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Home My WebLink AboutApplication and WC T � ' /6—�c�� ._.�_._�__ �0�-�-�5-�318-OI RECEIVED L�UL 07 2016 �� °� ` TOWN OF YARMOUTH � "EA�T °EPT � �� - -�r-�e�� ',�'� �Eo = 1146 ROUTE 28, SOUTH YARMOIJTH,MASSACHLJSETTS 02664-24451 �`- � �1�"`„� �'` Telephone(508)398-2231, ext. 1241 �� Fax(508)760-3472 '" ' D�isi�"' 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: �p/ � Site Address: ' �� Site Address: o�/� ff'�Q'(o� �� c�pvl�r Y�i,�iv�lT c: O2('oG� Tax ID Number(FEIN or SSl�: ► " E-mail �=-�L��'-�Zc2-G1��C6'/1C. Type of Camp: Day(less than 24 hrs.) !/ Residential(24 hrs.) �f Hours of Operation:_ �•3a �,�,� ..- a!•�� Dates of Operation: Opening:�9� /�Closing. �',, ��y Z L� ?p/i(. T Name of Camp Owner: /�b,/�f .l. �,y; ��„ Office Address: �O �j j��,� �QQ/ � �j/,�f f� �� .!� �G, D�� , .r-� Office Telephone Number:�8.-39�/• �j,/O„� Name of Camp Operator(if different): Address: Telephone Number: ' Camp Director: /�►f��.� �; �,�;��j,� Address:_ 7� ��1!`/i�t�d /�o� w<!f �4'�iKid/� �t,�q, QZG�3 ♦ Age:�� Telephone Number:__ J t�8-,3��' ��j" Coursework in Cam ing A ' 'stration: � � l ,`�� 1��.�� . Previo��mC��di1�� !!�� ,! •� f. G��J�C✓i� !<�/�C�E� !� /1�1 '' p Admimshation expenence: . r y�� , Health Care Consultant: o ' Type of Medical License: � jan MA License number: �3�,3(p� ; Address: ` � j Telephone: � Q8- ��Q-Zps� ' ; �,/ ; °'i3m,s t�jQ.>�,i �QiI/9Io.J/�l •�'r_ 1 of 3 I � 02�� , � � Hospital for Emergency Services:�� ,/ /�l,p�f�� I � Health Supervisor: �4',� 1�,� /�v��y Age:� Type of Medical License,Registration or Training: /Q/� Swimming Area: Yes No � � If Yes: Fresh Water Ocean Pool CPO Specific Onsite Locations: Water Quality Testing Performed By: Aquatics Director: Name: Age: Lifeguard Certificate issued by: Exp. Date: American Red Cross CPR Certificate: Exp. Date: American First Aid Certificate: Exp. Date: Previous aquatics supervisory experience: WatercraftlBoating Activities: Yes No Describe: ' Compliant with Christian's Law: Yes No Food Service: Is food handles, served or prepared? Yes No ✓ To what extent? Snacks Cooked and Served by Staff If cooked onsite,Food Manager(submit copy of ServSafe) Catered if so,by whom? Is refrigeration available for perishable foods? Yes No Fire Arms Instructor: Name: National Rifle Assn. Instructor's Card(or equivalent) Date certified: Expiration Date: . ��0��5 2 of 3 '� � ; ( Background Checks: I 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 i i 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, 105 CMR 430.000. SIGNED: �� ' �.� PRINTED:_/.�p �.li/ � ��N: �j�� DATED:_ ��p "/�!o See the nezt 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 egpedite the process. ; � oaisons 3 of 3 ! ; �4 � ! 1 � ' � Required Documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV-105 CMR 430.000 and the guidance documents issued by the Department of Public Health, Division of Community Sanitation for additional assistance with developing the following documents. Check Documents Submitted *Staff inforxnation 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).................................................................. *Fire evacuation plan—approved by local fire deparhnent(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)............ *Written statement of compliance from the local fire department(105 CMR 430.215)........... *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): ➢ Buildings, structures, facilities and fixtures ➢ Proposed source of water supply ➢ Works for disposal or sewage and waste water Su ervisorv 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. �4f3�„5 , I , � ;�,F'a--��a��ca`�, �_,. ,� The Commonwealth of Massachusetts � ��- � Department of Industrial Accidents � ' v Office oflnvestigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaplicant Information Please Print Legiblv Business/Organization Name:��g��j'�� /��r,�� j�� Address: �� r��/�,/ ��,✓ City/State/Zip: �/ p� ,.rir•6� �G�. Phone #: .�o��..5�'�� .39 Are you an employer? Check the appropriate 6ox: Business Type(required): 1� I am a employer with_C�employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real esta.te,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ 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 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, . with no employees. [No workers' comp. insurance req.] 12.❑ Other r'�p �y„� *Any applicant that checks box#1 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#l. I am an employer that is providin workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: " " ,f'v Insurer's Address: /?� /�p� �� City/State/Zip: /�/�jl/,f ,l�'�/ G`/� Sry�2 " ��.�a / y Policy#or Self-ins. Lic. #_ �� .3/s' — �/,t"�t�/�•�lj''f Expiration Date: � l B!� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpirallon 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 Investigations of the DIA for insurance coverage verification. I do hereby certif under the pains and penalties of perjury that the information provided above is true and correct. . Si ature: �� .-N�� Data• �^�i /rs Phone#: O��- ��- S��J� 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.gov/dia i