HomeMy WebLinkAboutApplication and WC � f S_�0�/6 o t� C.-1 S�2(S8 R�6�ae��
MAY 0 71015
HEAITH DEPT.
°� `� TOWN OF YARMOUTH B�dof
� Health
1146 RO[I'I'E 28,SOU"ITI YARMOUTH,MASSACHUSETTS 02664-24451 Health
e.o.• Telephone(508)398-2231,ext. 241 Division
Fmc(508)760-3472
APPLICATION FOR A LICENSE TO CONDUCT A ^���-� "� �
RECREATIONAL CAMP FOR CHILDREN �" ' �� �
(Ose back of appGcallon if additional space is necessary) �, �5.� •� ��
U�- EU't'E I n1C• @
Name of Camp: Q,rY1�G [XtP. K�r KI n�n c�
�7
sit�naaress:�9 V�(hi t2 R�GK Rd. �Inrmnu�l-� Port , Ml� 02(�� S
Site Address:
Ta�c ID Number(FEIN or SSN):
'(� `
Type of Camp: Day(less[han 24 hrs.)_ Residential(24 hrs.) ✓
Hows of Operation:
DatesofOperation: Opening:�r� 2�S�m Closing: TVe,l�J� 2�m
Name of Camp Owner: V�inaate K�c K� an d ►2ea1 Esta►-e l.�C .
oftice Address:_.1 � N 1n i t� Q o CK I�.CI• y m1 a�.�1-h Q�r Ey l�'IA �i�
Office Telephone Number:�.�C)$� 3(02` 3lq�
Name of Camp Operator(if different): U K E I i t,e SnCC�Y� �n.C.
Address: IOZ Mc�in st , Su� �e 2�� K�n�ct-on, MA U2��y
Telephone Number: C?$1� S$s ' � a'-j�
�— ` ` \
Camp Director: .�n..� �v�'�r�o�T
Address: -�-�,,t�� . .. c.tS 0.bo�'e---
Age: Z� Telephane Ntunber:_�O� -�lS-���� `Le-���
.r--
Coursework in Camping Administration: —
Previous Camp Administration experience: � ��c S .'�� � )�r"i �l��L ct_1��
Health Care Consultant: r. Q Y1(1 g ��'\ LQ.(,U S (��'�,
Type of Medical License:C�'` � BC �'.rn��,pl1Lu �1�Q/� MA License number: �](p � ��p
� ��' C2�� '1 g�-Z34- USQ7
Address: ��Sv �{re SF .gfOCK�OfI,� 62a62 Telephone:OCC � 5�& � �I`li -1143
OB/19N8 1 Ol 2
... _.._ C� C,� \�Q.-��..\
Hospital for Emergency Scrvices:
Health Supervisor: 1 CSD �j��� �Ot'�-� C�C �1e q�< G�E�
�;;, .:. Type of Medical License,Registration or Training:
Swimming Arca: Yes X No_
IfYes: FreshWater� Ocean Pool_ CPO_
Specific Onsite L,ocations: e � ��
Water Quality Testing Performed By:
Aquatics Director: �+..1 ��� ��5�+�'�
Submit Certifications: CPR_ First Aid_ Water Safety C(y.�
Other Lifeguards and Credentials: �ti-
WateroraftBoating Activities: Yes_ No� Describe:
Food Service:
Is food handles,served or prepazed7 Yes� No_
To what eatent? Snacks_ Cooked and Served by Staff�
Ifcooked onsite,Food Manager(submit copy ofServSafe)� ��--
Catered_ If so,by whom?
Is refrigeration available for perishable foods? Yes� No_
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� No_
IMPORTANT! CONTACT THE YARMOIIT'II HEALTH DEPARTMENT 48 HOURS PRIOR
T0 DP�NIlYG TO S(;HEDiILE-AN INSPECCION! THIS IS MANDATORY! OVERDTIGAT
CAMPS MUST ALSO SCAEDULE AN INSPECTION WITH THE BUILDING AND FII2E
DEPARTMENTS.
