The URL can be used to link to this page

Home My WebLink AboutApplications, WC and Licenses TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-070 FEE: S 160.00 In accordance«-ith re�►lations pronnilgated under authority of Chapter 94,Section 30�A and Chapter 111, Section 5 of tl�e(ieneral La��s,a penuit is hereUv oi•aiii�d to: Wui�ate Kirklaud Operatui�, LLC, 79 Wliite Rock Road, Yarmouthport, MA Whose place of business is: Camp Wul�ate-Ku•klaud Type of busuiess: Food Seivice To o�erate a food establislunent in: Towu of Yaimouth Pei�nut expu•es: Deceniber 31, 2009 BOARD OF HEALTH: .��E¢Q¢ft SP[aPl, J�.JV., C'Pcabcnzart (agax�P�3 .�. ��i�'QP�iPle�t `UiCe C'.Puaci�l»tafZ � .�. 53�cuu�c, C'�e�cP� � ��J2, .✓Y. Deceniber 16,?008 Bnzce G. iuphy, . ., CHO Director of Health H �. . �lleag 30.�o a,a�Q 800� 9I taqLtta�aQ . ,� .�..� ��a� �� .� �� O�i �JI�II.Id3S �r�r��r�� a�� a�n�a�JL' 3f' r�� N�� `�dS �'�'d�' �H.L'I�3H 30 Q2IdOg �sa m��ua^is j�t�y�o.nau�pa�� o�una tau an�u pauats.�apun au� `�oa ta��fuonn�sal uI 'o�ataLi; s�uaLupuaure pTre `Oi,T •ta�d�qJ `snn�Z i�aaua� �iq sat�T.rou�n� atnsua��a�� o� P21�•T3 ��I.IOii�1lL 2Ij�LI�IAc1 t��TLLT.IO�LTO� LII p2T1SSI Si 2SLT2�Ii STLj� 'S�I2jIL11��TA LIOILILiT0��0 �LIISiIa�Ti 2Li� �LII��2CIS2I LIjI�2A1LTOLIIiLTO� aii��0 SAc1Lj 2i��0 iiOI�EiOTA IO� p2xOA2�TO p2pIT2C�SilS I2LIOOS ssajun 600Z �S�-��1 taqtua�aQ san xa pLre �i�to a��Id��LI�� pu��nour.re��o unnos pres ZtI �S1�I��I'I S�2I�'I'I�I1.L�IA �iOI�iL�iO� d Q3.L!�d2IJ Ag32I3H SI FTj/� �-IO LI�l10LLi.TL� pLO�7I�0� 2�IL� (L p��a�x-a��arzT� uz�� JZ'I n?��ta p pu�PI-T�I a��Bui� ��u��t�a� o� si snu 00'09S �333 OSO-60# =2i3gY�Il11�I;LIY�I?I3d H.LflOI�RI�'� 30 I�IAAOs. S.L.L�SI1H��'SSVI�I 30 H.L'I��AAI�IOL�IIAIO� �H.L �:s �� !�— w . a � � i,� ;;'`!� L� 1 �`�t,Y�� TOWN OF YARMOUTH BOARD OF HEALTH �' r �N� ' APPLICATION FOR LICENSE/PERMIT-2008 �,�r� � ;� ?��7 � �:��s �� ..,�.. : *Plea,se complete form and attach all necessary dQcum�nts fiy Dece E PT. Failure to do so will result in the return of your application pa� . , � , NAME OF ESTABLISHMENT: ^ +� � -�- �Cl!f,Lt,�'N(� TEL. # �C�S. 3(��L...�f`�.�5 LOCATION ADDR£SS: ` (L��" -, aJ � �(ct� � MAILING ADDRESS: � ` � �'�' ��z.(.�� OWNER NAME: " � i, (.� -�Iv_>'(�1ti TAX EIN r N : L_ Z'4'a- -�,�' �4� CORPORATION NAME ( F PLIC LE):� i"��;�- (G1��1� (��'�-,n.A�l�v^� �,LG• MANAGER'S NAME: S �N � TEL. #��5 31��1 3�i�t�� MAILING ADDRESS: � �:. ,, ;(� . 1�'�} �u.< �'S POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot OperAtor,as required bti�State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Depart�nent will not use pRst years' reeords. �'ou must provide ne��- copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitaiy Code for Food Seiwice Establislunents, 105 CMR 590.000. Please attach copies of certificationto this application. The Health Department�viH not use past 3�ears'records. You must provide new copies and maintain a fite at your establishment. . 1. ��;�� z. _�'��.N'��,�. , _PERS9N_i_N�HAIZ�E: _ _ _ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � i��l�V;1.�.�" Z. 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-chokmg 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 business. � �._,c �'�� v�P�c.�n)�iL�N 2. ��t�1t;`�' �'��Ui�.�.. 3. 3 � 4. RESTAURANT SEATiNG: TOTAL # � 5� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'�1IT# LICENSE REQLTIRED FEE PER'�IIT� LICENSE REQL'IRED FEE PER�IIT= B&B S50 CABII�T S50 MOTEL SSU '�' i '_`�I�("�� S50 �CA.'�IP S�0 ��0� !S�'I\�LVIING POOL S75ea. - LODCiE SSO TRAILERPARK S100 �'�'HIRLPQOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE P£I�:'11IT� LICE:�SE REQL,'IRED FEE PER'�iIT= � 0-100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S'S �>100 SEAI'S S150 O �Q (o r CO:��:'�ION VIC. S50 �Os�6��p _��I-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S7� LICENSE REQUIRED FEE PER��IIT� LICENSE REQL'IRED FEE PER�4IT= LICE?�'SE REQtiIRED FEE PER��iIT= � _<50 sq.ft. S45 _>25.000 sq.ft. S200 _�'ENDING-FOOD S'0 _<25,000 sq.R. S75 _FROZEN DESSERT S3� _TOBACCO S�0 �TAiVIE CHA�IGE: S 10 AMOUNT DUE _ $ a50-O C� *****PLEASE TL?R\OVER�\D C0�IPLETE OTHER S1DE OF FOR�1*"��* W � R ' an�s�TTort Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �� 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 us�. 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 thirty (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 sha11 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. * NOTE: En�losed Motel Census must be com�leted and returned with tnis app�icat�on. POOLS POOL OPENING: All swimming,wading and whirlgools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and c�uarterly thereafter. POOL CLUSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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: Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cool�i�g;pregaratiori;or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�VCEMENT. RE�tOVATIONS MAY REQUIRE A SITE PLAN. .,--. � �/ � DATE: � 1 (� SIGNATURE: '` PRINT NAME&TITLE: ,��t�.L'll� ��f�tyV .}ll%�?`' 1t1300i �O�,Y�� TOWl�T OF YARMOUTH � ; o 0H � ' �'"� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 ` MATTACMEES � � h��q�ORATE0�6�� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 B O A R D O F H E A L T H APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN ([Tse back of application if additionat space is necessary) FEE:-�59:�'' Name of Camp: �,� �i?� �''�1� �-- J�.jl�t.flw� Site Address: � 1�V�� '�'�' OtNi� �:mv.-� ,,��:I 6�''��f C1�.t,�fiS� Site Address: Tax ID Number(FEIN or SSN): '��Z - 2��} �j�1}� Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.)�_ Hours of Operation: Dates of Operation: Opening:�(��1 � � , �� Closing: �I�� `��'M�"Y�- � �� r'� Narne of Cam Owner: � � �� R� p �, V'� w�,,;�� Office Address: �� t'�1� i.� ('�,� �ri-!V�'t/T��" ��v'� � �1.�:�3�� Office Telephone Number: �'J� � �U'�� `1 � Name of Camp Operator(if different): Address: Telephone Number: . Camp Director• �hv�l' `_ �+ +� ��"� Address: '� �I C��Y'i �L� �.� LI'��il�l'+�� '/�� Mfi� � �v'�� --� / - Age: �`j ..� Telephone Number: ��1,��t � Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: ��- • �I �� #�� 1/UY�' �,'�t�'7�'t�;� Type of Medical License: I'v i.� - MA License number: Address: �j� "I 1�� vv°� ��(¢- Telephone: �t� � .��".`Z�« 11/05 1 Of 2 �� Printed on � � Recycled Paper �,� ' Hospitai for Emergency Services: ��i �.t� (� ,��r'��'t-- Health Supervisor:_�� JI�' ��-�(� _ _ Age:� Type of Medica.l License,Registration or Training: ��(1 ST� ��/r�i -T Swimming Area: Yes_� No If Yes: Fresh Water � Ocean Pool CPO Specific Onsite Locations: Water Quality Testing Performed By: �yl(�1 S't'f�3� �,fi;� Aquatics Director: Submit Certifications: CPR First Aid Water Safety Other Lifeguards and Gredentials: WatercraftLBoating Activities: Yes No Describe: Food Service; Is food handles,served or prepared? Yes�_ No To what e7ctent? Snacks Cooked and Served by Sta,ff� If cooked onsite,Food Manager(submit copy of ServSafe) � 1"f I V��l�t,� Catered if so,by whom? Is refrigeration avaiiable 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 ma.y have contact with a camper? Yes� No IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS PRIOR TO OPENII�TG TO 5CHEDULE AN INSPECTION! THIS IS MANDATORY! OVEI2NIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. SIGNED: r� PRTNTED: �ol. t�i� � 'S 1�"�`� DATED: ((( (t1 �� —T See the next page attached for a list of documents that must be completed and submitted before your application can be fulty processed. You are strongly enconraged to complete t6ese documents as soon as possible and submit them in advance. This will egpedite the process. i iios 2 of 2 ' � The Commonwealth of Massachusetts Depantment of Indushzal Accidents > Nlif�t�l�l�f/li� 600 Washington Street, f"'Floor Boston,Mass. 02111 Worlcers'Compensation Iasnrance Affidavit:Bnilding/Plambing/Electrical Contractors t . � name: ldl,� U��:JC�JS��'� � address• �� Vv+Ch i�i �lr��' Yw�;,� citv !1`(�N�(�.��" ��.tiT state• �� zin• C�/,L(,?�S 2 phone# �� ll-��. 7'�1'� i work site lceation(full address: 1 '�� !l.-`C-�,-�/� � ((��'� � �(��--�� C��,fC�� ❑ I am a homeowner perfomung all ork myself. Project Type: ❑New Construction�Remodei ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition �I am an employer providing workers'compensation for my employees wo�lcing on this job. comusnv same: �i�l Y��l" G��Y��f� r 1 1 � �'l!'��v'�`N'� address: ,� �-' :``�� , �-!vlwn-� d�ti� �#• C Z � fit � � �. �� - I� . ��1��- � � � n"Z. (� �� b� � : , ;: . . . . : :� � .;.� � ❑ I am a sole proprietor,geHera!coatractor,or�omeowner(circle o�u)and have lured the co�ractors listed below who have the following workers'compensation polices: commav namr addresa: chv oiioae#- iasmaace co. �tev# c�mmsv'ame: adslreas- citw ��#• iBs�aree co. ,�poHcy�# A141e1��lire�l�� _ _ , . .; . , . .; .:; Fa�im�e�o xcme cuvvaae as req�rcd aeda Sectle�2SA sf MGL 152 cu lad t�fYe�n ef eri�ioal pe�aNia�f a 8ase�b i1,59d.M aadlor one yean'imprbonment as we�aa civY penaltles in t�e form of a STOr WORK ORDER aed a 6ne et 5106.OA a day against�e. 1�4ud t6at a capy ot this statemmt may be forwarded ro t�e O�ce o[lave�doffi of t6e DIA for eeverage vari&atloa /do hereby ce ' u die patns and penalties of perjrny that tAe iwforra�oe provided abov�e is hrre wed cerrect Signature � v� Date �� I� � Print name 1 f\��t+��'�-�� r��J'f�/U Phone# ��%' � . �lr?L.. �� . _ ., .� _ . .. official ase only do not write in this area to 6e co�pieted by cHy or to�vn o�cial city or tewn• permiHlicenx/t �Baiding Department QLicen�ing Bosrd ❑chedc if immedlate nspe�e is required OSelectmen's Office ❑HeaUb Depae�ent rnntact peraon• pho�#; �� (��3'. ��iCORD TM � ��„sR"7� � ��e� '� ��rt � � s u � fi9e1 ��DATEfMM/DD/YYI� s�� . ° � � � � -'-r E. ,�=,,,_ c-.,—_.-_ Y.-4._�'��,�._-'•—.,_��".t�:_ <�, .�, ....; e.,4Y,ss��4 .., :�..:_„�;�a�„=,3•�,�, . „�:...�: .. � ___. _�'.:�—�:�—EK-.-;+.�_'�=��} �� R x 11/06/2007 ' Tf-IIS BINDER IS A TEMPORARY CONTRACT,SUBJECT TO THE CONDITIONS SHOWN�ON THE REVERSE SIDE OF THIS FORM. � ------- - --- ----- PRODUCER Phone: (570)226-4571 COMPANY BINDER# A. M.Skier Agency Star Insurance Company WCO266031 ; 209 Main Avenue --------- ---__.__------------- - Hawle PA 18428 EFFECTIVE EXPIR,4TI0 Y� DATE TIME DATE TIME CODE: �susco�e: ---- 11/01/2007 r 12:01 A.M. 11/01/2008 12:01 A.M._ __L----- AGENCY CUSTOMER ID THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY#: INSURED � � DESCRIPTION OF OPERATIONS/VEHICLES/PROPERTY(Including Locat(on) Wingate Kirkland Operating LLC Children's Resident Camp 20 Linnell Lane Yarmouth Port,MA 02675 '�lX�, ,;"�� '"` �� - ir � , � y �:�.�� A � 33�{,s S �ba 3 � d w � F C i, _ � ,r`st r � m� � �'�.� "��">,_ E.� A�� 1"nnm, r �, v ='�a a � p_3d ,� � - .. ..a....4,� �. � f«.,:`�3`. �"��r. ��. ��t�..��..�.u._ _TYPE OP INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% � AMOUNT - ---------- ----------- PROPERTY BASIC �BROAD �__�SPEC ------___ _--__--- --------- ---------- .------ GENERAL LIABILITY � EACH OCCURRENCE $ _ _-� COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ �CLAIMS MADE r__IOCCUR MED EXP(Any one person) $ ---- � � OWNERS AND CONTRACTORS PROT PERSONAL AND ADV INJURY $ GENERALAGGREGATE $ - --- _ _ I - _________ RETRO DATE FOR CLAIMS MADE PRODUCTS-COMP/0P AGG $ --- -- ------------ _------ - --__--- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ BODILY INURY(Per accident) $ ALL OWNED AUTOS _L' ^_� - PROPERTY DAMAGE $ 'HEDULED AUTOS ,�RED AUTOS MEDICAL PAYMENTS $ - -- ----------- NON-OW NED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORST $ ------ -----_______.__ $ -- -----_.--.. _..--- - --------- . _._.. ._... ._.. ..-� -----�-- ---.__i AUTO PHYSICAL DAMAGE �ALL VEHICLES�] SCHEDULED VEHICLES ACTUAL CASH VALUE $ i DEDUCTIBLE ----------------___ COLLISON STATED AMOUNT $ __ __-- -- ---- -- --___i OTHER THAN COL. OTHER $ ----- __ _ ---- --- ---- -----_ __ _�.__- GARAGE LIABIUTY AUTO ONLY-EA.ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY � I - - ---- --- - EACH ACCIDENT$ i - - -__ -- -- AGGREGATE $ --- - . __ --._._-- EXCESS LIABILITY ---- ---.---- --..__._ ___ _ __ _------ -- --- _ EACH OCCURRENCE $ ; -1 UMBRELLA FORM t - -�---``4-- -, AGGREGATE $ -! OTHER THAN UMBRELLA FORM I RETRO DATE FOR CLAIMS MADE SELF-INSURED RETENTION $ - ---- -------- _ _ .. _ � WC STATUTORY LIMITS $ WORKER'S COMPENSATION I _ �_.__.__- --------_. ___---- __._ AND E.L.EACH ACCIDENT $ 500,000 � ------- ---------- -- ___ __ EMPLOYER'S LIAB�LITY ;E L DISEASE-EA.EMPLOYEE $ 500,000 ! � � ------- - __ _._. i E.L.DISEASE-POLICY LIMIT $ $00,000 I __-- --_-- -- ----_ ____ _ ___ _ _ -- -----_ ----..__ . _ SPECIAL IFEES $ � CONDITIONS! � � OTHER TAXES $ COVERAGE�. ' '- ---- � i EST�MATED TOTAL PREMIUM $ �� -- � � - _ � _ ._ �...n N'- , . .� .." , .._ .:' �,: = y, : , �• ��.j .� __�...__i . ,�„__�_......._._.__. . .: . _ _,_;_,_ ___�_:. _ � . .: ... _ '.__..v....�_< ......�.,__�:�......_..._..-� . ''� f- I � � MORTGAGEE � ADDITIONAL INSURED � � I LOSS PAYEE , ___ _ __ I I LOAN# ____---- -____ i �� IAUTHORIZED REPRESENTATIVE6 , .,� , � HENRY M.SKIER ,:--_ _ _ ,—�---�--- - - AG`. , � � �� `�' , �� :`F��"�''�..' --- r: `, , AG�I�b:C P012A"CIQ�11;988 _.._�_....__�__._._� . _ . _� _._._ .