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Home My WebLink AboutApplication and WC TOWN OF YARMO TH � �'�'� � ��K APPLICATION FOR E ' <� � 17 � DEC � 5 2Q16 :�-�:� Ml >.�,.y . � * Please complete form and attach by censber 16 2016. Failure to do so will result in the return of your applicah -�� = ESTABLISHMENT NAME: _ T�x : LOCATION ADDRESS�9 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 �L.#;508.362.3798 MAILiNG ADDRESS: 79 WHITE ROCK ROAD YAR UTH P RT, M 2 75 E-MAIL ADDRESS: HEYSANDY@CAMPWK.COM OWNER NAME: SANDY & WILL RUBENSTEIN CORPORATION NAME(IF APPLICABLE):�N�NGATE KIRKLAND OPERATING LLC MANAGER'S NAME: SANDY & WILL RUBENSTEIN 'I'EL.#;508.362.3798 MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 FOOL CERTIFICATIONS: , The pool aupervisor mnst be certiffed as a Pool Operator,As required by State lAw. Please list the designated Pool Operator�s)ar�attach a copy of the certification to this form. 1. 2. Pool operators must list a minimwn of two employees curnently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employe.es below and attach copies of their certificadons to this form.The Health Department will not use past years' records. You must provide new cop�es and mAiob►in A file at your place of buainess. � L 2. 3. 4. FOOD PROTECTION MANAGERS-CER'ITFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Proteation Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application, T6e Heatth Department will not uae past years'records. You must provide new cop�tes and maintain a file At your establishmen� 1, THOMAS STARK 2, SANDY RUBENSTEIN PERSON IN CHARGE: Each food establishment must have at least orie Person In Charge(PIC)on site during hours of operation. '�j I.THOMAS STARK 2, SANDY RUBENSTEIN � � ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, � as defined in the State Sanitary Code for Food Service Establislzments, 105 CMR 590.009(Gx3)(a). Please attach copies of certification to this application. The Health Deparlment will not use past yenrs' records. You must � provide new copies And maintain a file at your establishment. C� 1,THOMAS STARK 2. SANDY RUBENST�IN � HEINfLICH 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 em loyees trained in anti-choking procedures below and n attach copies of employee certifications to this form. The ealth Department will not use past years' records. You must provide new copies and maintaiw a file at your place of business. � 1.T�iOMAS STARK 2, SANDY RUBENSTEIN 3.C__YNTHIA CLIFF�RD 4. WILL RU RESTAURANT SEATING: TOTAL# 175 OFFICE USE ONLY LODGIIVG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� SSS CAMP SSS —MOTEL S110 =I.ODGE SSS �LER PARK 5105 �3 =WHIRLPOOL�LS1�l0e�s. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-1�SEA'!'S 5125 CONTINETITAL S35 NON-PRO�IT S30 �>100 SEATS 5200 � �j� =COMMON VIC. S60 ��7 W[-jOLESALE S80 RETAIL SERVICE: —RES1D.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERM[T# LICENSE REQU[RED FEE PERMIT N <SOsq ft. S50 >25,000sq ft. 5285 =�25,000 sq.ft 5150 =FROZEN DESSERT �40 ='TOBA CO_F�$SIO NAME CHANGE: SlS AMOUNT DUE _ $;�`�� s *****PLEASE TURN OVER AND GOMPLETE OTHER SIDE OF FORM•**"* �3(S�� Bo�4�-t5-(lai-6Z �ti1�F- �5-t1o2-62 �� ADMINI�TRATION Under Chapter 1.52,Section 25C,Subsection 6,the Tovm 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 X 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 APP�tOPRIATELY IF PAID: � YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitadons of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 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)manth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L. c. 64G or 830 CMR 64G,as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to o ning. Contact the Health Department to sehedule the inspection three(3) days prior to opening. PLE SE OTE: Feople are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform arid standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. 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 forn�s can be obtained at the Health Department,or from the Town's website at www.�armouth.ma.us under Health Departcnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results � submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been me� OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�nust 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. NOTICE:Permits run annually from 3anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQiJfRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIpMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATION5 MAY Q SITE PLAN. � DATE: 1 ti16/16 SIGNATURE: PRINT NAME&TITLE: S Y UBENSTEIN OWNER/DIRECTOR Rev.10/!2/t6 , � The Com�nonwealtli of Massachusetts Depart�nent of Indus�b�iurl Accidents Off ce of I�vestigations 1 Congress Stree�Suite��(! Boston,MA OZ114-2017. www mas�gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv BusinessJOrganization Nazne: CAMP WINGATE*KIRKLAND Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT MA 02675 Phone#: 508.362.3798 Are yon an employer?Check the appropriate boa: Bnsiness Type(reqnired): 1.