I am a sole pruprietor,geaerat captraetor,or hamenwner(circle o�e)anci have hired We contractors listed belaw:who�bave,
the FoIlowing workets'compensa6on paticxs: _ . . .� . �. .
rnm rauae: • . . . . . - _
addreaa:
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Faqate ts�eemt eo�eraEe a reqaitsd�ndes Seetio�2SA ef hlGL!S2 cas Ind b fMe iea�»�Itlat�lar�foaE pe�aMfa�[a�e qe te SI;aM.ef aadfar
one years'Impl'boament b we9 s!dv�peettfin le t6e Csr�ota$7'Or WURK ORDER a�d��e dSFUO.OS a day against me. t�detffaad lhat a
copy a[thia tlitrmcnt may be forwuded te the OQlce ot lnvntlgstlom of the DIA far eorerase vdriflptlee,
!do�ierebp�etYi lkirdea'�tJte ins and pexslHes ufpeijury tl�iat Nie tr�foneratloa provided abos�e Ps�rrte mrd aormt
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of�da!uye oaty `" do ant_artilr in thNi rrca Eo 6e rnmpiefed 6y dtq or�+rti o�al� °:`--'%: . ` - . . . , _ .
eityartown: . , . .. _... _ - ":::.•.'..: . � -
permlt/Elceme/l. :[]BnidlnE DeEtattment..
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RCORD TM CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDlY�
� �' ��� :� 12/12f2Q1� �
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
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
tenns and conditions of the policy,certain policies may require an endorsement A statement on this certificate dces not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAMEACT AMSkier Agency,Inc.
A.M.,SkierAgency ' PHONe
209 Mai�pvenue (ac,No,�►: 570-226-4571;800-245-2666 jac,No>: 570-226-7105
e-Ma�
Hawley,PA 78428 a��Ress: amskier�amskier.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A pMA Insurence Group
INSURED W��9��������d Qperafing LLC iNsuRER a:
79 White Rock Road ' . iNsuReR c:
Yarmouth PorE,MA OZG7S INSURER D:
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 ADD SUB POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE �NSR VWD �UCY NUMBER (MM/DDIYWI� (MM/DD/YWY)
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY D�AMA'GE TO R E�NTED $
�CLAIMS MADE ❑OCCUR � � MED EXP(My one person) a
' PERSONAL AND ADV INJURY a
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG
POLICY E�T LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E
ANY AUTO BODILY iNURY(Per person) $
ALL OWNED � SCHEDULED � ❑ BODILY INURY(Per aceident) s
AUTOS AUTOS
HIRED AUTOS � NON-OWNED PROPERTY DAMAGE �
❑ AUTOS
UMBRELLA LIAB OCCUR EACH OCCURRENCE a
EXCESS LIAB CLAIMS-MADE � � ' AGGREGATE E
DED RETENTION$
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYER5 LIABILITY YM TORY LIMITS ER
A;; ANYPROPRIETORIPARTNERIIXECUTIVE ❑ N/A � 2011010291401Y 11M/2011 1'I/7J�O'IZ E.L.EACHACCIDENT $ 5�0,���
OFFICEIMEMBER EXCLUDED7
(M�daOory in NF� EL DISFJSE-EACH EMPLOYEE $ 500,000
Ifyes,describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT a SOO,OOO
❑ ❑
DESCRIPTION OF OPERATtONS/LOCATIONSNEHILCES(Attach ACORD 101,Additional Remarks Scheduie,If more space fs required)
Conflrmation of coverage for Workers Comp Insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLIqES BE CANCELLED BEFORE
, '
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVEB *
HENRY M.SKIER
President
m 1988-2010 ACORD'CORPORATION.AU>.rights reserved
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