�__, __ __��,___..�__�_: _.._.__ .._ . � � - THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NITMBER: #0$-005 FEE: $50.00 This is to Certify that Wingate Kirkland Operatin�, LLC. dJb/a Camp Win�ate-Kirkland 79 White Rock Road, Yarmouthvort MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS This License is issued in conformity with the authority granted to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is sub;ect to the provisions of the Laws of the Commonwealth of Massachusetts relating theretq and upon such terms and conditions,and to the ruies and reg�tlarions in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. December 28_2007 BOARD OF HEALTH: .�1�.E.�EfZ S�Y�t� �.,,JV.� (�Laft �,'I�avc�e� .`�. `.7'Ge�P,�i.Pl�c `UiCC('PcacvrntlXrZ ��J3�u�cutt,�C� � Bruce . Murphy, ,R. .,CHO Director of Health ..Y..W�IO�I 30�mS 2I�H.LO�Z�'IdIAiO�aNIV?I�AO N2If1.L�SV�'Id..... �-o�L�S = �I1Q Zl�InoL1i� oi$ =��uv�awvN os$ o��dgoi S£$ .L2I�SS�Q N�Z02L3— SL$ '8'bS 000`sz> oz$ aoo�-�t�c[ts�n ooz$ ��-bS 000`sz< sv$ �u��os> a i��a a� Q�una�x asr��iz #.t.u�x�a �� a�una�x�sr��i�z a��a �� a��naax�srt��i� , sc$ ��.r.tx-�s�x— =�ainu�s�za� sc$ ��sazoF-rnn C-eO-LP � os$ ��rAxornuKo�/ � �- c� OST$ S.L�7'3SOOI< l sz$ i�oxa-xox oE$ ��ru.usoa— s�$ s.td�s oot-o �i��a �� a�na�asrr3�rz #��a �� a�xrna�x�sr��1� #1��a � a�na�x�sr��iz -��in��s aoo3 ��s�$ �ooa��nc� ooi� �ax��x.ti os$ ��aoz ��sc$�ooa�r�ununns— },00-L D � os$ �a j os$ x� os$ z�tovs os$ rua�� os� g�g #�raa �� a�na��su��Iz #z��a � Q�na��sN��rz #z��a �� a�na��su��i� ��M9Q0'I �zuo �sn ��I�o #�ios ��ui�as i�n�ss� �v -�-�� -� �£ �z �� vd�� 1 •ssau�snq 3o aagid ano��g a��B ui�ui�w puB saidoa Mau apinoad �sn�n no� •sp.�oaa.c �sa�a�f;s�d asn�ou iii,��uam��daQ q�i�ag aqs �uuo�sTq�o�suot��gi�a� aa�ojduia�o saido�u�e��e pu� nnojaq sampa�old �u�ou�-i�u� ui paui�i�saa�oidcua mo� �sti as�aid �saiui� i� �E sas�.ua.zd ac��uo iannau�yy q�T�,uiaH a�� ui paur�� aa�oiduia auo �s�aj �� an�u �snuz a.�ouz io s��as SZ q�inn s�uaunjstjq��sa a�in.ias poo� I� �SI�IOI,L��I�.L�T��H�I'IY1II�I �Z �� t �uoi�eiado�o s.znoq�uunp alis uo (�Id)a��u�uI uos.�ad auo�s�aj �E an�u�snu��uau�sijq�e�sa poo�u�e� _ _ ��tJ2IHH�I�II �iOS��d �L� �� Z N�S �''1� � �I ..�- , •�uaeuqsi�qg�sa.cno��a��e u��u��w pu� saidoa Mau ap�noad�snw no� •spaoaaa �s.�Ba�f�sgd asn�ou��,��uaw�BdaQ q�luaH aqy �uoi��Tidd�sn��o�uoi�e�g��a��o saido�u��e��as�ajd '000�065 2II�i� SOT `S�uaun�sijq��sg a�in.ias poo3 io� apa� ��5 a��s au}ui�paugap se `ia��uey�uoi��a�o.�d poo3 �e sB pa�i�za� si oc�� aa�oiduia au�u-IIn� auo �s�ai �� an�eu o� paimba.� a.re s�uaun�stiq�e�sa a��n.ias poo� I� �Si�IOI.LK�I�.L2I�� - S2I�tJ�N�'Y�I NOI.L��.L02Id Q003 �� '£ 'Z .I •ssau�snq,�o aaeld ano,��aiy g uiB�u►wui pag saidoa n�au apinoad �sn�u no� •spaoaa.� �sa�a��s�d asn ;ou i��n�►�uam��daQ q��ag aqy -uuo� sn�� o�suoi��gi�a� aa�ojdura3o saido�u��pue n�ojaq saa�oiduza asau��sij as�ajd '(gd�)uoi��i�snsag�xeuoLuindoip.re��iimuzuzo� pue p��s.�,�pi�pu��s `�a�s la��nn�is�q ui pagi�a��f��.ua.un�saa�oiduxa onn��o uznu�iunu e�sii�snui s.�o��.zado Iood 'Z �j .uuo�sn�� o�uoi�e�gi�a�au��o�do��e u��pue (s).zo��.�adp iood pa��eu�isap au��sri as�ajd •ns�J a��s�Cq pa.�inba.�s�'.�o��.�adp iood s sB pag��aa aq�snm.�os�naadns�ood aq,I, �Si�IOI.LK�I�,L?I�� 'IOOd �S S�IQQ�'JNI'�II�'I�I �b-�.Z . ,S�?5 # �`I�.I. d�f t�5 � (��' ��I�I S�2I�JHN�L�I • �`� (,� ��'I�'�I'Id� �) �1I�N NOIZ�'2IOd2I0� o b��-b�b-� �.S �iNss ��ru� � z ��, aw ' ��v �-�1�� N x�mo � �s��xaa��ru� Sk��?0 -�dlnl �-'ti'� J�'0 � �SS�IQQ�'NOIZd�O'I ,��CZ:��.�05 # �z�s �� r �� sN�slz�isa 30 �N _� ,--- �1d3Q � ��d uoT�e�ildd�mQ��o u.m�a.�aq�ui��nsa.z�inn os op o�ainire3 �a��l�f j qcu�a �q s�uau��i�op 6.ressa�au ire u�E��pue uuo�a�aiduio�as�aid * soo� t o � �' � � "� F� �o ��0 ab� £ �'. �4��dl�Sl�I��I'I 2I031�IOI.L�'�I'Idd�' � . � aN a � �; � �� :,, :n x�o ��og gsno��o un�oi ��dA;o� . Y . ��`,c-��.,`'�-.Y .- i i .� v 1 90/LI/OT '�11-�� t'�' � s�� ►G� �a�.li��u.r.�uxa < �, ' ��2I11.L�1�IIJIS A � � ��L�'Q 'N�''Id�.LIS�+'�2IIf1��2i��I SNOI.L�AOI�I�I '.LI�I�NT��I�I��U�tO� OZ 2IORId H,L'I��-I 30 Q2I�'Og�i.L�g Q�.A02Idd�'QNV O.L Q�.L'iIOd��g,LSf]Y11`('�.L� `.Ll�I�difla� t41�I�I `1J1�II,LI�IIKd `'a'i) 'IOOd 2I0 'I�.LOI�I `.LI�I�ff-iSI'Ifl�',LS� QOO� 1�I�I� O.L SI�IOI.L�TAON� 'I'I�' �9ooz `i£x��a��Q�g ts)a�a�na�xx ar.t�� (s)Nolz��lzaa� aa.t.a��o��u.T. I�INt1.L�I O.L A,LI'IIBISI�IOdS�2I 2IIlO�i SI ZI 't£laquxa�aQ o� I �nu�r uio.r��ij�nucre uru s�tuuad��I.LOI�i ��;�q�qo.�d s��uaur�s�q��sa a�rluas poo3�o jre�al��{q��npoid poo��u�3o�C�ejdsip io`uoT��.r�da.�d`�ur�oo�.zoop�np =��oo�xooQzno �u�a�o p.�og a�u�o.��eno.zdde ioud an�eu�sncu`(a�in.ias ssai�i�nn�.�a�Y�nn��inn�ui��as loop�no`�a�i)sa�apis�np � � � �s�� aissno ��.aui uaaq an�u suua�anoq�e au� ji�un�nuiad�assaQ uazol3 ino��o uoi��onai .to uoisuadsns au�ui �jnsai ijim os op o�a.znlre3 •�uaui�.redaQ u��eag au� o��uas aq�snu� s�jnsai�sas �q�j pa�i�a� a��s ��q sis�q�i��uoui�uo pa�sa�aq�snui s�assap uazol3 �S.L?I�SS�Q I�I�Z02I.� ��uaui�.redaQ q��ag aq��e paure�qo aq ue�suuo�asauZ ��uana pa�a��aq�o�ioud s.�nou zL,uuo�uoi��cjdd�r a�in.ia� poo3��iodu�as pa.imbaa a�{��uRg�iq�uauz�redaQ u�leaH u�nouue�a��i�ou�snw u�nouue��o u�oi au�u��inn s.za��ounn auo�uy �1�I'IOd�I1I2I�.L�� IA2I�S Q003 ��u�soi� �o s�C�ep (�)uanas u��inn paiano�io pau►�e.zp aq�sntu iood�unu�urnns puno�ui ioop�no�S.�ang :��SO'I�rI00d �ia�ea.�au��ilia�nb pue `�uivado o�ioud `q�ei pa�i�a�a��s ��iq �uno�a��id pi�puE�s pue uuo�rio�j��o� `sEuocuopnasd ao�pa�.sa�aq�sni.0�a�e�a�Z :��ZS�,L g�,L�'AA ZOOd '�uivado o�ioud s�f�p(S)ang uoi�adsu�au�ainpaq�s o��uau.i�.redaQ u��aH au��uo� ��u►uado o�ioud�uau��redaQ ql�aH aq��Q pa�adsut aq�sricu uos�eas au�.�o�pasoj�uaaq an�c�q�n�nn sioodj.zn��n puB�c�ipEnn`�u��nns ti�d =�I�II�i�dO'IOOd S'IOOd ��uaisu�.zs paiapisuo�aq��elaua�jj�eus `papuaure s� `��,9�� 0£8 io Jt�9 '� ''I'J'Ni�pau�ap s�e `asi�xg �auedn��p ucoo��o uoi��ajjoa au� o� ��afqns si ��q� �i�u�dn��p •�.uaisu�.z� pa.�apisuo� aq �ou i�qs �n.m �uijjannp io a�uapisa.��s��nm�san� e�o asn •pouad u�uoui(g)xis�u�u��in�s��p (06)�auiu u�q�a.�ouz�ou�o a��ai�� ue pue `s�Ep (0�) A�n�� ueu� alouz �ou�o �i�uedna�a snonui�uo� o� .�a�al �I�e.zaua� �eus ��u�dn��o �uaisueaZ �aiaunnasia a�uap�sai�o a�id�d�uud�u��u�ui�aq��q�a��e.r�suouiap o�aiqE aq pu�aneq�snui s�u�dn�o�uatsueiZ �asn ja�ou pue ia�ouz u�inn pal�ei�oss�e�tr.r�u�o�sn�pu��fjueutp.�o `��u�dn��o uua��oqs pu�e�reioduza�.au�o�pa�nutj aq�e�s�u�dn;r�o�uatsu�is `asn ja�og io ja�oy��o suot��nutl au�.�o sasod.md l03 :�N��O.L11I�S1�I�2I.L S.L1�I�LIIHSI'IBV.LS��l�IIJQO'I 2I�HZ0�I�'S'I�,LONI OI�I �S� =QI�d�A'I�I,�RIdO?Idd� ?I��EI��S�'�'Id 's�.iuuad mo�i�o aauenssi io�nnauai o�ioud pi�d aq�snux suaii pu�e saxe�u�nouu��o trnnoZ Q�H��'.L,L� QN�d Q�I�IIJIS .LIA�'�33�' 'dY�tO� S�2I�?I2IOt1A �O � a��ss��N�xns�u�o �ixa� xo `Q�u�ls Qx�Q�s�za�oa �g acsn�iTn�� I�i�'2Il1S1�II I�tOI.LVSI�I�dI�iIO� S�2I�}I2IOh1 �.L�.LS Q�H��.L.L� �H.L 'a�u�.znsui uoi��suaduio� s�.zaxio��o a��i�a� � an�u �ou saop �fu�duio� .zo uosiad ��i ssauisnq � a��.zado o� �iuuad .�o asua�ii �iu��o Tennaua.�.�o a�u�enssi piou o�pa.�mba.�nnoa si u�noui.re��o un�os au� `9 uoi��asqnS `aSZ u�i��S `ZS i ja�d�e��.zapun I�IOI.L�.Sll�tINIQd „� „ o�° �� ` � ,,, o F �JJ `�" � -- =-°• a`'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 � MATTACMEES )� � �M�Oq��Rat�O\6�'� ��1 Telephone (508} 398-2231, Ext. 241 — F� (508) 760-3472 L— l9 � O L'1 l� L O S Yl G � L 1 IY � APPLICATION FQR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN b�C,W�E�ON c'MER (Use back of application if additional space is necessary) FEE: �5&99 qQp. Name of Camp: C,�� '� ��L:LAi�10 Site Address: �'� �i'�"1'� �.4(•�C �-D/� Site Address: � �Q �} d.'lT � (��..��""� � 'Iax ID Number(FEIN or SSN): �� ' �. ��- ��Q Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.) �� Hours of Operation: Dates of Operation: Opening: �r�{9'�.��' � , 2��'' Closing: ��jA/1$�- �S y Z O b� Name of Camp Owner: VV��5�1� �11'�l�i� �I��.�fi1lV i;-� l�l�� Office Address:__�'� 1�C�11"� �(�- �.o�0 �I t�•'1Y�" �c3.� �� b L,Ca��"S —� Office Telephone Number: �o�� ,�(�2 • ��`L( �j Name of Camp Operator(if different):��1'��i�� K��,,�f p Q�i�51�n(ir (,� Address: Telephone Number: � Camp Direcfor: � �i l,V tJ � C NS`��l Address:--- 'I `"\ ��" �(.,�C� �(,��+iQ ��(Yl J�1�" �t'L)!� �� Age: 3� TelephoneNumber: �aY ,,3(FZ . �`�{ S' Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: �_� �v�(, ��/�1'�;I C.S � ��1, Ltl('L1 �� Type of Medical License: MA License number: Address: �� 1 Telephone: �jU� '3� ��..�� ll/05 1 Of 2 � Printed on ( Recycled �,��s Pager Hospital for Emergency Services: C.��- r�Q��- Health Supervisor: < u� � � Age:�_ Type of Medical License,Registration or Training�(� � �� i�11.S''�l l�lj� {`�Y��,5� Swimming Area: Yes j� No If Yes: Fresh Water � Ocean Pool CPQ Specific Onsite Locations: � ' � ��%�C�t,'�' � ��tlr�.� Water Quality Testing Performed By: �, 5�1\.E Aquatics Director: �(�D � ,��N�IN'C� Su�mit Certifica.tions: CPR First Aid Water Safety Qther Lifeguards and Crede�tials: WatercraftBoating AcCivities: Yes No Describe: Food Service; Is food handle�;served or prepared? Yes� No To wha.t e�rtent? Snacks Cooked and Served by Staff X � If cpoked onsite,Food Manager(submit copy of ServSafe) Cj�D��Q�5'�� 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 ma.y have contact with a camper? Yes� No IMPORTANT! CONTACT THE YARMpUTH HEALTH DEPARTMENT 48 HOURS FRiOR TO OPENIlVG TO SCHEDULE AN INSPECTION± THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITIi THE BUILDING AND FIRE DEPARTMENTS. SIGNED: � PRINTED: �MnD 1lPt' S"�� AATED: �11'J O(� See the negt page attached for a list of documents that mast be completed and submitted before your application can be fulty pracessed. You are strongly encouraged to complete these documents as soon as passible and submit them in advance. This will ezpedite the process. i vos 2 of 2 Workers Compensation and Employers Liability �� Insurance Policy I N S U R A N C E Folacy Num.:her �romotCcy t�tr��d To _ _ _ _.. _ _.. _. .. C O I�/� P A N Y WC 0266031 11/01/2006 11/01/2067 � 12:01 A.M.Standard Time at themailing address 26255 Amer�Can �r�Ve of the Insured as stated herem ` R�n�wal af ': Trans�ctic�n; < ; Southfield, MI 48034-6112 wc 0266031 Policy Declaration ;1 Named lnsur�d and Mailmg Addre�s. >:. . ��-�l''� WINGATE KIRKLAND OPERATING, LLC F � � S�� 20 LINNELL LN �-} YARMOUTH PORT MA 02675-2305 �� r'�"� �' : ��w��'�� 1t�2� UNEMPLOYMENT ID# CARRIER#: FEIN# t Entity of Insured 24562 522443840 £„ LTD LIAB CO Other Workplaces Not Shown Above: sEE ATTACHED SCHEDULE 2. The Policy Period is from 11/01/2 0 0 6 to 11/01/2 0 07 12:01 a.m. Standard at the Insured's mailing address. . 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: rtA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 5 0 0, o 0 o each accident Bodily Injury by Disease $ 5 0 0, o 0 o policy limit Bodily Injury by Disease $ 5 0 0, o 0 o each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except North Dakota, Ohio, Washington, West Virginia, Wyoming, and states designated in item 3.A. above. D. This policy inctudes these endorsements and schedules: See attached schedule 4. The premium for this policy will be determined by our Manuals of Rules, Class'rfications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Assessments and Taxes SEE EXTENSION OF INFORMATION PAGE MA $296 Total Estimated Annual Premium $ 7,458 Expense Constant $ 284 Minimum Premium $ 274 Premium Discount $ `� Deposit Premium $ 7,754 ] This is a Three Year Fixed Rate Policy ,. Premium Adjustment Period: � Annual; ❑ Semiannual; ❑ - rt � CY lF�C Countersigned this Day of , � QRESIt2ENi Issued Date: 10/2 6/2 0 0 6 Authorized Representative Issuing Office WC 00 00 01(Ed.12/04) INSURED Y'� �..:��^ ��, _ +S� :� �v fH Y 2`.�' 6 ! ` . � .^.� � ':� ,., oC:...r..v u..'i-a..�'"'..+'�`��; � q��CD� � � DATE/MM/DD/YY) c� �i[J.J TM �'�a�'3 ��'*rs�� ,��,�� :.�s �s � s� �,� 10/19/2006 ��F� � ,.H;.�.,.�._ �.w�_..�� ,r.....�-�..:.. ., r,. .a... �..� ....;, s„; ,� .. ,, x., y>. -�. .� :��'��., �. ��a. , '� '� t %�€ � `' ��.. �.;, ,. ... �, .� . :<... � ....... .. .... . .,...�,,. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE A.M.Skier Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 209 Main Avenue ALTER THE COVERAGE AFFORDED NY THE POLICIES BELOW. Hawley,PA 18428 COMPANIES AFFORDING COVERAGE COMPANY A ACE American Insurance Company INSURe� COMPANY Wingate Kirkland Operating LLC B 20 Linnell Lane COMPANY Yarmouth Port,MA 02675 C COMPANY D � 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. CO TypE OF INSURANCE PO�ICY NUMBER POUCY POLICY LIMITS. : LTR EFFECTNE DATE EXPIRATION DATE GENERAL LIABILITY GENERAL AGGREGATE $ 2,��0,�0� X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ 2,000,000 A ❑CLAIMSMADE aOCCUR PERSONALANDADVINJURY $ 1,000,000 OWNERSANDCONTRACTORSPROT D35776837 11l1/2006 11/1l2007 EACHOCCURRENCE $ 1,000,000 FIRE DAMAGE(My one fire) $ 5�,�00 MED EXP(Any one person) $ 5,�00 AUTOMOBILE LIABILJTY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INURY(Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INURY(Per accident) $ NON-OWNED AUTOS Comp De PROPERTY DAMAGE $ Coll Ded GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: $ EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE S UMBRELLAFORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND WC STATUTORY LIMITS $ EMPLOYERS'LIABILfTY EL EACH ACCIDENT $ THE PROPRIETORY/ � INCL. EL DISEASE-POLICY LIMIT PARTNERS/EXECUTIVE $ OFFICERS ARE: ❑ EXCL EL DISEASE-EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCFcisaECIAL ITEMS ,�tT[F�'G:T�� ,e�� ti'� �; � �� ,� � ��' �e��F�! E�. � �I�I!