SIGNED
PRINTED: f�e� n DATED:�29��-��S
See the neat page attached for a list of documents t6at must be completed and snbmitted before
your appGcation can be fa11y processed. You are strongly encouraged to complete these docaments
as soon as possible and sabmit them in advance. This will eapedite the process.
u��wns 2 of 2
,4coRv' CERTIFICATE OF LIABILITY INSURANCE °"'�'°�°°"'�""
3/27l2015
THIS CER7IFICATE IS ISSUED AS A MATTER OF INFORMAiION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TNIS
CERTIFlCATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THI$ CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER�S�, AUTHORIZED
REPRESENTAi1VE OR PRODUCER,AND THE CERTIFICATE HOLDER.
I IMPORTANT: If the certificate hdder is an ADDIiIONAL INSURED,the policy(ies)must 6e endorsed. If SUBROGATION IS WAIVED,subject to
� the terms and conditions of the policy.cerlain policies may require an endorseme�M. A statemeM on th�cert7ficate does not co�Her rigMs M the
i certificate holder in lieu W such endorse s.
rrcooucea
xnre:
RPS Bollinger Sports&Leisure vxo�E Fnx
101 JFK Pa�kwaY �� ac xo. -
Short Hiils NJ 07078 ^����
INSURE AFiOR01N6COVERAGE lWCR
INBURER A:
INSURm
INSURER B:
U.K. Elite Soccer, Inc. iruunenc:
210 Malapardis Road-Ste 101 ���p:
Cedar Knolis NJ 07927
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2025336575 REVISION NUMBER:
THIS IS TO ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERI6D
INDICATED. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDI710N OF ANY CONTRACT OR OTHER DOCUMENT NATH 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,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�� TYPE OF INSURIII�E yyyp POl1CV NUM�R ��Y EFF POIICY E%P U��
A GENERI1LUR&LIiY Y N 8502AH008823 15/2415 15/2016 EpCHOCCURRENCE E1,000,000
X COMMERCIALGENERALLIABILITV a1MAGETORENTED
PREMI ES Eeomnence 5100,000
QAIMS-MADE �OCCUR MEDEXP(Myanap�son) $5,000
x IIItl.P3lb. PERSONALBADVINJURY E1,000,000
GENERALAGGREGATE E3,000,000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG E7,000,000
POLICv P�' LOC AbiselMd SEtmill$2mil
AUTOMO&LE W&IJTY
EaecCiOBfrt
ANVAUTO BODILVINJURV(Perpersm) E
ALLONMED SCHEDULED BODILVINJURV(Perartitlent) $
i AUTOS AUTO$
NON-0WNED PROPERTVUAMFGE E
HIREDAUTO$ A1f�0$ PeractlCeM
I
� A X UNBRELLAWIB OCCUR Y N 4602AH027343 15/T015 15/2018 EqCHOCCURRENCE E5,000,000
O[CESS WB CLAIMS-MADE AGGREGATE $5,000,000
DED REfENTION 10000 §
WORKERSCOMPENSAiION WCSTAN- OTH-
AN�EMPLOYERSW18RlT'/ YIN
ANYPROPRIETORIPARTNERIEXECUTIVE❑ N�A E.LEACHACCIDENT $
OFfICEWMEMBER EXCLIlOED?
(MantlatoryinNH) E.L.DISFASE-EAEMPLOV S
nYes,tlaunGe urMer
DESCRIPTIONOPOPERATIONSEeIow EL.DISFASE-POLICYLIMR $
AccitleM Inw2nCe 4102AH233287 152015 15/2016 Metl Mez: 5700.000
Full Exoass paC: gp
PTlimi[ 82,000
� oESCRIPTION OF OPERR710N8I LOCAipNS I VEXFlES(AMx�pCORD 10f.AUtlMbnel Ramnlu ScheUule,M more apees b rtqWre�
� Coverage is provided for the sponsored/supervised activities of the named insured. The Certificate Holder is named as an additional insured
under the liability paliey.
