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Home My WebLink AboutApplication and WC P W�NGXtt'E - s-ifC7�.xarar � d �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATTON FOR LICENSE�P�I�� '� ��;,'y � ' 2U il `� * Please complete form and attach all necess�ry�lo : eh ec be �,�.�EPT Failure to do so will result in the tetum-of yCiurappiication p ESTABLISHMENT NAME: CAMP WINGATE*KIRKLAND TAX ID• LOCATION ADDRESS79 WHITE ROCK ROAD YARMOUTH PORT MA 02675 TEL.#: 508.362.3798 MAILING ADDRESS: 79 WHITE ROCK ROAD YARMOUTH PORT MA 02675 E-MAILADDRESS: SANDY & WILL RUBENSTEIN OWNER NAME: CORPORATION Nt1ME(IF APPLICABLE): WlNGATE KIRKLAND OPERATING LLC MANAGER'S NAME;SANDY & WILL RUBENSTEIN TEL #• 08 6? ��q8 MAILING ADDRESS:79 WHITE R K POOL CERTIFICATIONS: The poo[sapervisor musf be certified as a Pool Operator,as required by State Iaw. Ptease tist 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 basic water safery, siandazd First Aid and Community Cardiopulmonazy Resuscitation (CPR), having one certified employee on premises at all times. Please list the emptoyees below and attach copies of their certifications to thzs for�n. The Health Department witl not use past years' records. You must provide new copies and maintain a file at your place of business. ]. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIF'ICATIONS: All food service establishments aze 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 pastyears'records. You must provide new copies and maintain a file at your establishment. 1. THOMAS TARK ?. SANDY RUBENSTEIN PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. THOMAS STARK 2, SANDY RUBENSTEIN ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-tima 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 establishmeet. 1, THOMAS STARK 2 SANDY RUBENSTEIN HEIMLICH CERTIPICATIONS: 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 wili not use past yeats' records. You must provide new copies and maintain a file at your place of business. t, THOMAS STARK 2. SANDY RUBENSTEIN 3.GYIVTHIA CLfFFORD 4.WILL RUBENSi'EIN RESTAURANT SEATING: TOTAL# ��$ OFFICE USE ONLY LODGING: LICENSEREQUIRED FEE PERM[T# L,iCENSEREQUIRED FEE PERMIT# LICENSEREQUfRED FEE PERMIT# S&B $55 CABIN $55 MOTEL $110 INN $55 1� CAMP $55 .�� 'SWIMMINGPOOL$IlOea �..ODGE $55 _7RAILERPARK SI05 _WHIRLPOOL $IIOea. FOOD SERVICE: LICENSE REQUIRED F6E PERMIT fl LICENSE REQUIRED FEE PERMtT# LICENS&REQUIRED FEE PERMIT# 0-100 SEATS $125 CONT[NENTAL $35 NON-PROFIT $30 T>t00 SEATS �200 f� =COMMON ViC, $60 �'J WHOLESALE $80 —RESID.KITCHEN $80 IiETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED �EE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $I50 _FR02ENDESSERT $40 =TOBACCO 3110 NAME CHANGE: $IS AMOLTNT DUE _ $ IS • 'k*°*PLEASETURNOVERANbCOMPLETEOTHERSIDEOFFORM***** �`�-�-� ZZ`� C,h:-�'?Z�`{ 1� 1"� ��`1 ' ADMINISTRATION Under Chapter.152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or'pernut to operate a business if a person or company does not have a Cer[ificate of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSi.IRANCE 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 X NO MOTELS AND OTHER LODGING ESTASLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the ternporary and short term occupancy,ordinarily and customazily 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 shatl 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 OPEPTING: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 Departrnent to schedu(e the inspecHon three (3) days prior to opening. PLEASE NOTE: People aze 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 Heaith 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(�days of closing. FOOD SERVICE 5EASONAL FOOD SERVICE 4PEI�TING: 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 