��s' �� w�'��„-a�� ' �.;�- �'��",,��..� , . . ,�.... .�.�r5;�.��.�, i�..° u�<�r�.,,�..��.,e,.. �,e�svv ,�,as �.. �y'"��,.. � -:`��. �.:��:.:�`' SHOULD ANY OF THE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVER TO MAIL , �O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENT OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE6 ' HENRY M.SKIER A�Ok�D 25-5(1 �� ,� � ` � `� � . � � �",� �Ct�2t3�ftt�� 9 $�°3 �� ; F � � b � k � �� x � � __.�_. _.... _.�___��.2= .,�_ ��_ "�_.__�__-____�_. ��____.. �_.__ ._._��_�'�� ..��..��,a.�• THE COMMONWEALTH OF MASSACHUSETTS TOWN QF YARMQUTH BOARD OF HEALTH PERMIT NUMBER: #07-004 FEE: $50.00 This is to certify that Win�ate Kirkland Operatin� LLC. dJb/a Camp Win�ate-Kirkland 79 White Rock Road Yarmouthport MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and e�ires December 31,2007 unless sooner suspended ar revoked. January 30,2007 BOARD OF HEALTH: Q �. �[o�s,/��., . d��;s`�, �r.�., v� e�� a�t�. B�, �►� ��J�a.�S�� Bruce G.Murphy, ,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #01-042 FEE: 150.00 In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the C,eneral Laws,a pemut is hereby granted to: Wingate Kirkland Operating LLC, 79 White Rock Road, Yarmouthport, MA Whose place of business is: Camp Wingate-Kirkland Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2007 BOARD OF HEALTH: L�es ' `h. �c�orc, /LI.`15., ' ��st�, .lv., v�e�� 2�t�. e�, �i!� � p�k A�l��.,�,tt �!��j , R.N January 30,2007 ` � Bruce G.Murphy, ,RS.,CHO Director of Health � � v� � � � \ p � � � s� �' �i � o1J �'l � bA �` � � �•�.�.,'� . � ;•� . � � �� o � � � � � � � . a w `� � �' �.� � ~; • • � � ,r� ,�..� � •� � �;,.� Ey �,�� ,� . � � ,� w � r.., � �..� � •� �� x vl � � �, o �� ' ��.� o p � � Cq U � � � � .� . �` a . V � � � � o � � � �3 �; � �+ �,� a pa�o� � �' �c ^ �� p ao Q� .�� o � � w '� � w �� o H � . a b � �. � � � .� � � �•1 � �, °? � � � ��,,� a, a� � � � �o � .� '�,�.�'� .� w � � � � � �U °o �� y � W � �d� � � � �u � � '� � ° v, a�°'� ,.,�� -d � � w � � r,,, �,� a� O E-� O � � O �o..�� . ,�.� E.., � .�b � �� ;y� � �" e� o.. �� V b � O ,� C�-� O �� '��' V � � � � � � a� � o �;�',� � � '� '�� o 0 W .� �.,,,° °� a � o �� 0 � � � q� �+ N U.� i� � N U S �"`''' � � � O � � C,� � � F' o E-� v� bp.�., ,� � � y � � �� W '�,�- � O � ..� E-� � � A-, H � �;� ° � rWi� , � . " '` � f'lYa r-•�; 6.�.►� .n'i�-CIRJLCANC �.� ,� R.�c TOWN OF YARMOUTH BOARD OF HEA�:�1� °' �a [ti !- �� L� �r�`�� .. "�s APPLICATION FOR LICENSE/PERMIT , 2�1t�6 F�` DEC20Z005 * Please complete form and attach all necessary documents by Decem r 31 2005. Failure to do so will result in the return of your application pac E'ALTH DEPT. NAME OF ESTABLIS�IMENT: � � i(�.tt l.,l�� 'TEL. # ��vrZ�j�� LOCATION ADDRESS: � "1�t�Y1� � � 11/�u•�� c�l,, L�' � MAII.,ING ADDRE S: OWNER NAME: { e - , �F �� T ID E or S : 2' O � eo�o�Trorr N� ��pLIcaBLE�: ` rN(.=ft�s�� '��,��..�'� C�P��i,114-- i,�.� MANAGER'S NAME: �'E TEL. # MAII,IlVG ADDxEss: S�Ir�t � POOL CERTIFICATIONS: � The pool supervisor must be ce ed as a Pool Operator,as required by State law. Please list the designated Pool 4perator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees 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 tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments axe required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CNIR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide_g�,w copies and m�'��.��le at your establishment. �1��', /Y/ 1. � � �►L�!`�i ``��" l r� (�'Ci �l�,l' ��C1 iy �!� � ��.t,'�v� �ii ��i 1..�� •�.��'"r C�G ��?l Cr�1�'� lt'v� � '��, i'�1J1� �d`�i11.i�iLL . PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. � ��g�5�� 2. � HEIlb��EH 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-choking procedures below and atta�i copies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �S� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQIJIIZED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 INrr $so t c� $so 06-OOS _SWIIvIr�II1VGPOOL$75ea. _LODGE $50 TRAII�ER PARK $50 WHIRI,POOL $75ea. FOOD SERVICE: - - - LICENSE REQUIItED FEE PERM[T# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 �>100 SEATS $150 66''�Z3 4 COMMON VIC. $50 �o6-Q8�/ _WHOLESALE $75 RETAIL SERVICE: LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _<15,00asq.ft. $75 _FROZENDESSERT $35 TOBAGCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �.SO.00 "•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""" � � .�� ADNIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ` Compensation Insurance. THE ATTACHED STATE WORKER'5 COMPENSATION IN5URANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� � � � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S) AND REQUTRED FEE(S}BY DECEMBER 31, 2005. SEASONAL ESTABLISI�VIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPE1vING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swirnming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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. FROZEN_DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be serit to tl�e Health Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: _ _ _ ._ Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE: �Z �1 O SIGNATURE: � � PRINT NAME&TITLE: :J�r�'��y � 'v�C�ti'�1�1�% ��L f;-i,,;ti� ,- ��ti1�vt��-- 09/28/OS ��:�_ s��- ��` �� : �� ,��-�.- �� 1146 R0� 1t �8 SC�L T'I� 't�iH'v10'iTi-I il�1PtiS4CFiT SI;TTS 02664-�i4>'1 � 1�Fss` Y� -'FfEEa ��/ '�' �^aoaa�tv`'� �c3'd' ttiv�,�.0��:' .��l�,l _:`J�-. _..31, �1iL Z�}i — 7'�3X �.��) �)�f7 '�huS .�� .'.--'., ,r'a ' . g J3 �f � Ti � �.J � � [1 � � � S �@ APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) FEE: �50.00 Name of Camp: ' � � �� Site Address: � � 0 1� f3,►� �'��"� Site �'elephone: �4� ',�(�J�� ________ ____ Tax ID Number (FEIN or SSN) : Type of Camp: Day (less than 24 hrs.) Residential (24 hrs.)�_ Hours of Operation: � _ d Dates ofOperation: Opening � �C�°1 ��3 ZG� �� Closing: ��C��'�j'�� GC� � �� , Name of Camp Owner: ��,�1� ��Iti��+�� C C:�� L'� _ _ Office Address: • � �'�-�.� 1�� !� �.� o� � ��h� c i� Office Telephone Number. -�j("�1��Z.�� 'a. , �� ,-- Name of Camp Operator (if different): �J rf y''�� Address: T�lz}��on��,T�.��ber: _� ---------- -- Camp Director: ' ( � t, ,. `� w�� `��5�� - Address: ��..0 � �� ,�, � iYl�}t/3� �^,�' � Q;"Z��,�, Age: �. ��? ' �Z. Telephone: �.�� - �� + Coursework in Camping Administration: ��`(G L�� I �1z2��1�-�S (i3��'C— (�^i!�'�.LC� Z�U� R Previous Camp Administration experience:�16�Ct��,�'�.-� �,�,k7+�, C'1�t1;�' y'��- �`S� �5 5 i 51�U' �.�,c'v�— �'fin;t� v�'1 d�m�n ��;�cy�"" �x:��:,-��- cp�w� C:`�rLr�-c�� Health Care Consultant:�� C ,��i�l.� � Type of Medical License: ��'�+ MA License number: Address: �,�;�1 ' " �'uq�.. �� V J�t� � Telephone: �� Z-��t�'i� �' �� i�alu3 i of 2 �.,; ' ' .� �� Y�X}pY�4�.. 5.�. Hospital for Emergency Services: �� 1� '[►1��1`f��.,.-- Health Supervisor: �� ,�1A.'� Age: Type of Medical License, Registration or Training: Swimming Area: Yes �,/ No If Yes: Fresh Water_� Ocean Pool: CPO: i Specific Onsite Locations: �i L1� i��1��S �(��, � � �� Water Quality Testing Performed By:_�,>j� ' � Aquatics Director: �� Submit Cert:fications: CPR 1�` Aid_ Water Safety _ Other Lifeguards and Credentials: WatercraftBoating Activities: Yes � No Describe: �.��I:��'' , ��!v4'` Food Service: C�''��''�� Is food handled, served or prepared? Yes � No To what extent? Snacks Cooked and Served by Staff ✓ If cooked onsite, Food Manager(submit copy of ServSafe) �� Catered if so, by whom? Is refrigeration available for perishable foods? Yes No Backround 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?Yes � No IlVIPORTANT! CONTACT THE YARMOUTH 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 FIltE DEPARTMENTS. ) : �?C_'�. SIGNED: f ' �(��-� PRINTED: .��,��-� ��,ti�T�:'v DATED: I� �' Q� E 5ee 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 advance. This will expedite the �rocess. 3/28/03 2 of 2 � � � �„�� The Commonwealth of Massachusetxs �--_'___�__i -- Depart�nent of Industrial Accidents � _=_ -_ NII�Nin�11f� � _= _ _ == 600 Wasl�ington Street, f""Floor ---�,�' Boston,Mass. 02111 � Workera'Compeesahoa I�saraaee Affidavit:Baildwg/Plambu�lElectrical Coetraetors �•.t�.. - xy x . r,: r "�,�w'.fi's;:` L ,,<it3. t�.:,...,��s.� t�f�3.. �: (..��M � 'v'�°r�� 'L�J�!� ,� r� � �; �{� �°�En;S1�n C� � �s: '� � ��.!'fi t� P c� �� ih' �!\�`M�'li1 'Y�Y\� state• {" �"�1 zio• �'if..�'°�/ nhone# �Q� ��/� ?''�"l � work site locati�ffnll addressl: ❑ I am a homeowner perfom�ing all wark myseif. Project Type: ❑New C�structi��Reanodel I am a sole �netor and have no one working m any ca�aci ❑Buil Addihon � , . � _. . `k ��. . . "� v�.�.�° � . ��e. � �.-��..� .,., � �. .:�_�"`��'�� , . � �� ,�' ��__ �� . � I am an eanployer�xoviding w�kers'compensatios►for my employees working on this job. � � ' � �,� �.� L' ' �^�� N r �„�. � L{i U�'(-� �.'l.� (ti�� / #; � l � �� . u" l C-�r''✓ � Q I am a sole proprietor,gederal coatractor,or�omeow�(circle o�e)and have lrired tbe�listeci below who have the following wotkers'compensation polices: commnas��: a�1d�: �ir: n�c�E: # <ti,,- , � ,.i' „.�d�:�, f _ � :,._,a �,.,^:�: � s '� � �: CH,Y' DY9�C�' __—-- �1 # . - _ ,� �. � _�,� . `� '��, �� . ;� �, � _ �.�� .�� .;� _ ..,�,;�..,� ._� ... � , � � � ��, � �,. . < � � �: � Failm�e to�ccme eeve�e�req�ired�eder Sa1Ma 2SE►ef MGL 1S2 aa Id�d b IYe idpa��f crisial pnaNia�f a�ue�p b 51,91Y�.N a�dhr one yars'imptben�eat as weY as dv�peaaltlea ia the firs of a STO!WORK ORDER aed a Bqe d x180.Os a day�t me. 1 aadentiad t6at a cepy ef thla shtemeat maq 6e fonvardcd ta tee Onke of Inve�aqoffi et t6e D1A for eevayge veripatlo�. L do hentby c itn er ns and peeelties of perjwry tlYet dYe i�foranatton provlded abot+e is bxe Rad comrG �8�� Date 1 L,J�I(W �J Print name �S'r,tv�� I"'r�-L�� Phone# �� U�t () efficial ax only do not wr#e la this area to be eompk�ted by dly er�wa e�l city ar tewn: permtHticease# ��t ❑c�eck if immedia�e respesx fa req�+ed ��s p�� centact u• �� P�*'� • phane#; �p�� tTM'��-�7) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #06-005 FEE: $50.00 This is to c�-tify that Win�ate-Kirkland Operating, LLC. d/b/a Camp Win�ate-Kirkland 79 White Rock Road, Yarmouthport, MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMI'S, OVERNIGHT CAMPS This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such teims and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2006 unless sooner suspended or revoked. January 31.2006 BOARD OF HEALTH: �, �. ,/��., ' ��'�s�, �'�`�, v�e�� a�t�. e�, �!� �� , R.�v. �� Bruce G.Murphy, RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUIV�ER: #06-123 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Wingate-Kirkland Operating, LLC, 79 White Rock Road, Yarmouthport, MA Whose place of business is: Camp Wingate-Kirkland Type of business: Food Service � To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2006 BOARD OF HEALTH: L3 r�s�$. �o�Crc,/Gl._`h., ' ��s�, �v, v�e�� R�t� B�, e�,� p��la�� I��n�.�l��, R.N. Januaty 31,2006 Bruce G. Murphy, ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT N:UMBER: #Ob-082 FEE: $50.00 This is to Certify that Win�ate-Kirkland O�erating,LLC d/b/a Cam�Win�ate-Kirkland 79 White Rock Road, Yarmouthport, NIA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B �is�`h. o�o�s, /�?.$., ' ��s�, k�.�v., v� e�� SEATING: 150 /�o�itt�, ,Q�t, C� /�a.tiiic�/�c$� �I.�� , R./V. Januar�31.2006 ruce . Murp , H,R _, H Director of Hea f ��°�`��, �'�""'"� ��' :: _ .�� rI' � F � A ]�. U T H o �-M �'� l 146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACMEES � � N��4�ONAtE06fl"� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-34'72 'U B O A R D O F H E A L T H To: Yarmouth Board of Health Pernut Holders �-.._.....--•_ ,_, �� r� � _ � � From: David D. Flaherty Jr., RS. �r�r ��,� ; � 2005 Health Inspector TownofYarmouth H�r;_,�~jr.{ ,��E��`r. Re: Federal Tax ID Number Date: March 22, 2005 T'he Massachusetts Department af Revenue is now requiring that we furnish detailed information to them regazding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federa.l Employer ldentification Number(FEIN)otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do noi hesitafe to cail. T'he �ffice nours are N`ionday io Friday, �3G a.m. io 4:30 p.m. �e telephone number is(508} 398-2231,e�. 241. --2 � Establishment: W t � � FEIN or SSN: _I ��0 V" / dd7 �Q r // '� _ ,( � Location Address: 't"t WIM•��-- Signature: , � � D Print: W �f� U.� ��,n -�+� Title: t�t��' t�e..�- � �r;� � � Printed ot� �� Recycl � Papery:.t;�`. ..� .J_ � o3`zu(6� 3�� ab�3,� �MPW��-�.