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Home My WebLink AboutRecreational Camp for Children Inspection Reports'� ! : Department of Public Health ' Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 NAME OF CAMP: k ADDRESS: ' /E� t' OWNER/OPERATOR: OFF SEASON ' ADDRESS: CAMP DIRECTOR: S i L INSPECTED BY: ' TYPE � (Circle) WATER i��,,,.,� DATE OF INSPECTION: Da esidential SOURCE: (Sport/NoSport) CAMPER .�ol?3��$ Trip Primifive Travel CAPACITY: "No"column= "�"marked below indicates a violation of 430.000. "Yes"column= "�"marked below indicates compliance with provision of 430.000. "N/A"column = "�"marked below indicates that the rovision of 430.000 is not a licable to this cam . Permits .451 Current Certificate(s)of Occupancy from local buildin ins ector for slee in /assembl areas. .215 Written com liance from local fire de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, ' >60 da s/ r . .300(A)(2)(b) Private water supply-BOH approval and chemical and bacterial analyses <25 eo le, <60da s/ r Plans and Policies-Written ' .090(A) Procedures for background review of staff and ✓ volunteers. .090(C) � CORI and SORI , previous work history, 3 references, out of state�ntemational criminal back round checks for staff and volunteers .091 Staff and volunteer orientation lan and review. .093 Abuse and neglect prevention/reporting rocedures. .191(B)(C) Discipline Policy with: appropriate discipline ✓ methods and rohibitions. .210 A Fire evacuation lan and drills .210 B Disaster Plan .210 C Lost Cam r Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contin enc lans-Da Cam : .211 A Cam er doesn't show u for da B Cam er doesn't show u at oint of ick u C Child not re istered arrives Contin en lans-Primitive,Travel and Tri : .212 A Itinera dail -co to arents B Source of emer enc care � .190 Camper released only to parents or parent- � designated individual in writing. Other plan r approved in writing by BOH. r , Promotional literature/ acket contains: .159(B)(2) Copy of policy re:care of mildly ill campers, / . administration of ineds and emergency ✓ health care rovision. .190(C) Statement re: regulatory compliance and licensin . .190(D) Inform parents of right to review background . check, health care, discipline policies and rievance rocedures u on re uest. Trans rtation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers AND driver is camp coach, director,etc. private vehicles may be used. � >14 passengers,vehicle must be school bus All vehicles must be RMV com liant .253 Pro er automobile insurance .251 Seatbelts must be worn and special needs of cam ers communicated to driver .251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Cam Director .102(A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons ex erience. .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons ex erience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex erience. .102(D) Designated substitute when director off-site ✓ �„E7 r✓!c 6s// >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: Counselor- 16 rs. Junior Counselor- 15 rs. .100 Other camps: Counselors= 18 yrs or � graduated from high school. Junior Counselors= 16 rs .100 All counselors 3 rs older than cam ers Re uired Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs � : y 1 staff er 5 cam ers 6 rs and under .101(B) Primitive,Travel,Trip: 1 counselor er 10 cam ers.2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor er 2 severel disabled cam ers I f .103 Aquatics Director: Name:�,,vi�, �J�.ae�None � American Red Cross Lifeguard Tmg cert., CPR ,� for Professional Rescuer and First Aid Cert.or their equivalents. If supervise 2 staff,21yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Tmg cert., CPR for Professional Rescuer cert.and ✓ First Aid Cert.or their e uivalents. List names. .103 Certifications for other high-risk activities,eg: � NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs,2yrs driving / experience, current license for type of vehicle ✓ First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159(A) Health Care Consultant � ��a �v 4 Name: s�s Qcrqc�• 2� MD NP PA(w/pediatric training) Check for Health Care Consultant A reement .159(C) Health Supervisor(on site at all times) � �vc�2s` Name: Su�t i2vacL. 0� s'��h[ti 18yrs, First Aid and CPR certified OR, v�v i1-r�4/� T�^� MD PA NP RN LPN .159 B Health Care Polic .160 A Medication stored in ori inal containers. .160(B) Meds stored in secured cabinet and if necessa refri erated in affixed box. .160 C Medication administered b Health Su ervisor ✓ .154 Injury Reports completed for fatality or serious in'u . Co sent to MDPH. .155 Medical log book-bound, pre-numbered pages, ink entries, no ski ed lines. .161(A) Infirmary provided-day and resident.camps Exterior li ht-resident.cam s .453 Li htin rovided in infirma .161 B Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares, compresses, adhesive tape, bandage scissors,triangular and rolled bandages, CPR mask,tweezers, cold ack, loves. .150 Health record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental permission for meds and emergency care. Residential,Sport,Travel/Trip: Health History, Physical Exam(<2yrs) Record of Immunizations(noted below) Day Camp Non-Sport: Health History, Record of Immunizations(noted below Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: MMR: 15`dose = 12 mos or older, 2U Measles: 2"d dose=grades K-12 or age equiv Polio: 3 doses IPV or OPV, or � 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above,Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if bom on or after 1/1/92 .152(B) Campers and staff 18 yrs.or older: Number of records Measles: 2 doses(exempt if bom before 1957) checked: 20 Mumps: 1 dose (exempt if born before 1957) / Rubella: 1 dose (exempt if born before 1957) � Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to � health/safe . .163 O erator encoura es sun rotection for all. A uatics .430 Swimming Pool: in compliance with 105 CMR 435.00- ermit osted. .204(B) Bathing Beach: in compliance with 105 CMR � TcSt� ��! 3Y 445.00-weekl water sam lin conducted. � �r► .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers ✓ 1 counselor per 10 campers � Plan to check swimmers udd s ste "' .204(C) Swim test to classify swimmers y ability. � .204(A) Swimming areas clean and safe, no swimming at undesi nated sites or at ni ht without li htin . .204 E Piers and floats in ood re air. .204(G) Watercraft: equipped with US Coast Guard approved flotation devices and wom by all � campers and staff participating in watercraft activities. I R . � A uatics cont'd .204(H) Campers must be certified by American Red � � Cross or equivalent for white water, hazardous salt or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh � water activities. Crafts .205 Equipment in good repair,safety precau6ons / taken. � Pla round/Athletic E ui ment .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete under/around it, liable swin seats. Firearms .201 Sin le shot rifles onl . .201 Shootin ran e awa from other activi areas .201 Firearms in good condition,stored in locked cabinet.Ammunition locked in se arate cabinet. Arche .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly ✓ marked as danger area. Must have common firing line and 25 yards clearance behind each ta et. .203 No ersonal wea ons, bows, rifles allowed. Horseback Ridin .208(A) 1 certified instructor per 10 campers(Min.2 � counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors rovided. .455/.456 Egresses comply with BIdg.Code and are free ✓ from obstruction .453 Li htin rovided for stairwa s .454 Floors maintained. Residential Cam s/Slee in Areas: .458 Provide adequate space: � 40sqft/person in single bed 35sqft/person in bunk bed 50sqff/person in sleeping area requiring special e ui ment .470 Provide bed/cot per person with 6 feet befinreen ✓ sleeper's heads and: 3 feet befinreen sin le beds/4'�feet between bunks , i Residential Cam s/Slee in Areas: .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or � ram rovided. .452 Screens rovided. Screen door self-closin . .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame � nearb . .458 35 s ff/ erson in bunk bed Toilets/Showers .360 Pro er sewa e dis osal .301 Plumbin in ood workin order .370 Adequate#of toilets All camps: 2 toilets/privy seats for each sex Day Camp:>60 of one sex,provide 1 additional � toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex,provide 1 additional toilet er eve 10 eo le of that sex. .372 Toilet less than 200 feet from sleeping rooms.Toilet paper provided.Windows/ ,/ o enin s screened.Screen doors self-closin . .373 Adequate#of sinks: Day Camp: 1 per every 30 people ✓ Residential Cam : 1 er eve 30 .374 Adequate#of showers(residential camp): ,/ 1 shower/tub er 20 eo le .378/.380 Special needs campers provided facilities that ✓ meet their needs .453 Li htin rovided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks,showers/tubs not more than ✓ 112°F. .377 Sanitary facilities maintained in clean condition. ✓ Shower room floors washed dail . Laund .162 Residential Cam : laund facilities rovided .472 Bedding and towels laundered; no common / towels �� Grounds: .300 Potable water rovided. .300/.304 Adequate and centralized drinking water ✓ facilities. No common drinkin cu s. .209 Telephone readily available with#s of HCC, EMS, police,fire. �/ Da and Residential Cam s onl 213 Eme enc communication s stem. .165 Tobacco use restricted to designated areas not � accessible to cam ers. .350/.355 Pro er stora e and dis osal of solid waste 1 �� , � I � i A , • ! .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled � and stored in locked unoccu ied buildin . .400 Rodent and insect control. .401 Weed and noxious lant control. �/ .450 Site location does not cause undue traffic ✓ hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR � 590.000, Minimum Standards for Food Establishments. Permit posted in food service � facili . .330 Nutritious meals that include a variety of foods served. Menus osted. .331 Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dieta Allowances RDA .332 Day camps—Each meal provided must meet ✓ 1/3 of the RDA requirements. .334 Adequately trained staff and equipment / provided to ensure handicapped campers are ✓ eatin nutritious meals. .335 Proper methods for storing meals brought from / home. Meals provided to campers who arrive ✓ without a ba lunch. .452 Screening provided for food preparation and � food service areas. Screen doors must be self- closin . .453 Li htin rovided in kitchen and dinin area. .471 Slee in rohibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE y,�l��vvt� Name of City or Town STATE SANITARY CODE:CHAPTER IV,MINIMUM SANiTATiON AND SAFETY STANDARDS FfJR RECREATIONA�.CAMPS FQR CHII.DREN, 105 CMR 430 000 � .� ��I��"t'�{��A��4�VlF'�� -- � � �� ? �� ,* : � NAME OF CAMP: G _ � ADDRESS: � � � ,r� � ,�� OWNER/OP�RATOR: OFF SEASON ., + r.v,i � i'Zc,Q e�+s k.�.� ADDRESS: CAMP DIRECTOR: s�.-.c INSPECTED BY: �o�� ;- � n D TYPE OF CAMP: (Circle) � WATER DATE OF INSPECTION: Day sidenti SOURCE: (Sport/NoSPo�) CAMPER �/��S Trip Primitive Travei CAPACITY: "No"column= "�f"marked b�low indicates a violation of 430.00�. "YesA column= "�'marked below indicates compliance with prnvision of 430.000. ' "N/A"column= "�1n marked bebw indicates that the rovision of 430.DQ0 is not a licable to this qm : � Permits .451 Current Certificafe(s)of Qccupancy from local buildin ins ector for slee in assembl areas. .215 Written com liance from local fire de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, >60 da s/ .300(Aj(2�b) Private water supply-BOH approval and chemiql and bacterial analyses ✓ <25 e,<60da Plans and Policies-Written .090(A) Procedures for background review of staff and ✓ volunteers. .090(C) CORI and SORI , previous work history, 3 references,out of stat�ntema6onal criminal back round checks for staff and volunteers •Qg� Staff orientation lan.Reviewed with all. .093 Abuse and neglect preventioNrepofing roc�dures. .191(B)(C} Discipline Policy with:appropriate discipline � methods and rohibitions. ✓ .210 A Fire evacuation lan and drills .210 B Disaster Plan .210 C Lost Cam er Plan .21Q C Lost Swimmer Plan .210 D Traffic Control Plan � Contin en lans-Da Cam : .211 A Cam er doesn't show u for da B Cam er doesn't show u at int of ick u C Child not ist�red arrives Contin en lans-Primitive,Travel and Tri : .212 A Itinera dail -co to arents B Source of eme enc car�e •�90 Camper released only to parents or parent- designated individual in writing.Other plan ✓ a proved in writin b BOH. ,. � - ;=a �`'.a'a!�3 .�.� .x'- a ' �a�"�€� *� •'� s�' n`.� -� t> ;�" �"� � .�"„�:�._ t }��G� � t j�4�.�y�#�yy ,� �. .s�. .`�� i�1.��1� �:$:�� '�: �'�. �� re;,� ��.,��,�� ^* :x 4 ��.a ��.Yk.�-` �Gr7 �� ti?�!';l�1l�� '_ . _ � Promotional literature/ cket contains: � � .159(B)(2) Copy of policy re:care of mildly ill campers, administration of ineds and emergency health care rovision. .190(C) Statement re:regulatory compliance and licensin . .190(D) Inform parents of right to review background chedc,health care,discipline policies and rievance rocedures u n r uest. Trans ortation .25Q Vehide must comply with MGLc.90 s7B87D: <14 passengers AND driver is camp c:flach, director,etc.private veli�cles may be used. . >14 passengers,vehide must be school bus All vehicles must be RMV compliant .253 Pro er automobile insurance. 251 Seatbelts must be wom and speaal needs of cam ers communicated to driver � 251 Camper<7yrs not transported bnger than 1 hr to cam Staff Quafifications Cam Director .102(A) Residenfial Camp:25 yrs,completed course in camp administration or at least 2 seasons e rience. .102(B) Day Camp: 21 yrs,completed carr�p admini.stration course or 2 seasons e rience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex rience. .102(D) Designated substitute when direc�or off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: ✓ Counselor-16 . Junior Counselor-15 .100 Other camps: Counselors=18 yrs or graduated irom high school. Junior Counselors-l6 rs .100 All counselors 3 rs older than cam rs Re uired Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs 1 stafF er 5 cam rs 6 and under .101(B) Primitive,Travel,Trip: 1 counselor er 10 cam ers.2 counselor min. .101(C} Speaal Needs: 1 counselor per 4 mildly disabled campers � 1 counselor er 2 severel disabled cam ers ,g� `"r._�,:kt�,.�j.��' '��.r _", �� '�',�4+2�+.,=�?�n.z, �"�� f: r'%r �` -� ��+� �1'��,��P11'� ��'k� ��a-��r „ :��11�IC1�IQ�i � �� ;� � n,: ��„ ;s, � F:�� ' � �.. ,; t _��. �� _ . .. _ �, �� _ � : _ ._ �_�,_ ._a= _ . ?.� � .103 Aquatics Director: � Name: American �ted Cross Lifeguard Tmg cert.,CPR for Professionai Rescuer and First Aid Cert.or their equivalents. If supervise 2 staff,21yrs and experience , w/mana ement .103 Lifeguard:American Red Cross L'rfeguard Trng cert.,CPR for Professional Rescuer cert.and First Aid Cert.or their e uivafents.List names. .103 Certifications for other high-risk activities,eg: NRA instructor certification#or firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs,2y�driving experience,current license for type of vehicle First Aid certfied iF no other trained staff aboard. Medical PersonneURecords/Facilities .159(A) Health Care Consulkant Name: MD NP PA(w/pedi�tric training) Check for Health Care Consultarrt A reement .159(C) Health Suoervisor(on site at all times) Name: 18yrs, First Aid and CPR certified OR, MD PA f�P RN LPN .159 B Health Care Poli .160 Pro r sto e of inedication .160 Medication administered by Health Supervisor or licensed medical rofessional .154 Injury Reparts completed for fataliiy or serious in'u .Co sent to MDPH. .160 A Medications stored in ori inal containers. .160(B) Meds stored in secured cabinet and if necessa refr' erated in affixed box. .155 Medical log book-bound,pre-numbered pages, ink entries,no ski lines. .161(A) Ir�firmary provided-day and resident.camps Exterior I' ht-resident. cam .453 L' htin rovided in infirma .161 B Area for isolation of ill child .161(C) First Aid�t: non-�rfumed soap,sterile gauze squares,compresses,:adhesive tape, bandage scissors,triangular and rolled bandages,CPR mask,tvweezers,cold ack, loves. .150 Health recorri for each camper and staff: �mergency contact info -camper<1$yrs must have writtten parental permission for meds and emergency care. rf yr� #� �'�� ;i �� ,, a ,�„� -�� 4�y ';y .s � .w � ��F�' '*;�. r�,�r �t��7�.