Yazmouth Heaith 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.varmouth.ma.us under Health Deparlment, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sarnple resutts submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above tertns have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts 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, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUI SITE PLAN. � DATE: 11/`20/14 SIGNATURE: � PRINT NAME & TITLE: SA D RUBENSTEIN OWNER/DIRECTOR Re¢ lll03/14 � The Comrnonwealth ofMassachusetts Department oflndustrialAcctdents Offace oflnvesfigations 1 Congress Street, Suite 100 Boston, MA 02114-20I7 www.mass.gov/diu Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Leeiblv Business/Organization Name: CAMP WINGATE*KIRKLAND Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT MA 02675 Phone #: 508.362.3798 Areyou an employer?Check the appropriate box: Busiaess Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partneiship and have no 7, � p�ce 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 aze a corporarion and its officers have exeroised 9. ❑ Entertainment their right of exemption per c. 152, §l(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance requiredj* I1.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other Chlldrens Summer Camp *My applic�t tha[checks box#1 must also fill out the section below showing their workers'compensation policy informaiion. "'If the corporate officers have exempted themselves,but the coiporation has other employees,a workers'compensatioa policy is required and such aa organization should check box iit. I am an employer that is provideng workers'compensation insurance jor my employees. Be[ow is the policy information. Insurance Company NameTHE 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. # 201401-02-91-40-1 Y Expiration Date: 02/01/15 Attach a copy of t6e workers' compensation policy declaration pase(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penakies 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 forwazded to the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certi ,un e d penaUies of perjury that the injormation provided above is true and correM. Si ature: r f Date:NOVEMBER 20, 2014 Phone#: 508.3 3798 Official use only. Do not write in this area, to be comp[eted by city or tawn oJficiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1. Board of Aealth 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: ,�..,.,,m,��o,.,,r.�:a ACORD ,M CERTIFICATE OF LIABILITY INSURANCE �ATE�MM/DD/YY� 3/25/2014 ' 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 REPRESENTATNE 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 tloes not confer rights to the certifiwte holder in lieu of such endorsement�s�. �� PRODUCER '�CONTACT nnre: AMSkierAgency,lnc. A.M.SkierAgency �rHONe Fau 209 Main Avenue lac,eo,�q: 570-226-4577;800-245-2666 I �q�c,No�: 570-226-1105 E-MAIL Hawley,PA 18428 nooness: amskier@amskier.com INSURER(S)AFFORDING COVERAGE NAIC# iNSUaea w Markel Insurance Company , INSURED W�n9aS2 KI�klBfld OrCI'OIIOQ LLC ,'INSURER B:ThE CORII112fCE IOSOfdfICB �' 79 White Rock Road iNsuaea c pMq��surance Group '�, Yartnouth Port,MA 02675 INSURER D:EWnSWD INSURER F: _— �_'- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: � THIS IS TO CERTIFY 7HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTNITHSTANDING ANY REOUIREMENT,7ERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER7IFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEC7 70 ALL THE 7ERMS, , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. ' INSR rypE OF INSURANCE ADOL SUB pp��y NUMBER oO�ICY EFF POLIGV EXP LIMffS LTR INSR WVD (MMIDD/YYYY) (MM/OD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ ��OOO�OOO