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HomeMy WebLinkAboutApp-License-Certifications .---\ TOWN OF YARMOUTH BOARD OF HEALTH '; APPLICATION FOR LICENSEIPERMIT- 2022 r� (` ' ' 021 * _ Please complete form and attach all necessary documents by December 18, 2021. r Failure to do so will result in the return of your application packet. 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 ROOD 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. 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 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 file at your establishment. I. 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 tile at your place of business. 1. THOMAS STARK 2. SANDY RUBENSTEIN 3. JUIlITH JACKSON 4. ICII DA BFI L RESTAURANT SEATING: TOTAL # 175 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $110 INN $55 _CAMP $55 —SWIMMING POOL$I IOea. LODGE $55 _TRAILER PARK $105 WHIRLPOOL $1 IOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 NTINENTAL $35 _NON-PROFIT $30 7>I00 SEATS $200MMON VIC. $60 _WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sqq ft. $50 >25.000 s ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ . ki"--) *****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. 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 18, 2020. ALL RENOVATIONS TO ANY FOOD ESTABLIS MEN , MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AN APPROVE E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ RE% ITE PLAA. DATE: 12/7/2021 SIGNATURE: /• PRINT NAME &TITLE: SANDI RUBENSTEIN OWNER & DIRECTOR IZo 1(1/1'i/19 /7.-111 The Commonwealth of Massachusetts Fee Town of Yarmouth $55.00 Lodging License Number: BOHL-15-1101-07 Issue Date: 1/1/2022 Mailing Address: Location Address: WINGATE KIRKLAND OPERATING LLC 79 WHITE ROCK RD CAMP WINGATE*KIRKLAND Yarmouth Port. MA 02675 79 WHITE ROCK ROAD YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Camp This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 4111 A I Bruce '. Murphy, 'H, ' .'., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-15-1102-07 Issue Date: 1/1/2022 Mailing Address: Location Address: WINGATE KIRKLAND OPERATING LLC 79 WHITE ROCK RD CAMP WINGATE*KIRKLAND Yarmouth Port, MA 02675 79 WHITE ROCK ROAD YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston41i A / a Bruce G. Murphy, P R.S.,CHO Health Director ..o --=_ TOWN OF YARMOUTH '` =• ;„ r 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS - _ ����\N,......_ 02664-24451 Telephone(508)398-2231, ext. 1241 '3 2°2\ Fax(508) 760-3472 \ . ,T. 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): 52-2443840 E-mail HEYSANDY@CAMPWK.COM Type of Camp: Day (less than 24 hrs.) X Residential(24 hrs.) X Hours of Operation: Dates of Operation: Opening: APRIL 1, 2022 Closing: NOVEMBER 15, 2022 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: 48 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 04/30/15 1 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 Sanitary Code Chapter IV , MR 430.000. SIGNED: � PRINTED: C./SANDY RUBENSTEIN DATED: 12/7/2021 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. \ ` 3 211 04/3015 3 of 3 s► 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 Conttnonwealth of Massachusetts Department of Industrial Accidents I= �_� � Office of Investigations i 1 Congress Street, Suite 100 ��,, "''� :,..,,--i Boston, MA 02114-2017 -F-,t 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 employees (full and,' 5. ❑ Retail or part-time).* 6. E. Restaurant/Bar/Eating Establishment 2.j] 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. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 1 DEC 1 ? 7 n 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, l 1 ❑ Health Care with no employees. [No workers' comp. insurance req ] l2.® Other SUMMER CAMP *Any applicant that checks box #I 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: PMA INSURANCE GROUP Insurer's Address: 380 SENTRY PARKWAY P.O. BOX 3031 City/State/Zip: BLUE BELL, PA 19422 Policy #or Self-ins. Lic. # 1021010291401Y Expiration Date: 2/1/2022 Attach a copy of the workers' compensation policy declaratiion 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 Investigation ,. IA for insurance coverage verification. I do hereby rtify, under and penalties of perjury that the information provided above is true and correct. Signature: /1" Date: 12/7/2021 Phone#: 8-362-3798 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.gr v'di 1 ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YY) 3/24/2021 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 FAX (A/C,No,Ext): 570-226-4571;8004454666 (Afc,No): 5704264105 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 e: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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DDNYYY) (MM/DD/YYYY) GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 1,000,000 X PREMISES(Ea occurrence) B ' CLAIMS MADE X IOCCUR ❑ ❑ 8502CY4078717 2/1/2021 2/1/2022 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 —PRO- LOC JECT $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ ALL OWNED SCHEDULED ❑ ❑ BODILY INURY(Per accident) $ _ AUTOS AUTOS HIRED AUTOS NON-OWNED DAMAGE AUTOS $ Deductible: $ .^ UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE DED RETENTION$ 1 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $ 500,000 A OFFICEMIEMBEREXCLUDED7 I N N/A 1112021010291401Y 2/1/2021 2/1/2022 (Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE $ 500,000 IDESC PON OF OPERATIONS below EL DISEASE-0OUCY UMT $ 500,000 ❑ ❑ I DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCES U�j , S(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Confirmation of Coverage. L . ! - 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 © 1988-2010 ACORD CORPORATION.All rights reserved ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD