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' � T�'1WN t9F YARMOUT�t B�ARD UF l�A,]L'T.H
� � A�.'PLICATIUN FUR LICE1VSElPE �- 0 0��
.... FSY�.�-���
*P lease aomp te te form an d a t tac h a l l necessary documen t s by Decem ber I S,L,Z O t 1 9.
Fai�ure ta do so will result in the return of your applicati�n packet.
NAME QF ESTABLI5HMER1'I': CAMP WINGATE*KIRK�AND TEL. #508.362.3798
LOCATIUl�t t�DT3RESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
MAILING AI�DRE�S: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
OWNER NAME: SANDY & WILL RUBENSTEIN TAX ID FET1�3 or SSN :
CQRPt?R.A.TION NAME{IF APPLieABLE). WINGATE KIRKLAND OPERATING LLC
MAT�TAGER'S N.A.ME: SANDY & WILL RUBENSTEIN TEL. # 508.362.3798
MAILING ADDRESS:79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
POC}L CERTIFICATTONS:
The poQl supervisor must be certi�ed as t�Poo1 Qperator,as required by St:�te la�v. Please list tlie designated
Pool{�perator(s} and attach a copy af the certifi�ation to this foirn.
1. 2•
Pao1 operat�rs must list a minimum of two ernpluyees c�u7rently certified in basic water safety,standard Fixst Aid and
Community Cazdiopulmanary Resuscitation{CPR}. Please list these employees helaw and attach copies afemployee
cerrificatians to this form. The Health Department wi11 not use p�►st years' rec�rds. Yc�u must provide new
copies �nd maint�in a f�e nt your place af b+usiness.
l. �
3. �.
Ffl4D PROTECTIOfN 1vIANAGER5 - CERTiFICATIONS:
A1l £aod service establishments are required tc� have at least one full-tune ernployee who is certified as a Food
Procection Manager, as defined in the State Sanitary Code for Food Servic� Estatalistlments, l U5 CMR 590.000.
Please attach�opies ofcertificatian to this application. The Health Department wiil n+nt use past ye�rs' recQrds.
Ypn must provide ne�v capies �nd maints�in �fle at your establishment.
�, SANDY RUBENSTEIN 2. JANET MCGILL
PERSON IN CHARCE:
Each food establishment must have at�east one Persan In Charge (PIC} o�i site durin�l�ours of o�eratian.
�,LISA MOORE 2. SANDY RUBENSTEIN
HEIMLICH CERTIFICATIC}NS:
All foad service establishments with 25 sea#s or more must �iave at Ieast oz�e employee trained in t}�e Heimlich
Maneuver on the premises at all times. Please list yonr employees trained in ann-choking procedures belaw and
attach copies of empl4yee certifications to this fo�m. The Healt� Department wili no#use past years' recnrds.
Yoa must provide new capies and ma►intairc a fiie at your piace at basiness.
1, SANDY RUBENSTEIN 2. JANET MCGILL
3. 4.
RESTAtIRA.NT SEATING: TOTAL# 175
���r.wss�nnis� �i i��n��sn
OFFICE USE �NLY
LODGING:
LTCENSE REQUIRED FEE PERMIT# LICENSE ItEQUIR£D FEE PER.MLT# LICENSE REQUIRED FEE PERMiT u
B&B $�S _CABA�t 5�55 „_,,,.NtOTEL �55
_,_„1NN �55 9 C.4MP 5SS ,�Q�D0 _S��jlIt�bIING POC?I.. �80en.
�LC}llCsE �55 _TRAILERPARK 5105 _WHiItLPOOL 58Qen.
�'(2G13�sEP.:'ICE:
LICEN5�REQUII2.ED FEE PETtMIT# LiCLNSE REQiJTREE} FE� PERMI7 ri LiCENSE ItEQLF1R�D F�E PLi2MIT#
0-I00 SEATS �85 ..._.CONTINENTAL �35 N�N-PFt�FIT 530
{ >10(15EATS �IGfl �fQ�� _� �C�MMONVTC. . S6U ��Q?J'� _WI�OLESALE �8�
R�xAIL gERUICL: —FtESTD.KITCHEN 580
LtCENSE REQTJiREL3 FEE. PERMIT#1 LTCEN�E REQUIRED FEE PER.I+�i1T# LIC�NSE REQtJtRED FEF PERMIT�
��50 sc�.f3. �50 >25,Ct40 sq,ft. 5?25 VEI�TDING-FCtOD S25
<�S,Op�sq,ft, $gp ._,,.FROZEN DE55ERT 540 _TCli3ACC0 5SS
�v�c�c�: �is AMQUNT DUE _ � 2��.c>o
«�»"*PLEASE TURN C�VER ANA COMPL�TE OTIiER SIDE OF FOItivt""**"
A]f3MIl�TIS'T1�ATIUN
Under Chapter 1�2, Section 25C, Subsection 6,the Town ofYazmauth is now requ'vred ta hold iss�aance t�r renewal
af any license or perrnit to operate a business if a persan ar cc�mpany daes not have a Certificate af`lVQrker's
Cc�mpensation Inswrance. T.HE ATTACHED STATE WUR.KER'S COMPENSA�'IOI� INSURANCE
AF�A'�ILT MIIST BE COMPLET�D.AND SIGNED,UIZ
CERT. l�F INSURANCE ATTACHED X
DR
WORI�R'S COMP. AFFIDA'�IT SIGNED A�TD ATTACHED
Tawn of Yarmouth t�es and lians xnust be paid priar to renewal ar issuance af your pem�its. PI.EASE CHEC�.
APPROPRIATELY IF PATD:
YES X I'�Ta
Ma�ELS AI�D QTHfEII�LO]DGING ES'�AB�..TSHMCEN�S
TRANSI�NT OCCUPANCY: For pu�poses afthe limitatians afMt�tei or Hotel use,Transient occupancy sha[i be
limited to the temporary and shnrt term accupancy, ordinarily and custornarily associated witl�mcrtel and hotel use.
Transient occupants must have and be able to demonstrate that they maizrtain a principal glace ofresidetace elsewhere.
Transient occupancy shail generally �efer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety (90} days wi�lun any six{6)manth geriod, Use c�f a guest unit as a resi+�ence or
dweliing unit shalt not be cansidered transient. Occupancy tha�t is subject to the collection af Raam Occupancy
Excise, as defined in M.G.L. c. b4G or 83Q CMR 64G, as amended, shall generally be considered Transient.
PUaLS
PQC)L UPENING:All swimrning,wading and whirIpools which have been closed for t�e season mus#be imspected
by the Hea.ith Department prior ta c�pening. Contact the Health DeparErnent to schedule the inspect�on three(3}days
pnor to apening,PLEASE NUTE:People are N'4T allowed to sit in the pool azea untii the pool has been inspected
and opened.
PUQL WA'TE�i TES2'�NG: The water rrtust be tested for pseudaman�s,totat caliform and standazd plate count
by a State certified laki, and submitted ta the �Iea2th Department thr�e (3) days prior to apening, and quarterly
thereaf�er.
PUt3L CLUSIlYG:Every autdoar in ground swzmming pofll must be drained or covered within seven�7'}days af
closing-
FUUD SERVICE
CATERLNG POLIC`Y:
Anyone wl�o caters within the Town ofYarmouth must nafiify the Yarmouth Health Aeparlment by filing the reqc�ired
Temporazy Foad Sezvice Agplication farm 72 hours prior to fihe catered event. These farms can be obtained at the
Health Departrnent.
FRUZEI�T DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified 1ab. Test results must be s�nt to the Health
Department. Failure to do sa will result in the suspension or r�voca�ion af yaur Froaen 17essert Pernut urrtil the
above terms have been met.
{3UTSIUE CA�5:
Outside cafes{i.e.,autdoor seating with waiter/waifiress service},must hav�prior approval fromthe Baard ofHea�th.
t)UTDU�R CUUKIl+�TG:
Qutdoor coolcing,prepazation,or display ofany faod�roduct by a retail or food service establishmezrt is prahi6it�.
IYfl7��E:�ermits run annuaily from 7anuary I to]December 31. I'�IS YO�JR�PC31���BII.l["�Y TO R]c�TR:N
THE COMPLETED RENEWAL APPLZC.A:TIQN(5}AI�TD REQUIRED FEE(S) BY L7ECEMBER 15, 20Q9.