Group Code: MA260
CERTIFICATE HOLDER CANCELLATION
SXOULD ANY OF THE ABOVE DESCRIBED POIJCIES BE CANCELLED BEFORE
THE EXPIRATION DATE 7HEREOF, NOTICE WILL BE DELNERED IN
Camp Wingate Kirkland ACCORDANCE WITH iHE POLICY PROVISIONS.
79 White Rodc Road
i Yartnouth Port MA 02675 nu RQED REPRESENTAINE
0 7988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2070/05) The ACORD name arnl logo are regis[ered marks of ACORD
� The Commonwealth of Massachusetts
Department oflndustrialAccidents
O�ce oflnvestigations
' I Congress Sbeet,Suite 100
Boston,MA 02114-2017
www ntass.gov/dia
Workers'Compensation Insnrance Affidavit: General Bnsinesses
A�nGcant Informafion Please Print Le¢ibiv
Business/Oiganization Name: U K E I i (-� S o C Ce r,�c.
Address: 210 Mc� la�parC'a �S Q�'.� . Stlit� � �I
City/State/Zip: Cec1c�r Kr�o I IS , tv1 �79Z7Phone#: a 7 3-b 3 i - 98U Z
Are yoa an employer? Check We appropriate boz: Basiness Type(reqaired):
l.� I am a employer with 2O employ�s(fiill and/ 5. ❑Retail
or part-time).* 6. ❑RestauranUBar/Eating Fstablishment
2.❑ I am a sole proprietor or partnetship and have no �, � Office and/or Sales(incl.real estate,suto,etc.)
employees working for me in any capacity.
[No workers' wmp. insurance required] g• ❑Non-profit
3.❑ We are a corporation and its officeis have exercised 9. ❑Entertainment
their riglrt of exemption per c. 152, §i(4),and we have �0.0 Manufacturing
no employees. (No warkers' comp. insurance required]s �1.0 Health Care
4.❑ We are a non-profit organi�ation,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.�Oiher Yoytr,spor� P,ov;d�(
'A�applicsnt that c6ecks box#I mus[elso fill out tlu su�tion bebw shoadng their workers'caopensation poGcy informa[im.
•'If the corpoiate officers have exempted themselves,but the coipufation hes other empbyecs,a workers'compensa[ion poticy is required aod such sn
orgm'vati�should check box#l.
I an►an employer tkat is providing workers'cornpensation insurnnce for my employeec Below is the policy injormatio%
InsuranceCompanyName: TU1iR C�itl� F�t'P 1r�C�,rOh�P �OYYI'pC]Y�U
Insurer's Address: 3 O I W oOf.� R'i r K �1-i VP.
c,tyis�z�p: _�I i^ �o�, N Y ► 3 3 2 3
Policy#or Self-ins.Lic.# t 3 W E.A A y 7 y O Expiistion Date: �I�2 � �2��b
Attach a copy of the workers' rnmpensation policy declaration page(showing the poGcy namber and eapiratioo date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalUes of a
fine up to$I,500.00 and/or one-y 'i riso as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against e viola . Be advi that a copy of this statement may be forwarded to the Office of
Investigarions ofthe DIA fbr e veri8 'on.
I do kereby ce ' u th pains ofperjary that the inforniation provided above is true axd corred
s� �: t n�: 5/i /2015
Ph ne#: q� ' 1 ' �
Officia!use on[y. Do not wrtte tn this area,to be completed by city or town oj�'iciaL
City or Town: PermiNLicense#
Issning Aathority(circle one):
1.Board of Health 2.Bailding Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Otfice
6.Other
Contact Person: Phone#:
www.mass.gov/dia