�� f_Y�l � �° ,�:R o TOWN OF YARMO BOA� OF ��TH, ��4�a APPLICATION FOR LICE� -u2005' � � �, �r -= i; �'�" - �� " , � � I * f h 1 n cess docu ''�ts b V,Decemb r 3 [E2(� ,.0 Z 004 Please complete onn and attac al e �n y � I� Of� Failure to do so will result in the return�f your application pac t. AL-i�H a�.F'�. NAME OF ESTABLISHIVIENT: '�' � L. # - `��3 LOCATION ADDRESS: � �� MAILING ADDRESS: i OWNERICORPORATION NAIVIE: L ��✓� L[ �: MANAGER'S NAME: � �" TEL. # MAII.,ING ADDRESS: POOL CERTIFICATIONS: � ,� 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. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (yCPR). Please list these employees 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 business. 1. 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 Protection 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' records. You must provide new copies and maintain a f e at your establis ent. ' ` �� 1 �jh r� w.1/ ve�t'� ce✓7� ta�� 1. �� Q� �+�� n�,� L �S �v f P- . 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site d�ring hours of operation. 1. 2• HEIMI.,ICH 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 a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years',,reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3 4. RESTAURANT SEATING: TOTAL# IJ�� OFFICE USE ONLY LODGING: LICENSE REQiJIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# B�g $gp _CABIN $50 MOTEL $50 � $50 _ I CAMP S50 , C,._ �(v ._3WIIvIIvIII1G POOL$75ea. LODGE $50 TRAII.ER PARK $50 WHIItLPOOL . $?Sea. . FOOD SERVICE: LICENSE REQUIRED FEE PERNffT# LIGENSE REQIJIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 �'7�l G-� _COMMON VICT. $50 �"�'(.�� WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRBD FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 <25,Q00 sq.ft. $75 FROZEN DESSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ �0^O O ...�. PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""'` t ' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED x OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to ewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-� SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLISf�VIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE. � �,� �� SIGNATURE: ��, �,,,.,�� PR1NT NAME& TITLE: t � /� . �j �( f�,, Q. .�r 10122/04 ��.,� �� Y ,��-�.��. �`;��. - � _,.�� i�� +� 114(i RO�'TE �8 �,Ot'Ti-I YARNIOLiTH l�[ASSACFiI�SF,T"C'S 02664-44�1 ��, � � � `°,Rs.arrr�r_nees ��,�,��,,;eoaanTco�.e�'�c�' �'c�t'7i�?C>,..:' i;�l � 2.`)`i�:�j1, FXt. ��'ri — Fa�(.>()�) j��i-ZjG� i9 V Cl Il .� i� 1' 1 1 E � L i i X APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) FEE: $50.00 Name of Camp: �Gl'v�P ��n �"�- ��G�i c1 Site Address: 71 W� �� (�'YhQu Z o�' ,�°f d�� Site Telephone: �� " �`�� Type of Camp: Day (less than 24 hrs.) Residential (24 hrs.) �/ � Hours of Operation: �u� �� — �u� 3� �U� Dates of Operation: Opening: Closing: Name of Camp Owner: UV�L�1'� ��'��.� ��'��"� ��"�" Office Address: "`Z-�`J �-�4,�v1 JMh�( ��,��!'�O''��'�' ��'�� Office Telephone Number: ��, ""�� -" � � � Name of Camp Operator(if different): Address: Telephone Number: Camp Director: ! `�i ��lr ` Address: L- � �� ' Age: ��' 3 Telephone: � � '��'� aJ� ��,.�� Coursework in Camping Administration: �C- � �- ' �� '�� Previous Camp Administration experience: `� L�� l�� ""� �;uJ a�'YS ��q.p(�,,, ' a�t �T ��rso��v �� +�s •-,�,,,�:��s�,� Health Care Consultant: � y Type of Medical License: �J v MA License numbe� Address: 7� wh�� Cl� �r � ;��-�` Telephone: 5 0��3�� '"1� �� 3/28/03 1 of 2 �' ��v�i��i pa�r , - Hospital for Emergency Services: cyR� �� l"��/�l�/ Health Supervisor: % Age:�_Type of Medi 1 License, Registration or Training: 7��-i� Swimming Area: Yes V No If Yes: Fresh Water V Ocean Pool: CPO: Specific Onsite Locations: � ��5�GfS f v�� Water Quality Testing Performed By: �✓hS t� Cvuh�7 � Aquatics Director: � g� Submit Certifications:CPR 1� Aid Water Safety Other Lifeguards and Credentials: WatercraftBoating Activities: Yes No Describe: �,,,, �firt,v . �� Food Service: �� Is food handled, served or prepared? Yes ✓ No To what extent? Snacks Cooked and Served by Staff_� If cooked onsite, Food Manager(submit copy of ServSafe) 'rR.� Catered if so,by whom? Is refrigeration available for perishable foods? Yes�_ No Backround Checks: Has the Camp Owner or Director obtained and reviewed the CORI a SORI of each staff person and volunteer who may have contact with a camper?Yes No IlVIPORTANT! CONTACT THE YARMOUTH 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 FIIZE DEPARTMENTS. . � SIGNED: l.�' r �l l /'.t.�w� ,_ ` ` ��.�'� DATED: l �" .v J� PRINTED: � 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 advance. This will expedite the pracess. 3/28/03 2 of 2 ;� �tCORD TM CERTIFICATE OF LIABILITY fNSURAtVCE °"TE',2„°2004 _ ,_ _--; - ----- -_---- __ , _. ___ PRo�uceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE A. M.Skier Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR I AtTER THE COVERAGE AFFORDED NY THE POLICIES BELOW. 209 Main Avenue __ -_ - -- -- _ , Hawley,PA 18428 COMPANIES AFFORDING COVERAGE _-- - - --- -- COMPANY iA Meadowbrook Insurance Company �li __ _ _ _ _ _- ---- -- - __ _- _------ - _ __ --- - _ _ _, -- INSUReo COMPANY 'i Wingate Kirkland Operating LLC B � 79 White Rock Road _ _ -- -.- ___ __--- __ __ -- -I� i COMPANY i Yarmouth,MA 02675 C - 'I � -_ ---- --- ---- . __ .. � COMPANY � D j COVERI�CES _ _.. ; <<., ; , � '� . < :. . , � , , ' : , , :;„� I�_-_ - — • ' ---�---- — ----...- -- -- ---- = - ' --..._ __= -=- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I i INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS � �I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I EXCWSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � II�� I _ -TYPE OF INSURANCE - � POLICY NUMBER POLICY I POLICY� � � f LiMITS I CO ' LTR � � _I EFFECTIVE DATE I.EXPI_RATION_DA_T_E_ I_ .______... . ___ __ ___ I II_.__ .__- ---. ___.__ .. _.._.. _... ._------------------ ._.._. GENERALLIABILITY � � GENERALAGGREGATE $ - ---- ___.-._- _.. .._. COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ �CLAIMS MADE ❑OCCUR � � - � - � � $ � PERSONAL AND ADV INJURY � � OWNERS AND CONTRACTORS PROT EACH OCCURRENCE $ �� FIRE DAMAGE(Any one fire) $ � MED EXP(Any one person) $ -- --- ____..---�---- ---------- ---. _---._.._. _---.__._ � l AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ � � ANY AUTO I � � BODILV INURY(Per person) � 1 ALL OWNED AUTOS � $ �� _ SCHEDULED AUTOS � � � ._.._. ____- __��------ ------ i ' � HIRED AUTOS BODILY INURY(Peraccident) $ � � i � NON-OWNED AUTOS - ---- .-- --- ----- ! � CompDe ( PROPERTY�DAMAGE $ �I � ....._. _.._.__-__._ .__ . I � � Coll Ded _ , ---�----__._--- ..__._ ------.._____ . - � � GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ � j � ANY AUTO �O�THAN ACHOAOCC DENT $ � � -�� I � _ _ __ � �' ` AGGREGATE $ � ` ..___ ._.._ .. ---�-{ ------- ..__�._ ._.. - ---- �------ - $ --- ------ ._. EXCESS LIABILITY I EACH OCCURRENCE � UMBRELLAFORM AGC�REGATE �� .... --- -- --�-$ - ----�1 ! I OTHER THAN UMBRELLA FORM � � - �- - - ------- - -- --- ____ _----- -� --- --+ � WC STATUTORY LIMITS i � �WORKERS COMPENSATION AND $ SOO,OOO ._{ EMPLOYERS'LIABILITY EL EACH ACCIDENT _ i I r i � �g 500,000 i A � i 1�0�..$Q3� I c'�./3�12004 u{3i/.�.�^.a.ri �EL DISEASE POLICY LIMIT �g$ __ 500 00�� -- I PARTNERS/EXEOCUT/IVE � INCL ' ,n �R I �— — ! �_ . OFFICERS ARE: � EXCL � ';EL DISEASE-EA EMPLOYEE � $ SOO,OOO �I �----- - ---- � ---------- .._.. . .. __.. r--. ._.___. ..___-- ------ — — -- � �� .. ___. ._;- _-_—____. _1_ '.� OTHER , --- - --�- I � I 1 i �,._..._. _.____._____- - .____. _ ._.___ , .____ __.. ....... ...._.___ I _ _ __-___.. _._. .. .___.___ _� _--_._ __. -___.. ___._ __ ___.__� I DESCRIPTION OF OPERATIONS/LOCATIONSNEHI�CES/SPECtAL ITEMS � �. !, Evidence of Coverage. I F - -- GERTIFICATE HOLDER T CANCELLATIOIV � � __ --�� ___. _._._� _ _- ��, TOWII Of Y81"IIIOUtFI �) SHOULD ANY OF THE DESCRIBED POLIC�ES BE CANCELLED BEFORE THE �I, � EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVER TO MAIL �I Yarmouth,MA 02675 � 1� DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, � I , , BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY i '�, '�,, OF ANY KIND UPON THE COMPANY,ITS AGENT OR REPRESENTATNES. , iI---- - ._. .. .. ____- -- - -------- __ . .. .. . ._.._ ._.._. i ��. II AUTHORIZED REPRESENTATIVE6 � ! HENRY M.SKIER � �' ' AGORD 25-S(1/95}T _� _ �� AGORD CORPORATION 1988" ; THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-OQ6 FEE: $50.00 This is to Certify that Win�ate-Kirkland Operatin�, Inc. d/b/a Camp Win�ate-Kirkland 79 White Rock Road, Yarmouthport, MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS This Licex�se is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relaiing thereto,and upon such teims and conditions,and to the rules and regulations in regard to said Cabins so licen.secl as adopted by the Board of Health,and ea�pires December 31,2005 unless sooner suspended or revoked. February 2,2005 BOARD OF HEALTH: �est�russt�5. �jio�i�,oft, /��1. ' ��st, v� e��-.� a��,a�, �►�,� � s�, a�v. �v�r��, R.�v. Bruce G.Murphy; H, ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #OS-082 FEE: $50.00 This is to Certify that Win�;ate-Kirkland O�eratin�,LLC d/b/a Camp Win�ate-Kirkland 79 White Rock Road, Yarmouthport,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-first 2005 unless � sooner suspended or revokeri for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their offcial signatures_ BOARD OF HEALTH: Be�r�r,a�ri.`h. �'onc�ajs, /�9.`h. ' ��a��t, v�e�.�-� SEATING: 150 RoL�t�`�. Bnou�tt, G� �Sl�, R.NR.N , February 2,2005 ruce -1�4uiP Y, �R- -� H Director of Health M . r ' TOW�T OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-121 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Win�ate-Kirkland Operating, Inc., 79 White Rock Road, Yarmouthport, MA Whose place of business"is: Camp Wingate-Kirkland Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2005 BOARD oF HEALTH: l�er�xi�$. Cjoncli+�,/��. ' n��, v� e�� R�t�. a�, �!� � st� R�v. � ��r��,�, R.�v. February 2,2005 Bruce G.Murphy, , S.,CHO Director of Health � � � � �;I�o� —a-�-��. _.. °`;`-'R o TOWN OF YARMOUTH BOARD OF HE�L`�I'H ' �: ;,'� APPLICATION FOR LICENSE/PERMIT�20b4 F � �1�; ��6 �'+ r,r�.� � �� ,- p •�. ..•' ,� 'V' u * Please complete form and attach al( necessary doc.urner�s,by December 3�1, ��."� ;-; � � ?T ; Failure to do so will result in the return of�u�r application packet. ��"��" �1AME OF ESTABLISHM NT• ('� � � -� �� (c _.. TEL # �0 8- 35� �c�_�,;�.� � ►�l� 5�/� L CAT N ADD S : �? � , ADD i,� l V-_ _ �� . �1 a,� WNER/C RAT ON N Y� , ,{ �,C , MANAGER'S NAME• �:,r,-, ��,t-FS�,,, TEL # 5��-35� -��>� � MAILING ADDRESS• ►'� � �<-,� ,-,'�lc.e P.�t � � c�A',� �l.'li� a��-�� POOL CERTIFICATIONS• N�(� 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. 1. � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these empioyees 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 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 Protection 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' records. You must provide new copies and maintain a file at your establishment. l. ��e �ii�i-� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �- C' _ t��-t�. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premi.ses at all times. Please list your employees trained in anti-choking 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 business. 1. � J �� C�.►�,+�, 2. `S�_"��r 3. �S 4. RESTAURANT SEATING: TOTAL# �5 a 4FFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FGE PERMIT# LICENSE REQUIRED FF.F. PERMIT�? _B&B $50 _CABIN $50 _MOTEL $50 _INN $SO I CAMP $50 �-60�, _SWIMMtNG POOL$75ea _LODGE $50 _TRAtI,[;R PARK $50 WHIRLPOOL $75ea. �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# [.ICGNSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 O ��7 _CONTINENTAI. �30 _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $SO _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FEE PERMIT# LICENSE REQIIIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.R. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _PR07_EN DESSERT S35 _TO[3ACC0 a25 NAME CHAN .• $io AMOUNT DUE _ $ l 25 •00 **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* r " ADMINISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_�� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLET�D 1iFFLICATIC,N(S)r�N�i RE�UI�E� FE�:(S) IiY UECEMBER 31, 3003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEAI,TH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL F.(;ULATION POOLS - P��L�PErJING:All swimming,wading and whirlpools wf�ich have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TE�TIN�: The water must be tesiec� for pseudomonas,total coliform and standard plate count by a State certified lab,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 SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESS��T .� Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OU'�'DOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: 12�i�/�_3 SIGNATURC: �- r � PRINT NAME& TITLE: - � l� �c�,r-c�a�+ C��-�� Ct-�r'1cS��s'" � 10/22/03 l _ � � �q�� a�� i ... �. � ��`�� :r _ , � � � � � F � � � � t '^=:.; � � ��3 € � � �� 1146 ROIJTE 3z� � "'_ � _' �`�„ `�OliTFi �'�R�10IiTH �� H�i�L 1 i t U��=�T.._,� �MA�T�cr+ees� i�1ASSAC HIJSF,T"fS 026�i4-4-1�1 .J� ��°'paxnico•.s�9� Te12��70IIf. � ��9�'--2�31. E%�. �-�ti — .i,- �'�13C(.