� - �$'��la r ._.�.� � �.� f ,I,,�s� ��'a "�.��:n s �� .��-�" �".- _ ��fY1I17U111Zat10t1S: � .152(A) Campers and staff under 18yrs: Number of records MMR: 1�dose= 12 mos or older, chedced: Measles: 2`�dose=grades K-12 or age equiv Polio:3 doses OPV or IPV,or 4 doses mbc IPV and OPV Diphtheria and 7Qtanus Toxoids and Pertussis*: • 4 doses DTaP/DTP/DT *Booster dose of Td requined if more than 10 yrs since last dose. He B: 3 doses if bom on or after 1/1/92 .152(B) Campers and staff over 18yrs: Number of records Measles: 2 doseS(exempt iF bom before 195� chedced: Mumps: 1 dose (exempt iF bom before:1957) Rubella: 1 dose Diphtheria and Tetanus Toxoids*: 3 doses DT/Td � "Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers;do not pose hazarrl to health/safie . .163 O er�tor encou es sun rotection for all. A ua�ics .430 Swimming Pool:in compliance with 405 CMR ✓ 435.00- ermit ed. .432 Bathing Beach:in compliance with 1 Q5 CMR 445.00-wee water sam lin conducted. .103 Proper supeniission at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers-"budd s tem" .204(B) Swim test to dassiiy swimmers by ability. .204(A) Swimming areas d�an and safe, no swimming at undes' nated sites ar at ni ht without li htin . .204 E Piers and floats in ood r� air. .204(G) Watercraft:equipped with US Coast Guard approved flotation devices and wom by all campers and staff participating in watercraft activities. .204(H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities: .103(C) Minimum 2 counselors in separate watercraft / supervising wMite�water, hazardous salt or fresh �/ water adivities. �4� 41�Q��d��''��s`',�'��xr'�'��§� $ �3 '�""�^rs - {� ,j .t. �-,� ax�:i ��+� e .� �� !�� - �`d 'r s�,.�:�: .� �,i_"�'��-.•.�.t, �:�...-r . .;� ..4m.�s. x s h" .,.l .�;� Ci"dftS �� .205 Equipment in good repair,safety precautions taken. Pla round/Athletic E ui ment .206 Equipmen#properly maintained,fields/surFaces free of holes/accident hazards .206 Playground equipment secure,no concrete under/around��t, liable swin seats. Firearms .201 Sin le shot rifles onl : .201 Shooti ra e awa from other activi areas .201 Firearms in good condition,stored in lodced cabinet.Ammunition locked in se rate cabinet. Arche .202 Equipment in good condition,stored in loelced area. .202 Range away from other activity areas,clearly marked as danger area.Must have common firing line and 25 yards clearance behind each tar et. .203 No rsonal wea ns,bows, rifles allowed. Horseback Ridin .103(G) 1 certified instruckor per 10 campers(Min.2 ✓ counselors .103 G Riders must wear harci hat .103 G Licensed stable_, CabinslStructures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors rovided. .456 Ad uate resses fr�e from obstruction .453 L' htin rovided for stairwa s .454 Floors maintained. Residential Cam Slee in Areas: .458 Provide adequate space: N/A for primitive,trip and 40sqrt/perscm in single bed travel camp. 35sqftlperson in bunk bed SflsqNperson in sleeping area r�equiring speaal ui ment .470 Provide bed/cot per person with 6 feet belween sleeper's h�ads anrJ: 3 feet between si le bedsl 472 feet between bunks .459 Campers and staff with limit�mobility housed on ground level;egresses leading to grade or ram rovided. .452 Screens rovided. Screen door seFf-dosin . .45� Floors maintained. Tents: .217 Fire-retardant and non-toxic.No open flame nearb . .458 35 erson in bunk bed t S �� +r�'�IQ, � �." ��; r: � :� ��J� ��;.x �' ��. , __ > , , x - . � . _ _. _, .470 Provid�bed/cat per person with 6 feet betwe n N/A for primitive,trip and sleeper's heads and: #ravel camp. 3 feet between sin le beds/412feet between bunks ToiletsiShowers .360 Pro er sewa e dis al .301 Plumbin in ood workin order � .37p Adequate#of toi{ets: All camps:2.toilets/privy seats for each sex Day Camp:>60 af one sex,provide 1 additional toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex,provide 1 additional toilet r eve 10 le af that sex. .372 Toilet less than 200 feet from sleeping rooms.Toilet paper provided.Windows/ o enin s screened.Screen doors seff-closi . .373 Adequate#of sinks: Day Camp:1 per every 30 people Residentiaf Cam : 1 r eve 30 .374 Adequate#of showers(residential camp): 1 showet/tub r 20 1e .378/.380 Speaal needs campers provided facilities that meet their needs .3Qi Plumbi in wqrkin order _ .453 L' htin rovided. .375 Toilets and shower rooms venti�ated to outdoors .376 Mot water at sinks,st�owers/tubs not more than 112°F. .377 Sanitary facilities mairitained in dean condition. Shower room fl�oors washed dai . Laund .162 Residential Cam :laund facilities rovided ,472 Bedding and towels laundered;no common towels Grounds• .300 Potable water rovided. .300/.304 Adequate and centralized drinking water facili4es.Na common drinkin cu . .209 Telephone readily avaitable with�fs of HCC, local hospitals,police,fire,ambulanoe. �a and Residential Cam n .213 Eme en communicatian s tem. .165 Tobacco use restricked to designated areas not accessible to cam rs. .350/.355 Pro er sto e and dis 1 of solid waste 207 Proper storage and operation of power e ui ment. .214 Flammable and hazardous maferials labeled and stored in locked unoccu ied buildin . .400 Rodent and insect controL .401 Weed and noxious lant tx�ntroL .450 Site location does not cause undue traffic hazards and is accessible at al!times. ��il � a . . { .' . . ,y�� - . r. . ' "�� ,. ....- , ..c-��,..,l ..... .. , . f.� _ .;. � � ;�a y:�� _'�. ��l7• ��._� �� \iR��.;. a�+*�t �,;g�3e . - �� ."'.-3+:� .., .c....- , Food Service .320 Food service in compliance with 105 CMR 590A00, Minimum Standards for�ood Establishments. Permit posted in food service facili . .330- Nutritious meals that indude a variety of foods served. Menus sted. .331 Residen�al camps—Provide at least three nutrikious meals. Foods must meet Recammended Dieta Allowances RDA .332 Day camps—Each m+eal provided must meet 113 of the RDA r uirements. .334 Adequately trained staff and equipment . � provided M ensure handicapped campers are eatin nutritious meals. .335 Proper methods for storing meals broughf from hame. Meals provided to campers who amve without a ba iunch. � .452 Screening provided for food preparation and food service areas. Screen doors must be selF closi .453 L' htin rovided in kitchen and dinin area. .471 Slee in rohibited in food areas. RE�uu►noN NO. THE SPACE BELOW DESCRIBES VIOLA�IONS MARKED ABOVE . , Department of Public Health Division of Community Sanitation STATE SANITARY CODE:CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 . ` �� : ; . ��` ' ��: ��►" e � � _ � � NAME OF CAMP: � �i - / ` / ADDRESS: 79 w/S/i/'�' OWNER/OPERATOR: OFF SEASON ADDRESS: CAMP DIRECTOR: F G INSPECTED BY: �,- ,� r TYPE O�F�(Circle) WATER T'o� DATE OF INSPECTION: Day dentia SOURCE: �o� �/�5��7 (5port/NoSport) CAMPER Tnp Primitive Travel CAPACITY: "No"column= "�1" marked below indicates a violation of 430.000. "Yes°column= "�l°marked below indicates compliance with provision of 430.000. "N/A"column = "�1" marked below indicates that the rovision of 430.000 is not a licable to this cam . ,, ,� �'' �;. '�� Permits .451 Current Certificate(s)of Occupancy from local buildin ins ector for sl in /assembl areas. .215 Written com liance from local fire de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, >60 da s r .300(A)(2)(b) Private water supply-BOH approval and chemical and bacterial analyses <25 eo le, <60da s r Plans and Policies-Written .090(A) Procedures for background review of staff and � volunteers. .090(C) CORI and SORI , previous work history, 3 references,out of state�ntemational criminal �' back round checks for staff and volunteers .091 Staff and volunteer orientation lan and review. .093 Abuse and neglect preventioNreporting rocedures. .191(B)(C) Discipline Policy with: appropriate discipline methods and rohibitions. .210 A Fire evacuation lan and drills .210 B Disaster Plan .210 C Lost Cam er Plan .210 C Lost Swimmer Plan a/'� .210 D Traffic Control Plan Contin enc lans- Da Cam : 211 A Cam er doesn't show u for da B Cam er doesn't show u at oint of ick u C Child not r istered arrives Contin enc lans-Primitive,Travel and Tri : .212 A Itinera dail -co to arents B Source of emer enc care .190 Camper released only to parents or parent- designated individual in writing.Other plan ,�'' approved in writing by BOH. ; � .�►, � ��+ �� , , , _ Promotional literature/ cket corrtains: .159(B)(2) Copy of policy re:care of mildly itl campers, administration of ineds and emergency health care rovision. .190(C) Statement re: regulatory compliance and licensin . .190(D) Inform parerrts of right to review background check, health care, discipline policies and rievance rocedures u on re uest. Transportation .250 Vehicle must comply with MGLc.90 s768�7D: <14 passengers AND driver is camp coach, � director,etc. private vehicles may be used. >14 passengers,vehicle must be school bus All vehicles must be RMV compliarrt 253 Pro er automobile insurance .251 Seatbefts must be wom and special needs of � cam ers communicated to driver .251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,completed course in � camp administration or at least 2 seasons e erience. .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons e erience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of e erience. .102(D) Designated substitute when director off-site � >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: Counselor- 16 s. Junior Counselor- 15 rs. .100 Other camps Counselors= 18 yrs or graduated from high school. Junior Counselors= 16 s .100 All counselors 3 rs olderthan cam ers Required Counselor Ratios .101(A) Residentiaf and Day Camps: / 1 staff per 10 kids over 6 yrs ✓ �� i 1 staff r 5 cam ers 6 rs and under /.' � .101(B) Primitive,Travel,Trip: 1 counselor er 10 cam ers.2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor er 2 severel disabled cam ers ; �; � �'` ��R� .103 Aquatics Director. Name:5�1 t �.��''�o`ne American Red Cross Lifeguard Tmg cert.,CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21yrs and e�erience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Tmg cert., CPR for Professional Rescuer cert.and First Aid Cert.or their e uivalents. List names. .103 Certifications for other high-risk adivities,eg: �� / NRA instn�ctor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs,2yrs driving �y,� }� experience,current license for type of vehiGe ,� � i First Aid cert'�fied if no other trained staff aboard. Medical Personnel/Records/Facilities .159(A) Heaith Care Consultant �y��„�QR.� ��cz�, Name: Loar � Z�� NP PA(w/pediatric training) Check for Heafth Care Consultar�t A reemerit .159(C) Health Supenrisor(on site at all times) Name: ��c-��cti.�► � 18yrs, First Aid and CPR certified OR, MD PA NP N LPN .159 B Heatth Care Polic .160 A Medication stored in ori inal containers. .160(B) Meds stored in secured cabinet and if necessa refi erated in affixed box. .160 C Medication administered b Health Su ervisor .154 Injury Reports completed for fatality or serious in'u .Co sent to MDPH. .155 Medical log book bound, pr�e-numbered pages, ink entries, no ski ed lines. .161(A) Infirmary provided-day and resident.camps Exterior li ht-resident. cam s .453 Li htin rovided in infirma .161 B Area for isolation of ill child 3 2oc--. .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares,compresses,adhesive tape, bandage scissors,triangular and rolled bandages, CPR mask,finreezers,cold ack, loves. .150 Heafth record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental permission for meds and emergency care. Residential,Sport,TraveUTrip: Health History, Physical Exam(<2yrs) Record of Immunizations(noted below) Day Camp Non-Sport: Health History, Record of Immunizations(noted below Y� �► �A Gv��t F Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: MMR: 1�dose= 12 mos or older, i'a Measles: 2nd dose=grades K-12 or age equiv Polio:3 doses IPV or OPV, or � 4 doses mix IPW OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to compy with above,Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT �rades 11-12 need booster if more than 10 yrs since last dose of DTaPlDTP/DTlTd Hep B: 3 doses if bom on or after 1/1/92 .152(B) Campers and staff 18 yrs.or older. Number of records Measles: 2 doses(exempt if bom before 1957) checked: � Mumps: 1 dose (exerr�pt if bom before 1957) Rubella: 1 dose (exempt if bom before 195� Diphtheria and Tetanus Toxoids": 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the ✓ needs of campers; do not pose hazard to health/safe . .163 O erator encoura es sun rotection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR � 435.00- ermit osted. .204(B) Bathing Beach: in compliance with 105 CMR 445.00-weekl water sam lin conducted. ✓ .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers ✓ 1 counselor per 10 campers Plan to check swimmers-"budd s stem" .204(C) Swim test to classify swimmers by ability. � .204(A) Swimming areas clean and safe, no swimming � at undesi nated sites or at ni ht without li htin . .204 E Piers and floats in ood re air. .204(G) Watercraft:equipped with US Coast Guard approved flotation devices and wom by all v� campers and staff participating in watercraft activities. �� -' .-�} � ��. A uatics cor�t'd ._ , .204(H) Campers must be certified by American Red Cross or equivalerrt for white water, hazardous � salt or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh . water activities. Crafts .205 Equipmerrt in good repair,safety precautions ✓ taken. Pla round/Athletic E ui ment .206 Equipment properly maintained,fields/surFaces �/ free of holes/accident hazards .206 Playground equipment secure, no concrete � under/around it, liable swin seats. Firearms .201 Sin le shot rifles onl . .201 Shootin ran e awa from other activ' areas .201 Firearms in good condition,stored in locked f cabinet.Ammunition locked in se arate cabinet. Arche .202 Equipment in good condition,stored in locked area. 202 Range away from other activity areas, clea�ly � marked as danger area. Must have common firing line and 25 yards clearance behind each tar et. .203 No ersonal wea ons, bows, rifles allowed. Horseback Ridin .208(A) 1 certified instructor per 10 campers(Min.2 � counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide she�er for on-going camp � activities. .216 Smoke detectors rovided. .455/.456 Egresses comply with BIdg.Code and are free � from obstruction .453 Li htin rovided for stairwa s .454 Floors maintained. Residential Cam slSlee in Areas: .458 Provide adequate space: 40sqft/person in single bed ✓ 35sqft/person in bunk bed 50sqft/person in sleeping area requiring speaal e ui ment .470 Provide bed/cot per person with 6 feet befinreen sleeper's heads and: ,/ 3 feet befinreen sin le beds/4��feet between bunks � � � _.. Residerrtial Cam s/Slee in Areas: .459 Campers and staff with limited mobility housed / on ground level; egresses leading to grade or V ram rovided. .452 Screens rovided. Screen door seff-closin . .454 Floors maintained. TeMs: .217 Fire-retardant and non-to�ac.No open flame nearb . .458 35 s ft/ erson in bunk bed Toilets/Showers .360 Pro er sewa e dis osal .301 Plumbin in ood workin order .370 Adequate#of toilets: All camps:2 toilets/prny seats for each sex � Day Camp:>60 of�e sex,provide 1 addfional toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex,provide 1 additional toilet er eve 10 e le of that sex. .372 Toilet less than 200 feet from sleeping rooms.Toilet paper provided. Windows/ +� o enin s screened.Screen doors self-closin . .373 Adequate#of sinks: � Day Camp: 1 per every 30 people Residential Cam : 1 er eve 30 .374 Adequate#of showers(residential camp): 1 showerftub er 20 le .378/.380 Special needs campers provided facil'rties that meet their needs .453 Li htin rovided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks, showersl�ubs not more than 112°F. .377 Sanitary facilities maintained in Gean condition. Shower room floors washed dai . Laund .162 Residential Cam : laund facilities rovided .472 Bedding and towels laundered; no common v towels Grounds: .300 Potable water rovided. .300/.304 Adequate and cer�tralized drinking water ✓ facilities. No common drinkin cu s. .209 Telephone readily available with#s of HCC, � EMS, police,fire. Da and Residential Cam s onl .213 Emer enc communication s stem. .165 Tobacco use restrided to designated areas not � accessible to cam ers. .350/.355 Pro er stora e and dis osal of solid waste `�� ... ; '��` ,; ' .207 Proper storage and operation of power equipment. � .214 Flammable and hazardous materials labeled � and stored in locked unoccu ied buildin . .400 Rodent and insect control. .401 Weed and no�aous lant co�rol. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food senrice in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permit posted in food service facil' . .330 Nutritious meals that include a variety of foods v, served. Menus osted. .331 Residential camps—Provide at least three nutritious meals. Foods must meet ,� Recommended Dieta Allowances RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA re uirements. .334 Adequately trained staff and equipment � provided to ensure handicapped campers are eatin nutritious meals. .335 Proper methods for storing meals brought from � home. Meals provided to campers who arrive without a ba lunch. .452 Screening provided for food preparation and food senrice areas. Screen doors must be self- closin . .453 Li htin rovided in kitchen and dinin area. .471 Slee in rohibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 5 \ � ` J /1'�.Q�--T� T �G!//f/ G� 1��iT77' i ' - oepartmer�t ot Pubric Heara, Division of Community Sanitation STA'!`E SANITARY CODE:CHAPTER IY,MiNlMUM SANlTATIQN AND 3AFETY STAWDARQS FOR RECREATIONAL CAMPS FOR CHILDREN 10.5 GMR 430.000 i NAME OF CAMP: � i ADDRE�S: Gv�i 7� OWNERiOPERATOR: OFF SEAS0IV � �/fl/ >`S�o /2 f-�ii�%' ADDRESS: j CAMP DIREC �R: � iNSPECTED BY: G� �J`c ' TYPE OF C :(Cirde) WATER -�-�.�� DATE OF INSPEGTftMi: i e SOURCE: � (SportMaSport) CAMPER �/o? ��D� Tr�p Primitive Travel CAPACITY: �No"c�t�mn= "�l"m8rked belaw indicates a violation of 430.000. "YesA column= '�"marked below indicates comptiance w�h piro�rision of 43E�.Q00. "N/A"column= "�"marked below indicates tha�t the vision of d30.000 is no�a {icable to this cam . Permits .451 Cumerzt Certificate(s)of Occupancy from locai � buildi i or for ' assem ar�eas. .215 Written com 'rance from local fire .300(A)(2)(a) Private water supply-DEP approval(>25 people, >60 .300(A)(2)@) Private water suppy-BOH approval and chemical and bacterial anayses �/ <25 , Plans anc! Policies-Written .0�{A} Procedures far backgrnund review of stafif and ✓ volurtteers. A90{C) CORI and SORI ,pr�evious work history, / 3 referenoes,out of stateJirrtemational criminal '✓ ' ba round checks for stafi and wluMeers .097 Staff and volurrteer orierrtation lan and r�view. .093 Abuse and neglect preverrtioNreporting � r�edur�s. .191{B}(C) Discipline Policy with:aPpr�priate disapline ✓ i methods and hibiiti�ons. .21 Fire evacuation n a�d drill� .21 D"isasker Plan 210 C Lost Cam r Plan 210 C Lost Swimmer Plan .210 Traific Corrtrol Plan �/' Cor�tin en lans-Da Cam : .211 Cam r dcesn't show u f�r Cam r doesn't show at 'rrt of ' u C Child nat istered arrives Corrtin en lans-PrimiWe,Tra�nel and Tri : .212 Itinera dai -co to nents Sou►�ce af eme care .190 Camper released only to pa�Ms or parent des�nated individual in writing.C�ther plan approved in writing by BOH. Promotiiorrai libetatu�t cke�t carhair�s• .159(B)(2) Copy of policy re:car+e of mildly itt camp�ers, administr�ion of ineds ar�d emergency heaith care vision. .190(C) Statement re:regu�itory comp6ance and licensin . .190(D) Inform parerrts of righ#to review baekground chedc,heaRh care,discipline poliaes and rievance rocedures u uest. Tra rtation 250 VehiGe must compy with MGLc.90 s7B�7D: <14 passengers AND driver is camp coach, directar,etc.private vehic�s may be usett. >14 passengers,vehicle must be school bus All vehicles mus#be RMV iant .253 r automobile insurance .281 Seatbelts must be wom ar�d speC�at needs of cam rs communicated to driver 251 Camper<7yrs not transported longer than 1 hr to cam St�ff Qualifications Cam [?inector .102(A} Residerrti�l Camp:25 yrs,vompl�ed t�ourse in camp adminis�ration or at least 2 seasons e .102{B) Day Camp: 21 yrs,completed camp admin'istration course or 2 seasons e rience. .142(C) Primitive,Travel,Trip: 21 yrs and proaF of e rience. .102(D) Designated subst�ute when dir+e�#or off-site >12 hrs. Sub must meet criteria abo�e Counselor�lJunior Counselors .1� Day Camp, non-sport: / Counsetor= 16 . Juniar Counsetor= 15 V .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counse� 16 .1� All caunselors 3 older than cam rs R uired Counselor Ratios .101(� Residerrtiai and Day Camps: 1 staif per 10 kids over 6 yrs 1 staff r 5 cam rs 6 rs and under .101(B) Primitive,Travel,Trip: 1 counxlor 10+cam rs.2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers � 1 c�ounselor 2 se disabled c�n a � ; .103 Aquatics Dir�ecto�r�� Name:f�X�P u'i�lane � American Red Cross Lifeguard Tmg cert.,CPR / for Professional Rescuer and First Aid C.ert.or 1� their equivaients. If supervise 2�a�f,21yrs and experience wrlman emerrt .103 Lifeguard:American Red Cross�uard Tmg cert.,CPR for Professionai Res�c;uer cert.and First Aid Cert.ortheir uivalerrts.List names. .f 03 Certificat�ns for other high-risk activ�ties,eg: � NRA instrudar certification for fir+earms. List Plames and Certifications: .252 Camp vehide dmrers: 18yrs,2yrs drivirig / experience,cumerrt license for type aP vehide ��/ First Aid certified if no other trained�aff aboard. Medical Personnel/RecordsJFacilities .159(A) Health Care Consultarrt �3�ss cav�'-�. Name: .l�R�Lv� 2r i� � �ec�z��-S � NP PA(w/pediatric trainin9) Che�k for Hea�hh Car�e Consultant A reement .159(C) Health Suaervisw(on site at all�'pes} Neme: 5� �o�'�-`�'� .)'v/i� Guf'i'+P/✓ � 1�rrs, First,4id a CPR certfied OR, MD PA NP LPN .159 Healtn Care Pol' .160 Medication stor�ed in ' 'nal c�tainers. .160{B) Meds stored'm securied cabinet and if � necessa r�fii ed in atTuced bo�c. .1 C Medica�iion adrr�inistereci b Hea�h Su 'sor .154 Injury Reports compl�ted for fatality or serious in'u .Co sent to MDPH. .155 Medical log book bound,pre-numbersd pages, � ink errtries,no ski lin�s. .161{A) Ir�firmar�r provided-day and residerrt.camps �/ E�derbr� ht-resident.cam s .453 Li htin videt!in infinn .161 Area fqr isolatio�of iA child .161(C} First Aid I(it: nqr�perfumed saap,stetile gauze squares,compresses,adhesive tape, bandage , / sassors,trianguiar and ro8ed barxi�jes,CPR V mask,iwe.ezers,cold , tav�s. .150 Heatth necord for each camper and staff: -emergenr.y corrtar.t info -camper<18 yrs must ha�written par�ental permissbn�or'rr�eds ar�d emer�gency cat�. Re�sideMial,Sport.TraveVTriP: Health History, Physical E�mL2yrs) Record of Immuniza�ions{noted bebw) Day Camp Non-Sport: Health History, Record of Immunizations(n�ed below � i . ' � ; ��,�o�- � .152(A) Carr�ers arui staff under 18yrs: Num�of�cords checked: MMR 1�dose= 12 mos or older, � Meas�s: 2nd dase=grades K 12 or age equiv � Polio:3 doses IPV or OPV,or , 4 doses mix I PV/OPV i Diph�eria and Tetanus Toxoids and F'ertussis*: 4 doses DTaP/DTPIDT or, ' 3 doses of Td (persons 7 yrs or older needing additional vaccines to compy with�ov�e,Td is to be US� "`Bakster dc�se af Td �rades 7-10 need booster if>5yrs sir�ce last dose of DTaPJDTP/DT �rades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DTtfd He B: 3 doses if bom on ar after 1/1/'92 .152(B) Campers and statf 78 yrs.or older: Number of r�cands Measleg: 2 doses(exemp�'rf bom before 1957) Checked: /�.�.. Mumps: 1 dose (exemp�if bom befiore 1957} Rubella: 1 dos� (exempt if bom be#ore 1957) / Diphtheria and T�anus Toxoids": ,/ 3 dose.s DT�/DTPiDTJTd *Booster dose of Td required if more than 10 yrs since Nast dose. AC�V�I�S .190 Activities and physical envi►nnment rr�the needs of campers;do not pase hazard to � health/ .163 O or encau sun ection for au. A uafiCs .430 Slwimming P�1:in compGance with 105 CMR 435.00- rm� ed. .204(B) Bathing Beach:in compbance w�hh 105 CMR � 445.�-w water sren i c�nduded. .103 Proper supervision at swnnnming v+�nue: �; � 1 lifeguard per 25 campers � 1 counselor per 1 Q campers Plan to chedc swimmers-"bud m" .204{C) Swim test to Gassify swimmers�r abi�ty. ✓ .204{/� S1�vimm�ng areas clean and safe,no snrimming at undes' nated s�es or at ni wi�out I' htin . .204 Piers and fl�oats in re ir. �/ .2Q4(G) Water�craft:equipped wi�t US Coast Guard approved flotation devices and wom by ail ✓ campers and sta�participating in w�erc�aft activities. , � � I " � A uatics cont'd + 204(t� Campers must be certified by Amer�an Red � Cross or equivalent for white water,haza�s ✓ satt or fresh water adivities. .703(C) Minimum 2 counsebrs in separate watercraft supervising white water,hazardous salt or fresh water activ��s. � Crafts � ' .205 EquipmeM in good repair,safeiy pr+ecauuti�ons n � taken. Pla roundlAthtetic E i errt .206 Equipmerrt properfy mairrtained,flelds/surtaces ftee of holestacciderrt hazands .206 Playground equ�ment secure,no concrete under/around�, iable swin �ats. Firearms .201 Si le shot ti�es on . .201 Shootin ra e aw from ather ' areas .201 �irearms in good cond�ion,stored in locked ✓ cabinet.Ammunfion lodced in e cabinet. Arctte .202 Equipmerrt in good condition,stored�locked / area. J� .202 Range away frnm other adivity areas,clearly mariced as danger ar�ea.Must hav�e common firing line and 25 yards clearance behind each ta et. .Zai No nal wea ns,baws,rifles�lawed. Horseback Ridin .208(A} 1 certified instructor per 10 campers(M�.2 ✓ counselors .2 Riders must wear hard hat .208 B Licensed st�le Cabins/Struc�res: .457 Day Camp provide shetter for on-going camp � ac�ivities. 216 Smoke detectors rovided. .4551.456 Egresses compty with BIdg.Co�and are free � from obstruction .453 Li htin vided for skairw .454 Floors mairrtained. Residerrtial Cam in Areas: .458 Provide adequate space: 40�qft/person in si�le bed / 35sqft/per�n in bunk bed �� 50sqfr/person in sleeping ar�requiring special u" r�t .470 Provide bed/c�t per person with 6 fe+�befween ✓ sle�per's heads and: 3 feet beMreen ' le beds/4i2 feet beiv�een bunks Residential Cam 'n Are�s: .459 Campers and staif w�h lim�ect mobiti#y fioused on ground level;egresses leading to grade or �/ ram ovided. .452 Screens rovided.Scr�een door sel�c�os' . .4�54 Flaars mairrtained. Tents: .217 Fire-retardant and non-to�tic. No open flame / nea o� .458 35 rson in bunk bed ToiletsJShow�ers .360 P sew e dis I .301 Piumb" in worki order .370 Adequate#of toi�ts: A!i camps:2 tale�s/privy seats for each sex Day Camp:>60 of one�c,provide 1 additiorral � toilet per every 3Q peopie of that sex. Non-0ay Camp:>20 of one sex, �o�ride 1 additional toi{et r ev 1 d of that sex. .372 Todet less than 200 feet from sleeping rooms.Ta�t paper provided.Wmdaws/ � o nin s screened.Scneen doors self-dosi . .373 Adequate#of sinks: / Day Camp: 1 per every 3Q people V Resider�ral Cam : 1 ev 30 .374 Adequate#of shawers{r�esiderrtial camp): ' / 1 showedtub r ZQ V .378/.380 Special nesds campers provided faali6es that � m�eet their needs .4.ri3 rovided. .375 To�ets and shower rooms ventilated to outdoors .376 Hot water at sinks,showers/tubs nat more than 192°F. .3T1' Sanitary facilities mairrtained in dean cond�ion. Shawer roam floors washed da' . Laund .162 Residential Cam : laund facilities rovided .472 Bedding and tawels laundered;no c�mmon � towels Grounds� .3� Patabie water rovided. .3001.304 Adequate and cerrtra�zed drinking water ✓ facilities.No common drinkin cu s. .209 Telephone readily available with#s of HCC, � EMS,palice,fire. and Residenti�l C�n on .213 E en communication stem. .165 Tobacco use restr�ted to designated areas not ✓ accessib�to cam rs. .35W.355 P r st and di I of so�id waste 1 i ' � 207 Proper storage and operation of power / equipmerrt. ✓ ' .214 Flammable and hazardous materials labeled and sta�ed in locked unoccu ' bu�di . .400 Roderrt and insed corrtroi. � .401 Weed and no�tious lant controL i .450 Site lacation does not cause undue tra�ic � hazards�d is accessible at ail times. Focx! Service .320 Faod service in campliance with 105 CMR 590.�00,Minimum Standar�ds f�Food � Establishm�rrts.Permit posted in food service facii' .330 Nutritious meais that include a variety of foods ✓ served. Menus ed. .331 Residerrtial camps—Provide at least three nutritious meals. Foods must meet �/ Recommended Dieta ANawances D .332 Day camps—Each meal pro�must me�t � 1/3 ofthe RDA uiremeMs. .334 Adequately trained staif and equipment provided to ensure handicapped campers ane �/ eafr nutritious meals. .335 Proper methods i�storing meals brougfit from home. Meals provided to campers who arrive � without a ba lunch. .452 Scr�eening provided for foad preparation and faact senrice�reas. Sa+een doors mu�be setf- ✓ closi . .453 ' htin vided in kitchen and din� area. .471 S roh�bited'+n food areas. r�u�a�noN NO. THE 3PACE BELOW DE3CRIBES VIOLATtON3 MARKED ASOVE � �- x ,r �� : .► � y��.� � �� Division of Community Sanitation STATE SANITARY CODE:CHAPTER IV,MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREAl10NAL CAMPS FOR CHILDREN 1Q5 CMR 430.000 NAME OF CAMP: I�j j'n fe � �'Nt� ADDRESS: Gv��! OWNER/OPERATOR: � OFF SEASON �ir� ��5�, ADDRESS: CAMP DIRECTOR: �5' �2 INSPECTED BY: p ` TY E OF CAMP: (CirGe) ATER r d�_ DATE OF INSPECTION: N�+�S y errtial SOURCE: o CAMPER �-/�O Lf��j�o C�� Trip Primitive Travel CAPACITY: �No°column= °�'marked belaw indicates a violation of 430.000. °`Yes°column= ��"marked b�ow indicates compliance w�h provision of a30.�0. °N/A°column= ��1°marked betow indicates that the 'sion of 43U.0�is not a icable to this cam . Permits .451 Current Certficate(s)of Occupancy from local � buildin ins or for slee in assemb ar�eas. .215 Written com liance from local fire de . .300(�(2)(a) Private water supply-DEP approval(>25 people, �t• >60 d .3�{A}(2)(b) Private water supply-BOH approval and chemical and bacterial analyses 1e� <25 le,<60d Plans and Policies-Written .0�(A} Procedures for background review of staff and � volurrteers. .090(C) CORI and SORI ,previous work history, C 3 references,aut of statefirrtemational criminal � back round checks for stafF and volurrteers .091 Staff and�lurrteer orierrtat�n an and review. .093 Abuse and neglect preverrtioNreporting � rocedures. .191(B)(C) Discipline Policy with:apprnpriate disappne � methods and rohibitions. .210 A Fire evacuation lan and drills .21 Disaster Plan .210 C Lost Cam Ptan ✓ .210 C Lost Slivimmer Plan ✓ .210 Traffic Corrtrol Plan Corttin en ans-D Cam : .211 Cam r doesn't show u d �' Cam r doesn't show u `at irrt of ick u ✓ C Chi�not istered arrives ✓ Corrtin en lans-Primitnie,Trav�el and Tri : .212 Itinera dai -co to rerrts � Source of em en care ✓� .190 Camper released anly to par�errts or parerrt- designated individual in writing.Other plan � approved in writing by BOH. 5 Promotior�ai literature/ cket coMair�s: .159(B)(2} Copy of policy ne:care of mildly ili campers, administration of rneds and emergency heafth care ovision. .19Q(C) Statemerrt re: regulatory compliance and � licensin . .190(D} IMnrm parents of rigM to review background check, heatth care,discipline�liaes and ✓ rievance rocedures u n uest. Trans rta�ion .250 VehiGe must comply with MGLc.