ALL RENtJVATIONS TO ANY FO+DD ESTABLIS�-iMENF, MOTEL OR P(30L {i.e., PA.►�'ING, NEW
EQUTPMENT,ET�.), MUST BE REPOR.TED T�AND APPROVED BY THE B�ARD 4F HEALTH PRI(?R
TO COMMENCEMEI�IT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
DATE: 12/1/09 5IGNAT'UItE: °�
PRINT NAME&TITLE; SAN Y RU EN OWNER/DIRECTOR
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� � T �} W N C� F �" 1�i R. l��I C� U T H Ba����
� H�ith
I 146 I�UIJ'I"E 28,�C}LiTH YARNit3tTi'H,MASSA�H�.lSET"CS 0266�#2�451 H�Ith
'��' Tel�hone{508) 39�,223I,e�ct. �41
Fa.c{508) 7�U-3472 Di�ision
APP�CATIUN FUR A LICENSE 1'C3 CUi�t3,1UCT A
REC'REA'�`�U�tAL CANTP FOR CHILDREN
{Its�brck oC�pplic�tiQu if additi�ns�l s�ace is t�c�cess�ury) �'EE. �-5�.-0#!
i�.sc�.��� �€.s c���-
�ame o�'����; CAMP WINGATE*KIRKLAND ��'��`��`'�'
Site Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Site Address:
Ta��c II�Num6er{FEIN or SSI�t}: 52-2443840
Type of Camp: Day{less than 24 hrs.) Residentia!{2�hrs.) X
Haurs of Op�era#ian:
Dates QfUperation: Upenin,g: APRIL 1, 2010 ��a�ing: NOVEMBER 15, 2010
Name�fCamp t}wner: SANDY &WILL RUBENSTEIN
p���pd���: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675
Gtffice T'elephc�ne Nun,ber. 508.362.3798
Name of G�.mp Operator{if diff�r��t}.
Address:
Teiephdne Numbcr:
���,p�������,�; SANDY�WILL RUBENSTEIN
q����_ 20 LINNELL LANE YARMOUTH PORT, MA 02675
A�e: 37 TeIephone I�lumber: 508.362.3798 �
Coursework in Camging AdminisUation:
Pr�uiaus Camp Admini�tration�cperience:
Hea1t6 Care Consult�»t: SHEILA KANE
Type ofMedical License: RN/NP MA License numb�r: 115260
Address;11 KINGSBURY WAY YARMOUTH PORT, MA 0267-�J�pha��: 508.375.0419
oe�,wog 1 of 2
� �.
� �aspit�I fo�r Euxcargen�y Services: GAP€ C4D H4SPTIAL.
Health Supervisor; SUSAN RUACH
Age: �� T}=pe�fMadi�.l License,Regisktatir��or Trainin�: RNl MA#169125
Sw�mmictg Area: Y� X Nv
I�Y�s: Fresh Wat�r X 4ceat� Pool CPC)
�p�r�G 0����p���: BEACHFRONT LOCATED ON ELISHA'S POND
Water(tuality Testing Ferforined By:BARNSTABLE COUNTY HEALTH LABRATORY
Aquati�s Directar: TO BE DETERMINED PRIOR TO WATERFRONT OPENING JUNE 1, 2010
Subnut Certifi��tinns: CPR First Aid Water Safeiy
€}t�er Lifeguards a�d Cr�ientials:
Watercr�.ftlBoating Ac�ivi�ies: Yes X h�a Describe:
�'ood Service;
Is faod handles, served or pr�pared? Yes X 1Va
T�r�vhat�xtent? Snacks Ccsoked and Serv�d by Staff X
If caoked onsite, �ood Manager(submit copy csfServSafe) SANDY RUBENSTEIN
�a�tered if�v,hy�vhc�rn?'
Is re&igeration avaitabl�for perishable foads'? Yes Na
B�ckgro��d �hecks;
H�s the Car�np Otvuer c�r Directar obtained and c�vi�wed th����tl and S�.R�afeach staff'person and
voiunteer who rnay have contacz witb a canig�r? �tes � I�io
IMPUR'FAIVT! CUNTAGT THE YARMC�UTH HEALT`H UEPARTII�ENT �8 Ht�URS� PRICfit
T'Q UPENING T(} SC'�DULE AN Il'�SP'ECTtt}N1 fiHIS IS N�ANDATiJRY� �'i�'ERNIG�TT
CAMPS MUS'T ALSU SCHEDULE AN IN�PECTIt3N WI'TH T�E SUILDING AND FIRE
DEPARTtViENTS.
�IGNEI3:
#��..:. .. .
A DY RUBENSTEIN DECEMBER 1, 2009
PRINT�D: � L?ATED:
5ee the next page attac6ed for a list of documents thut must be compte#ed a�d submitted b�fare
your application can be fulEy processed. Yon are strongly encouraged to camplete th�se documents
as saon us poss►6le and snbmi#t#sem in advance. This will expedite the process.
av►9ros 2 of Z