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HomeMy WebLinkAboutApplication and WC 4 El TOWN OF YARMOUTH BO• ' ) t ALTIL 2 APPLICATION FOR LICENSE ' s i ' , ' EALTH DEPT.' .. , * Please complete form and attach all necessaioc ments 's'December 13,2019. OPS' Failure to do so will result in the return of your application NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN packet. NY NOVEMBER 15g. ESTABLISHMENT NAME: CAMP WINGATE KIRKLAND TAX ID: LOCATION ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 TEL.#:508-362-3798 MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 E-MAIL ADDRESS: HEYSANDY@CAMPWK.COM OWNER NAME: SANDY&WILL RUBENSTEIN CORPORATION NAME(IF APPLICABLE): WINGATE KIRKLAND OPERATING LLC MANAGER'S NAME: SANDY&WILL RUBENSTEIN TEL.#: 508-362-3798 MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 POOL 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. 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 file at your establishment. 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. JUDITH JACKSON 4. ICILDA BELL RESTAURANT SEATING: TOTAL# 175 60*c.-t5.-ItOt 000 -4S-t t(31-0/5— OFFICE 0Z-05OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _LODGE $55 LCAMP $55 "' -SWIMMING POOL$110ea 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-PROFIT $30 1:>100 SEATS $200 (43 1_COMMON VIC. $60 _�p..4.te3c WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.& $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'r0O *****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 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 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. 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 opening. Contact the Health Department to schedule the inspection three (3) days prior 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 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,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 in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: 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. 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 13,2019. 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 Q IRE A SITE PLAN. DATE: 11/25/19 SIGNATURE: ' PRINT NAME&TITLE: (J NDY RUBENSTEIN OWNER& DIRECTOR Rev.10/15/19 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY) 5/24/2019 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 w4ME: AMSkier Agency,Inc. A.M.Skier Agency PHONE FAX (A/C,No,at): 570-226-4571;800-245-2666 (A/C,No): 570-226-1105 209 Main Avenue 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:Markel Insurance Company 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE AMA sr°Rrr e� $ 1,000,000 B CLAIMS MADE X OCCUR ❑ ❑ 8502CY4078715 2/1/2019 2/1/2020 MED EXP(Any one person) $ 15,000 PERSONAL AND ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ ALL OWNED SCHEDULED ❑ en ❑ BODILY INURY(Per accident) AUTOS AUTOS $ HIRED AUTOS AONOSWNED PROPERTY DAMAGE Deductible: $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT A OFFICEIMEMBEREXCLUDED? N I WA ❑ 2019010291401Y 2/1/2019 2/1/2020 $ 500,000 (Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE $ 500,000 Ir yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 ❑ ❑ DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Confirmation of Coverage. CERTIFICATE HOLDER 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 REPRESENTATIVES HENRY M.SKIER President m 1988-2010 ACORD CORPORATION.All rights reserved ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ,, .....r TOWN O F YARMOUTH Board of c Health '�`$ i 1 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health 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) FEE: $55.00 Name of Camp: CAMP WINGATE*KIRKLAND Site Address: 79 WHITE ROCK ROAD Site Address: YARMOUTH PORT, MA 02675 Tax ID Number(FEIN or SSN): E-mailHEYSANDY@CAMPWK.COM Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.) Hours of Operation: Dates of Operation: Opening: APRIL 1, 2020 Closing: NOVEMBER 15, 2020 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: 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 Age: 46 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 Address: 403 QUAKER MEETINGHOUSE RD SANDWICH, MA Telephone: 347-628-9290 04.,30,5 1 of 3 Hospital for Emergency Services: CAPE COD HOSPITAL Health Supervisor: EMILY JOHNSON Age: 39 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: SAM KAUFFMAN Age: 22 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: Compliant with Christian's Law: Yes X No Food Service: Is food handles, served or prepared? Yes X No To what extent? Snacks X 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: 44!30/15 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 com liance with the State's minimum standards for Recreational Camps for Children,Stat an ary Code Chapter IV, 105 CMR 430.000. ;�. SIGNED: PRINTED: `SANDY RUBENSTEIN DATED: 11/25/19 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. 04,3075 3 of3 Required Documents 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. 04'30,15 The Commonwealth of Massachusetts Department of Industrial Accidents _s1 Office of Investigations = �= k 1 Congress Street, Suite 100 S11 != Boston,MA 02114-2017 p' 10' 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, MA 02675 Phone#: 508-362-3798 Are you an employer?Check the appropriate box: Business Type(required): 1.® 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, 0 Office and/or Sales(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. 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.© Other 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#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: THE PMA COMPANNIES Insurer's Address: P.O. BOX 3031 380 SENTRY PARKWAY City/State/Zip: BLUE BELL PA 19422-0754 Policy#or Self-ins.Lic.# E201901-02-91-40-1Y Expiration Date: 02/01/20 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 hereby c rtify,-under the pains and penalties of perjury that the information provided above is true and correct. ' - 11/25/19 Signature: Date: Phone#: ( 308-362-3798 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/dia