�s7 7D: <14 passengers AND driver is camp coach, / director,etc.private vehicles may be used. r� >14 passengers,vehicle must be school bus All vehicles must be RNM com liant .253 Pro r automobile insurance .251 Seatbefts must be worn and special needs of � cam rs communicated to driver 251 Camper<7yrs not transpated longer than 1 hr � to cam Staff Qualifications Cam Director .1Q2(A) Residerrtial Camp:25 yrs, completed course in camp administration or at least 2 seasons e rience. .102(B) Day Camp: 21 yrs,completed camp � administration course or 2 seasons e rience. .102(C} Primitive,Travel,Trip: 21 yrs and proof of � e rience. .102(D) Designated substitute when director aff-site �/ >12 hrs. Sub must meet aiteria above Counselor�Junior Counselors .100 Day Camp,non-sport: Counselor- 16 . Juniar Counsebr- 15 s. .100 Other camps: Counselors= l8 yrs or graduated from high sctrool. Junior � Counselor� 16 .100 All counselors 3 s older than cam rs R uir�ed Counselor Ratios .101(A} Residerrtial and Day Camps: 1 staff per 10 kids over 6 yrs � J� �f 1 staff r 5 cam rs 6 and under .101(B) Primitive,Travel,Trip: 1 counselor r 10 cam rs.2 counselar min. _101{C) Special Needs: 1 counselor�r 4 mildy disabled campers 1 counselor r 2 severe disabled cam rs .103 Aquatics Directo . � Name:��,��one American Red Cross Lifeguard Tmg c rt. P for Professional Rescuer a •irst' ' .or � their equivalerrts. If supervise 2 staff,� wtmana emerrt .103 LiFeguarcl:American R�Craoss Lifeguard Tmg cert.,CPR for Professional Rescuer cert.and ✓ First Aid Cert.or their uivalerrts. List names. .103 Certifications for other high-risk activities,eg: NRA instrudor certfication for firearms. � List Names and Certifications: .252 Camp vehiGe drivers: 18yrs,2yrs driving experience,currerrt license for type of vehide � First Aid certified if no other trained staff aboarcf. Medical PersonneURecords/Facilities .159(A) Heafth Care Consultarrt � �� z� Name: NP PA(w/pediatric training) C eck for HeaRh Care Consuftarrt r�eemerrt .159(C) Health Supervisor(on site at all times) Name:s�� .�csi 18yrs,First Aid and CPR certified OR, MD PA NP LPN .159 Health Care Po .160 A Medication stored in ori 'nal corrtainers. .160(B} Meds stored in secured cabinet and if �/ necessa refi rated in affuced box .160 C Medication administered Health Su 'sor r/ .154 Injury Reports com{�eted for fatality or serious � in'u .Co serrt to MDPH. .155 Medical I�book bound,pre-number�ed pages, � ink errtries,no ski d lines. .161(A} Infirmary pravided-day and r�esiderrt.camps � Exterior li ht-residerrt.cam s .453 Li htin rovided in infirma .161 Area for isolation of ill chitd .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares,compnesses,adhesive tape,bandage scissors,triangular and rolled 6andages,CPR mask,iweezers,cold ck, loves. .150 HeaRh record for each camper and staff: -emergency corrtact info -camper<18 yrs must have written parerrtal permission for meds and emergency care. Resider�tial,Sport,TraveUTrip: � Health History, Physical F�cam(<2yrs) Record of Immunizations{noted below) Day Camp Non-Sport: Health History,Record of Immunizations(nated below Immunizatior�s• .152(A) Campers and staff under 18yrs: Number of r�ecords checked: MMR 1�dose= 12 mos or oider, � Measles: 2"d dose=grades K 12 or age equiv Polio:3 doses IPV or OPV,or 4 doses mix IPV/OPY Diphtheria and Tetanus Toxoids and Pertussis": 4 doses DTaP/DTPJDT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to compiy with�ove,Td is to be used) '"Booster dose of Td: -grades 7-10 need boost�if>5yrs sir�e last dose of DTaPJDTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaPlDTP/DT/Td He B: 3 doses if bam on or after 1/1/92 .152{B) Campers and staff 18 yrs.or older. Number of r�ecbrds Measles: 2 doses(exempt iF bom before 1957) N / Chedced: L�� Mumps: 1 dose (exemprt if bom before 1957) V Rubella: 1 dose (exemp�if bom before 1957) Diphtheria and Tetanus Toxoids*: 3 doses DTaPlDTPtDTIfd "Booster dose of Td required if more than 10 yrs since last dase. ACt1V1'tJ@S .1� Ad'nrities and physical environmerrt meet the ✓. needs of campers;do n�pose hazard to healtlVsa .163 O rator encoura sun rotection for all. ✓ A uatics .430 Swimming Pool:in comp�ance with 105 CMR � 435.Od- rrrtit sted. .204(B) Bathing Beach:in comp6ance with 105 CMR � 4d5.00-w water sam lin conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers / 1 counselor per 10 cam�rs i/ Plan to chedc swimmersr°bud s �em" .204(C) S�vim test to classify swimmers by ability. ,/ 204(� Slwimming areas Gean and safe,na swimming � at undes' nated sites or at ni without I' htin . .204 Piers and floats in re ir. .204(G) Water�crait:equipped with US Coast Guard approved flotation devices and wom by all ✓ campers and staff participating in watercraft activities. A uatics cont'd .204(H} Cam�rs must be certified by American Red Cross or equivalent for white water, hazaMous � salt or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft supervising white water, hazardous sait or fresh ,,/ water adivities. Crai'�s .205 Equipmerrt in good r�epair,safety precautions ,� taken. Pla round/Athletic E ui mer�t .206 Equipmerrt properly mairrtained,fields/surfaces � free of holeslacciderrt hazards .206 Playground equipmerrt secur�e,no concr�ete under/around it, liable swin seats. Fireartns ✓ .201 Sin le shot rifles on . .201 Shootin ran e aw from other ' areas �/' 201 Firearms in good condi�on,stored in locked cabinet.Ammunition lodced in se arate cabinet. Arche .202 Equipment in good condition,stored in locked area. ✓ .202 Range away from other�ivity areas,clearly mariced as danger area.Mu�ha�re common � firing line and 25 yards clearance behind each ta et. .203 No rsonal wea ns,baws,r"rfles allowed. ✓ Horseback Ridin .208(P� 1 certified instructor per 10 campers(Min.2 counselors � 1F�` s� .208 Riders must wear hard hat ✓ .208 B Licensed stable Cabins/Structures� .457 Day Camp provide sheiter for on-going camp activities. .216 Smoke detectors rovided. .455/.456 Egresses canply with Btdg.Code and are free � from obstnadion .453 Li htin rovided fo�stairwa .454 Fl�rs maintained. Residentiatl Cam Slee in Areas: .458 Provide adequate space: 40sqft lperson in single bed 35sqft/person in bunk bed 50sqftlperson in sleeping ar�requiring speaal ui er�t .470 Provide bed/cot per person with 6 feet between sleeper's heads and: 3 feet bet�n�een s' le be�/412 feet between bunks Residerrtial Cam lee in Areas: .459 Cam�rs and staff with limi�ed mobility housed on ground levei;egresses leading to grade or � ram rovided. .452 Screens rovided.Screen door seff-closin . .454 Floors mairrtained. Tents: .217 Fire-retardarrt and non-to�ac. No open flame �,,/ nearb . .458 35 s rsan in bunk bed Toilets/Showers .360 Pro er sew e dis sai .301 Plumbin in ood worici order .370 Adequate#of toilets: AII camps:2 toil�tslpmry seats for each sex Day Camp:>60 of one sex,provide 1 additional � toilet per every 30 people of that sex. Non-Day Camp:>20 of one sac,provicie 1 additiornal toilet r ev 10 e of that sex. .372 Toilet less than 2�feet from sleeping rooms.Toilet paper provided.WindovvsJ ,/ o nin s screened.Screen doors self-dosin . .373 Adequate#of sinks: Day Camp: 1 per every 30 people �" l� Residential Cam : 1 ev 30 .374 Adequate#of showers(residerrtial camp): � ,� �� 1 showner/tub r 20 .378/.380 Special needs campers provided faalities that meet their needs .453 Li htin rovided. .375 Toilets and shower rooms verrtilated to outdoors .376 Hot water at sinks,shrnnrer�tubs nat more than � 112°F. .377 Sanitary facilities mairrtair�d in clean condition. � Shower room floors washed dai . Laund .162 Residerrtial Cam : laund faci{ities rovided .472 Bedding and towels laundered; no c�mmon towels Grounds• .300 Potable water rovided. Ta>-�--� .300/.304 Adequate and cerrtralized drinking water � facilfies. No common drinkin cu s. .209 Telephane readily available with#s of HCC, � EMS,police,fire. a and Residential Cam on .213 Eme en communication s stem. .165 Tobacco use restricted to designated areas not � accessible to cam rs. .35Q1_355 Pro r stora e and di sal of solid waste ✓ , • . - � C .207 Proper storage and operation of power equipmerrt. �,/ .214 Flammabie and hazardous materials labeled � and stored in bcked unoccu ied buildin . .400 Roderrt and insect corrtrot. .401 Weed and no�aous larrt controi. .450 Site location does nat cause undue traffic hazards and is accessible at all times. FOOd SeNIC@ .320 Food senrice in compliance with 145 CMR � 590.000, Minimum Standards for Food Establishmerrts.Permit posted in foa!service facil' .330 Nutritious meals that include a variety of foods served. Menus sted. .331 Residential camps—Pnnvide at least three nutritious meals. Foods must meet � Recommendec!Dieta Allowances RDA .332 Day camps—Each meal provided must meet 1l3 of the RDA uiremerrts. .334 Adequately trained statf and equipmerrt provided to ensure handicapped campers are i/ eatin nuhitious meals. .335 Proper methods for storing meals brought from � home. Meals provided to campers who arrive without a ba lunch. .452 Scrieening prorrided for food preparation and fnod sen�ce areas. Sc�+een doors must be self- ✓ closin . .453 Li htin rovided in kitchen and dinin area. .471 Slee in r�ibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE � y��'r�-/ Name of City or Town STATE SANITARY CODE:CHAPTER IV,MINIMUM SANITATION AND SAFETY STANDARDS FQR RECREATIONA�.CAMPS FOR CHILDREN, 105 CMR 430.000 ::- {��`�c ; ":��/��##�� TT/ -�1� `.i;��ifi��:��Y�� 3�� NAME OF CAMP. �� ,-.�/' ADDRESS: OWNER/OP�RATOR: � OFF SEASON x�� l2U�c�`�C"i� RDDRESS: CAMP DIRECTOR: � INSPECTED BY: i r� TYP OF C P: (Circle) WATER � DATE OF 1NSPECTION: a s' ' I SOURCE: �; po CAMPER � "� �/,�/`�� Trip Primitive Travel CAPACITY: "No�column= "�1"marked below indicates a violation of 430.000. "Yes"column= °�1"marked below indicates compliance with provision of 430.OU0. "N/A°column= "�l"marked below indicates#hat the rovision of 430.000 is not a licable to this cam . �� `�iF ��'�' .z�." `Te .,R_% �:.�y ^{-��,v� �r�- ,�!� �� .�� '�`'-:X� �'.i � �--•� ` � . ,. ", .. .. . ,...�a r ,."s.__ .._ . _, . .. . ....v �.: .,�.: . . ,.. Permits .451 Current Certificate(s)of Occupancy from local buildin ins ector for slee in assembl areas. .215 Written com liance from local fine de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, � >60 da s/ .300(A)(2)(b) Private water supply-BOH approval and � /� chemical and bacterial analyses � <25 eo e,<60da s/ Plans and Policies-Written .090(A) Procedunes for background review of staff and ✓ volunteers. .090(C) CORI and SORI , previous work history, 3 references,out of statefintemational criminal back round checks for staff and volunteers .U91 Staff orientation lan. Reviewed with all. .093 Abuse and neglect prevention/reporting � rocedures. .191(B)(C) Discipline Policy with:appropriate discipline methods and rohibi6ons. .210 A Fire evac�.iation lan and drills .210 B Disaster Plan .210 C Lost Cam er Plan .210 C Lost Swimmer Plar� .210 D Traffic Control Plan Contin en lans-Da Cam : .211 A Cam r doesn't show u for da B Cam er doesn't show u at oint of ick u ✓ C Child not r istered arrives Contin en lans-Primitive,Travel and Tri : .212 A ltinera dail -co to arents B Source of emer enc car�e .190 Camper released only to parents or parent- designated individual in writing.Other plan � a roved in writin b BOH. �te u�a�s�n z �� ,>�.��: � �* t �� '�" �' �fies Na ,N�A �i�i�nm�n� � t u� �.� ��. � �� Promotionai literature/ cket cantains:, � .159(B)(2) Copy af policy re:care of miidly ill campers, administration of ineds and emergency �/ health care rovision. .190(C) Statement re:regulatory campliance and � licensin . .190(D) Inform parents of right to review background chedc, health care,disapline policies and rievance rocedures u n re uest. Trans ortation .250 Vehide must camply with MGLc.90 s7B&7D: <14 passengers AND driver is camp coach, director,etc.private vehicles may be used. �/ >14 passengers,vehide must be school bus All vehicles must be RNN compliant .253 Pro er automobile insurance .251 Seatbelts must be wom ant]speaal needs of cam ers communicated to driver ✓ .251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,completed course in camp administration or at least 2 seasons � ex rience. .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons e rience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex erience. .102(D) Designated substitute when director off-site ✓ >12 hrs. Sub must meet criteria a6ove Counselors/Junior Caunselors .100 Day Camp, non�sport: Counsebr- 46 rs. Junior Gounselor-15 .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior ✓ Counselors- 16 rs .100 All counselors 3 rs older than cam ers Required Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs / � �f 1 staff er 5 cam ers 6 s and under � .101(B) Primitive,Travel,Trip: � 1 counselor er 10 cam ers.2 counselor min. .101(C) Speaal Nee�s: 1 counselor per 4 mildly disabled campers ,/ 1 counselor er 2 severel disabled cam ers `'Re �i.�tr��t �,�� , � � _ � � � �£ �e� £ ,�1� ��I{A ��i�t� _ � _r: .. �,., :�, _ , ,__: ��._, h �.. F ,..._. _. ., r, ... ,, _ .103 Aquatics Director: Na merican Red Cross Lifeguard Tm ce PR for r essiona escuer an �rs i e their equivalents. If supervise 2 staff�21 yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lffeguard Tmg � cert.,CPR for Professional Rescuer cert.and First Aid Cert.or their e uivalents. List names. .103 Cert�cations for other high-risk activities,eg: NRA instructor certification#or firearms. ,�cl,e� List Names and Certificafions: .252 Camp vehicle drivers: 1$yrs,2yrs drNing / experience,current license for type of vehicle � First Aid certified h no other trained staff aboard. Medical PersonneURecords/Facilities .159(A) Hsalth Care Consultant � pyz �n z'st-v me: i6�ss (2i� ��%��-s NP PA(w/pediatric training) eck for Health Care Consultarrt A reement .159(C) Health Supervisor(on site at all times) Name: J�,r,t Jotii►SG" �/ 18yrs, First Aid d CPR certified OR, MD PA NP R LPN .159 B Health Care Po i .160 Pro er sto e of inedication .160 Medication administered by Health Supervisor or licensed medical rofession�l .154 Injury Reports completed for fatality or serious � in'u . sent to MDPH. .160 A Medications stored in ori inal containers. .160(B) Meds stored in secured cabinet and if necessa refr' erated in affixed box. .155 Medical log book-bound,pre-numbered pages, � ink entries,no ski (ines. .161(A) Ir�firmary provided-day and resident.camps ✓ Exterior I' ht-resident.cam .453 Li htin rovided in infirma .161 B Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap,sterile gauze / squares,compresses,adhesive tape, bandage ✓ sassors,triangular and rolled bandages,CPR mask,tweezers, cold ack, loves. .150 Health record for each camper and staff: -emergency contac�info � -camper<18 yrs must have written parental permission for meds and emergency care. j '' ; 4 x'+' � � �,�+�?�' i � �� Q ��_, ��¢�W � i�,:�'�' h"� : ..�Qi a��a`IQ� -F :E .,r.`i 'c t � . . ... . . ......�.,... � ._�. _ ..�,_ ,. ,� .. ,_ . ,.._.._ _' ,. ,>, ..