HomeMy WebLinkAboutApplication and WC�
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� � r TOWN OF YARMOUTH Bo�dof
� � Health
�e = 1146 ROUTE 28, SOIJTH YARMOUTH,MASSACHUSETTS 02664-2 51 (3L��'� �p
Telephone(508)398-2231,ext. 1241
Fax(508)760-3472 Division
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APPLICATION FOR A LICENSE TO CONDUCT A HEALTH DEPT.
RECREATIONAL CAMP FOR CHILDREN
(LTse back of application if additional space is necessary) FEE: $55.00
Name of Camp: Qn(�
Site Address: !3� ��;�.�Q n� ��f.�
Site Address: S�(,(,`4'� �(,�,��� (� � (� (� L4
Tax ID Number(FEIN or SSl�: E-mail p�ks q�t1d reCr,e,pfi pr�� yC�-ry�p�-�_
Mc�.-U.S.
Type of Camp: Day(less than 24 hrs.) ✓ Residential(24 hrs.)
Hours of Operation: �(�30 —�:?�p
Dates of Operation: Opening: �1�C{ p� ��,(�.e, Closing: �i'1C� D-F Ad -t
Name of Camp Owner:'�O t�n p.� �Q y�yV10 �(n "�'i Y C�1'k� `� CX cl-}-'�r-�
Office Address: �'"j1� �p t,,r}e, �g W�f yQ;r►•},,o�.�-YI., , f YtC�► Q�(EZ• r 3
Office Telephone Number: �jU�- ��¢- o'�3� �� �c��
Name of Camp Operator(if different): P�-j�LC��,�„ (�,( . (�t-I�Yy�,S�c�MI�► ;
Address: �{-��} Qt�� 1-4-e 2� t lA'�S�- �/Ct,IrM OU.,�'1 ��114 OZIo�! 3
Telephone Number:_ ��- �� - aa3 i t�X� 1��� ;
Camp Director: _ �V1(1 Y�CL �Jl � � �
Address:
Age: 2 q Telephone Number: '�jQ� - (o�� - �j�e� a
Coursework in Camping Administration:�` "y� �,(,�r�Q�� �- �R �YeC,{Z� �/n r�S h(�P. ,
Previous Camp Administration experience: j„ �/rr� '��� �, YF,t,��
Health Care Consultant:_`�S �tV'2�' S�.e,C}�a,}-Y' �r �r Kev� �(7( p�
Type of Medical License: M . � . MA License number: N� � l�O 2� 3 �
Address:23-7 �!-rtlipr-� � Uarrnou-�, i
I,AIf� �IdQ�Telephone: ��' �v��' 'Lll b , ;
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, Hospital for Emergency Services: �,CAQQ �,OC��E7(]��tT(�Q,
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� Health Supervisor: Tf3� �
� Age: Type of Medical License,Registration or Training:
i
Swimming Area: Yes�� No
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If Yes: Fresh Water � Ocean Pool CPO
Specific Onsite Locations: �i,�'311M w11 Y1 q �Cc�C h
Water Quality Testing Performed By: �(�r�(1(�p�'�'�1 `�(�(�1�� Q.� �P�,�.� ,
Aquatics Director:
Name: C O � �2e�1 � ,Q�n� Age: a`�
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� Lifeguard Certificate issued by: �$ EC�, C`�(�S Exp. Date: �.01�
American Red Cross CPR Certificate: �� Cj(DSS Exp. Date: �O1 g"
American First Aid Certificate: � �rQSS Exp.Date: �-U 18'
Previous aquatics supervisory experience: ��1 1�,�u�(� �"�h �,q�,�'�pr 5 �t f5.
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WatercraftBoating Activities: Yes_� No Describe:
Compliant with Christian's Law: Yes_�/ No
Food Service:
Is food handles, served r prepared? Yes ✓ No Dy��+s Fooc� SeY V tc-e o-�
bc.� �ur�chez (o-ff s%!-,e prep)
To what extent? Snacks Cooked and Served by Staff
If cooked onsite, Food Manager(submit copy of ServSafe)
Catered /. If so,by whom? �1r '�S►,� �od �r V t G-e
Is refrigeration available for perishable foods? Yes ✓ No
Fire Arms Instructor:
Name: � � p�
National Rifle Assn. Instructor's Card(or equivalent)
Date certified: Expiration Date: �
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i Background Checks:
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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 r/ No
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I, 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 IY, I05 CMR 430.000.