�nc5)j9H-'�;iV, B EJ tA iii � V L' � Y 1 L' 1'l L % d7 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHII.DREN (Use back of application if additional space is necessary) FEE: �50.00 Name of Camp: ` . � � I w \ �� 'l ^ �1...� 1 .�t� Site Address: �-� l,�h;}-e � m� c�-1- �f� o Zia�S"" Site Telephone:�= ?�b� _ -��l g Type of Camp: Day(less than 24 hrs. ) Residential (24 hrs.) ✓ Hours of Operation: • Dates of Operation: Opening:��,� ��u Closing: � o ��. � Name of Camp Owner:_ '�;.rn , ,�� Office Address: � ;� � � � � ' `'`'' Ct.r,-�-,�� 1�-�-� Office Telephone Number:�og -3�� _5�i � Name of Camp Operator(if different): Address: Telephone Number: � Camp Director: ;� � `� � Address: 1, ► .,�-,�i�,c�c.e � ' , ►� �, I.. , �� i3 A e: � g Telephone: 5�;� - �g_ S g� � Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant:_�"�,�� _ Type of Medical License: � — MA License number: �3�,z� � Address: N� 3 3bg 3 3�-��o U ld .�; i�.�,� Telephone: �� _z�i_ �3�-v 3/28/03 1 of 2 �� r;,7c��, ��c�� . Pap�r I t Hospital for Emergency Services: �� S -�� Health Supervisor: �� {N��✓ � Age: �� Type of Medical License, Registration or Training: Swimming Area: Yes ✓ No If Yes: Fresh Water ✓ Ocean Pool: CPO: Specific Onsite Locations: C 1;s�.s �� Water Quality Testing Performed By: ct2n�S�4�a� �h� Aquatics Director: Submit Certifications:CPR 1�Aid Water Safety Other Lifeguards and Credentials: Watercraft/Boating Activities: Yes No Describe: Food Service: Is food handled, served or prepared? Yes � No To what extent? Snacks Cooked and Served by Staff � If cooked onsite, Food Manager(submit copy of ServSafe) �J� C a /ti�u — �r � 4 Catered if so, by whom? Is refrigeration available for perishable foods? Yes No Backround Checks: Has the Camp Owner or Director obta.ined and reviewed the CORI a SORI of each staff person and volunteer who may have contact with a camper?Yes I/ 1Vo Il�'IPORTANT! CONTACT THE yAR1VIpUTg gEALTg DEPARTMENT 48 HOURS PRIOR TO OPENING TO SCHEDULE AN Il1TSpEC�'IpN! T'�IS �S MA►NDA'�ORY! OVERNIGgT CAMpS MUST ALSO SC�I)LTZ.E A.�'V INSPECTIf21�T�YITH TH�BITITt.DIIVG Ai1TD�IR�DEPARTMENTS. SIGNED: PRINTED: M I/VG��✓ DATED; Z 3 � See the nezt page attached for a list of documents that must be completed and submitted before your application can be fully processecl. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the pro�ess: 3/28/03 2 of 2 0311512004 15:05 5083580249 WINGATE KIRKLAND PAGE 02 - V � The Commnnwealth ojMassachu�setts � DePartment ojlhdust�ial�ccidents ; Olflrsafle�sdys�►i�s _ 600 Washington S�reet ,� Bostnn.Mass 02111 " � VHorkers' Compensation Insuraace Aftidavit Ag � L,r, p c�*�k-- Q� s�YRaPTTi�'hYit n�m�_ � Cl�„n.!, �1J 1� '9c L`�-�C. '^,Y�.�.. G..r-►OA � �:M 5..,G C C S Or� � L�(�-✓ Igcatinn� �l l x„)�c�--< �c�r i.� � r . � C7'Lb� p � I � a homecwner perroRning all H�ork my�scif_ ❑ I am a solr proprizror.�� h��e no one ��orking in an.�capatin� [„r'I am an empto.•er pro��ins M�ork�rs- compensation for mv cmplo��ees workine oo�his job. _.---cemnan�� name: ��,�� LJJ1!1�� ✓l��M� -- w -- �Eld css: ��1 W�ii+s l2.oc�c..' �� ' �t � �.,..y,n..�1_ F�vrt-, �/l� o z�� pAone N; '�aP�- 3f� �i - 3�9 8 n ��F-,�' 1! � I am a solt prpprietor. �enera�contractor.or homeowner(eircle ontl and ha�•e hirrd the contractors lis�ed beloµ� ��bo ha�e the follu�►in� ��orl:rr� :ompensation policrs: �omp9n. name• stddress- Sjry�- phone N: incu��nrr rn OO�1f�W cem�,�ny name� �ddree�- " sjl.y; �6cee i�: ins■...r.� r�^��y� 1lelitl►1! ' Fiilute t0 sccure covc�ag!�s required uedet$ectioe ZSA of MGL 132 n�Itad�o Ift iOpo�ifb�of ertAfY1 pe�dAd of�Qae op to flri00.00��d/o� vac yca►a'imprisonment as w�cll�►a civit pcaalNd io tbt[orm of�STOP WORK ORDER aed�flAt o�S100.0��A�y Kshut se. 1��deAblM t��t■ copy o�tRy st�ttmtnt rt1�v be forw�rded to tht Ofllct of lnve�tle�tioas ot�At DIA fOr tOrersgt veri�lcatla�. /40�hrreby ceni�}•unde�rhe pains ond penal�la ojpery"ury rl,ar rhe injnrmotlon provided abort Jt d�rt a�d camex Signaturc • � 3��S <�`� Print namc �� D� R.n pne k_, °.�(��'3�J�-c5�No .. ortici9l utc onl� do not��ite ie t!►is�n�to be comple�ed by eitr or tow�o q111eu1 cfrv or town: Y��T� _ pt�telUlleenae h nBnitding Departmeot �Licceaine Bo�rd (] eheck if immrdi�te raponac i�r�qui�rd ❑Seleennrn'�ORice 2bl.. .. •-�}(c�l1A Depart . . meet � . .. . .. ._.-. ..._ I— :. - - (5�8 398�•.2231 ext_ con�a,c�per�oa: _ -. . .. -.. ...-_ _ . . pAone M;_ nOtt�er 03f1512004 15:05 5083580249 WINGATE KIRKLAND PAGE 04 � F�� 10'2o0G 19•02 5'10226:147 t�:ns�s,��c � �� +�y�� _ .,.„:�,: ,.�� , . . . ,� ,,, [��Od� If1(,�.+�� f" �.I _ _ ,... . : ?,'.'.-��_ ....... . ... . . . , . .,.......,.....,._..�__ _ : . ..,........ __.__..._��.......,_... . _�_.....__..� ..�..__...,_,,.:.,..... _.... .. . . --.,,,-.;.,..:..,....._...__._._..__.....,.,.,.,�__.__,__ ��a c��ro�t�a°r��u��a�a M�'rt�R oF►NFa¢MaT�oN o��an�x�sp �a�s Y,uvo��s�R��s r�FaA�HTa taPe�N r�E�ar�p►r.�tY� K69lpBR.TH15��aR79FilCATE 1?Q�81i0TAM�N�l.I�9RLjND��t A.NT.Dkl�r A�onc�r A(.T@R 7F1E CI��Ed�3E�F�31�I��D WY T�i�PVUCIF�de1.oW...y.. , Z��YNe{�AYaonllB �.,. , . - r�u1PANl�S�dhFFaRQtNQ COVERA�JL _._.._ F1ewrl�iy.�A 1981� �e�i�v . - -----..... __,__._..... . _. q T►1IS 7roAv,M.etm in�un�r.cr t:o ,-...--....__...... . . . .,.._...,,.,..::-,.,.___....„. . .. , ._......_—........,,_._, . III4�JRCD Camp 1Aflnpate•Mtirict�nd,(nc. ._, ,�g -- --_..----_ .,_.... ... _. .::..........�---- Itlthiz�BZayk Road �pyr�v. ._ . _. �ror.noaTn P��rk.Mn n2ero C �^0l4di"ANY,.. ,. . . ,,._...,,,-,�,... ......,.,,---....._,..,�._._ �� ..� ..,... .. , � ...... ._..--.•- --' � .,-�......,.---..-- ..,.,. _-._ ._...._ I COY�RA� -----,.._.._.....�_:,___�-�--...�.._.�..r; � _.�.,..��......_.,� TMiS i6 TO GfiRTlf 1�17'1J�Y'�H��!NeURANCS I,IS7iD r�,Aw HRrl�EtEEN I�J�D TQTwE fN6�WRfitt NAiI�&D A�O+J�FC�Y'M�P�DLI�Y PrJ�tKN] IlNP�TRD�N�I7t�eTAN6�N6�ANY R�GtU1RIYM�tt+''t,ts►a�n oix r.or�a�r�t csr,as�Co�rtrtacr�Na c�TM�oacu��+'rv��w��[as ra vvMi�sN� i i CC�T;F��hTL I��T 9�1��6D QR MAr PBN7aK,T11�IN5uRANCE Al�FARRPD pY TT9�p0UC�8 D6sGRlatd�t�EF�N 4S�t�JE�T TQ At.1.THE T�11f��, � DCCLUSsOIVd xN��fONqN71G�Ns�I��tIJCH WGLICi�B,i.tMITA 9FIc9WN M�Y HA�l6�N RRRUCFD BY PND CI,AfMS• , �....... . ,. ,. ,..,-�,._.._..�.,.-----...,,....._._....-. . . . . .._-••-••.�.....�-�- ......_.,..,._....-�----�--- -._... . W)LICY ---__..._• �tCY �...... ._. _ _ �.. ICO I T1"PiLGPINS�I'iC9 I.TR ,� ., ,.,... . /CrLtC'/M� �.EiPM�TI.Sl6..I�1F_�._.P�f'IRML�R�9�_,�.... --- � �---.......�...__..�.�--�._.,�..,..,.......-. .....__,., � --- � ;�ALR1ApRfPY � �B�R+�I,KGf'mW� � I � � 1--,...........�.--.....__. . . .._ .. G9M�F.Rf,lA6 G e�foW�1.�.iui�u�'1' ' � �aR0!?11�•r,ptaP��"ALi�3 �� I ' ...—........�,..,..r—.� -----.._.. . �.� �ci.an�s n�a�� . .�xc+,� , � wLr�,.ai_anroaav u�r�ear_ � � ._. ' ' ---- .,..._�___,.._.. ! �1nN�3/ND GON'BR�t�p�i � rJiCM�CCiR6�•MCQ S � .— I — I ` - �- --.,_.. . ..... �FIRS P?AA�Or iMY'ene I�e� � .�.�� MCD rJ�P'Y1r`y ens oasa:) �----•......... , ,. . .,.,x..,.,,.....�_..._.._ ----_.,.,,_..,.. - !E .1MR � ....._......:... .. ..._. ..^—_...—._........ . ....,..___�-_. ... ...._ .. ,.�---• -• � /�I�DfI.E R1�3h.P1'/ i S�NR�!'161]� � I� P~ ANY�4n'D i 11fiC)ILYINJRYIp'lYpMsdt7 j I AI.40wMFfdAI�TOS ' ' 'r I 8CI1CbU�D AU'MS I . . ' � • NM�RJ Au'�Og � . .- �OR1��1�iredCL+Bsn'!� : ; ..- NONapwNk��rOs � .. � - � �� ,.W,' S I M f € a 9 2 s" ��I'�I�H�'n�OE g I . � d,oMpod i _� �r�ic�� .—. .,_,..-...,.�,...._ au70S��nc�Glo� S � -_ . .. , ....._ ,. r ��5�� ,�. I._ . .. . _ .--. . ,._ ��»� ...,..�,. . I I on.i��+�Aino�r: � � ANYNJ7R? u � A � c _.,, .... � � I ... , •--• pJ1�tACCDFiNY ,�' �_. i ...� _ I I . . .,.. ' --'__ ... . �,GR� t ; ______,..1 . ._�......._._.,.r ---� � ._ Na � I"� ��rsu�ai7Y,.... . . . ..........,.�.. ! ..... ._ .. ��ac�+oacuv�� .__� S � � IJM�iR,GIdJ�FaFm: ��'�` , � OTII�,i1 TN�N UAAf�WDLI-^FARW -�-^------.._..,... ,-.,._.. ..�- ...... ---- --•--,..... --�-- ........, ............ ...-"...__.... ...._.... ----...... .. . WG BrATU'1'CNV�.IMrrCr � W�IO�C O�M�TIDN�11 `^--- -._ .• �A�M.ov�R��IAen.r�v �i�n'cN Ii�C+c��'�� 6AO.OQA I .... i .. .._,..-- ----. ... a THF VFOpRRI 1PTARYf �` � nuc0.. I 7P,JUi37+��A�{q90a ' 9l9/20fl� BH/xt►o4 �,r��nsr•ra+.��rr � sao,doo ; FnR?FfCq9rExFCIJ7IV� :.:.. � ' -�----.._._.,., _..Y � ar�Ficr�ra.�n�� ;..� �i. � �L pl9en�.r�Er�ovE� � !Cflp�ppfi � .., ., ,. . ....... . ....._T. ...,,.�.., ........_.,.... ...,....._.__—.^___.�. - —.__.. ----•-- ,._..---�- � OTNiR' .._ ^ � ^� � � i� . ..,._.._w- ....�......, .. ,.. ..,�.,......'-'--._..._... . � .,_•._-r�. �w.... . • • ' j�C�piION f��►ISµ��&�.ocanv��nn-Crw�ilc�1��9 � �vldslN'.e r�t Cov�er�pa. _._._...�..,_......... ,.:.._..._.._._ - ....�..,_ . _. .. .,.. _ -----• _.._. .,„.._.^_ ,—��...,.._.., -- -- .. :: C�RTIFIC/1'�![NQL�ptPl ' ; I CAIVCF�I.ATIqN , ._. ...... ,,.............---- ...._..._.��.,,,....___.__� ._._.� �.,..... •. ,. __...,....._„�._.__....�...... _.._.,.� I Towr�o�YrrsnauNt I sNru�o euw oP t►�a�sc�n Po�ce�s rn�eues►�ma � �a�►�narr c�TrNa�or>rr+e qau��ca�wrti,a s►�e�ae�oeR ro r�rw. I YAM1IOGrh.NIA OffiT�a" ��a6 wEiRtd�N MOTk%E TQ 7M�C�RTA��1i M�ADCR NANRR�70�i,�'Y> i � RlU1'PM.I�w To row�,Suc�N�6N�LI.M+POSi lwr��L.R,A�t+OR W91LP� ' ' OC M�l IQN�IJPQw Ta1q CQMPAwY,ff6ac�lli OFi R�►IMO�NTATd� �.. ,._.... ..... ._ ..,�.... , --_... ... .. . .. ----- ��AAfT1#pRQ�3 R�TA1TA1� -� f�fRY M,!lKl�it � __.__............._.__�..� ... Mr --- ,. , ., ... _ ,... . d►CQR�26,�6 g1191&� ' �'a1COftQ�QIiPQRATICIN019�9! . �....-......,.,..:..__._..�.__..,.:._ I ,........�_.-..,._,.�__... --�--- 03I15l2004 15:05 5883580249 WINGATE KIRKLAND PAGE 05 � F��,1J��U04 iQ:G� 5'0226�"_47 A��KIpR ��vyb' Y. 'JVC(VUG Vn14��t�wv✓�r�� ; ,,��...� ,� �.:��t e ��r��,�w � �.►r �.i��a�� a�r��a�� ,��oe� , � . � . --..,.� - ,... .,..,.. _.,n.�. ,..:......_____. ,....._..^—�----__....��....,_. ......._�. _ _--__..,_..__..___.._�-�. -- ___.__ . . .:. . ._�� _ p��Are6� TMI'�CrEttl"I�IICAT�1�I�U'�C�A'�S/�MAT?l�f�t�IffFO�iMa1iON JNLY�MD CJNF�l14S NO RMfiFI'�11P�iN'9i�i�GElt7'IF�Ce►T� �M�Sklse�Qney N�o.��.TNIE�C�N'C6��CdkT�Dd�3 N�TAJ�APNP1,�XTElVD OR ��l�R Ma(t+aur�nus dJ.'TEEt 7b9�GB�41'FI�'AC#�AFFRIRp�CA NY T��'PlfiLtC61!!!l�R�LCAWI', ..��.�....,...., . . ..:.,,.. .._... ...__ ,. ,_. . _..._.�_�,.....-._.. ..�e�i�a��r�s�ti cavrr�v� . IM�„la�r.►n �ea2� �c�nivx'�_........ . ..__._.._.....�... A t�t9 Pr�v�linm 4a�4uranr�a Co ...v�--,.,--... . . ...._......,_.,.....,..._....,.... .. . . ., . _ _..__.._._........,...,.�. .._............... . , , _ � �� Cm�np Wlr�qat�-Pilrklanrl,I�r,. r=fJ�0.NY � 9�Vhlts Rark R��+Q ---. ......_..,...,,........_..._.._,........,... . , __ _,.......__-- -- COMF'e�NY � Yarm�e:4h I�ort.MA a�5r5 � ; r�a�_� ... ,. . . ......_. . ,....__....._.. ._.._,�. �._..., 1 �Qv�ito��8 _..._,.:. --.._..,.. — , � -„ _ , __._.�..._.._.,, _,._....._... --_...,� -------.....,....,...._:_,.,,,..__ .,.....___..�_____�_._.. ��_.._.,_�..._..:_...,�� i TH19 t�T0 Cf.R7fE1F THAT THIG��J.CMME..E:s[1F ENSUI�ANO��.I�1'�b brJ.tfw HAyR e�M e�s�rFP�7a 1t�eNdvRRd NeuAi�7�e�VR►t1P+TN�wou�r►�feron I � INnICA'CrCtA,Nb7VvtTFtS7f�Np7Nr,AroY FdROtJtFtl�Nt.7'�RM OR COffOITlON�F AN9��01vtRACT qi(1''�'M�t P1q!;VNDF�IT'WI91�1�&�6PE�7'TO�1VhI1CM'tHl� � CERTIPICA°16 Noa7 i�6166UED t9R MAY Ri417AlN.THE IMStiRMMGE AFF�D BY TH�1►%7LICIk�3 P�llpCA1�EG'►1ENLIN 1�8100�CT T4 AW.YI$1!'tl'LRMfB. � � exCl.UsdAlu4 aWD CQrh4�Yf10M�pd�SiJ�CH At'�.IClEe�I.IMNt'fg€9i9RlWN MAY HA'VP.�'i6N NIi�iUC�I?!97 PAIR Ct�1!�RS. �._... .. ,. �.M...,...._,�-..,_.•----...,._.....,......w...�.,.._... . . , ... ___.------------�-----..._.... .._.. --- .._�.,.,..,.__..,_-----..,., . , - co � rrae oF iN��eun�s ' r�ti�r�t.q�wtaR �,�r '�f rq�.rc�, . �aNrrd I_t�t ..__..,.. . , ..�.,.... - , . .�1'YRA1�11B�..R�M11G�...I.,f�'�!A�T.12"AP_►'�u .„�., -- - ---�- _....-._....... . . . ...,,....... . ....m....,.,...., Y ,...�..,... . GPWF��LRJA�ILITY I d�ddGF�.Y.RG6R�6n7`6 � . ., i ....,r...,v_. ' CAM1��5�f;tlY1.411�VRAqL I.U41�'l7rY : I�l1GT89^C0�7FM9P•�Qs � � . �...,..,..._,,,�_ -,.-_--•-.._.. . ., ,,. : � � c,.a�asn+au5 ;xcr� : f►�asosw_�Noanvi�.iGs�r � � �� ...... � ;-,...._..._ ..--------- -----_..__. ....i � ONVNP.RS lwl�CflHTRAG7r�pRqT� � 6�►C l a Q C C U R 1�1 t F�� ; I �� I � I i�qolNAG�(�^Y_a,v p!e�;,,_ ��--..., �.�. � ! t�'Effi F)fP d^.^y urM 4tdii�m! _ :,.,.,....�^_... � ,.. .. ...., _........ i �r� i ? � __..._.. . . -� .,...,. ....._--..�..._-._._..____.._....,., . ......,....�....., _.,�.. __ ,_......,, , . _—. ........., �1�f'�1L5 ti�11,Mf7 i �pAAB�I�p 61NCi1.6 41TeQ►� � ----�-- ' �nNr�+o✓r� � ..�........ Ai.l.�'�N�p�,ilfPs � ar�turrraurtreFet'v�nrnil g - eero�n�.P�,a.vlros � , . . . . '/.. 1 � �� I��a�tro6 j . _ i �Il,Y1Fti1X�'IWarveelC�c1) �, � � a . i r= r�or�.ownar-n��ros ( .._ � 1 N � E w ._... _ ......_. 1 � 2 ID � I pnore'ar`ri su►w�c� y..._c�ro�'.. _ . � S -- .�.._. - c�w a,a ! �� •- . .. __,...__..._._...._. .. . � .. , ......_., �• � ......_ ___.._.._...___._,.. _,.� �. .� pa�ab�u��.rrY �' S� a�nac��r•sn.nccw�vT � � �_.—.._........ .. . ..... .._ � ...I�vM,�v .�� 1 N S U g � � �+�FA,w,a�ui+�rroa�n_r � _ �I � —{_____.___ ._ . �: �A JV � ------ R.APUMCGiPf�ItT S , , i �....-- ---- ..--- 'aCaF�G�r� -..,_.�.._.—_.--�---._.. � � � � ._�_; � I,._:..-.._...__..^�_—._. ,.,,.... .... °.::. ....,.. _ .. ._._..._......