X COMMERCIALGENERALLIABILIN OAMAGETORENTED E 'IOO�OOO A ❑CLAIMSMAOE �X oCCUR ❑ ❑ $502CY4078710 2I7I2014 2N/2075 MEDEXP(Myoneperson) E 5�000 ' PERSONALAN�ADVINJURV $ 7�000�000 �' � GENERALAGGREGATE $ $�OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 1�000�000 ' ��,POLICV '.PRO- LOC - JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1�OOO�OOO i X ANVAUTO BOOILVINURV(Perperson) f AILOWNED � SCHEOUIED B AUTOS AUTOS ❑ ❑ BODILVINURV(Peracciden�) S X HIREOAUTOS � NON-0WNED 12MMRXJ710 SM/2O7$ 9N/YO'I4 pROPERTYDAMAGE ❑AUTOS Detlucuble:Comp.;Coll. j 1000;1000 UMBRELLALIAB OCCUR EACHOCCURRENCE $ 10�000�000 p EXCESSLIAB CLAIMSi�MDE � � XONJ493712 17/1I2013 ��/2��4 AGGREGATE � DED RETENTION$ �I WORKERS COMPENSAiION WC STA7U- OTH- '�.. ANU EMPLOVERS'LIABIIRY TORV LIMITS ER '�, ANYPROPRIETORIPARTNERIEXECUfIVE �M E.L.EACHACGDEM C OFFICE�MEMBEREXCLUOED7 �N N�A ❑ 2014010297407Y 2N/20�4 2I112075 $ $�� ' R�AantlaWryinNM E.L.OISEASE-EACHQAPLOYEE $ $DO,000 «re:,a�o��a�r DESCRIP710NOFOPERATIONSbebw EI.DISEASE-POLICYIIMIT E SOO�OOO ❑ ❑ DESCRIPTION OF OPERATIONSiLOGATIONSIVEHIlCES(AHach ACOR0101,Adtlitional Rema�ks Schatlule,If more s0ace is required) Certificate is confirmation of coverege '� CERTIFICATE HOLDER CANCELLATION �I Wingate Kirkland Operating LLC 79 White Rock Road SHOUlO ANV OF THE ABOVE DESCRIBED POLIGIES BE CANCELLEO BEFORE YaRIIOU�h POR�MA 02675 THE EXPIRATON DA7E THEREOF,NOTICE WILL BE UELIVERED IN ., ACGORDANCE WITH THE POLICY PROVISIONS. '. ,AUTHOR¢EDREPRESENTATNEB '��. HENRY M.SKIER � �� President . � 1988-2010 ACORD CORPORATION.All rights reserved ACORD 25(2010I05) The ACORD name and logo are registered marks of ACORD °F r TOWN OF YARMOUTH BT � Board of _ �` y Health = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 � � � Telephone(508)398-2231,ext. 1241 Health Fax(508) 760-3472 �"�"�—�`iO° 2��4 APPLICATION FOR A LICENSE TO CONDUCT A HEALTH DEPT. RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) �9.bt 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. 2015 Closing: 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: 42 Telephone Number: 508.362.3798 Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consuitant: SHANE PETERS Type ofMedical License: NURSE PRACTIONER MA License number: RN252623 Address: P•O. BOX 441 MARSTONS MILLS, MA 02648 Telephone: �0:�9��3 1 of2 Hospital for Emergency Services: CAPE COD HOSPTIAL HealYh Supervisor: MARY COLWELL Age: 64 Type of Medica]License,Re�istration or Train'rng: 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:TO BE DETERMINED PR10R TO WATERFRONT OPENING JUNE 1ST Submit Certifications: CPR First Aid_ Water Safety` Other Lifeguards and Credentials: Watercraft!@oating Activities: Yes X No� Describe:SMALL CRAFT BOATING: ROW BOAT, KAYAK, Food Service: CANOE AND SUNFISH SAILING. Is food handles, served or prepazed? Yes X No_ To what e�ctent? Snacks� Cooked and Served by Staff X lf cooked onsite,Food Manager(submit copy of ServSafe) THOMAS STARK Catered_ If so,by whom? Is refrigeration availab(e for perishable foods? Yes X No` Background Checl:s: Has the Camp Owner or D'uector obtained and reviewed the COR1 and SORI of each staff person and volunteer who may have contact with a camper? Yes X No_ IMPORTANT! CONTACT THE YARMOUTA HEALTEi DEPARTMENT 48 HOURS PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS I5 MANDATORY! OVEI2NIGHT CAMY5 MUST ALSO SCHEDULE AN INSPECTION WTTH THE BUTLDING A1VD FIRE DEPARTMENTS. ,� SIGNED: `f PRINTED:� NDY RUBENSTEIN DATED: NOVEMBER 21, 2014 See the next page attached for a list of documents that must be completed aud submitted before your appGcation can be fully processed. You are strongly encouraged to complete these documents as soon as gossib(e and submit them in advance. This witi expedite the process. osn_a�a 2 of 2