SIGNED:
PRINTED:��1 GiA I�_ (��Y(YISfi'f'0 Y1Q DATED: J 5
See the negt 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 ezpedite the
process.
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� � � � The C'vmmor�wealth vf 11�assachuseiis
Departm�nt afln�tustrial�4ccidenis
Q�ce vf Irtvestigativns
1 Congress Sfreet,Suite IOQ
Bvsta�,M14 C12114-2(1�7
' www.m�ss.goutdiu .
; Workers' Compensation I�urance Affidavit: G�neral Businesses
;
I�.Dp�ieant Infarma�io� Please Print Legiblv
3 Business/C�}rganization N�1ne; Town of Yarmouth Parks and Recreation
Ad�ress: 424 Route 28
; City/State/Zip: West Yarmouth, MA 02673 Phone #: 1-508-398-2231 x-1�`20
� Are yc�u an employer?Ch�ck the�pprapria�e box: Business Type(r+�uired}:
l.Q I afm a empioyer witFi employees(full and/ 5. ❑ Retaii
;' _ ��-p�rt t�x�e�.* 6, ❑Restaurant7Bar/Eating Es�.blishment
, 2.❑ I am a sole proprietor or partnership and have no
' 7. ❑ Qffice and/Qr Sales(incl.real estate,auto,etc.)
empioyees working for me in any capacity.
' [I�To workers' comp,insurance required] S. �It}�n-prafit
' 3.❑ We are a corparation and its offtcer�have exercised 9. � E�at��tainrnent
their right of exemption per c. 152, §1{4),and we have 10.Q Manufacturing
no employees.[No workers'comp.insurance requiredj*
4.❑ We are a non-profit organizatian,staffed by voiunteers, 1 l.[] Heaith Caxe
with no employees. [No workers' comp. insurance req.] 12.[� �ther
*Any app�icant that chxks box#i must also fitl out tha section beiow showing thcir worfcs�^s"campensation goIicy iaformation.
**If the corporate officers have exempted themselves,but the corporatian has ather emgloyees;a warkers'r,ompen�tian�ticy is requu�d and such an
organization shouid check box#1.
I am an empinyer thai is praviding workers'cvmpensation insurrcrsce for my employee� Betow is the poliey informrztit�n,
insurance Cornpan�IrTame: MIIA Property and Casualty Group Inc
Insurer's Addres5: One Wnthrop Square
CitytStatelZip; Boston, MA 02110
Policy#or�elf-'rn.s.Lic.# Contrac## 15-210 ExpirationDate; 7-1-2016
Attach st+ci�py of the�vvorkers'com�nsatian paticy declaration page{showing the�o�icy aumber and eapiration d�te).
Failure ta secure cuverage as re�uired under Section 25A of M{GL c. 152 can lead to the imposit�an ofcrimirtai penaIties of a
�
fine up to$1,500.0{l andlor one-year imprisonment,as we�as civil penatties in xhe f4rm ofa 5T'�P WCJRI�ORT�ER and a fine
of up to$250.�a day against the vialator. Be advzsed that a copy afthis statement may be forwarded to the Office of
Investigatians of the DIA for insurance eoverage verification.
I drr hereby certify,under �es n �af perjury thrat�he informaliQn prvvider!above ds true and correcz
Si Date: � �
I'hone#: � .
Official use only. Do nvt write in lhis area,#n be completed hy city ar trr�wwn offzcial �
City or Town: PermitlLicense#
Issuing Authority(circie one):
1.Board af HeaIfh 2.Buiiding Departiuent 3.Cify/Town Clerk 4.Licensing Board 5.Selectmen's Qffice
6.Ot�er
Cautact Persons Phone#r
�'ww.mass.gav/dia j
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ac�c�c�od��
j Reauired Documents � 11t.l: ';' 7 �U15�
� See the MA Regulations for Minimum Standards for Recreational Camps fo Ch#�ti�'H DEPT.
State Sanitary Code, Chapter IV-105 CMR 430.000 and the guidance documents issued
by the Deparhnent of Public Health, Division of Community Sanitation for additional
assistance with developing the following documents.
Check
� Documents
� Submitted
� *Staffinformation 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).................................................................. f
. *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)............ tn pYac.css o�
*Written statement of compliance from the local fire department(105 CMR 430.215)........... S�x-d�c.l,��
*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):
➢ Buildmgs, structures, facilities and fixtures
➢ Proposed source of water supply
➢ Works for disposal or sewage and waste water
Supervisorv staff ineans 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/IS � '.