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HomeMy WebLinkAboutApplications and WC [tag �/I ALJ NOV 3 0 2018 TOWN OF YARMOUTH BOARD OF HEALTH , APPLICATION FOR LICENS ' ;1 T: 019, ;Y HEALTH DEPT (C5\` � Please complete form and attach all n- �`` R u r 15 2018. * �.�tac by�Dfjibe NOTE:ALL BUSIN SES WITHLJQUQR LICENSES i LST REI IRNFORMS BY NOVEMBER 1.0. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: CAMP WIN(ATF*KIRKI AND TAX ID: LOCATION ADDRESS: 79 WHITF RACK ROAD YARMOUTH PORT, MA 02R75TEL.#: 508 369_3798 MAILING ADDRESS: 7A WHITF ROCK ROAD YARMOl1TH PORT, MA 02675 E-MAIL ADDRESS: HEYSANDY@CAMPWK.COM OWNER NAME: SANDY 14 WII L RURENSTFIN CORPORATION NAME(IF APPLICABLE): WINGATE KIRKLAND OPERATING LLC MANAGER'S NAME: SANDY & WILL RUBENSTEIN TEL.#: 508.362.3798 MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 POOL 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 employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past yearsrecords. You must provide new copies and maintain a file at your place of business. I. 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. 1. THOMAS STARK 2. SANDY RUBENSTEIN PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 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 Establishments, 105 CMR 590.009(G)(3)(a). 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. 1. THOMAS STARK 2. SANDY RUBENSTEIN 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-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. THOMAS STARK 2. SANDY RUBENSTEIN 3. CYNTHIA CLIFFORD 4. WILL RUBENSTEIN RESTAURANT SEATING: TOTAL# 175 L3ott tr—ts—t l a t--o BOW.-ts- Ito 2,-01 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 NN $55 ICAMP $55 -'. .-• =SWIMMING POOL$1l0ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PRO $30 j>100 SEATS $200 -#.1 I-0E16 1 COMMON VIC. $60 14-11-46-6-56- WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT# X50ft $50 >25,000 sq.ft. $285 VENDING-FOOD $25 —<25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 315.0C) PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 APPROPRIATELY IF PAID: YES X 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 use. 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 shall not be considered transient Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L. c. 640 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 inspectedby the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3rior to opening.PLEASE NOTE:People 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 and 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 Departmenty filing the required Temporary Food Service Application form 72 hours prior to the catered event These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth,ma.us under Health Department,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 m 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 Heath. OUTDOOR COOKING: Outdoor cooking preparation,or display of any food product by a retail or food service establishment isP rohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO = PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ` Q 4 i DATE: 11/30/18 SIGNATURE: PRINT NAME&TITLE: SA 1 V RUBENSTEIN OWNER/DIRECTOR Rev.I0n3/18 (14:— TOWN OF YARMOUTH Board of Health \i,- 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451Health Telephone(508)398-2231,ext. 1241 Fax(508)760-3472 Division APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space 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 SSN): E-mail Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.) Hours of Operation: Dates of Operation: Opening: APRIL 1, 2019 Closing: NOVEMBER 15, 2019 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: 45 Telephone Number: 508.362.3798 Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: DR. BONNIE ARZUAGA Type of Medical License: MD MA License number: 258069 403 QUAKER MEETING HOUSE ROAD Address: EAST SANDWICH, MA 02537 Telephone: 347-628-9290 04130!15 1 of 3 Hospital for Emergency Services: CAPE CID HOSPTIAL Health Supervisor: FMJI V JOHNSON Age: 38 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 Testing Performed By: BARNSTABLE COUNTY HEALTH LABRATORY Aquatics Director: Name:TO BE DETERMINED PRIOR TO WATERFRONT OPENING AIME 1ST Lifeguard Certificate issued by: Exp. Date: American Red Cross CPR Certificate: Exp. Date: American First Aid Certificate: Exp. Date: Previous aquatics supervisory experience: Watercraft/Boating Activities: Yes x No Describe: SMALL CRAFT BOATING: ROW BOAT, KAYAK, Compliant with Christian's Law: Yes X No CANOE AND SUNFISH SAILING. Food Service: 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: 04/30/I5 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 OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. By signing this application, I acknowledge that I have submitted all required documentation and I am in compliance with the State's minimum standards for Recreational Camps for Children,State . nt , ode Chapter IV, 105 CMR 430.000. SIGNED: PRINTED: S ►,Y RUBENSTEIN DATED:NOVEMBER 30, 2018 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 process. 04/30/15 3 of 3 Required Documents Text See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary 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 Documents Submitted *Staff information forms(see attached) *Procedures for the background review of staff and 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 Supervisory 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. ** PER SANDY'S CONVERSATION WITH PHIL RENAUD ON 11/30/19** REQUIRED DOCUMENTS WILL BE PRESENTED AT PRE-INSPECTION MEETING WITH HEALTH DEPARTMENT IN MAY 2018. FOLLOWED BY A 0 4 "0/15 SITE INSPECTION JUNE 2019. The Commonwealth of Massachusetts ,. _ ____ Department of Industrial Accidents > i y� Office of Investigations n ' 1 Congress Street,Suite 100 a''_ Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:CAMP WINGATE*KIRKLAND _ Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT 02675 Phone#:508.362.3798 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 80 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ID Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees.[No workers'comp insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.5EI Other Childrens Summer Camp *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. Iam an employer that is providing workers'compensation Insurance for my employees. Below is the policy information. Insurance Company Name: A.M. SKIER AGENCY 209 MAIN AVENUE Insurer's Address: City/State/Zip: HAWLEY, PA 18428 Policy#or Self-ins.Lic.# 201801-02-9140-1Y Expiration Date: 02/01/19 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herehy ill , nder the pains and penalties of perjury that the information provided above is true and correct. Signature ,," Date:NOVEMBER 30, 2018 Phone#: L5363798 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): ` 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/die ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYY) 9/24/2018 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 PHONE Ext): 570-226-4571;800-245-2666 FAX No): 570-226-1105 209 Main Avenue E-MAIL Hawley,PA 18428 ADDRESS: amskier@amskier.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:pMA Insurance Group 23850 INSURED Wingate Kirkland Operating LLC INSURER B: 79 White Rock Road INSURER C: Yarmouth Port,MA 02675 INSURER D: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDNYYY) LIMBS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PRFUISFS(Fa occurrence) CLAIMS MADE OCCUR ❑ ❑ MED EXP(Any one person) $ PERSONAL AND ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY —PRO- LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ AALL UTOS OWNED SCHEDULED ❑ ❑ $ BODILY INURY(Per accident) HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE Deductible: $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICEMMBEREXCLUDED? N WA ❑ 2018010291401Y 2/1/2018 2/1/2019 (Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 600,000 ❑ ❑ DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Confirmation of workers'compensation insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVES 44.4104)644,0=...,1 HENRY M.SKIER President © 1988-2010 ACORD CORPORATION.All rights reserved ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD