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Home My WebLink About2025-26LICENSE FEE $ I50 l+ TOWN OI' YAR}IOUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION CONIPLETE THIS APPLICATION AND RETURN IT WITH THE LICEN-SE FEE BY JUNE 30, 2025 cr&0'\q PLEASE COTITPLETE ALL OUESTIONS NArvrE or- BUSINESS Camp Winqate'Kirkland IlL;SlNtrSS I l:l ,, 508-362-3798 BUSINESS ADDRESS IN YARMOUTH 79 White Rock Road Yarmouth Port, MA 02675 BEQIJIBEIMANAGER/CONTACTPERSON SANdYRUbENStEiN TELEPHONE# 5NR.362.379R ('ORPORATION ADDRESS- tsEIllJ.ltsEDowNER NAME Sandy Rubenstein t'EL.# 508-362-3798 HOMEADDRESS 20 Linnell Lane Yarmouth Port, MA 02675 MAILTNG ADDRESS 20 Linnell Lane Yarmouth Port, MA 02675 TAx ID (FEIN OR SSN)REQUIruD 52-2443840 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. tT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30, FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check aoorooriatelv ifoaid: ves no rva Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed Workers Compcnsation Affi davit, lf not aDplicablc. oleasc cxolain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORK.ERS COMP AFFIDAVIT ENCLOSED N ALL SAFETY DATA SHEETS ON FILE YN ANY NEW CHEMICALS NIUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RF,NEWAL APPLICATION NEW APPLTCATION- APPLICANT'S SICNATURE pa1g 06/11/2025 MAILTNG ADDRESS 79 White Rock Road Yarmouth Port. MA 02675 F.MArr ADDRESS hevsandv@CamOWk.COm coRpoRATroN NAME (rF APPLTCABLE)wingate Kirkland operating LLC rEL. fl 508-362-3798 ACORD CERT!FICATE OF LIABILITY INSURANCE OATE Ii'M'DO/YY] 4t9t2025 THIS CERT1FICATE IS ISSUEO AS A MATTER OF INFORMATIOI{ ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ,:ERIIFICATE DOES NOT AFFIRMANVELY OR NEGATIVELY AItEND, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES 6elow. rxts cennncarE oF rNsuRANcE DoEs Nor cor{srrurE a coNTRAcr BETwEEN THE rssurNG rNsuRER(S), AUTHoRTZED REPRESEI{TATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER. IMPORTANT: lf ths certlficate holder ls an ADDITIONAL lt{Sl,rREO, tho policy(ies) must have ADOITIONAL INSUREO provisions or be endorsed, tf SUBROGAIION lS WA|VEO, subiect to tho terms and conditions oI the policy, csrtaln policiss may roquiro an sndoEoment. A staloment on this cortificate does not confet rights to the certiticate holder in ligu ol such endorsement(s). AMSkier Agency, lnc. lA/c,No): 570'225'1105A. M. Skier Agency 209 Main Avonuo Hawley, PA 1842E 570-2264571; 800-245-2666 amskior@amskier.com INSUREO INSURER A K A K Insurancs Group, lnc INSURER B PMA Insurence Group NSURER C CRC REVISION NUMBER: NAIC # 23850 $ 1,000,000 Camp Wingats Kirkland 79 Whlts Rock Road Yarmouth Port, I$A 02675 NSURER O COVERAGES THIS IS TOCERTIFY THAT THE POLICIES OF INSURANCE LISIED BELOW HAVE BEEN ISSUEO TO T}IE INSUREO NAMED ABOVE FOR THE POLICY PERIOD INOICAIED. NOTWTHSTANDING ANY REQUIREMENT, IERM OR COI{DMON OF ANY COIITRAC] OR OTHER DOCUMETITWIIH RESPECTTO WHICH THIS CERTIFICATE MAY AE ISSUEO OR MAY PERTAIN, THE I SURANCE AFFOROED BY THE POLICIES DESCRIAED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIOXS A}lD CONDIIIONS OF SUCH POLICIES. LIMITS SHOWiI MAY HAVE BEEiI REOUCED BY PAIO CLAIMS' INSR LTR IYPE OF INSURAI{CE s POLICY EXP LIMITS EACH OCCURRENQE ERAL UASILITY .1]occun t_.i_ GEML AGGREGATE TIIIIT APPTIES PER: E OAMAGE IO RENTEO 2t1t2026 PERSONAL ANO AOV INJU RY GENERALAGGREGATE .COMP/OPAGG COMBINEOSINGLE I MIT @DILY INURY (F'oT P€rso.) 21112026 Deductible Comp iColl ECT AUTOMOBILE LIABILIIY A1A0004,125003301 211t2025 AlLOWNED AUIOS HIREOAUIOS LOC -- l scHeouro: AUTOSv NON-OWNEO4 Auros trtr 2t112025 UMBRELLA L|AE _occuR 1+ n EACH OCCURRENCE 11t112025 AGGREGATE B tr irKLv1EULr04824 11t1t2024 T-wc sraru- f oi[ ronv uu,rs I ER ANO EMPLOYERg LIABIUTY ANY PROPRI€TOR,PARTNER]EXECUII!,E OFACErcIBER EXCLUO€M nFs:RlPnoN oF oPF RATTONS b.b* vr ii Jl 20250'l02el'olY 2t 2t1t2026 E L EACHACCIOENI E L DISEAS€ . E,ACH EIfLOYEE S soo,ooo E L DISEASE . POLICY UUT $ 500,000 ! OESCRIPTIOI{ OF OPEiAnONS/LOCAIIONS/VEI||ICES ( tt ch ACORD lol, Add on.l R.mrlc Sch.dul., ll mE .p.ce l. rlqulr.nl Confl rmatlon ol Covarage. rr.rsuRER(s) AFFoRDTNG COVERAGE $ 1,000,000 $ t $ $ $ 1,000,000 3,000,000 5,000 r,000,000 3,000,000 $ BODILY INURY (Pera@de.t)5 $ 1000;1000 $ 5,000,000 s 500,000 N CERTIFICATE HOLDER CANCELLATION Camp Wingate Kirkland 79 White Rock Road Yarmouth Pon, MA 02675 SHOULOANY OF THEABOVE DESCRIBEO POIICIES BECANC€LLED BEFORE THE EIPIRATION OAIE THEREOF. NOTICEWLT BE OELIVEREO IN ACCOROANCE WIH IHE POLICY PROVISIONS, AUTHOiIZEO REPRESENTATVE6 HENRY M. SKIER Prosldont o 1988-20i0 ACORO CORPORATTON. Att rtghts rG€rvsd lhg ACORO namo and logo a.e reglstercd marks ofACOROACORD 25 (2016/03) CERTIFICATE NUMBER: POLICY NUMAER n 1 ArPooo345o39s5or -l +F t- oeo ftqeurrijr x s WORKERS COMPENSATION x I