❑ I am a employer with $� employees(full and/ 5. ❑Retail or part-time).# 6. ❑ Resta.urantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �pff��d/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertaininent their right of exemption per c. 152,§1(4),and we ha.ve 10.�Manufacturing no employees. (No workers' camp.insurance required�* 4.❑ We are a non-profit organization,staffed by voluntcers, 1 l.(�Health Care with no employe�s. [No workeis' comp.insurance req.] 12•�Othe�' Childrens Summer Camp `�r�PPlic�t thffi chcd�s box#I must atso 5ll out the section below showing thea worloas'compensation Pulicy information. ••If the ooipo�ate offiars have exempted ttxmselves,but the oaporation has other employas,a workers'oomp�sation policy is required and such an organizatio�should chedc box#1. I am an employer that isprovlding workers'compensation In�irance jor my employee� Betow Ls thepo/i%y injormatlon. Insurance Company Name: THE PMA INSURANCE GROUP � Insurer's Address: 380 SENTRY PARKWAY P.O. BOX 3031 City/State/Zip: BLUE BELL, PA 19422-0754 Policy#or Self-ins.Lic.# 201601-02-91-40-1 Y �P�on�; 02/01/17 Attach A oopy of the workers'compensation poHcy declaration page(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the un�ositian of criminal penalties of a Sne up to a1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for ins�u�nce covera.ge verificarion. I do hereby eertify palns and p�naltles ofperjary that the�iiformation provtded above�s true and corree� ,� �' . DECEMBER 16, 2016 �. 508.3 798 Offlclal use onfj. Do not wr�te in this area,to be completed by city or town ojj''iciaL City or Town: PermitlLicense# Issuing Anthority(carcle one): 1.Board of Heatth 2.Bnitding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mags.gov/dia , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: AMSkier Agency,Inc. A.M.Skier Agency 209 Main Avenue lac No,�t►: 570-226�571;800-245-2666 jac,No�: 570-226-1105 E•MAIL Hawley,PA 18428 aooRess: amskier�amskier.com INSURER(S)AFFORDING COVERAGE NAIC# iNSUrteR a:Markel insurance Company INSURED yyingate Kirkland Operating LLC INSURER B:Th2 CO�YIrtI@rC@ InSU�allCe ; 79 White RoCk Road iNSURER C:PMA Insurance Group Yarmouth Port,MA 02675 INSURER D:EVet1St011 ' INSURER F: ' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OF INSURANCE ADDL SUB pOLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MMlDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OOO , X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED a 'I OO,OOO /� �CLAIMS MADE �OCCUR ❑ ❑ 8502CY4078712 2/1/2016 2/1/2017 MED EXP(Any one person) � ��,00� ' PERSONAL AND ADV INJURY $ 'I,OOO,OOO GENERALAGGREGATE $ S,OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PR�- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 'I,OOO,OOO X ANY AUTO BODILY INURY(Per person) $ ALL OWNED � SCHEDULED � � BODILY INURY(Per accident) $ A AUTOS AUTOS X HIREDAUTOS � NON-OWNED 1021CY0074071 2/1/2016 2/1/2017 pROPERTYDAMAGE ❑ AUTOS Deductible:Comp.;Coll. S 1000;1000 UMBRELLA UAB pCCUR EACH OCCURRENCE $ 1 O,OOO,OOO p EXCESS LIAB CLAIMSav1ADE � � MKLV10LE104605 11/1/2015 11/1/2016 AGGREGATE 1 0 0 DED RETENTION$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS �R C ANYPROPRIEfORIPARTNERIIXECUTIVE YM N/A 2016010291401Y 2/1/2016 2/1/2017 E.L.EACHACCIDENT $ 500,�p� OFFICEIMEMBER EXCLUDED? � ❑ E.l.DISEASE-EACH EMPLOYEE (Mandatary in NH) $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT a SOO,OOO ❑ ❑ DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate is confirmation of coverage. CERTIFICATE HOIDER CANCELLATION Wingate Kirkland Operating LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 79 White Rock Road Yarmouth Port,MA 02675 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE6 � HENRY M.SKIER �.� President � 1988-2010 ACORD CORPORATION.All riqhts reserved r °� TOWN OF YARMOUTH Bo�of � Health 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 • Telephone(508)398-2231,ext. 1241 Health Fax(508)760-3472 Division APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHII,DREN (Use back of applicstion If additional spaee is necessary) Name of Camp: CAMP WINGATE*KIRKLAND Site Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 Site Address: Tax ID Number(FEIN or SSI�: E-mail Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.) Hours of Operation: DatesofOperation: Opening: APRIL 1, 2017 Closing:__NOVEMBER 1, 2017 � (ON OR ABOU� Name of Camp Owner: SANDY & WILL RUBENSTEIN Office Address: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 Office Telephone Number. 508.362.3798 Name of Camp Operator(if different): Address: Telephone Number: Camp Director: SANDY & WILL RUBENSTEIN Address: 20 LINNELL LANE YARMOUTH PORT, MA 02675 Age: 44 Telephone Number. 