_... ��,....... � f�ca��&irr+sn.t'�Y,,. I . . �ca�rc�ccur�wa�e ,� � IjPm3P�I,IJ�F6F1+7 i A�GC'if�+�T�: _ .__.._ �.. -.� �--,_ _... ,..,... - Q1)I�R7NAN�1MDf�ELLAFCRM ' , ., . ..�._..,.....-�...'_...,,. ..._ ------------�..... ,... �----...._� .. . � N1ARK6R5�COAAr�MiATIpN AND � � I WI�.6TRTIA7'O�IY I,tMRC3 $ i CIMpp,QlYqjRM'1.I�t1N.N'A' � � . _....,._.., _._.... . k7.6+�ClIv,�:lD&P+'C $, �6QD.� A r��w�ovra�to�arr �. ) INc;�,. i '/PJUB?'�PA�SD109 I ��9da�03 � �1�t2�o4 R p�,k�,axi�'u�irt - ,FN�ERSm.xEri,�tNp -... i � 0�I7 OOCi .._,_._.__._. i��le.RS nf+�; I;..I �� l DIS&/+�FE.�F�N1f�t.nYP!G S 6faD,CJOfJ ,,,,........,-. ... .. .. . ...__...,,. . . . . .........._......r, .,_....., . ,, ,.,,,,...._- ._.—..T__...,,._,,.,-._.,.., -�_ ._ --_--.,.,.•.•• O?HCR ' . , ' � I I �_.,.,., , . ...:,,....,:..--........... . ......---- ..._............_... � ,.. ......w,_.,..._.. .,,,-.-,� l�r,�r�aN D!►01'�6pA'rIONsliF�CA�Mn�c�ortvr�OM.l1"l'�5 �-_... �w9del�Ce�of GtavMr�A, I , :.. _ ......._..,.,.,,,�.......... .. ...._,..._..._,..�._. _.... ._------,••-- . ..._... ......—..— u..,,,,-.�.... .. __._.._.._...... . C�RTtCdCA1'�Hi�A�iR � ^�� NC�f��17fO�i _ . W - ,_ ,._,..-...._.,.. . ..._..,-.,..._...,..:. f + _. ......... . :...n..�....._,...--_ _---.._.._.,.,...:.__....y_ - .. �._._. . � I T�nn aR��r�no�a�� ' aa+oRa.e�owr a�n�pQsc�ce ra,,rct+a��C�ar_��n e�►�aar rr�e � F�IPN�'A77dN!r/�T?s�Ms�Rk�P,'PHE{�9VlNG CpMW1Nz'WN.IL�I�IIl�k�PER TO MAIL j i Y�rrnouf,h,MAb2�67d ��Da�vlPlNpf�P94dMqf7C9:T07f��R'1�76A�TRM04081PtlAMF_DTOS'FIC4��'I: i 631JY'p1�16�70 MYWL RVGW P�D1'KJtl4M1AlI.D�O�!h'O�I.dCp7i01s ONl.8f11lBl.fl°W j OI��IV kDNh elPUtt'►14�GOMDhKf,Yt'aAr�NY dA RE►�IF.DPN7A7�R �......_.,..., .,,. ..,.._ ... ,-._ �'nlilN�PLF�RFJ�R6S�'1ATd1� `�__ , .......,... .� .._... ... ., _ . -.,..,,..I .....-�--�..�..�.._....-.�._...,...-•-..... �.- 81�NRY fA.$ltl61� �"�r� A�C�D 26e8(i196) bRf�?S�° _ ...�. ..^N'� , ,,. d C DliPORA�ICM�i�19� _, ,, . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-127 FEE: $75.00 In accardance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a permit is hereby granted to: Camp Wingate-Kirkland Inc., 79 White Rock Road, Yarmouthport, MA Whose place of business is: Camp Wingate-Kirkland Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l, 2004 BOARD OF HEALTH: L3esr�ti�rc�5. (�'a�, /LI.`h. ' ��, v� e�.� a�t�. a�, e� � s�, a.N. February 5,2004 H, .,CHO Bruce G. Murphy, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-004 FEE: $50.00 This is to Certify that Camp Win�ate-Kirkland Inc. d/b/a Camp Win�ate-Kirkland 79 White Rock Road, Yarmouthport, MA HAS BEEN GRANTED A LICENSE TO � OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMI'S This License is issued in confomuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adapted by the Board of Health,and expires December 31,2004 unless sooner suspended or revoked. Februay 5.2004 BOARD OF HEALTH: Qea��tti�t�. �'v3c�oit, /y�., ' /�c�iC��lc$�co�, ?/ice e1s�,riwc Rodw�r��. ,Qnocuss, G�l�k � st� a�v. , � Bruce G. Murphy,MP , . .,CHO Director of Health i� � "'' Ck_.#�6�64 �E?� � f_�,q CramP W�N6arE-Kca�caND .o�;R.r, TOWN OF YARMOUTH BOARD OF HEALTH • � - " =° APPLICATION FOR LICEN,S�►/PERI�IT -2003 ,:,Lr; ,r; �_� i� �v,' f�; � . �,: . .,,�, �� i ,.�r. �C .. � .- * Please complete form and attach all ne�essary€documents by Dece er8�,�2(�� 2�a2 Failure to do so will result in the ieturn of your application pa ket. NAME OF,�ST�ABLISHMENT• r�1�.�P ln; t�C�'��t. kl 2�/�qni D TEL #5ok-35�-��(� L A I N RE S: /.t1 I Z� � A DRESS• IN�DIZi,�G-e IL.i � Q' 77 � OWNER/CORPORATION NAME• ►� � i��- �� '�G• A ' E: � C1!-f�fu�✓ T L # d' �358'-S�/(o D SS• �' �� r' I _ �1 ! POOL CERTIFICATIONS: �� The pool supervisor must be ce 'fied as a Pool Operator,as required by State law. Please list the designated P�ol Qp�rator(s)_�clattach a copy of the certification to this form. . 1. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Ci�mmunity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provicle new copies and maintain a file at your place of business. l. 2• 3. 4. �� FOO�► PROTECTION MANAGERS - C�RTIFICATIONS• All food service establishments are required to have at least one full-time em�loyee who is certified as a Food Protection 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' records. You must provide new copies and maintain a.file at your establishment. � �� ((I S � - �t�� d Ut� �'Q'✓�S' � 1. [�L' GtnC ��l�j � 1�(� � 2. PERSON IN�HARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEII�LICH CERTIFICATIONS• All food service establishments with 25 seats or more must hav� at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking 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 business. l. 2• 3. 4. RESTAiJRANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICF,NSE REQUIRED FEE PERMIT# B&B _ $SE3_ . _ _CABIN $SU _MOTEL $50 INN $50 I CAMP $50 _SWIMMING POOL$SOea. LODGE $50 ^TRAILER PARK $50 _WHIttLPOOL S25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 �ETAIL SE V,�t ICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 ____TOBACCO $20 _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ I 2S.� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*k*** �_ i � ..�..�_--� ADMINISTRATION = � „ Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEL� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISf�VIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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. OUTSII)E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: C Z �L SIGNATURE: PRINT NAME& TITLE: ✓k (�oN �r�f�c�� 10/18/02 / ��l�P+,.�J�Go&i � ��' 7.` ��r'�'� � ��g "s+��a "�-�� Yy��?�,. �:w_��w x mx,�t. x� _.�r'�_�.:^reT..1t�._..W'.^...—P_, _. ..-s ...1.. ._ ..._...�_, , r.� st �•t � ,.'.�.�e.�'..i��`� �� a�� ` 4 .. � . ._ ._. .L� .... ...� ._. ... u�-,1�,. ..u«,>_<,�v.�..Ai .. C,•p`t+,)�,7CFR ,qi� , .xr,i� f,� e' r �'r � � _ ?� _ a "�"��2 �- `+t.'�t,� �,a' ,Y�t ', . , g,�, . .: �k, iv;. - .. � -,:.- :..� p. 9 ....:1'I. :.r :_:�W, .i :,...�, �-,.,. � � . _x . ,. ,. . , .. � �.f'r. �kirr,9� ;r�,- �__ 1 �=„ s „x`'�, > . t+� �. � ._ . �°i . � ; . . e;: �i ,� .:`_-. � ._ ::t X,,,.." ..` _ ,� f , . ,;, „: �.�, :.s ,.�,�, a�, aR, �!��r,�<<r��,;m _ . .... -'' - .. .. . __.__ -..,.. ,. . , .,.. .,. r f _�;+��,��~r .. . ..,._ � : ""'.3'hi�;C yJ ��; W'�:7.. . . ,� ... . _. ....._ _ _.._,..... :� _ ' r. . . . . . .. .. .. ._ _ .. ... ! � �� ' S r. -. {. .Sf . '-I ,ti.. . .._.. __..__. _.'_.._.._....... . ... ... ,............. . . . . ... . .,........,. _..,. . _ .. ._. .,,.. ..._:.�... _ ....„_.. .. ___ .... ..__... ... .. ._....._.,�.� ......_.__.._. � +ti�K'.f#E"�✓ .�..f�,,. .. .. . �'�i{sxtty�'`,:�:a ?r." : ' "._ ._...,,.._. _ .,_ .. ..._ _._._...� ....,. _ . ��4 5.nl.,P,�..?;74K,�++�.,''.:; - .., .. . . .._ ... ._ . .. _. �'�r*° �`�. W� 4��','�s� _ -.,. . I " �� ..� �� xj i,r �� W� . �a�e . ��i`X�tU..-tii.. �_,.� ��.�-�.. , " :�..r. ..__._. ., _ ' - - ��g+f1 , ;i , o .fFs �`��.�r�� .`A��*� , _a...._.... ..� . . . .._.. ..__._ ... `�V�:r: .3�F. .. _... .,_ _ .... ..� . ..,. .. ,_.��.,... ,, r.S�,., .. �-. It:-q-a.rJ4G!�rf. .a"r+ b ..,.. .. -0...r.v r .:f. . ... .�. lw.., . �S: . .f' '+l:�s�„ . �Y,t r.��Y _ ...r 1 ,.. . .. .,.� . � �,.,m y` .�.. ., '� .. .h�.•,�.,,..�E-_r,.:;"'TYC'�i$�"`a't�ix+:toi�.:v ak F 'i:��.m.. ..�e�;��=, ..''�._F,.3 .:.}t's:1 ,��. ::i� .l:`f ... < . ,. � . �„ t �t'^'. . .«an �._ . ,..,. . � � .�:� ., . . . . . _ , . .#-° '�ti'... Ci:id"FG^�..t't`F'iwa. ` .• . . , � , -. �,- ..!"�.�. i:r4-'e�`v'r`�rt r�:Ps. `��ci ��;i�, , c.r: ` = z�..�!'-r t ._ . . `"� . * � � ;+r � - _ ..... _ ^�.�" . . . . _ . . , .. . .. . . .. . � �.?�:.a)$Iv"v:i�47t?`..3+s1v1'� t; . , _. 'i/.i_ .�:a .�� , fi-�.. `� w}: .�.. �� . ., .. �� . , a�'_ .,..e , __ . _..,_, . _ _ _ . r.; , _ ._ ._.w...,. � �.`-.w�':'' ��`=��f�;i„ � .. �...'Y� . R.?i3•a . . - _ .. `� . . , ti � .. x �.% � a v ; __.. ._.�<.._. ..�..._ .. ...._. -.. ....' ..,' __.. ._._ . ,.�_ . ' ''� - - - _ ' ' ,_r.�, . . : ._.._..,.....,..,....�. _ ._ . . ,.: . _ . . ._. . .:..:.. ..._. _._._. ..._ _.._..__.. .._._.. ._..,_ ___. ..._.._. . . . . .. ' �.,�'��i'J.n..lA.r�".f'!J . _ . . .. . � . _.�, ° t`n K..�.,-r�.. :>..Ft�t i .,�r„ , . . � . .... . _.. . .... .. ... .... ...... .. .. . ..-. . . . , ., �. .. 6:' . ._ � ._ . _ _ - . ......_. ..,,,, ,.F,;:::#,!a�.j.. ....._ .. . ,, ._._..... _ . .. . .. ... �. . (lt.'4 ::_.`,., f'4' .:... ;.-.:��_..a .._...... . . . .......... �. . .. . .. __... :_._ .....,...., . . . _. ._..»..,_:.. . . . . . ..___ . . ..__. .._. _._...,.�.._.,...,_ . ..._ .....____ . ... . .. -.......... . __ . . _._.....� . . . . . ......_ .. ... _ .:u��'�JMl�,ES�i,?t..t"�i�ri"r' . . . ,. . , ... � . .. �rNY�,""r�� .. .. :__ . .,. .__. .. ... .. _.._.� � A;.t.C"�17^�.. ^.-r�r� � , .. .- , .. . '.fi; .. ".h . � � . � �_....I :;.. �.. �.i.. i Fd'�..�"? �irr"^�.:' � . ... .. .. ' ". .. -�. ..._. . .. .. . __... . _ . __ ' ' ��S �i� -. � , . . �- d . � � . . ' i•t+«'F7. t'-"'�. ...�� .. ....,.......«_., �.a.... ..... � ,, ._ ...i � _ .a _ ... .r. ' .�d 7 � �" 1$""' g, - _ . �,.,.. .. . ,. . � ; ... �e'YMI7+±S . . �C +�.�0 k��•f� � � S�� .. .. .. , e ... ... .. ..._.. .._.__ .. .... ' ,. .. . ¢. �h.Tr , . iE �i.. � i..A'.t iSq.y.�i �«.. , . - - -..a....� .. .,......... . , . ,._ .. . ... _ .- -•�... .._ . .._. _.. . .....a.a..._,,._ - - . .. .._. . . .:.,._ ........_.. -�:� ,� �Sf�l.i�f��.A�?I<.i��r . .. . . ... _ � � f � ..- . ,. ` . +t 4 i, . .. . i.NY ��.F.,;` �..t..._e...,._. ,._._.�.._... . _.,..._...,.,.._.. �' .. .. .. . _ . _. _.._ ....��......_.. . . _._ i ' : . .,.. _,.,... . . ; . .. . . .. .. ..... ...__ ..'__ _... ._ . ____. . -..:....,....�..,_:,._ . . . . � . � �Yf�.fq., . i�-.ry . _ __�_.. . ... _. ,-_.. ... .. .. .. ��. . ._. ;;'A;:'�'�f,�,�tF�;�'J.� . . _. ..... .. �.. .._ . . ..... ...._. ._. ._ _., irrv�.-�rii.^?,;..R�,e�,"�....-'.'..;,; . . � . ...._._. ...._ _. _.._ .__ «...._..._..._. . .._ .. ... _... _ ..__. .. ..._._ .. .. . ._. . . .. ,... .. .�_.... ._ . _ _ ,.� .. ._ -�„ �.. . „ ...-;,...: ..._:... ... � '!Vf?c74C�. r .�e<acfJ3r .',ia[�iy� � , . ' r' . . . . . .. ... .. .�.. I :'scat[; i' c,; .'S��i,".� ,_ _ . . ,; , ' � r�?�,s�'a.',>ai� ==4�� .- ' . .. �" .�,. ` . ,. _ _ . � ... . ti -rJ...-17;r �qk. .. . _-`. ':z r: ,_��i'I , . .. <�„' . >. - � ' ' ; ,: ..V.-��) ,.. .!'. �.r . Cf !Ca:�� >F ,:,.� ;:- ,�; . _ ---r....._.........._ _ _._. ____ __..._._. _ t) ,•:��q .» ... . ,_ ._ _<... _ . . _ _ � _ _ __ �_, _. __ .. � _- -..__ .__ . ._ _. _. . ._. . _.. _... . ._ _. _ � .. ...._.._ . '.err..f.?TI'i:V. R ,�^nr r-_��tr} a�?":.;{: r�r x�.� k `... ` 'i. . . .._._ .. ....._... . . . .,.. ._.. ...... ._. . �er".if'�,C6�>8`*`i�: r 't-. ��e,=h� . � ;,..... .�,...�.�a,n.,....,,..a- «.�. _, ... � .. _a..._� _ ___ _. _ �,'�"��.�...`��+,C�►7�t��R _ �� • ,. , '`'' ; .1 � '�� . " �r _ . .., � �_.__W_._ ,.... ...... , . , . . '� . � � _ ____...__, .. ___ _ � , _._ . .u, _... . � , . , �,�`1f1�Al4S-4�frkf��7t1. nG , �,f, , , . r' : . . -�F 7'}`�+rhiie€t�i<�ec�� ; ._ .. . . , -.,. . �,. , .. YarmOti��n,�If�+v".k�i� "�! . . . � , : . ,., f,, ..�F :'K : ,,-r �_. r. „ _. ... :. . .'r.�,. �.�'"'�'�� . . . . . , . . :.. .. � .,i;. . � �r.�',. �h ,...:.rr .._ .r . .. , .::.. . . .. �'r-^ . �`q� 4w a. '.r� `•�:. ,... . .�„�.:,,.,..«�........ ... ... .. .. _ ... . .. . .... ,.-_ .. . _; . . ,.....� __. �..<_� � _ . �� t�7 t . .. . . . . . .. _._. .._ ,- .,-.., r. ,,; 1 "?i pG,,, . . � �,rGt ,e�� _.��+�___.._,_ . _..._ _ _ _. _ �` - THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #03-004 FEE: $50.00 This is to certity t�at Camp Win�ate-Kirkland Inc. d/b/a Camp Wingate-Kirkland 79 White Rock Road Yarmouthnort MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS . This License is issued in confomuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, , 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as a�pted by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked. --- ---- January 23.2003 _ ____ _ BOARD OF HEALTH: �a�rfed'�f. i�e�ll�'t�c, �ai�t�rca�c _ _ _. ____ ____ ---- --- ��. �no�u�, (� ' tce �aacic��c��t r�e�.��c, i�� ruce G.Murphy,MPH, .S O Director of Health _ TOWN QE YARMOUTH BOAR�I�OF HEALTH ; � �' :` PERMIT TO OPERATE A FOOD ESTABLISHMENT s - PERNIIT Ni7MBER: #03-124 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: - Camp Wingate-Kirkland Inc., 79 White Rock Road,.Yarmouthport, MA . - Whose place of business is: Camp Win�ate-Kirkland ` " Type o usmess: oo ervice - - -- To apera.te a food establishment in: Town of Yarmouth Pemut e�cpires: December 31, 2003 BOARu oF��,TH: ��. �ef�i, ��ra.� $'e.afa�rr�D. C�,mrdo�,c. �11.?�., 2/ice ,�o6�rt�. �aaaac, C'� �aarick'�D� `�el�.5�, ��Z. January 23.2003 ruce G.Murphy,MP , .,CHO Director of Health / �s��NRI03.30�QIS N�H.LO�,L�'IdWO�QN�'2I�A0 ARIf1.L�Sd�'Id��s�+� oo� z� s = �nQ iuno�� ot$ �� H �Wdl� S£$.L2I3SS�Q I�I�Z02I,3 OOZ$ 'ki'bs 000`SZ< Sb$ 'g'bs ps> OZ$ O��dgO.L SL$ '8'bs 000`SZ> OZ$ 0��'gO,l #.LIY�I2I3d 3�d Q32IIf1a�2I 3SN3�I'I #,LIY�I2I�d �33 Q�2IIf1a�2I 3SI�I��I'I #.LIL�i2I�d �33 Q�2IIf1a32I 3SN��I'I � �IA 'II�,L SL$ �'I`dS�'IOHM OS$ '.L�IA NOY�IY�IO� OSI$ S.LH�S OOI< SZ$ .LId02Id-I�IOI�I 0£$ 'It�.Lt�I�I�II.LI�IO� 'L�-e p„� SL$ S.Lt�3S OOi-0 r J #iiv�aa a�� a�ina��sNa�i� #iiv�x�a ��.