508.362.3798 Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: SHANE PETERS Type ofMedical License: NURSE PRACTIONER Mp L�cense number: RN252623 Address: RO. BOX 441 MARSTONS MILLS, MA 02648 Telephone: °�'Q"s 1 of 3 Hospital for Emergeacy Services: CAPE COD HOSPTIAL Health Supervisor: MARY COLWELL Age: 65 Type of Medical License,Registration or Training: RN Swimming Area: Yes X No If Yes: Fresh Water X Ocean Pool CPO Specific Onsite Locations: BEACHFRONT LOCATED ON ELISHA'S POND Water Quality Tesring Performed By: BARNSTABLE COUNTY HEALTH LABRATORY Aquatics Director: Name: TO BE DETERMINED PRIOR TO WATERFRONT OPENINC�NE 1ST Lifeguard Certificate issued by: Exp. Date: American Red Cross CPR Certificate: Exp. Date: American First Aid Certificate: Exp. Date: Previous aquatics supervisory experience: Watercraifi/Boating Activities: Yes X No Describe: SMALL CRAFT BOATING: ROW BOAT, KAYAK, Compliant with Christian's Law: Yes X No CANOE AND SUNFISH Food Service: SAILING. Is food handles, served or prepared? Yes X No To what extent? Snacks Cooked and Served by Staff X If cooked onsite,Food Manager(submit copy of ServSafe) THOMAS STARK Catered if so,by whom? Is refrigeration available for perishable foods? Yes X No Fire Arms Instructor: Name: ACTIVITIES WITH FIRE ARMS ARE NOT OFFERED AT CAMP W*K National Rifle Assn. Instructor's Card(or equivalent} ' Date certified: Expiration Date: ��5 2 of 3 , Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and volunteer who may have contact with a camper? Yes X No IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1) WEEK PRIOR TO OPENIIVG TO SCHEDULE AN INSPECTION: THIS IS MANDATORY! OVEIZNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. By stgning this application, I acknow[edge that I have submitted all required documenta!tion and I am �n compl�ance with the State's minimum standards jor Recreational Camps for Ch�ldren,State S ode Chapter IV, 105 CMR 430.000. SIGNED: � pRINTED; S Y RUBENSTEIN DATED: DECEMBER 15, 2016 See the nezt 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 documeots as soon as possible and snbmit them in advance. This will expedite the process. � i °'�0i'15 3 of 3 Reauired Documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitazy Code, Chapter IV-105 CMR 430.000 and the guidance documents issued by the Department of Public Health, Division of Community Sanitation for additional assistance with developing the following documents. Check Documentc Submitted *Staff information forms(see attached).................................................................. *Procedures for the background review of staffand volunteers(105 CMR 430.090)............. *Copy of promotional literature(105 CMR 430.190(C))............................................. *Procedures for reporting suspected child abuse or neglect(105 CMR 430.093).................. *Health care policy(105 CMR 430.159(B)),including immunization records................... *Discipline policy(105 CMR 430.191).................................................................. *Fire evacuation plan—approved by local fire department(105 CMR 430.210(A)).............. *Disaster plan(105 CMR 430.210(B)).................................................................. *Lost camper plan(105 CMR 430.210(C))............................................................. *Lost swimmer plan(105 CMR 430.210(C))........................................................... *Traffic control plan(105 CMR 430.210(D)).......................................................... *Day Camps—contingency plan(105 CMR 430.211)................................................. *Primitive, Trip or Travel Camps — Written itinerary, including sources of emergency care and contingency plans(105 CMR 430.212).............................................................. *Current certificate of occupancy from local building inspector(105 CMR 430.451)............ *Written statement of compliance from the local fire department(105 CMR 430.215)........... *Aquatic plan,including Christian Law,PFD fitting tests,water testing and swim tests...... Attach the names, ages, applicable current certifications (if any), such as First Aid, and the anticipated role at the camp of all supervisory staff(see below). Use as many pages as necessary to complete this. Please: If you are applying for an original camp license for a camp based in Yarmouth, you must file a plan showing the following with the board of health at least 90 days before your desired opening date(See MGL Ch. 140 § 32A): ➢ Buildings, structures, facilities and fixtures ➢ Proposed source of water supply ➢ Works for disposal or sewage and waste water Sunervisory staff means those persons with the responsibility, authority and training to : provide direct supervision to camper groups. This may include counselors, junior counselors, general activity leaders or other staff who provide supervision to campers without assistance. ��s