� Q�ina��sN��i� #si��a aa� a�ina��sN��iz :� inx� a o� •EaSZ$ 'IOOd'RIIHM OS$ ?RIVd 2I�'II`d2I.L OS$ �iJQO'I ��aoss�ooa�ruwwUns �c�p-Pp os$ a��-T os$ � os$ za.t.ov� oss ru�� os$ g�g #iiv�aa a�a Q�ina�asKa�i� #.i.l�aa �� a�ina�asNa�i� #.i.lv��a a�.� a�ina��sN��i� :�ui�Qoz � I33 �.,Ap�l� �/V�li ��1�1'YJ /'r�D hnl�ilil'�vi ' �° # 1 V.1.�.1, '�J1V1,1.V '�' �7 .l,l�l V Cil l V.l..�a(1 ,„��y �, ... � � . � �£ .Z •t •ssautsnq;o aa�jd.�no�� aig� ut�;uiem pu� saidoa n�au apinoad�snui no� •sp.�oaa.� �s.�ga�f;sgd asn�ou Iji,�;uatu��daQ q�Igag a�,I, •ur.zo�si�o�suoi��i�i�a�aa�oiduza3o saido�u�� pue nnojaq saanpa�o�d�urxoq�-t�ue ui paui��saa�folduza zno��stl as�aid •sauzi�ji�� sasiuxa�d au�uo�.zannau�y� u�iiuxtaH a� ut paurez� aa�ojduza auo �seaj �e an�u �snuz a.zouz .zo s�eas SZ u�1nn s�uauzusijq��sa a�in�as poo� iIH -; � •SNOI �d�IdI.L �� H�I I�H � 'I 'Z � •uoi}�xado o smo �uun a�is uo a�.re u uosaa auo�s�a �� an� �snuz�ua si �sa oo �� :� '_ _� u P . ��Id) u� I d i u �I .ia P 3 u � - _ _ _ _- ._ :��'-��1�II 1��4S�i�d___ � 'i � Z l� •�uamqsijqB�sa ano,f��aJg� uig�ai�ai pue saido� ,�au apino.�d�smm �o� � •sp.�o�a.� �s.��a�f;s�d asn�ou pi�;ua�BdaQ q;iBag aq,I, •uoi��iidd�s�o�uoi��i�i�za��o saido�u��aseaid -�, '000'06S 2IL�i� SOI `s�uauzusiiq��sg a�in.�as poo3.zo� apo��s a��s au�ui paugap s� `.za��uey�uoi��a�o.zd , p��s� pai�� a� �I o�� a�olc�,ua aM i�-I�n3�o u�o��s�a1 �� an�u o� paambaa aa�e s�uauzqstiq��sa a�inaas poo� jid �S 7 M� � �v►►n�9 j��o��P �,��YI�(1'� •SNOI.L��I3I.L?I�� - S2I�rJF�l�t�'Y�NOI.L��.L 2Id Q003 � � � � s .� .£ 'Z �j •ssauisnq;o aa�id ano�f�� ap,�� ure�ui�u�pu� saidoa nsau apinoad ;snu� no� •sp.�oaa.� �saga� ;sBd asn ;ou IIinA �uaui�BdaQ q;iBag aq,L •uuo� siq� o� suoT��i�a� aa�oiduza �o satdo�u�� pu�nnoiaq saa�fojduza asau��sij as�atd '�2Id�) uoT��t�snsa��.z�euouzindoip.re� �tunuiuio� pu� pi��s.�i,�p.repu��s `�a�s�a�enn�is�q ui pa�i�a��i�ua.un�saa�oiduza�onn��o umuzruiuz��si1�snuz s.�o��zado jood •Z 'I .uuo�stu�o�uot��i�t�a� a��o�do��uo��e p� (s)ao��.�adp iood pa�eu�isap au��stj as�aid •n�e�a��;s�q pa.�inba.�s��.�o��adp jood� s� pagwaa aq�sncu.�osin.�adns jood aqZ ' � `�v� n L�— � NO I I.L 00 � ��L -blrv ��'1 � � � � �SS�2IQQH�JI�II'TIHNi r�l�r�. -�c�� `�.r�- # "I�.L No�t .(� ��L�iF�I�I S�2I��JHNVY�i �rp -�1-1 � �� NOI.L�2I0 �/2I Nt1c10 ��I n�/'i 'a !-� �SS�QQ�' �JI�II'II�dI^t�l�,��, SL �' � �Q� �OZl ��-��!� , �S Q NOI.L 'I # "I�.L � ?r /Y 1 W �.LN�Y�iHSI'Ig�.LS� 30 �L�I�' '�_ci�C] i-;1�Ib�N •��c��o�i�ijdd��c��a.z au� ��nsa,z l��nn os op o� �nji�3 'iOOZ `t£zaQ�a�aQ�q s�uauzn�op�ressa�au jj�u��pu�ur�o�a�ajduzo�as�ajd * �.. � <; ° . ., `�� `, ��,.��: � . ZOOZ- ,LIL�i2I�d/�SI�i��IZ 2I03 l�iOI.L�'�I'Idd�' ' ' �1 =� �r; � �,� �'�` <'1z�, � . __.�,�......___.��.._.....__ H.L'I��H 30 (I2I�0g H,LIlOI�i2I�'1�30 I�IAAO.L _ , �N�av>�_�.�.��v��►-�� _ a i0/I i/60 -y�L7�,-�►1� � �,�_!'�. ,�p� �/ � � •�'I.LI,L �8 �I�iVN,LI�II2�d �� xns�u�Is � p �� i► ��idQ -��` � •pa;iqiqo.�d st�uauzusiiq�sa a�Tnzas poo�ao ire�a��iq��npozd poo��u�30��idsip.�o`uoi��a�da�d`�uixoo�aoop�np " � � u�oo�xooQino •c�leaH�o pa�og a�uzoa��no�dd�.zoud anec��snuz`(a�in�as ssaz�renn�aa�renn�rnn�ut��as aoop�no`•a•t)sa��apts�np � � �5�,�'� �QIS,LR •�auz uaaq aneu suua�anoq� au� ii�un�iuuad�assaQ uazoa,�.�no�i�o uoi�e�ona.�ao uoisuadsns au�ui�insaa Iiinn os op o�amjT�,� •�uauz�z�daQ u�reaH au�o��uas aq�snLu s�insaa�sas •q�I pagi�a� a��s��q sis�q�ii��uoux�uo pa�sa�aq�snuz s�assap uazol3 _ _ . __ _ _ _ -�S 2I�SS •�uauz�.redaQ u�i�aH au��e paure�qo aq ue� suuo� sasc�s •�uana pa�a�� au� o� aot.�d s.znou Z� uz.zo� uoi��ildd� a�in�as poo3 �.reaoduzaZ paambaa aul �uii� �iq �uau��daQ u�1�aH u�nouu�� au� �i�ou �snux u�nouu��3o unnoZ au� uiu�inn s�a�� ounn auo�fu� ��i I �I�I ,LV� -sauosinp�aaumsuo� �sod o�pazmbaa a�s��npozd�uz�paxoo�zapun.zo nn�a��a-o�-�ip�aa sjlas.�o sanaas t��n�n��uauiustlq�sa poo�u��g � � 2IOSIA 2I SI�I ��IA2i�S QOO,� •�utsoj� �o s��p (�)uanas utu�Tnn pazano�co paut�.zp aq�snuz Iood�uicuuzinns punoz�ui aoop�no�.zang :��SO'I� 'IOOd •aa��a.�a��iaa�nb pue `�uivado o�.�oi.�d`q�j pa�i�a� a��s ��q �uno�a�e1d p.repu�s pu�uuo�ito� �o�`seuouiopnasd ao�pa�sa�aq�snLu.�a��nn au,I, :�uI.LS�.L 2I�.L�'AA'IOOd •�uivado o�aot�d�uauz�daQ u�I�aH au��Q pa��adsui aq�snuz uoseas a��o�pasoj�uaaq an�u r��ic�nn sjoodj��nn pue�uipenn`�uiuzuzinns Ii�'��I�III�i�dO'IOOd S'IOOd S�I I �"If1��2I 'I l�I I.L Q�' 'N�'Id�.LIS V�II1��2I�F�I�i SNOI.LF�AOI�I�2I ',LN�Y�i��N�Y�tY�iO� O.I, 2IORId H,L'I�'�H d0 Q2IdOg �H.L�g Q�A02Idd�' QN�' O,L Q�,I.2IOd�2I 3g.LSIlY�i `t'�.L� `.LN�Y�Idifl�� tY1�N `rJI�II.LNIdd `'a'i) 'IOOd 2I0 'I�.LONi `.LI�I�Y�IHSI'Ig�'.LS� Q003 �l�i�' 01, SNOI.LF�AON�2I 'I'I�' 'NOS�'�S �HZ 2I03 JI�III�I�dO O.L 2IOI2Id SX�'Q OT-L NOLL��dSI�II�03.LN�i.L2I�d�Q H.L'I��I�I.L.I,��.LNO�O,L�S.LN��SI'I�.LS�'I�'NOS��S 'i00Z `i£2I�gY�I��3Q�g �S)�33 Q�2II11a�2I QN�' �S)NOI.L�'�I'Idd�'Q�,L�'IdT�IO� �H.L l�I?If1.L�21 O.L X.LI'IIgIS1�IOdS�2I?I110A SI,LI 'i£�aquia�aQ o� j �.renuer uio.g�fii�nuu��m.z s�iuuad��IZOl�i ON /� S�� / �QIHd 3I A'I�,I.�'RId02Idd�' ?I��H��S�'�'Id 's�tuuad zno��o a�u�nsst ao j�nnauaa o�aotad pred aq�snuz suaij pu�sax��nou.u��3o unnoZ Q�H��.L,I.�QN�' Q�NJIS .LIA�'QId,�� 'dY�IO� 5�2��Ohc1 � Q�H��'.L.Ld ��N�'2IIISI�II 30 ',L2I�� 2i0`Q�1�i�IS QI�I�'Q�.L�ZdI�IO� �g.LSl1Ni ,LIA�QI33V ��11I�'2I11S1�iI I�iOI.L�'Sl�i�dI�O� S�2i�?I2IOAA �,L�.LS Q�H��'.L.L� �H.L 'a�u�msui uoi��suadu,io� s�zaxaom�o a��T�i�a� � an�u �ou saop �fueduio� .zo uos.�ad ��t ssauisnq � a��.�ado o� �iuuad .zo asua�ii �fue�o i�nnauaa ao a�u�,mssi plou o�pazmba.�nnou si�nouu��o unnoZ au�`9 uot��asqnS `�SZ uot��aS `ZSi �a�d�u�aapun 1�IOI.L�,LSII�IINIQ�' . , � , + � � . `� � Th e Common wealth oj Massach usetts � � Department ojlndustrial.-�ccldents o Olflce o//�ves�IpstJiis 600 Washington Street ' •' Bnston, Mass. 02111 �'" "�y Vb'orkers' Compensation Insurance Affidavit Anolicant information• Please iNTTe�+'W� n m • GtMI WIVI G1� k�J�Cn��l a o n� � w �r �GK 1'�-`^ • , �r�,, ;� n.� 021�� 5c� -35�- S�/� � I am a homeowne pert�rming all work myself. li:�+�`�Q- -�f � I am a solz proprietor _-� ha�e no one ��ori�ine in am�capacit�� I am an empio�er pro�i�ino workers' co_m�ensation f_or_mv employees w�orkin�_on this�ob,_ �-- _ —_ . _ __ _ om an � nam : �� ddress: �� V'� citv: ��'`��1� f11 T7,� nhone t�• S6�5- 35�� S�jls� iasu�nn¢e co. �i-M S iCIN'L =�elicv M �`1 A 2(��O�CY7%�--U/ � I am a soie proprietor. qenerai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ �corker �ompensation polices: companv name: address• city: phone t!• insur�ncc co. Qolic�•# com a�nv name• idd ress• _ 1ty: nhoee M• iesurance co ��M _ e Failu�e to secure coverage as required uoder Secnoo 2SA of MGL 152 n�ind to the iopaidoa of erimi�al pesdtles o(a d�e ap to 51.500.00 a�d/or one yean'imprisonment as well a�civil pendde�io the form of a STOP WORK ORDER aed a tine of 5100.00 a day at�iost ma I s�denn�d t6at a copy of thh statemene may be fonvarded to the 011icr of investigatioru ottbe D1A tor eovera;e veriBeatio�. I do hrreby if}•under rAe po'ns a d penaleies ojperjury that lht injornration providtd abovt is true and cvneex Signamre � � ate r� f�(v/�1 Print name `-�a�'� !` . � �`�� Phone N J�o�— 37� � '��l� .. otTici�l use onlv do not+.rite in this�rea to be completed by eitv or town oAltial city or town: yA��DT$ _ permiNicense q n8uiidiog Department �Liceasiog Bo�rd �check if immediate response i�required 261 ❑Seleetmen'�01Tiee �Healt�Departmeat concact person: phoneq:_ �508} 398�2231 ext. nOther THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #02-005 FEE: $50.00 'rhis is to Certify that Jim Wolfson d/b/a Cam�Wingate-Kirkland 105 White Rock Road. Yarmouthport.MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERIVIGHT CAMPS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A, 32B, 32C, 32� and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and condirions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and e�cpires December 31,2002 unless sooner suspended or revoked. ��n aa ,Zooa Bo�xn oF��,�: �?ka��f x�, ��a� 1a.r�1.a D. C�azal�.t. D., 2/u;e ,�'o�e�ct� b"`naau.t, LP,erk �a.�riek�f�Der.uat� � Skak. 72. Bruce G.Murphy, R ., HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-091 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Tim Wolfson, 105 White R�ck Road, Yarmouthr�ort MA Whose place of business is: Camp Wingate Kirkland Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2002 BOARD OF HEAI.TH: �a�rled�f. �e�ll�ez, ��xa.� �fa.xuc D. C'mid.o.a. J1L D.. `�/�ee ,�a�ez�� xa�vc, L� �a�'iiek'j1l�D� � s� �n March 22 ,2002 ` ce G.Murphy, .5.,CHO Director of Health �.GlY7`1� V`V 1�1�°Cl"rC- �J r"� k t i�C l } _ :, _ _ � � c� r� oM � � � TOWN OF YARMOUTH B�ARD OF HEALTH _ APPLICATION FOR LICENSE/PERMIT-2000 , D E C 2 3 1999 * ~ �°-�3�� H ALT�-1 EPT. Please complete form and attach all necessary documents by December 31, 1999. Failur tlie return of your application packet. ------------------------------------------------------------------------------------------------------------------------------------------------• N F EST IS N : GM�' ifJ 1�t!F-G 12-- I 2 K(�q-�.� T L. # 3(�L'3 7�� LOCATION ADDRESSi.�� iN it'i�� -V�" 1�� u�rw�oul�,pc�,�( /�I�'1 MAILING ADDRESS: � �� (,Uoa�l�i�� R� �.�A�/�� •��-� �r �� OWNER/CORPORATION NAME: �M P w i N�4 re 2vsu�-�✓.� �c, MANAG R�'S NAME: �^^ W�►�c�.so TEL # ��oy--3 5�5��b 1V�A�II,ING ADDRESS: f � ��u�o�a-►��e R� w��j�� Mil- ��l�� POOL CERTIFICATIONS: The pool supervisor must be ccrtified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifica.tions 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 business. 1. 2. 3. 4. HEIMLICH�:ERTIFICATIONS: All food service establishments with 25 seats or more must have at teast one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of ernployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fil at your pl�cg of bu iness. a1�. v�Tg � r�.ee�'l%h�d bY � ��•tie � a�e^�• 1. S�-e.��- ,D�n�eP�— coo� 2. 3. Ti r^ WQ►�o n/ 4. RESTAURANT SEATING: TOTAL# NON-SMOKING 5EATS: T�TAL# �5g - -------------------------------------------------------------------------------�-----------------------------------------------------------------• OFFICE U E ON Y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT # B&B $50 CABIN $SO �INN $50 �CAMP $50 ?,�G�7 LODGE $50 TRAILER PARK $50 MOTEL $50 SVVIM1VIIlVG POOL $SOea. WI�tLP�UL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIlZED FEE PERMIT # I 0-100 SEATS $75 �Z�'�O� �CONTINENTAL $30 >100 SE�iTS_. _ _ $150 _ __ ___ N�N-�'ROFIT _ _ $25 _ COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE:� LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $24 _<25,000 sq.ft. $75 FROZEN DESSERT $35 ?25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ j 1 c] .� "*""'PLEASE T(JRN OVER AND COMPLETE OTI�R SIDE OF FORM•"•"" VV _ .,, . . �- ADMINISTRATION � ' :LTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUI�ED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A ' PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE�F YOUR PERMITS. PLEASE CHECK AP OPRIATELY IF PAID: YES--� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUiRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHN�N'TS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR T4 OPENIlVG FOR TI-� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE�EPORTED TO AND APPROVED BY TT-�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DDITIONAL REGULATIONS POOLS POOL OPENIlVG: ALL SVV:[NIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARU PLATE COUNT BY A STATE CERTIFIED LAB, _ PR�Oi�'�{}f3P�i��iNC,-ANf?Q�ARTER�,Y THEREAFTER. _ _ _ ---- POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �ATERING POLICY: ANYONE WHO CATERS WITHIN TI-�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPAR.TMENT. FRO�N�ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN TI-� SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OIJTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR • APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD ` SERVICE ESTABLIS�IlVIENT IS PROHIBIT DATE:�'Z Zd �� SIGNATURE: PRINT NAME& TITLE. I M �v�J��''� �ll'eG� 11/12/99 a y � .� • 1 � ' The Commonwealth ojMassachusetts � � Department ojlndustrial.-fccidents 0 omce oiiav�sr�os�r,is � 600 Washington Street � ' -` Boston, Mass. OZI11 �~ ��y W'orkers' Compensation (nsurance Affidavit n a m� C��(' �i v�5 f�� -Z'i G vic� �✓I!L "i t M W(� � �� Locati�n: ��ni �-i h�� ,�, ��v►�oa7��,a�7 ��}- d2�(� �.�' Sv�s-36� -37q� phone# � ( am a homeowner pert�rmin�all w�ork myself. � I am a sole proprizror �-� ha�e no one ��orking in anv capacin� �m an employer pro��in� workers' compensation for my empioyees w�orking on this job. comnanvname• ��"� (�J�1�� lr�`a`�' ��" ddress: g �t�u' �� sltv: li v �`�� ri vt� / M�' nhone ff• J�t�� d"� �d �C7 �_ �%msurance co �'-:`DJ'I u�? �' ��f�OQ�iU�"BG � policy# � I �m a sole proprietor. generai contractor. or homeowoer(circfe onel and ha��e hired the contractors listed below �►ho ha�e the follo��in_ ��orker ,ompensation polices: comoanv �ame• address• ��n" nhone t�• insurancc co. oolicv# comnanv name• address• �'� nhoee M• insurance co. ��n,* t Failure to secure coverage as«quired uoder Secnoo 25A of MGL l52 n�Iead to t6e ieposidoa oterisi�d pesdtles o(a 6�e ap to Sl¢00.00 a�d/or one yean'imprisonment a�w•ell a�civil pendtiea io the form of i STOP WORK ORDER aed a line of 5100.00�day attio�t ma I s�dersta�d t6at a copy of thy satement m�y be forwarded to the OtTice of Inve�tiguiom of the DIA f�eovenge veritfatio�. I do hrreby e '}•under t/re ains and pertal�iys ojperjury that t/rt infornrotivn provid�d abort is true and corr ct ��/ Signature � � � � � Print na �� w��v� Phone K s��'��J `��"' .. otTicial use only do no�M�ite in this area to be compieted by eiry or town oflleiil ciry or town: YA��IIT� _ permit/lieeese M nBuiidiog Department pLiceasiog Board Q cheek if immediate response ie required 261 �Seieetmen'�Otiiee �HesltA Department contact person: phone p;_ �508� 398�2231 eat. nOther _ _ � ..,,, r__.---� . .— „ ,.r- _� � _... . . . . i ' r . _., ' _ _ - _ . . _.�.,.. . _, _'_'.''_'._�__._.__�.� _ . . ........^._�__.�. .. .-1.,�_,.�.� _ �ACE�RD� �;�' �T{��C A T E ��' �.. -`•��' � �� t�`..s' �,.��,��.�;�' ,�� . 1 A, 1M,�f i 4,� - • ---�- �_ __ _ _ . _ . . _ .___ ,.�,;�-,., „ ... - �.,:c r-:i�� ;,fg Sc�:<.� .,_. . , .�:; • . ; Ex't".t�c�R �•� . . ,. � ` �i .. ..��s� H�{,OV'� , — , .. �.. ,:��._. ... . .. , .,_ , F ,..._, . .. .�.,, s' ._c. I � - . .. . . � . � . . .. . . , . , . �- i . . . � � . . � . . . . . . .. ..- � i : 1 i __.— . � ` .. ._._"� . • i X . � ! i ! � , j �_. _ _ .. { . t � f ..._-_.__. ___. .�.f � � . . � . . . � � - i .. .. . , . , . . . , i � � � . . � . . , - . . . �� , 1 _. .. . � -..,� � .. .. . . . . . , . , . . . . .._ � � ` I �__ . . . . . .. . ' - .-_. _._...�..I " ., _._... . _. , . . _ _ _ _..._. . . c•� F r•,;'a�� ti:' r,r',- . „r - _ _ __.._ _.__-.-.._..._.._ ,. ._. ...�........ . _. . ' - . . �. ' � _ . ' . .. ' . r.l. �'t'l�4V:il� � .�� ' � . . . , . . . i . . . . y.C.�.. . . .. 1� .. . ...�.IF:...�':.:. � �, r .:�r�.• ..� A ......_ _ .�. . .. . . .. . . . . •i.r' , r�`1 ,�..�� ! � . .. . ,1,`r 4 �...�., r .,i .. . . ._ .. .._.. . . . .... ... ...._...__...�_. ....� ,^ I I . , � 1 ,. '� ' > ' �'� '�ty . J f �,, � 4 - ��.�+ ,. . . �— _.. � ( 4_F�i . . ) ,. . <a ii�.:�� 79�6 TOWN OF YARMOUTH BOARD OF HEALTH . PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-108 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: C:am� Wingate-Kirkland inc_, 105 White Rock Road, Yarm�»th�, MA Whose place of business is: Camp Winsate-Kirkland Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�'d�/. �el��, C'��r,�� oan� �ullivaa, K.�� Vice l.hairma Ko�e�t� 4.�rown, �lerh abrielle Jahol�hc�-.�too e ic oCau��[in Januarv 14 ,2000 Bruce G. Murphy, MP R. . HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-7 FEE: $50.00 1'his is to Certify that Camn Wingate-Kirkla�nd Inc dlb/a Camp Wingate-Kirkland __ 105 White Rock Road Yarmouth�ort MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERIVIGHT CAMPS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating ' thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked. Janu ,arv 14 ,2000 BOARD OF HEALTH: �c�� e�e�, �`iairman �oan� �ulCivan� K.//., Vice �hairmaa KoberE,}. O,rown� �lerh a�rielle�a�oG��Zc�-..l�tooPe� ' �l �� ou hlin Bruce G.Murphy,MP , R. , HO Director of Health - �� _ �4_: �- � ��., i _ i i f ' •�r y wIA1H0�lI 30�1I�S?I�S.LO��L'3ZdHI0.7 Q11jV�I3A0 NtI11s�tISV3 Idr y y�+� ; _Sz � $ _ �na ixno�� ' ot$ .� u � ; �G ooz$ ��bs 000`sz< , � SZ$ .�2I�SS�Q I�I�Z02i3 SL$ '�T'bs 000`SZ>` ' � OZ$ O��gO.L Sb$ '8�� OS> ; #,LIL1i2I�d ��3 Q�2IIf1a�I�S1�I��I'I # ,LIYII2I�d ��3 Q�2IIf1��I�SI�I��I'I i i � ; SL$ �'IHS�'IOHt1c1 OS$ '.LaIA l�iOYVNiO� � S Z$ .LI30�Id-I�iOi�i O S I$ S.L�'�S OO I< � 0£� 'I�ZN�PII.LNO� ��-b SL$ S,L�'�S OOi-0 � �', ; # ZIY�I2I�d ��3 Q�IIf1��I�Sl�I��I'I # ,LIY�I2I�d ��3 Q�2IIf1TJ�I�SN��I'I •� �I� '�aSZ$ 'IOOd'T2�II3AA ; '�aOS$ 'IOOd rJNII^U�IIMS OS$ 'I�,LOY1I OS$ ?I2I�d�I�'II�2is OS$ �rJQO'I OS$ dY�t�� OS$ l�il�ii � - OS$ NI�H� � OS$ g�8g #ZIL1i�I�d ��3 Q�2IIf1��?I�SN��I'I #.LIY1RI�d ��3 Q�IIf1U�2I�S1�I��I'T --------------------------------------------------------------------------------------------------------------------- --- - �#��.oi �si�as�ruxov�s-Nou �� #�ioi ��ui�as �n�is� .� �£ 'z . � ' � �I �, •ssauisnq;o aauid ano�f�g a�,�g a�g;uiBw puB saidoa n�►au apinoad ;snw no� •sp.�o�a.� �s.iea��sgd asn;oa p�,+�►;uam�BdaQ y��Bag aqy �uuo3 s��o�suoi��agi�as aa�iojduxa 3o satdoo u�.1� pue nnotaq sainpaoo.zd �u�oc��-t�cr�ut pau�.��saa�oiduxa ino��sii as�ajd �saLui�j� �� sasnx�a�d at��uo iannau�y� qoijctiiaH at�� ui paure.�� aa�oiduia auo �s�ai �� an�q �snuz aiouz io s�.�as Sz q�im s�uau�ctsiiq��.sa a�uuas poo3 I� , ' g .b .£ •z � 't •ssamsnq 3o a�gid ano�f�g a�g u ui�; igm pug saidoa ,ti+au apinoad ;smm �o� •spaoaa.� �saBa�;sgd asn ;ou ili,+�;uaw�agdaQ y;jtcag ayy �uuo3 s��o;suot��ogT�ao aa�ojduTa 3o satdoo t��u pue nn,ojaq saa�foldcua asa��s�as�aid '(gd�)uor��snsag�uouz�nc�oip.�e��nuziuo� P�P�'�s�id p.�pue�s `�a�s.za��m�is�q ui payt��t�ua.una saa�ioi uta onn��o umunuiuz��sc��sntu s.zo�.iado jood -- ----Z-------- - _ _'i - i ---- ------ ---- --- _ __ �uuo�sn��o�uoi�e�gt�a�au��o�do��uo�� pere (s).�o��iadp tood pa�.�u�isap aq� �sii as�aid •�g� a�u�� ti+au �q pa.��n�aa su '.�o�B.�adp iood B sB pa��aaa aq �sniu aos�n.iadns iood ayZ � I�I I ----------------------- � °�20 �O } 1 -, ,"a'1i �' '`: I�II � �3� RS � � � �-r � a �2�� _,�r, , S, � , -fi 1�I N Y1i -z ,� �o a ,�� S Q I � O ' �6__�=� #-�----------------�'-----------=------------------ �-----------�-----------------�=�----------------- � - -��- ��ax��d uoi��ijdd�.cno�3o u�n�a.�au� � ui�jnsa.z jjinn os op o�ainjr� .;�66�,,`�.�jaqutaoaQ�q s�uaumoop�ssa� oE ��ue uuo�a�ajdcuoo as�ajd * i I � �.id�t] N1ltJ3H � : � ' � �� 7d c��i'-irrn��u�su��iz�o�uoii � � . Z �3� " i �-��-� - �'t� �t�'� gs��o�a��og gsno�x�� o � � , � � � � � a � � z ; ��' � � � � � , �� i(7�►bl�l�`�'`a-4'�v'� d�w�� ` '� - , � .Er_ 3� 4` �: i � �� ) U �S � (�'� � (� ��z�li ��N.r.�a � � - � � � �� ni�u�Is � � 2� �a.i.�a � � � � �-- � � " 'Q�.LI�H02id SI ZI�I��SI'I�H.LS��IA2I�S Q003 2I0'II�',L�2I��g.L�f1QO2Id Q003�I�I�'30��+''IdSIQ 2I0`l�IOI.LH2I�'d�Id`rJI�I00�2IOOQZ110 O �H,L'I��i 30 C[�Og�I.L Y1i4�I3'I�'A02Idd�' 2IORId�t1�'H�SI l�`��IA2I�S SS�i.LIdMRI�I.IHAA H.LIM J1�II.L�'�S 2IOOQ.L[l0`'a'T) S��SZf10 • 3 � i- - —— - - - -- ---- -- __ - - -- --- - - - -- --- ------- �i�N��g�n�x _ i sv��noa��r.�n s�a i�ss�a�zo�xno��o uoii��on�x xo uoisuaasns� � 1vI.L'If1S�2I'I'IIAA OS OQ O.L�Ifl'II�3 'ZN�tZ2i�'d�Q HZ'I��-I�i,L O,L .L1rI�S �g,LSf1L�t S.L'If1S�2I I .LS�.L '�'I Q�I�,L�I�� .L�d,LS��g SIS�dg 1�'IIi,I.l�IOY�i�'I�tO Q�Z5�.L �g ZSflY1T SZ2I�SS�Q I�I�Z02L�i � -.LN�YII.L�d�Q HZ'I��-I � � .L�' Q�1�II�.LgO �g I�i�� SY1I2I03 �S�HZ 'ZN�t1� Q�2I�.L�'� �IZ OZ 2IORId SZIf10H ZL Y1RI03 NOI,L��I'Idd�' ��IA2I�S Q0031��OdY�i�,L Q�2IIf1��2i � rJI�tI'IId �g ,LN�1T.L�d�Q H.L'IV�I �r.Lnov�� .i. ��iou ssr� �.nov�� 3o Nmoi �. �.i.irn s��r.�� o�n �o�uv I � � ��IA2I�S Q003 � � '�� usoz� .�o s��a(c)uan�s t�-izlnn a�xano�xo Q��xa ag ssnv�zooa��nns a�nox�ru xooa.�.no�xan� ��usoz�zooa ��.i..��x�ix�na a� `�rurtaao oi xo�a � `�z Q��sxa� ai�ss��g s.Nno�-�.��za c�aa�is a�v�o�zo��ioi `snuor�toanasa _t xoa Q�.s��n��r.�.�`.r.��.i,x�aaa�,��.i.�g a�.�aasru ag isrun�Kos�as �r. i 2I03 Q�SO'I�l�i��g��'H H�IHM S'IOOd'I2IIHM QN�'JISIQ�'M `jJl�[IYtiY�IIMS 'I'I�' �jJNIPi�dO 'IOOd � S'IOOd I�I N I,L i i ! , E ��Za�i1s ��una�x��suoli�noN� �iN�a�u�oa oi �o�a��3o a�og��g a�noxaa�a� oi a�ixoaax ag isnv� `(��za `.��na� ; nn� `�ru.r.�a `�a't) 'IOOd 2I0 'I�.I.OY11 `.r..��slz�ss� aoo� � oi sKozi�vnou� �� uos�as �i xo.��aao oi xo�a s��a oi-c NOIZ��dS1vI ZI031.1�I�Y1I.L�'d�Q H.L'I�d�H�I.I, .L��1J.I�iO� O.L � S.LI�I��SI'I�'.LS�'I�'1�IOS�'�S ; '866I `i£2I��I��Q ; �g �5��3 Q�2IIIla�2I QI�I�' �S)I�IOIZ��I'Idd�' Q�.L�'IdY1i0� � I�I2If 1Z�2I O.L 1�.LI'IIgISI�iOdS�I 2II16�i SI .LI 't£ �I��NI��Q O.L T �2I�fll�idf Y�IO2I3 �'I'I�'fINN�' N112I S.LILtiRI�d ��I.LOI�i O.l�I � S� , ��a��.i,��ao�'aa�x�� as�a�a �si�xaa xno� ; d0��l�t�'f1SSI�IO'I�M�1�i�2I O,L'�IORId QIVd�g.LSf1Y1t SN�'I Ql�i�' S�.L H.lf10L�Ri�'� 301�It1c10,L � � � Q�-I�V.LZ�' QI�I�' Q�1�IJIS .LIti�'�33�' 'cIL�tO� S�ZI�RIOM j � a�a�ii�a��xnsru �o �ix�� o `a��is a�a��zarn�o��g isrua .r�n��,�� u�ns�u uois�su�a�o� s�x�on� ��.�is a�H��si� �� rns�u l�iOI.L�'S1�I�dY1i0� S�ZI�RIOM 30 �,L��I�.L2I�� F� �t1�H .LOI�I S�OQ 1�1�'dL1T0� 2I0 I�IOS2I�d �' � SS�L�IISIlg�' �.I.�'2I�d0 O.L .LII�112I�d 2I0 �Sl�t��I'I�il� 30 'IHM�1�i�2I 2i0 ��1�I�f1SSI Q'IOH OZ Q�2III1��MOI�i SI`H.LflOi��d�30 I�IAAO.L�L `9 NOI,L��SgI1S `�SZ NOIZ��S `ZSI 2I�.Ld�'H�2I�Q1�T11 , • l�iOI,L�'2I,LSIl�IIZ1IQV . . � � �� : i � I . , � i i _ The Con�neonwealth of Massachusetts , � � W Department ojlndustrial.-�ccidents �' � ; Olflce of/�st/�sdiis � � b00 Washington Street .� Boston, Mass. 02111 '�'" "•y W'orkers' Compensation Insurance Affidavit �Rn�j�ant infnrmafinn; �CBSC�INTTl��}dtc m• � � Incatinn• u,//I � �"� 7\ Q C✓{� � ' V(�✓.h� f 5��'� . , r � �r� ��--� �" #sv� � - � 1 am a homeowner pertorming all work myself. � I am a sole proprieror�� ha�e no one ��orking in am�capacity ' �t am an employer pro�idino workers' compensation for my employees workine on this job. , , i __ __ - __ _ _ _ _ _ _ _- _ _ - -- _ _ _ — — _ m n �T-- � � W rddress: � � � �� _ � � ; a., � � -S � � insur�nce co f 1' �! �� licy# ��D��.s� �� _ � � I am a sole proprietor. _eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed beloµ� «ho ha�e the follo��in� ��orker� .ompensation polices: com a�nv name• ..,,�ress• �• phone t�• ' iosur�ncc co R4��1� �omganv namr ' --- -- — -- ____- --- _ --- __------ addr s•• - — _ __ ----- -- �,. nhoee M• - insurance co RQ�� Failure to secure covenge as required unde�Secrioo 25A o(MGL 1S2 eaa lad to t6e iopaitioo o(erisi�l peealtla ota tf�e op to�1 .00 a�d/or oae yean'imprisonment a�w�ell aa eivil penalde�in the form of a STOP WORK ORDER and a Oae otS100.00 a day apiost ma I a■dersa.d e�a�a copy of thy statement may bc forwarded to tbe OlTiee of Investig�pow of t6e DIA tor eoven`e veritieatio�. /do hrreby � �under the poi 3 nd enalties ojper'i at�he injor►nation provided above is true end conect � Signature � —�� t �^ �/� c/ c�( �-- Print name �J �3 Y � one ll��d �J U � �1 �/ � ., olTicial use onh� do not..rite in this ara to be completed by city or bwn oAftial city or town• y�M��T� _ permitAietnse p nBuildiog Departmeut — pLieeasiog Board �eheck if immediate response is required 261 QSelectmen's Ottiee j (508} 398�2231 eat. �Healt6 Departmeot i cont9ct person: phone M:_ _ nOther � (rc��istd 3;9s P1A1 -- -- � ' TOWN OF YARMOUTH i BOARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-116 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section�of the General Laws,a permit is hereby granted to: _ 7im & Barb W�lf on, l OS White Rock Road, Yarmo � h�n�rt MA Whose place of business is: Camn Wingate-Kirkland Type of business: Food Service To o erate a food establishment in: Town f Y th p o armou Permit expires:_December 31. 1999 BOARD OF HEALTH:�d�/. �ef.��, �'�t�,r,��. �oan� �uLlivan,K.�, Vice C,hairmar� Ko�ert� O�irowr�, C.[er� � a�rFe6fa�ahol�ht�-.J�too ee � , � 'i/ic 0 u �lin � February 8 , 19 99 Bruce G. Murphy,MP RS , HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-6 FEE: $50.00 This is to ceraty that Jim&Barb.Wolfson d/b/a Camn Wingate-Kirkland 105 White Rock Road_ Yarmouth�ort_ MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERI�IIGHT CAMPS This Licen.se is issued in canformity with the authority granted to the Board of Health,by Chapter 140,S�tions 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and u�such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31, 1999 unless sooner suspended or revoked. Februxt,y 8 , 1999 BOARD OF HEALTH: �c`� �}elte�� iai�ma� ' • �oa�c � �utFlvan�K.�, Vice l��irman , ' , Ko�ert� i�rouin� l.[er� abriaGle�a�oldh�ooPed ' hael � ou�hlin ruce G. Murphy,MPH S. p Director of Health NUMBER FEE 93-6 THE COMMONWEALTH OF MASSACHUSETTS Yarmouth $50.00 .........Towrt..._........ of .......... .............••-•-•.............---.......... Board of Health Thie is co Cercify chac _..��?_.Winc�ate / Kirkland ..........................................._.......... ................................_ .....---•.............105..Whi�e_RQck_Rd_-,�__Yarmouthpor�....--•-....._........--- ..................•----•-.........--•--......_ HAS BEEN GRANTED A LICENSE To OPERATE � CABINS, � This License is issued in conformitv with the authority granted to the Board of HesIth, by Chapter 140, Sections 32A, 32B, 32C, 32D and 32E as amended, and is snbject to the provisions � of the Laws of thc Commonwealth of liassachusetts relating thereto, and upon sucl� terms and conditiona, and to the rules and regulations in regard to said Cam s or Cabins so licensed as adopted Ly the Board of Health, and expires D�}�er 31st-19.._��. u less so r suspeaded or revoked. r�� ....... . .. ......... .... -� -- - - - �- 1'�f.: . .. _. . . ..----�-------anuary...._.�..._.19.....93 --••--••--•-•-•---•• ----• - --� � Board -�-- -- - ----- ----•-•-•----.._.. ................... .. •---- .._.-� -�- - - --------�--•--.._..---• of ------.. . ..-�•- -�--�---�- -------� . --- --� --�--�- �----- ....... . ............,...-••.......... ........ Health ....... .. .. .....•-•-•- � Origina! License Fee �,�� G�lrj,L Renewal Fee ��- � ...... ........ •--... � . ............................. _... . r • .! FORM 5 ': A M SUIKiN �NC -�BOSTCV �617i 562-SB58 P,,, '��- � j --'--------------- -- `. . , . _....---- --. ... ____. . . '{: �-.