� Immunizations: .952(A) Campers and staff under 18yrs: Number of records MMR: 1�dose= 12 mos or older, chedced:_� Measles: 2"�dose=grades K-12 or age equiv / Polio:3 doses OPV or IPV, or � 4 doses moc IPV and OPV Diphtheria and 7etanus Toxoids and Pertussis": • 4 doses DTaP/DTP/DT "Booster dose of Td required if more than 10 yts since last dose. Hep B: 3 doses if bom on or after 1/1/92 : .152(B) Campers and staff over 18yrs: Number of recflrc�s Measles: 2 doses(exempt if bom before 1957) chedced: l� Mumps: 1 dose (exempt if bom before 1957) � Rubelia: 1 dose Diphtheria and Tetanus Toxoids": 3 doses DT/Td "Booster dose of Td required if more than 10 yrs since last dose. Activities .19U Activities and physical environment meet the needs of campers;do not pose hazard to � health/safe . .163 O erator encoura es sun rotection for all. A uatics .430 Swimming Pool:in compliance with 105 CMR ✓ 435.00- ermit ted. .432 Bathing Beach:in compliance with 105 CMR / 445.00-weekl water sam lin conducted. °� .103 Proper supenrision at swimming venue: 1 lifeguard per 25 campers ✓ 1 counselor per 10 campers Plan to check swimmers-"budd s tem� .204(B) Swim test to classify swimmers by ability. ✓ .204(A) Swimming areas dean and safe,no swimming /� at undes' nated sites or at ni ht without li htin . �� .204 E Piers and floats in ood re air. .204(G) Watercraft:equipped with US Coast Guard approved flotation devices and wom by all � campers and staff participa6ng in watercraft activities. .204(H) Campers must be cert�ed by American Red � Cross or equivalent for white water, hazardous saft or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft / supervising white water, hazardous salt ar fresh � water activikies. `:Re r�iat�a� s,� ��"�� ,.t � E 'Ye�� i1�/��" ��m�ri'� �� , _ � Crafts � � .205 Equipment in good repair,safety precautions � #aken. P1a roundlAthletic E ui ment .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete � under/around•it, liable swin seats. Firearms .201 Sin le shot rifles onl . .201 Shootin ra e awa from other activi areas .201 Firearms in good conditior�,stored in lodced cabinet.Ammunition locked in se rate cabinet. Arche .202 Equipment in good condition,stored in lodced ,�/ area. .202 Range away from other activity areas,clearly marked as danger area. Must have comrnon ✓ firing line and 25 yards clearance behind each tar et. .203 No ersonal wea ns,bows, rifles allowed. Hors+eback Ridin .1U3(G) 1 certified instructor per 10 campers(Min.2 S/� �j a .�U�.�.��'$ ��r/�6"'" �i�T .103 G Riders must wear harcl hat .103 G Licensed staale_ Cabins/Stru�tures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors rovided. .456 Ad uate resses free from obstruction � .453 L' htin rovided for stairwa s .454 Flflors maintained. Residential Cam Slee in Ar�eas: .458 Provide adequate space: N/A for primifive,fip and 40sqft/person in single bed / travel camp. 35sqft/person in bunk bed r/ 50sqft/person in sleeping area requiring speaal ui ment .470 Provide bed/cot per person with 6 feet beiween sleeper's heads and: � 3 feet between sin le beds/412 feet beiween bunks .459 Campers and staff with limited mobility housed on ground level;egresses leading to grade or ✓ ram rovided. .452 Screens rovided.Screen door setf-dosin . .454 Floors maintained. Tents. .217 Fire-retardant and non-toxic. No open flame nearb . .458 35 erson in bunk bed �/ ;'�G� Mf�`�� # ��''�Y�'._" C s`'� 2 ttSfi' �� '`£�.�� y� '��5 � ��a��f�� ST'r�� - � ��': ,. . � _ � *,' . < .. _ . . . ,., a _.-.. e t. ,. .� .. _�� .-�i,. . < ._�s�rv. .470 Provide bed/cot per person with 6 feet befinreen � N/A for primitive, trip and sleeper's heads and: � travel camp. 3 feet between sin le beds/4'�feet between bunks ToiletstShowers .360 Pro er sewa e dis sai .301 Plumbin in ood workin order .370 Adequate#of toilets: All camps:2.toilets/privy seats for each sex Day Camp:�60 of one sex,provide 1 additional / toilet per every 30 people of that sex. �� Non-Day Gamp:>20 of one sex,provide 1 additional toilet r e�e 10 te af that sex. .372 Toilet less than 200 feet from sleeping rooms.Toilet paper provided.Windows/ � o enin screened. Screen doors self-closi . .373 Adequate#of sinks: , Day Camp:1 per every 30 people � Residential Cam : 1 r eve 30 .374 Adequate#of showers(residential camp): � 1 shower/fub r 20 le .378/.380 Special needs campers provided facilities that ✓ meet their needs .301 Plumbin in worki order .453 L' htin rovided. .375 Toilets and shower rooms ven6lated to outdoors .376 Hot water at sinks,showers/tubs not more than 112°F. .377 Sanitary facili6es mairrtained in dean oondition. � Shower room floor�washed dai . Laund .162 Residential Cam :laund facilities rovided .472 Bedding and towels laundered;no common towels Grounds• .300 Potable water rovided. .300/.304 Adequate and centraliaed drinking water facilities. No common drinkin cu . .209 Telephone readily available with#s of HCC, ✓ local hospitals, police,fire,ambulance. D and Residential Cam sonl .213 Emer en oommunication s tem. .165 Tobacco use restricted to designated areas not � accessible to cam rs. .350/.355 Pro er sto e and dis I of solid waste .207 Proper storage and operation of power � e ui ment. .214 Flammable and hazardous materials labeled and stored in locked un�cu ied buildin . .400 Radent and insect control. .401 Weed and noxious lant controL .450 Site location does not cause undue traffic � hazards and is accessible at all times. ��i!�r, .�R�3�L� �;�. ��'�� — '� �Y- _ `M.t ..,�x.:� _��+�� s �!:,, r '�� - - . �Y � ., s�_ � � � ,��.� i: ._ . .. > ..., "-..:�. , _.,_.. . .�.. . . �:��_... .. , Food 3ervice .320 Food service in compliance with 105 CMR 59Q.000, Minimum Standards for Food � Establishments. Permit posted in food senrice facili . .330 Nutritious meals that indude a variety of foods served. Menus sted. � .331 Residentia!c�mps—Provide at least three nutritious meals. Foods must meet ✓ Recommended Dieta Allowances RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA re uirements. .334 Adequately trained staff and equipment provided to ensure handicapped eampers are eati nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who amve without a b lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be setf- ctosi . .453 L" htin rovided in kitchen and dini area. � .471 Slee in rohibiked in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED AB�YE � y��'r�-/ Name of City or Town STATE SANITARY CODE:CHAPTER IV,MINIMUM SANITATION AND SAFETY STANDARDS FQR RECREATIONA�.CAMPS FOR CHILDREN, 105 CMR 430.000 ::- {��`�c ; ":��/��##�� TT/ -�1� `.i;��ifi��:��Y�� 3�� NAME OF CAMP. �� ,-.�/' ADDRESS: OWNER/OP�RATOR: � OFF SEASON x�� l2U�c�`�C"i� RDDRESS: CAMP DIRECTOR: � INSPECTED BY: i r� TYP OF C P: (Circle) WATER � DATE OF 1NSPECTION: a s' ' I SOURCE: �; po CAMPER � "� �/,�/`�� Trip Primitive Travel CAPACITY: "No�column= "�1"marked below indicates a violation of 430.000. "Yes"column= °�1"marked below indicates compliance with provision of 430.OU0. "N/A°column= "�l"marked below indicates#hat the rovision of 430.000 is not a licable to this cam . �� `�iF ��'�' .z�." `Te .,R_% �:.�y ^{-��,v� �r�- ,�!� �� .�� '�`'-:X� �'.i � �--•� ` � . ,. ", .. .. . ,...�a r ,."s.__ .._ . _, . .. . ....v �.: .,�.: . . ,.. Permits .451 Current Certificate(s)of Occupancy from local buildin ins ector for slee in assembl areas. .215 Written com liance from local fine de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, � >60 da s/ .300(A)(2)(b) Private water supply-BOH approval and � /� chemical and bacterial analyses � <25 eo e,<60da s/ Plans and Policies-Written .090(A) Procedunes for background review of staff and ✓ volunteers. .090(C) CORI and SORI , previous work history, 3 references,out of statefintemational criminal back round checks for staff and volunteers .U91 Staff orientation lan. Reviewed with all. .093 Abuse and neglect prevention/reporting � rocedures. .191(B)(C) Discipline Policy with:appropriate discipline methods and rohibi6ons. .210 A Fire evac�.iation lan and drills .210 B Disaster Plan .210 C Lost Cam er Plan .210 C Lost Swimmer Plar� .210 D Traffic Control Plan Contin en lans-Da Cam : .211 A Cam r doesn't show u for da B Cam er doesn't show u at oint of ick u ✓ C Child not r istered arrives Contin en lans-Primitive,Travel and Tri : .212 A ltinera dail -co to arents B Source of emer enc car�e .190 Camper released only to parents or parent- designated individual in writing.Other plan � a roved in writin b BOH. �te u�a�s�n z �� ,>�.��: � �* t �� '�" �' �fies Na ,N�A �i�i�nm�n� � t u� �.� ��. � �� Promotionai literature/ cket cantains:, � .159(B)(2) Copy af policy re:care of miidly ill campers, administration of ineds and emergency �/ health care rovision. .190(C) Statement re:regulatory campliance and � licensin . .190(D) Inform parents of right to review background chedc, health care,disapline policies and rievance rocedures u n re uest. Trans ortation .250 Vehide must camply with MGLc.90 s7B&7D: <14 passengers AND driver is camp coach, director,etc.private vehicles may be used. �/ >14 passengers,vehide must be school bus All vehicles must be RNN compliant .253 Pro er automobile insurance .251 Seatbelts must be wom ant]speaal needs of cam ers communicated to driver ✓ .251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,completed course in camp administration or at least 2 seasons � ex rience. .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons e rience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex erience. .102(D) Designated substitute when director off-site ✓ >12 hrs. Sub must meet criteria a6ove Counselors/Junior Caunselors .100 Day Camp, non�sport: Counsebr- 46 rs. Junior Gounselor-15 .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior ✓ Counselors- 16 rs .100 All counselors 3 rs older than cam ers Required Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs / � �f 1 staff er 5 cam ers 6 s and under � .101(B) Primitive,Travel,Trip: � 1 counselor er 10 cam ers.2 counselor min. .101(C) Speaal Nee�s: 1 counselor per 4 mildly disabled campers ,/ 1 counselor er 2 severel disabled cam ers `'Re �i.�tr��t �,�� , � � _ � � � �£ �e� £ ,�1� ��I{A ��i�t� _ � _r: .. �,., :�, _ , ,__: ��._, h �.. F ,..._. _. ., r, ... ,, _ .103 Aquatics Director: Na merican Red Cross Lifeguard Tm ce PR for r essiona escuer an �rs i e their equivalents. If supervise 2 staff�21 yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lffeguard Tmg � cert.,CPR for Professional Rescuer cert.and First Aid Cert.or their e uivalents. List names. .103 Cert�cations for other high-risk activities,eg: NRA instructor certification#or firearms. ,�cl,e� List Names and Certificafions: .252 Camp vehicle drivers: 1$yrs,2yrs drNing / experience,current license for type of vehicle � First Aid certified h no other trained staff aboard. Medical PersonneURecords/Facilities .159(A) Hsalth Care Consultant � pyz �n z'st-v me: i6�ss (2i� ��%��-s NP PA(w/pediatric training) eck for Health Care Consultarrt A reement .159(C) Health Supervisor(on site at all times) Name: J�,r,t Jotii►SG" �/ 18yrs, First Aid d CPR certified OR, MD PA NP R LPN .159 B Health Care Po i .160 Pro er sto e of inedication .160 Medication administered by Health Supervisor or licensed medical rofession�l .154 Injury Reports completed for fatality or serious � in'u . sent to MDPH. .160 A Medications stored in ori inal containers. .160(B) Meds stored in secured cabinet and if necessa refr' erated in affixed box. .155 Medical log book-bound,pre-numbered pages, � ink entries,no ski (ines. .161(A) Ir�firmary provided-day and resident.camps ✓ Exterior I' ht-resident.cam .453 Li htin rovided in infirma .161 B Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap,sterile gauze / squares,compresses,adhesive tape, bandage ✓ sassors,triangular and rolled bandages,CPR mask,tweezers, cold ack, loves. .150 Health record for each camper and staff: -emergency contac�info � -camper<18 yrs must have written parental permission for meds and emergency care. j '' ; 4 x'+' � � �,�+�?�' i � �� Q ��_, ��¢�W � i�,:�'�' h"� : ..�Qi a��a`IQ� -F :E .,r.`i 'c t � . . ... . . ......�.,... � ._�. _ ..�,_ ,. ,� .. ,_ . ,.._.._ _' ,. ,>, ..� Immunizations: .952(A) Campers and staff under 18yrs: Number of records MMR: 1�dose= 12 mos or older, chedced:_� Measles: 2"�dose=grades K-12 or age equiv / Polio:3 doses OPV or IPV, or � 4 doses moc IPV and OPV Diphtheria and 7etanus Toxoids and Pertussis": • 4 doses DTaP/DTP/DT "Booster dose of Td required if more than 10 yts since last dose. Hep B: 3 doses if bom on or after 1/1/92 : .152(B) Campers and staff over 18yrs: Number of recflrc�s Measles: 2 doses(exempt if bom before 1957) chedced: l� Mumps: 1 dose (exempt if bom before 1957) � Rubelia: 1 dose Diphtheria and Tetanus Toxoids": 3 doses DT/Td "Booster dose of Td required if more than 10 yrs since last dose. Activities .19U Activities and physical environment meet the needs of campers;do not pose hazard to � health/safe . .163 O erator encoura es sun rotection for all. A uatics .430 Swimming Pool:in compliance with 105 CMR ✓ 435.00- ermit ted. .432 Bathing Beach:in compliance with 105 CMR / 445.00-weekl water sam lin conducted. °� .103 Proper supenrision at swimming venue: 1 lifeguard per 25 campers ✓ 1 counselor per 10 campers Plan to check swimmers-"budd s tem� .204(B) Swim test to classify swimmers by ability. ✓ .204(A) Swimming areas dean and safe,no swimming /� at undes' nated sites or at ni ht without li htin . �� .204 E Piers and floats in ood re air. .204(G) Watercraft:equipped with US Coast Guard approved flotation devices and wom by all � campers and staff participa6ng in watercraft activities. .204(H) Campers must be cert�ed by American Red � Cross or equivalent for white water, hazardous saft or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft / supervising white water, hazardous salt ar fresh � water activikies. `:Re r�iat�a� s,� ��"�� ,.t � E 'Ye�� i1�/��" ��m�ri'� �� , _ � Crafts � � .205 Equipment in good repair,safety precautions � #aken. P1a roundlAthletic E ui ment .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete � under/around•it, liable swin seats. Firearms .201 Sin le shot rifles onl . .201 Shootin ra e awa from other activi areas .201 Firearms in good conditior�,stored in lodced cabinet.Ammunition locked in se rate cabinet. Arche .202 Equipment in good condition,stored in lodced ,�/ area. .202 Range away from other activity areas,clearly marked as danger area. Must have comrnon ✓ firing line and 25 yards clearance behind each tar et. .203 No ersonal wea ns,bows, rifles allowed. Hors+eback Ridin .1U3(G) 1 certified instructor per 10 campers(Min.2 S/� �j a .�U�.�.��'$ ��r/�6"'" �i�T .103 G Riders must wear harcl hat .103 G Licensed staale_ Cabins/Stru�tures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors rovided. .456 Ad uate resses free from obstruction � .453 L' htin rovided for stairwa s .454 Flflors maintained. Residential Cam Slee in Ar�eas: .458 Provide adequate space: N/A for primifive,fip and 40sqft/person in single bed / travel camp. 35sqft/person in bunk bed r/ 50sqft/person in sleeping area requiring speaal ui ment .470 Provide bed/cot per person with 6 feet beiween sleeper's heads and: � 3 feet between sin le beds/412 feet beiween bunks .459 Campers and staff with limited mobility housed on ground level;egresses leading to grade or ✓ ram rovided. .452 Screens rovided.Screen door setf-dosin . .454 Floors maintained. Tents. .217 Fire-retardant and non-toxic. No open flame nearb . .458 35 erson in bunk bed �/ ;'�G� Mf�`�� # ��''�Y�'._" C s`'� 2 ttSfi' �� '`£�.�� y� '��5 � ��a��f�� ST'r�� - � ��': ,. . � _ � *,' . < .. _ . . . ,., a _.-.. e t. ,. .� .. _�� .-�i,. . < ._�s�rv. .470 Provide bed/cot per person with 6 feet befinreen � N/A for primitive, trip and sleeper's heads and: � travel camp. 3 feet between sin le beds/4'�feet between bunks ToiletstShowers .360 Pro er sewa e dis sai .301 Plumbin in ood workin order .370 Adequate#of toilets: All camps:2.toilets/privy seats for each sex Day Camp:�60 of one sex,provide 1 additional / toilet per every 30 people of that sex. �� Non-Day Gamp:>20 of one sex,provide 1 additional toilet r e�e 10 te af that sex. .372 Toilet less than 200 feet from sleeping rooms.Toilet paper provided.Windows/ � o enin screened. Screen doors self-closi . .373 Adequate#of sinks: , Day Camp:1 per every 30 people � Residential Cam : 1 r eve 30 .374 Adequate#of showers(residential camp): � 1 shower/fub r 20 le .378/.380 Special needs campers provided facilities that ✓ meet their needs .301 Plumbin in worki order .453 L' htin rovided. .375 Toilets and shower rooms ven6lated to outdoors .376 Hot water at sinks,showers/tubs not more than 112°F. .377 Sanitary facili6es mairrtained in dean oondition. � Shower room floor�washed dai . Laund .162 Residential Cam :laund facilities rovided .472 Bedding and towels laundered;no common towels Grounds• .300 Potable water rovided. .300/.304 Adequate and centraliaed drinking water facilities. No common drinkin cu . .209 Telephone readily available with#s of HCC, ✓ local hospitals, police,fire,ambulance. D and Residential Cam sonl .213 Emer en oommunication s tem. .165 Tobacco use restricted to designated areas not � accessible to cam rs. .350/.355 Pro er sto e and dis I of solid waste .207 Proper storage and operation of power � e ui ment. .214 Flammable and hazardous materials labeled and stored in locked un�cu ied buildin . .400 Radent and insect control. .401 Weed and noxious lant controL .450 Site location does not cause undue traffic � hazards and is accessible at all times. ��i!�r, .�R�3�L� �;�. ��'�� — '� �Y- _ `M.t ..,�x.:� _��+�� s �!:,, r '�� - - . �Y � ., s�_ � � � ,��.� i: ._ . .. > ..., "-..:�. , _.,_.. . .�.. . . �:��_... .. , Food 3ervice .320 Food service in compliance with 105 CMR 59Q.000, Minimum Standards for Food � Establishments. Permit posted in food senrice facili . .330 Nutritious meals that indude a variety of foods served. Menus sted. � .331 Residentia!c�mps—Provide at least three nutritious meals. Foods must meet ✓ Recommended Dieta Allowances RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA re uirements. .334 Adequately trained staff and equipment provided to ensure handicapped eampers are eati nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who amve without a b lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be setf- ctosi . .453 L" htin rovided in kitchen and dini area. � .471 Slee in rohibiked in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED AB�YE Departmart#of Public Healttt Division of Community Sanitation STATE SANt7ARY CODE: CHAPTER N,MINIMUM SANITATlON�1ND SAFETY STANDAi�DS FOR RECREATIONAL CAMPS FOR CHILDREN,105 CMR 430.000 �, ..' _ � � ��"" �� "�� . ,''� . ..: ��.: :� . . , . � �_ NAME OF CAMP: ` � r AD�RESS: � � • OWNER/OPERATO : OFF SEASON � �S�}-Npy �v�S�lN A,DDRESS: CAMP DIRECTOR:S . INSPECTED BY: � E OF :(Circis) WATER DATE OF INSPEC710 : e " errtial SfJURCE: �W� !./ / p� (Spo o po CAMPER Trip n nre Travet CRPACITY: v i "No°column= °�h'marked beiow indicates a violation of 430.000. "Yes°column= "�1"marked below ind�ates compliance with provisian of 430.000. "N/A"column= "�1"marked below indicates that the rovision of 430.000 is not a licable to this cam . ��s � ,.. �� _�. _� �_� �� s �� . � �E � �.:�, .�� -x� �;. ��'z: �� ;��-��:� il:� ._ .� _'� � , ��,�,� �� Permits .451 Cumerrt Gertificate(s)of Occupancy from local buikiin ins or for s in assemb areas. .215 Written com liance from local fire de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, >60 d .300(A)(2)(b) Private water suppy-BOH approval and chemical and bacterial anayses <2� �, <�a Plans and Policies-Written .090(/� Procedures for background review of staff and valunteers. .090(C) CORI and SORI , previous work history, 3 references,out of stat�rrtemational criminal back round checks for staff and volunteers _091 Staff and votur�teer o►ientation lan and r�view. .093 Abuse and neglect preventioNreporting � mcedures. .191(B)(C} Disapline Policy w�h:appropriate discipline methods and rohibitions. .210 A Fire evacuation lan and drills .210 Disaster Plan .210 C Lost Cam er Plan .210 C Lost Slrvimmer Plan .210 Tra�ic Corrtrol Plan Corrtin en tans-Da Cam : .211 A Cam r doesn't show u for d B Cam r doesn't show u at irrt of ick u C Child not istered arrives Conttin ans-Primitive,Travei and Tri : .212 A Itinera dai -co to r�errts B Source of eme en care , .190 Camper released only to parents or parerrt- designated individual in writing.Other plan / approved in writing by BOH. � `l�t I�IG� ; '��_ ,:�` '�/l�• . C��'1'M�� 3 ��. ,� _ .� rt . �:� Promotional literature/ cket contains: .159(B)(2) Copy of policy re:care af miidy ill campers, administration of ineds and emergency � health care ovisian. .190(C) Statement re: regulatory compliance and licensin . .190(D) Iniorm parerrts of right to review background� � check, heatth care,discipline policies and rievanc:e rocedures u on uest. Trans rtation .250 Vehide must compiy with MGLc.90 s7B�7D: <14 passengers AND driver is camp coach, director,etc.pm�a#e veMicles may be used. >14 passengers,vehicle must be school bus All vehicles must be RMV co liant 253 Pro er automobile insurance .251 Seatbelts must be wom and special needs of / cam rs communicated to driver �/ .251 Camper<7yrs not transported longer than 1 hr � to cam Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,completed course in camp administration or at teast 2 seasons ' e rience. .102(B) Day Camp: 21 yrs,c:ompleted camp administration course or 2 seasons e rience. .102(C} Primitive,Travel,Trip: 21 yrs and proof of e rience. .102(D) Designated subsfiitute when diredor off-site >12 hrs. Sub must meet criteria above CounselorsJJunior Counselor� .100 Day Camp, non-sport: Counselor- 16 . Junior Counsebr- 15 s. .100 Other camps: Counselors= 18 yrs or graduated from high schooi. Juniar Counselor� 16 .100 All counselors 3 older than cam rs R uir�ed Counselor Ratios .101(A) Residerrtial and Day Camps: 1 staff per 10 kids over 6 yrs 1 staff r 5 cam rs 6 rs and under .107(B) Primitive,Travel,Trip: 1 counselor er 10 cam rs.2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor er 2 severe disabled cam ers r � `.,.,�KlYQ�'.`I . ; �SriiR,: � :��[/� " '1�IM��tfi� a.. .103 Aquatics Director. Name: None � American Red Cross Lifeguard Tmg cert.,CPR for Professional Rescuer and First Aid Ce�t.or their equivalerrts. / If supervise 2 staff,21yrs and experience � w�mana emerrt .103 Lifeguard:American Red Cross Lifeguard Tmg cert.,CPR for Professional Rescuer cert.and First Aid Cert.or their uivalents. List names. .103 Certifications for other high-risk adivities,eg: NRA instructor ceRfication for firearms. List Names and Certfic+ations: .252 Camp vehide drivers: 18yrs,2yrs driving experience, current license for type of vehide / First Aid csrtified if no other trained staff aboard. v Medical PersonneURecords/Facilities .159(A) Meafth C•re Consuftant • o� ��/� D NP PA(w/pediatric training) C eck for Health Care Consultarit A r�eemerrt .159(C) Health Su enrisor(o site all times) Name:�� 18yrs, Frrst Aid d CPR t�rtfied OR, MD PA NP N LPN .15 B Health Care .160 A Medication stored in ori "nal corrtainers. .1&0(B) Meds stored in secured cabinet and if necessa refri erated in affaed box .160 C Medication administered b Health Su rvisor .154 Injury Reports completed�for fataiity or serious in'u .Co sent to MDPH. .155 Medical log book lmund,pre-numbered pages, ink entries, no ski lines_ .161(A) Ir�firmary provided-day and resident.camps Exterior fi ht-residerrt.cam s .453 Li htin rovided in infirma .161 Area for isota#ion of ill child .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares,campresses,adhesive tape, bandage scissors,triangular and mtled bandages,CPR mask,iweezers,cold dc, loves. .150 Health necord for each camper and stai� -emergency corrtact info -camper<18 yrs must have written parental permission for meds and emergency care. Residentiay Sport,TravellTrip: Heafth History, Physica)Exam(<2yrs) Record of Immunizations(notet!below) / Day Camp Non-Sport: �/ Health History, Recard of Immunizations(noted below �' �� , �� '�� riKlY7d�� '� ..,�' � �:.�. � '�f ,y 4 �-.� , . , , _ _: ,, ,� , ,. s .. Y, = ':,.- . ,'��,. . �<.. ��- a..- d, t � . ��.w ...: 2 �. . . �-, . . z.,h t_. -.,..< .n .� . . , ._.. �.P .ws: r t,..� - . .. . ,.� Immunizations: .152(A) Campers and staf�under 18yr�: Num r of records checked: MMR 1�dose= 12 mos or older, Measles: 2`�dose=grades K 12 or age equiv Pofio: 3 doses IPV or OPV,or 4 doses moc!PV!OPV Diphtheria and Tetanus Toxoids and Pertussis": 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs ar older needing additionai vaccines to camply with above,Td is to be usec� *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT �rades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTPIDTiTd I� B: 3 doses if bom on or after 1/1�92 .152(� Campers and sta#fi 18 yrs.or older. Number of�rds Measies: 2 doses(exempk if bom before 1957) CheCked: Mumps: 1 dose (exemp#iF bom before 1957) Rubella: 1 dos+e (exemp�ifi bom before 1957) Diphtheria and Tetanus Toxoids": 3 doses DTaP/DTP/DT/Td "'Booster dose of Td requi�c!if more than 10 yrs since last dose. ACt1Vl'tIE:S .190 Adivities and physical environmerrt meet the needs of campers;do not pose hazar�d to health/sa .163 O rator encoura es sun ratection for all. A uatics .430 S1+vimming Pool:in compliance arith 105 CMR 435.00- rmit sted. .204(B) Bathing Beach:in compHance with 105 CMR 445.00-w water sarrt lin oonducted. .103 Pr+oper supervisipn at swimming venue: 1 tifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmets-"twd s stsm" .2�4(C) Snrim tes�t to classiiy swimmers by ability. .204(A) Swimming areas clean and safe,no swimming at undes' nated sites or at ni ht without 1" htin . 204 Piers and floats in ood re ir. .204(G) Watercraft:equipped with US Coast Guard approved flotation devices and wom by all campers and staff participating in watercraft activfies. tl��i � � ' ' �� ..N� . ��:` :'�lN1'!�� ,. - �.� .�.t� . �. r. - � �, _ z- A uatics carrt'd) .204(ti} Campers musC be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103{C) Minimum 2 counselors in separate watercraft supervising white water, h2zardous sa�or fr�esh water activities. Crafls 205 Equipment in good repair, safety precautions taken. Pla round/Athletic E ui ment .206 Equipmerrt properiy maintained,fields/surFaces free of holes/acciderrt hazards .206 P�ayground equipmerrt secure, no concrete under/around it, liable swin seffis. Firearms .201 Sin le shot rifles on . .201 Shootin ran e awa from other acti ' areas .201 Firearms in good condition,stored in locked cabinet.Ammunitron locked in se rate cabinet. Arche .202 Equipment in good condition,stored in locked �r�a. .202 Range away from other activity areas,clearly marked as danger area.Must h�ve common firing line and 2�yards clearance behind each ta et. •2Q3 No rsonal wea ns, baws, rifles allowed. Horseback Ridin .208(A} 1 certified instructor per 10 campers(Min.2 counselors .208 A Riders must wear hard hat .208 B Licensed stabfe Cabins/Structures: .457 Day Camp provide shelter for ai-going camp a�tivities. .216 Smoke detectors rovided. .455/.456 Egresses comply with BIdg.Code and are free from obstruction .453 Li htin rovided far stairwa s •454 Flaors mairrtained. ResideMyal Cam s/Slee in Areas: •458 Provide adequate space: 40sqft/person in single bed 35sqff/person in bunk bed 50sqft/person in sleeping area requiring special ui ent .470 Provide bed/cot per person with 6 feet peiween sleeper's heads and: 3 feet beivveen si le bedsJ 4'�feet betw�een bunks t#la#i�: � �� r�� c� ��; ��` Residentiai�Cam� � Sfee in Areas. .459 Campers and staff with limited mobility housed on ground Ievel;egresses leading to grade or / ram rovided. V •452 Screens rovided.Screen door self-ciosin . •454 �loors mairrtained. Tents: .217 Fire-retardarrt and non-to�ac. No open flame nea .458 35 ft! erson in punk bed Toilets/Show�ers •360 Pro r sewa e dis osai .301 Plumbin in ood worki order .370 Adequate#of toilets: AII camps:2 toilets/privy seats for each sex Day Camp:�60 of one sex,provide 1 additional toitet per every 30 people of that sex. Non-Day Camp:>ZO of one se�c, provide 1 additional toilst r ev 10 o e of tha#sex. .372 Toilet less than 2�f�eet from sleeping rooms.Toilet paper provided.Windows/ o enin screened.Screen doors self-Gosin . .373 Adequate#of sinks / Day Camp: 1 per every 30 people_ ✓ Residential Cam : 1 ev 30 .374 Adequate#of showers(residential camp): j 1 shovNedtub r 20 ✓ _378/.380 Special needs campers provided facilities that meet their needs .453 L' htin rovided. .375 Toi{ets and shower rooms verrtilated to outdoars .376 Hot water at sinks,shcwvers/tubs not more than 112°F. .377 Sanitary faalities mairrtained in clean cond�ion. Shower room floors washed dai . Laund .162 Residerrtial Cam :laund facilities rorrided -472 Bedding and towels iaundered;no cammon towels Grounds: -300 Potable water rovided. -340/•304 Adequate and centralized drinking water facilities. No common drinkin cu s. .2�9 Teiephone readily available with#s of HCC, . EMS, police,6re. a and Residerrtial Cam s on .213 Eme en communication s stem. �16� Tobacco use restricted to designated areas not accessible to cam ers. .350/.�55 Pro r stora e and di sal of soNd waste � u�tion `, ,,. -. � , ' ;'�i� _ =,� ;Nll� �r't�l"n81'��s t .207 Proper storage and operation of power equipment. .214 Flammable ar�d hazardows materials lab�led and stored in locked unoccu ied buildin . .400 Roderrt and insed con#rol. .401 We�d and noxious lant carrtrol. .450 Site loc�tion does not cause undue traffic hazards and is accessibfe at ali times. F�OCI S@NICe .320 Food service in compliance with 1U5 CMR 590.000, Minimum Standards for Food Establishments. Perm�posted in faod senrice facil' . .330 Nutritious meals that include a variety of faods served. Menus sted. .331 Residerrtial camps—Provide at least three nutritious meals. Foods must meet Recommended Dieta �anc.es RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA uirements. .334 Adequately trained staff and equipmerrt provided to ensure han+dicapped campers are eatin nutritious meals. .335 Proper methods for storing meals brought from hame. Meals provided#o campers who arrive without a ba lunch. .452 Screening provided for food preparation and / foad service areas. Screen doors must be self- , / closi . v .453 Li htin rov�led in kitchen and dinin area. .4'71 Slee i rohibited in food areas. REGULATK?N NO. THE SPACE BELOW DESCRIBES V10LATIONS MARKEDABOVE l/ �yl, � 1 . , • Llepartment of Public Health Division of Cammuni#y Sanatation STATE SANITARY CODE: CHAPTER N, MINIMUM SANITATION AND SAFETY STANDARbS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 ` :R�CRE�TICIi� ` ` ��ltf�"��E��tL�IFiE� 1��PE��'f4N REPC3 T NAME OF CAMP: r %j� /.� ADDRESS: . OWNEWOPERATOR: / OFF SEASON ( �d/ S ADDRESS: CAMP DIRECTOR: r INSPECTED BY: • �t p TYPE O P: (Circle} WATER �� DATE tN PECTION: Qay esidential SOURCE: � ZQ �y� (Spa� � CAMPER / Trip Primitive Travei CAPACITY: "No�column= "�/n marked below indicates a violatic�n of 430.000. "Yes"column= "�1"marked below indicates compliance with provision of 430.OQ0. "N/An column= °�I" mariced bebw indicates that the rovision of 430.Q00 is not a licable to this cam . R ul��+an '' :° `1Fes Na I��i4 .. Cari�ents Permits .451 Current Cefificate(s)of Occupancy from local buildin ins ectorforslee in assembl areas. .215 Written com liance from local fire de t. .300(A)(27(a) Private water supply-DEP approval (>25 people, >6Q da .300(A)(2)(b) Private water supply-BOH approval and chemical and bacterial analyses <25 eo le, <6Qda s/ r Plans and Policies-Written .090(A) Procedures for background review of staff and ✓ valunteers. .09Q(C) CORI and SORI , previous work history, 3 references,out of stat�ntemational criminal � back round checks for staff and volunteers .091 Staff and volunteer orientation lan and review. .093 Abuse and neglect preventiaNreporting rocedures. .191(B)(C) Discipline Policy with: appropriate diseipline ✓ methods and rohibifions. .210 A Fire evacuation lan and drills .210 B Disaster Plan `/ .210 C Lost Cam er Plan .21 Q C Lost Swimmer Plan "_ .2t �? Traffic�ntro!Pl�� _ . . _. __ ._ . " �onti enc I�ns-Da Car�t : . . ._ , _ �. _._..- , . . . , .2't'k A . Carr� r doesn't show - far da : ° _ _ . _ __.. _ ; , B Cam r rf�esn't sFiow u at int o� ick _ '. . _., , C Child not isteted'arrives � .___ __ �:.,. � . ; CQn� ; lan`s-Primitive,Traval and Tri : .�1$ A Itirje �d� _� �� enis . . _ , _. _.__._. ...:. . . . g � . _ .urce of erne ert care __ _ ; , . _ _ ..- , _ . ,. ��s '' .190 ' Carttper ret@�$ed�{y ta paren�s or parenX _ � ... '.� '�!e's'i'�p�ateCf iridividua�'irt Wrih'pig.Other placi -� __ _ . , . �f 'aPRroved in w[ifiri�by BQH. . 'R utatio� �es Nv N/A Commen#s Promotional literaturei cket contains: .159(B)(2) Copy of policy re:care of miidly ili campers, administratian of ineds and emergency health care rovision. .190(C) Statement re: r�ulatory compliance and licensin . .190�D) Inform parents of right to review background checic, health care,discipline policies and rievance rocedures u n r uest. Trans ortation .250 Vehide must comply with AIIGLc.90 s7B8�7D: <14 passengers AND driver is camp coach, director,etc.private vehicles may be used. j� >14 passengers,vehide must be school bus � All vehicles must be RMV com liant .253 Pro er automobile insurance .251 Seatbeits must be wom and speaal needs of / cam ers communicated to driver f .251 Camper<7yrs not transported longer than 1 hr to cam S#aff Quatifications Cam Director .102(A) Residential Camp:25 yrs, compfeted course in , camp administration or at least 2 seasons ex erience. .102(B} Day Camp: 21 yrs,completed camp administration course or 2 seasons e erience. .102(C) Primitive, Travel,Trip: 21 yrs and proof of ex erience. .102(D} pesignated substitute when director off-site / >12 hrs. Sub must meet criteria above �/ CounselorslJuniar Couns�lors .100 Day Camp, non-sport: Counsebr- 16 rs. Junior Counselor- 15 .1 QO Other camps: Counsebrs= 18 yrs or graduated from high schooL Junior / Counselors= 16 rs ✓ .100 All counselors 3 rs older than cam ers Required Counselor Ratios .101(A) Residential and Day Camps: ��f C�� . � 1 staff per 10 kids over 6 yrs / 3•s ' 1 stafF er 5 cam ers 6 and under e� �j'�S�p.� .101(B) Primitive,Travel,Trip: 1 counselor er 10 cam ers.2 counselor min. .101(C) Speaal Needs j 1 counselor per 4 mildly disabled campers r� 1 counselor r 2 severel disabted cam ers R ulation Yes No NIA ��c�rnerr�s .103 Aquati Directq�'-,��,�. Name:��_'Uf7drie� American Red Cross Lifeguartl Tmg cert., CPR for Professional Rescuer and First Aid�ert.or tfieir equivalents. If supervise 2 staff,21 yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Tmg cert.,CPR for Professtonal Rescuer cert.and First Aid Cert.or their e uivalents. List names. .103 Certifications for otlier high-risk activities, eg: NRA instructor certification for firearms. List Names and Cert'r�icafions: _252 Camp vehicle drnrers: 18yrs,2yrs driving experience,current lieense for type of vehic{e First Aid certified if no other trained staff abaard. Medical PersonneURecords/Facitities .159(A) Heaikh Care nsultant e: I�, D N PA(w/p diatric training} eck for Health Care Consultant reement .159{C) Health Suoervisar(on site at all times) Name: "�aD� TO�s� 18yrs, Fir'�t Aid CPR certfied OR, MD PA NP N PN .159 B Health Care .160 A Medication stored in ori irtal containers. .160(B) Meds stored in secured cabinet and iF necessa refri erated in affixed box. � - .160 C Medication administered b Heatth Su ervisor .154 Injury Reports completed for fatality or serious / in'u .Co sent to MDPH. �/ .155 Medical log book-bound, pre-numbered pages, ink entries, no sld ed lines. .161(R) Irrfirmary provided-day and resident.camps Exterior I' ht-resident.cam .453 Li htin rovided in irrfirma .161 B Area for isolation of ill child .161(C} First Aid Kit: non-perfumed soap,sterile gauze squares, compresses, adhesive tape, bandage sassors,triangular and rolled bandages, CPR mask,finr�zers,cotd ack, toves. .150 Health recarc!for each camper and staff: -emergency contact info -camper<18 yrs rnust have written parental permission for meds and emergency care. Residential,Sport,TraveUTrip: Health History, Physical Exam�2yrs} RecorrJ of Immuniza6ons(noted below) Day Camp Non,Sport; / Health History, Record of Immunizations(noted f below .Y`es.. -I+�o -I�l�t Corn�rt�s Re u�atio�. � Immunizations: � � � � .152(A} Campers and staff under 18yrs: Num �of records checked: MMR: 1�dose= 12 mos or oider, Measles: 2"d dose=grades K-12 or age equiv Potio:3 doses IPV or OPV,or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis�: 4 doses DTaP/DTP/DT or, 3 doses of Td {persons 7 yrs or older needing additional vaccines to comply with above,Td is to be used) `Baoster dose of Td: �rades 7-10 need booster if>5yrs since fast dose of DTaP/DTP/DT -grades 11-12 need booster if more than 1Q yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if bom an or after 1I1/92 .152(B) Campers and staff 18 yrs.or older: Number of records Measles: 2 doses(exempt if bom before 1957j / chedced: (� Mumps: 1 dose (exempt if bom befor21957) �� Rubella: 1 dose (exempt if bom betore 1957) Diphtheria and Tetanus Toxaids*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more#han 1 Q yrs since last dose. Activities .190 Acfivities and physical environment meet the needs of campers;do not pose hazard ko health/safety. .163 O erator encoura es sun rotection for all. Aquafics .430 Swimming Pool: in compliance with 105 CMR 435.OQ- ermit ted. .204(B) Bathing Beach: in compliance with 105 CMR 445.00-weekl water sam lin conduc�ted. .1 Q3 Proper supervision at swimming venue: 1 I'rfeguard per 25 campers 1 counselor per 10 campers / Plan to check swimmers-°budd s stemA 1/ .204(C) Swim test to classify swimmers by ability. .204(A) Swimming areas dean and safe, no swimming at undes' nated sites or at ni ht without li htin . 204 E Piers and floats in ood re air. .2Q4(G} Watercraft:equipped with US Coast Guard approved flot�tion devices and wom by all c�mpers and staff participating in watercraft activities. Re ulation ` Yes �o NiA Comrnents A uatics cont'd .204(H) Campers must be certfied by American Red Cross or equivalent for white water, hazardous salt or fresh water actnrities. .103(C) Minimum 2 counselors in separate watercraft supenrising white water, hazardous salt or frresh / water activities. e/ Crafts .205 Equipment in good repair,safety precaufions taken. Pla round/Athletic E ui ment .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete under/around it, liable swin seats. Firearms .201 Sin le shot rifles onl . .2Q1 Sh�tin ra e awa from other actnri areas .201 Firearms in good condition, stored in locked / cabinet.Ammunition locked in se rate cabinet. +/ Arche .202 Equipment in good candition,stored in locked area. .202 Range away from other activity areas,clearly marked as danger area. Must have common firing line and 25 yards clearance behind each / tar et. � .203 No ersonal wea ns, bows, r'rfles allowed. Horseback Ridin .208(A) 1 certified instruc�or per 10 campers(Min.2 / caunselors �/ 208 A Riders must wear hard hat .208 B Licensed stable CabinslStructures: .457 Day Camp provide shetter fior on-going camp activities. .216 Smoke deteetors rovided. .455/.456 Egresses c�mply with BIdg.Code and are free / from obstruction a/ .453 L' hti rovided for stairwa .454 Floors maintained. Residential Cam Slee in Areas: .458 Provide adequate space: 40sqft/person in single bed 35sqft/person in bunk bed j 5t)sqftlperson in sleeping area requiring speaal '� ui ment .470 Provide bed/cot per person with 6 feet betwe�en / sleeper's heads and: / 3 feet beiween sin le beds/4'n feet beiween bunks V Fte ulation -' �: l�es : I�c� Nf� Cornments �' -: � � � .:,d... E Residential Cam Slee in Aneas: .459 Campers and staff with timited mobility housed on ground levei;egresses leading to grade or / ram rovided. �/ .452 Screens rovided.Screen door self-dosin . .454 Floors maintained. Tents• .217 Fire-retardant and non-toxic. No open flame nearb . .458 35 rson in bunk bed ToiletslShowers .360 Pro r sewa e dis al .301 Plumbin in ood workin order .370 Adequate#of toilets: All camps:2 toilets/privy seats for eacli sex Day Camp:>60 0€one sex,provide 1 additional toilet per every 30 people of that sex. / Non-Day Camp:>20 af one sex,provide 1 / additional toilet r eve 1 d e of that sex. �� .372 Toilet less than 200 feet from steeping / rooms.Toiiet paper provided.Windows/ `� o enin s screened. Screen doors setf-closi . .373 Adequate#of sinks: Day Camp: 1 per every 30 people /' Residential Cam : 1 r eve 3Q �� .374 Adequate#of showers(residential camp): 1 showedtub er 20 le .378/.380 Speaal needs campers provided facilities that meet their needs .453 L' htin rovided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks,showers/tubs not more than 112°F. .377 Sanitary facilities maintained in dean condition. Shower room floors washed dai . Laund .162 Residenfial Cam : (aund fiacilities rovided .472 Bedding and towels laundered; no cammon towels Grounds: .3Q0 Potable water rovided. .300/.304 Adequate and centralized drinking water facilities. No common drinldn cu s. .209 Telephone readily available with#s of HCC, EMS, police,fire. j Da and Residential Cam onl y .213 Emer n communication s stem. .165 Tobacco use restricted ta designated areas not accessible to cam ers. .350/.355 Pro er stor e and dis I of solid waste Re ulation `l�es. l�a NlA Comments .247 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labefed / and stored in�cked unoccu ied buildin . ✓ .400 Rodent and insect control. .401 Weed and noxious lant controL .450 Site location does not cause undue traffic hazards and is accessible at all tim,es. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permit posted in food serviee facili . .330 Nutritious meals that indude a variety of foods served. Menus ted. .331 Residential camps—Provide at least three nutritious meals. Foods must meet j Recommended Dieta Allowances RDA � .332 Day camps—Each meal provided must meet 1/3 of the RDA re uirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are � eatin nutrifious meals, .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a ba lunch. .452 Screening providecf for food preparation and food service areas. Sa-een doors must be seff- closi .453 L' htin rovided in kitchen and dinin area. .471 Slee in rohibited in food a�eas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE '� �.__� .� : • � � " . . ; � � Name of City or Town STATE SANITARY C4DE:CHAPTER N,MINIMUM SANITATION AND SAFETY STANDARDS FOR � RECREATIONA�.CAMPS FOR CHILDREN, 105 CMR 430.000 � � �� = . , , ��,�� M+ �' � �., � - - �,- ,n �.. � . _ � � � _ ,.. _� : ._ � .-;._ x �a .u.. _� __ �•�W , �; ,�. ^NAME OF CAMP: , t ADDRESS: ,' � OWNER/OPERATO • OFF SEASON , �yt�.. �1�C�� 3� ADDRESS: '� CAMP DIRECTOR: INSPECTED BY: i � TYPE O � Circte) WATER �, �, l DATE OF SPE N; � Da esidential SOURCE: GI W/`�' �S� ��R � 3 �� y "� Tri' Primitive Travel CAPACITY: � "No"column= "�1"marked below indicates a violat�on of 430.00p. � "Yes"column= °�l"marked bebw indicates compliance writh provision of 430.000. � `N/AA column= "�"marked bebw indicates that the rovisian of 430.OQ0 is nat a licable to this cam . � � Permits �� .451 Currer�t Certificate(s)of Occupancy from local ,�'` buildi ins or for slee ' assemb areas. � .215 Written com liance from local fine de t. .300(A)(2)(a) P�vate water supply-DEP approval(>25 people, �60 da s/ � .300(A)(2j(b) Private water supply-BOH approval and chemical and bacterial analysas V/`` <25 ,<60da Plans and Policies-Written .090(A} Procedures tor backgrourxi review of staff and �" volurrteers. .090{C) CORI and SORI , previous work history, 3 references,out of sta�ntemabonal criminal �`' back round checks for staff and volunteers .091 Staff orientatian lan.Reviewed with all. .093 Abuse and negted pneventioNreporting � rnc�edures. .191(B)(C) Discipline Poticy with:appropriate discipHne meNiods and rohibiti�ons. � .210 A Fire evacuation lan and drills .21 Q B Disaster Plan v'� .210 C Lost Cam r Plan .21 C Lost Swimmer Plan .210 D Traffic Control F'�an Conti ns-Da Gam : .211 A Cam doesn't show for da 6 Cam r doesn't show u at 'rrt of idc u C Child not ist�red arrives Conti en ns-Primitive,Travel and Tri : .212 A Itinera dai - to arents B Source of eme enc care .190 Camper released only to parents or parent- designated individual in writing.Other plan .�'' a roved in writin b BOH. � _ __ � � _� .� .� �� ,�� -� Promotionai literaturel cket contains: .159(B)(2) CoPY of policy re:care of mifdy ili campers, �.- administr�tion of ineds ar�emergency health care vision. .190(C) Statement re:regulatory compliance and �'� lic.ensi .190(D) Ir�form parents of right to review badcground chedc, t�alii�care,disapHne poficies and rievance ures u r uest. Tra rtation .25Q Vehide must comply with MGLc.90 s7B�7D_ <14 passengers AND driver is camp coach, director,etc.prnrate vehicles may be used. ,r ' >14 passengers,vehide must be school bus ✓ All vehicles must be RMV com iarit .253 Pro r automobile insurance .251 Seatbelts must be wom and special needs of �� cam communicated b driver .251 Camper<7yrs rrot transported bnger than 1 hr to cam `� Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,c�mpleted course in camp administration or at least 2 seasons ex rience. .102{B) Day Camp: 21 yrs,completed camp administration course or 2 seasons e rience. .102(C) Primitive,Travel,Trip: 21 yrs and prc�of of o ✓' ex 'ence. .102(D} Designated substituEe when direc�r off-site /""� >12 hrs. Sub must meet criteria above �/ Counselors/Junior Counselors .100 Day Camp, nor�-sport: / Counsebr- 16 . Junior Counselor- 15 n/ .100 Other camps: Counsebr�18 yrs or graduated from high school. Junior _ /� Counselors=l6 rs V ,� .10Q All counsebrs 3 rs older than cam rs R uired Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs � �—l(J 1 staff r 5 cam rs 6 and under .101(B) Primitive,Travel,Trip: 1 counsebr r 10 cam .2 counselor min. � .101(C) Special Needs: 1 counselor per 4 mildy disabled campers 1 cQunselor r 2 severel disabled cam rs _ � _.� � � ,, � �� ,. � ��:�� .�; .�a�� n��;. � � - .103 Aquatics Director: Name: American 12ed Cross LiFeguard Tmg ce�t.,CPR ��- for Professionai Resc:ue�r and Frst Aid Cert.or their equivalents. If supervise 2 sta�Ff,21 yrs and experienoe wlman ement .103 Lifeguard:American Red Cross Lifeguard Tmg cert.,CPR for Professional Rescuer cert.and '� �� First Aid Cert.or their uivalents.List names. .103 Certifications for other high-risk activities,eg: 9. ��_ NRA instrucbr cefifir.afion for firearms. ✓ List Names and Certifications: .252 Carnp vehide drivers: 18yrs,2yrs driving experience,cunent license for type of vehicle First Aid cerrtifified iF no ottier trained staf�aboard. Medicat PersonneURecords/Facilities .159(A) Health Care Cons �ant �� e: ,. . �. D NP PA(w/pediatric training) edc for Health Care Consultarrt r�ment .159(C) Health S�� on,sitg at ail times) Name: ��,iT,� 1$yrs, Fust Aid and CPR certified OR, �;, MD PA NP RN LPN .159 B Health Care PoG .160 Pro e of inedicafion .160 Medication administered by Health Supervisor or licensed medical ' al .154 Injury Reports completed for fatality or serious / in'u . sent to MDPH. � .160 A Medications stored in ' 'nat containers. .160(B) Meds stored in secured cabinet and if necessa ' erated in affixed bax. � .155 Medicat log book-bound, pr+�numbered pages, ink er�tries, no ski lines. ✓ .161(A) Infirmary provided-day and residerrt.camps Exterior I' ht-resident.cam �� .453 L' hti rovided in i�'irrrra .161 B Area for isolation of ill child .161(C) First Aid K'�t: non-�rFumed soap,sterile gauze squares,com�-esses,adhesive tape, bandage scissors,triangular and rolled bandages,CPR �' mask,tweezers,cold loves. .150 Heakh r+ec:orcJ for each c;a�nper and staff: -emergency contact info -camper<1$yrs must have written parental .�`�� permission for meds and emergency care. � , , � , � . , � H s .P�, .e � , � , � _ - Immunizations: .152(A) Campers and staff under 18yrs: Number of records MMR 1�'dose= 12 mos or older, chedced: Measies: 2'�dose=grades K-12 or age equiv Polio:3 doses OPV or IPV,or 4 doses muc IPV and OPV Diphtheria and Tetanus Toxads and Pertussis*: 4 doses DTaP/DTP/DT "Booster dose of Td required if more than 10 yrs j'� sirx:e last dose. � He B: 3 doses if bom on or after 1/1/92 .152(B) Campers and staff over 18yrs: Number of records Measles: 2 doseS(exempt iF bom before 1957) chedced: Mumps: 1 dose (exempt if bom t�ore 1957) Rubella: 1 dose Diphtheria and Tetanus Toxads*: 3 doses DT/Td � "Booster dase of Td required if more than 10 yrs since hast dose. Activities .19Q Ac�ivifies and physical environment meet the needs of campers;do not pose hazarcJ to health/ .163 O rator encou sun rotedion for all. A uatics .430 Swimming Pool:in oompliance with 105 CMR � 435.00- rmit ed. ;� .432 Bathing Beach:in compliance with 105 CMR / 445.00- water sam i conduct�. �/ .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counsebr per 10 campers , / Plan to chedc swimmers-"bu s tem" v .204(B) Swim test to classify swimmers by ability. �..t'� 204(A) Swimming aneas dean and safe,no swimming vr`" at undes' nated sites or at n' ht without li htin . .204 E Piers and flo�ts in re ir_ .204(G) Watercraft:equipped with US Caast Guard approved flotation devices and wom by all � campers and staff partiapating in watercraft ac�ivities. .204(H) Campers must be certified by American Red Cross or equivalent for white water, hazardous � salt or fresh water activities. �� .103(C) Minimum 2 c�unselors a�separate watercraft ai supervising wh�e water, hazardous salt or fresh � water activfies. -� _ �- _ � 7_ �� - � �,�� Crafts .205 Equipment in good repair,safety precautions �-- #aken. Pla round/Athletic E ui ment 2Q6 Equipment properly maintained,fiekis/surFaces �'` free of hdes/ac�ident hazards 2� Playground equipment secure,no concrete under/around it, liable swi seats. Firearms 201 Sin le shot rrfles onl . .201 Shooti ra e awa from other acti " areas 201 Firearms in good condition,stored in lodced �' cabinet.Ammunition locked in se rate cabinet. Arche .202 Equipment in good condfion,stored in lodced �'' area. .202 Range away from other activity areas,clearly marked as danger area. Must have common firing line and 25 yards dearance behind each � /' tar et. V .203 No rsonal wea ns,bows, rifles allowed. Horseback Ridin .103(G) 1 certified instructor per 1 U campers(Min.2 counselors `�^l .103 G Riders must wear hard hat i/'; .10 G Licensed stable Cabins/Structures: .457 Day Camp provide she�er fior or�-going camp adivities. ��: .216 Smoke detectors rovided. .456 uate resses free fi+om obstruction .453 L' hti vided for stairwa s .454 Floors maintained. Residential Cam lee in Ar�eas: .458 Provide adequate spacc�: N/A for primfive,trip and 40sqR/person in single bed travel camp. 35sqft/person in bunk bed 50sqf1/person in sleeping ar�ea r+e�.iiring speaal � ui ment .470 Provide bed/cot per person with 6 feet between sleeper's heads and: �/' 3 feet between si beds!4'�feet betw�en bunks " � .459 Campers and staff with limited mobility housed on ground�vel;egresses leading to grade or �' ram rovided. .452 Screens rovided.Screen door setf-closi . .454 Floors maintained. Tents: .217 Fir�e-retardant and non-toxic.No open flame nearb . .458 35 erson in bunk bed .470 Provide bed/cot per persan with 6 feet beiween N/A for primfive, trip and sieeper's heads and: ✓>'" travei camp. 3 feet beMreen si beds/412feet between bunks Talets/Shower� .360 Pro r d' f .301 Plumbi in workin arder .370 Adequate#of tdfets: Ali camps:2 toilets/privy seats for each sex Day Camp:�6Q of one sex,provide 1 additionai tflilet per every 30 people of that sex. y. Non-Day Camp:>20 of one sex,provide 1 � additionat lodet r ev 1 Q af that sex. .372 Toilet less than 200 feet from sleeping rooms.Talet paper provided.�ndows/ �'` o ni screened.Screen doors seff-da�si . .373 Adequa#e#of sinks: �y Camp:1 per every 30 people � Residenti�Cam : 1 eve 3Q .374 Adequate#of showers(residentiai camp): �' 1 shower/tub r 20 e .378/.380 Specaal needs campers provided facilities that P��' / meet their needs ✓ .3Q1 Rlumb' in work' order .453 L' hti .375 Toilets and shower rooms ver�tilated to outdoors .376 Hot water at sinks,showers/tubs not more than 112°F. �. .377 Sanitary facilihies mairrtained in dean condition. Shower room floors washed dai . Laund .162 Residenfial Cam : laund facilities rovided .472 Bedding and towels laundered;no oommon j�. `��--- towel.s ►` Grounds- .300 PotaWe water ided. .3�/.304 Adequate and centralized drinking water /' facilitie.s. No common drinki cu . °v .209 Telephone re�available with#s of HCC, local hospitals, pdioe,fire,ambulance. , / D and Res�dential Cam n �� .213 E ca�nmunication s tem. .165 Tobacco use r�estric:ted to designated areas not acxessible to cam rs. � .3501.355 P s and dis of solid waste .207 Proper storage and operation of power ui ent. .214 Flammable and hazardous materials labeled and stored in bcked ur�occu ied buildi . �- .400 Roclent and insed control. .401 Weed and noxious lant control. .450 Site lacation does not cause undue traffic j hazarcis and is accessibie at atl times. v Food Service .320 Food service in compliance with 105 CMR 590.00p,Minimum Standards for Food Estab6shments.Permit posted in food service �'dCl�� .330 Nutritious meals that ind�.xle a variety of inods seroed. Menus ted. .331 Residenaal camps—Provide at least three � nutritious meals. Foods must meet Recommended Dieta Allowanoes RDA .332 Day camps—Each meai pro�must meet 1/3 af the RDA uirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eati nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive �rt without a lunch. .452 Scr�eening provided for food pneepara4on and fnod service areas. Screen doors must be seff- cbsi .453 L' hti vided in kitchen and dinin area. .471 SI� i hibited in faod areas_ REGULATIOM NO. THE SPACE BELOW DESCTt18ES VIOlAT10NS MARKED ABOVE �G'd i � fL' r G��l I f ,,,N ��:a �r�/ V � Name of City or Town STATE SANITARY CODE: CHAPTER IV,MINIAAUM SANITATION AND SAFETY STANDARDS F�R RECREATIONAL CAMPS FOR CHILDREN,105��AAR 430.000 �... : :.� . �, �x,, . , -.�_. __,,.��, ,. , ..._ , ,,� . s�. .,. ., NAME OF CAMP: irl - t'�2 � ADDRESS: G✓ t . r-� �-- OWNER/OPERATOR� �y-- OFF SEASON �c�vl. �r} �� ADDRESS: CAMP DIRECTOR: INSPECTED BY: K� TYPE P: (Circle) WATER DATE OF INSPECTION: Day esidential SOURCE: ' �/Z�i�4,�' S CAMPER r ri nmitN� ravel CAPACITY: z5 d � °No"column= "�1"marked below indicates a violation of 43Q.�0. "Yes"column= "�"marked below indicates compliance with provision of 430.00Q. `N/A"column= "�l"marked bebw indicates that the rovision of 430.000 is not a licable to this cam . �F� `�► � �� Permits .451 Current Certificate(s)of Occupancy from locaf buildin ins ctor for slee in assembl areas. .215 Written com liance from local fire de t. .300(A)(2)(a) Private water supply-DEP approval(>25 people, � >60 da .300(A){2)(b) Private water supply-BOH approval and chemical and bacterial analyses <25 eo le,<60da Plans and Policies-Written .090(A) Procedures inr background review of staff and volunteers. .090(C) CORf and SORI , previaus work history, 3 reference.s,out of stat�ntemational criminal bac round checks for staff and volunteers .091 Staff orientation lan.Reviewed with all. .093 Abuse and neglect preventroNrepo�ting j rooedures. ✓ .191(B}(C} Discipline Policy with:appropriate discipfine '� methods and rohibitions. �� x'�'�� .210 A Fire evacuation lan and drills .210 B Disaster Plan .210 C Lost Cam er Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Conti enc lans-Da Cam : .211 A Cam er daesn't show u for da B Cam er doesn't show u at int of ick u C Child not istered arrives Contin en lans-Primitive,Travel and Tri : .212 A Itinera dail -co to arents B Source of eme enc care .190 Camper released only to parents or parent designated individual in writing. Other plan % a roved in writin b BOH. �,/ `----_...,.,�,4 _., � —, - , ;: . . : �. � ,. vh ;�.: _. .: � •., :. l� � , Promotional literaturel cket contains: .159(B)(2) Copy of policy re:care of mildly ill campers, � administration of ineds and emergency health care rovision. .190(C) Statement re:regulatory compliance and licensin . .190(D} Inform parents of right to review background chedc, health care,disapline policies and rievance rocedures u n re uest. Trans ortation .250 Vehide must comply with MGLc.90 s7B8�7D: <14 passengers AND driver is camp coach, director,etc.private vehicles may be used. >14 passengers,vehide must be sch�l bus All vehicles must be RMV compliant .253 Prfl er automobile insurance .251 Seatbefts must be wom and speaal needs of cam rs communicated ta driver ,,/� .251 Camper<7yrs not transported bnger than 1 hr to cam Staff Qualifications Cam Director .102(A) Residential Camp:25 yrs,completed course in camp administration or at least 2 seaso�ns ex erience. .102(B) Day Camp: 21 yrs, comp�ted camp administration course or 2 seasons e rience. .102(C} Primitive,Travel,Trip: 21 yrs and proof of / ex erience. � .102(D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: Counsebr- 16 rs. Junior Counselor- 15 .100 Other camps: Counselars= 18 yrs or graduated from high school. Junior / Counselors=�6 rs `�l .100 All counsebrs 3 rs older than cam ers R uired Counselor Ratios .101(A) Residential and Day Camps: �S�-- S � 1 staff per 10 kids over 6 yrs � � ' � 1 staff r 5 cam rs 6 and under .101(B) Primitive,Travel,Trip: 1 counselor er 10 cam ers.2 counselor min. .101(C) Speaal Needs: 1 counselor per 4 mildly disabled campers _ / 1 counselar er 2 severe disabled cam rs V � �x ;�� .� .103 Aquatics irector: Name: � encan ross Lif uard Tmg cert„�CPR r rofession id Cert.or their equivalents. If supervise 2 staff,21 yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Trng �/� 5�� cert., CPR for Professional Rescuer cert,and First Aid Cert.or their e uivalents. List names, .103 Certfications for other high-risk activities,eg: ' NRA instructor cerkfication for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs,2yrs driving ,� experience,current license for type af vehicl�- First Aid certfied if no other trained staff aboard. Medical PersonneURecordslFacilities .159(A) Health Care Consultant N me: ,r� �/ M PA(wlpediafi��c training) eck for Health Care Consultant reement .159(C) Healkh Supervisor(on site at a I times) Name: �dpy '��+5 18yrs, Fi7"st Aid CPR certified OR, • MD PA NP LPN � �J�S .159 B Healkh Care Poli .160 Pro er stor e af inedicatian .160 Medication administered by Health Supervisor or licensed medical rofessional .154 Injury Reports completed for fataliry or serious in'u .Co sent to MDPH. .160 A Medications stored in ori inal containers. .164(B) Meds stored in secured cabinet and if necessa re ' erated in affrxed box. .155 Medical log book-bound, pre-numbered pages, ink entries, no ski lines. .161(A) Infirmary provided-day and resident.camps Euterior I' ht-resident.cam .453 Li htin rovided in infirma .161 B Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares, compresses,adhesive tape, bandage sassors,triarrgular and rolled bandages,CPR mask,iweezers,cold ack, loves. .150 Health record for each camper and staff: -emergency cantad info -camper<18 yrs must have written parental permission for meds and emergency care. r, � W. . ,� .. . . .. .. ., , . .. , - . .,_ , . , , . .. .. .. ..a.. .,.. Crafts .205 Equipment in go�repair,safety precautions taken. Pla rouncUAthletic E ui ment 206 Equipment properly maintained,fieldslsurfaces ftee of hotes/accident hazards 206 Playground equipment secure, no concnete under/around it, liable swin seats. Firearms .201 Sin le shot rifles onl . .201 Shootin ra e awa from other activi areas .201 Firearms in good candition,stored in lodced cabinet.Ammunition locked in se rate cabinet. Arche .202 Equipment in good condition,stored in lodced area .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each tar et. .203 No ersonal wea ns, bows, r'rfles allowed. Horseback Ridin .103(G) 1 oertfied instructor per 10 campers(Min.2 counselors .103 G Riders must wear hard hat .103 G Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors rovided. .456 Ad uate resses free from obstruction .453 L' htin rovided for stairwa s .454 Floors maintained. Residential Cam Slee in Areas: .458 Provide adequate space: N/A for primfive,trip and 40sqft/person in single bed travel camp. 35sqft/person in bunk bed 50sqft/persan in sleeping area requiring speaal ui ment .470 Provide bed/cot per person with 6 feet between sleeper's heads and: 3 feet beiween sin le beds/4'n feet beiween bunks .459 Campers and staff with limited mobility housed on ground level; egresses leading to gratJe or ram rovided. .452 Screens rovided.Screen door self-dosin . .454 Fl�rs maintained. Tents: .217 Fire-retardant and non-toxic. IVo open flame nearti . .458 35 erson in bunk bed __ . F r , f � rv � � ,, . _; x- � � ., : .K., � � ..:. _ �. . n.�. _ Immunizations: .152(A} Campers and staff under 18yrs: Number of c.,�o�� MMR: 1�dose= 12 mos orolder, chedced: ;� Measles: 2"d dose=grades K-12 or age equiv Polio:3 dpses OPV or IPV,or 4 doses ma IPV and OPV Diphtheria and Tetanus Toxads and Pertussis*: 4 doses DTaPiDTf'/DT "Booster dose of Td required if more than 10 yrs since last dose. Hep B: 3 doses if bom on or after 1/1/92 .152(B) Campers and staff over 18yrs: Number af r�rds Measles: 2 doses(exempt iF bom before 1957) chedced: Mumps: 1 dose (exempt iF bom before 1957) Rubella: 1 dose Diphtheria and Tetanus Toxoids": 3 doses DT(Td "Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers;do not pose hazarri to health/safe . .163 O erator encoura es sun otec�ion for aIL A uatics .430 Swimming Pool:in compliance with 105 CMR 435.00- ermit sted. .432 Bathing Beach:in compliance with 105 CMR 445.00-wee water sam lin conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers-°budd s tem" .204{B) Swim test to classify swimmers by ability. .204(A) Swimming areas dean and safe, no swimming at undes' nated sites or at ni ht without li htin . .204 E Piers and floats in oad re ir. .204(G) Watercraft:equipped w�h US Coast Guard approved flotation devices and wom by all campers and staff participafing in water�craft activities. .204(H) Campers must be certfied by American Red Cross o ' water, hazardous salt fresh water activ'' � .103(C) Minimum 2 counse ors in separate watercraft superv' ' ' water,hazardous salt re \` iti „.. . .,, .„,, . . �� t>__ . :? � �..,,. . . . . . _ ;, . , , �. .., „ - , .. . , , ..�_ � .470 Provide bed/cot per person with 6 feet befinreen N/A for primitive,trip and sleeper's heads and: travel camp. 3 feet beiween sin le beds/4'�feet beiween bunks Toilets/Showers .360 Pro er sewa e dis al .301 Plumbin in ood workin order .370 Adequate#of toilets: All camps:2 toileis/privy seats for each sex Day Camp:�60 of one sex,provide 1 addition� toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex,provide 1 additional toilet r eve 10 e of that sex. .372 Toilet less than 200 feet from sleeping rooms.Talet paper provided.Windows/ o eni s screened.Screen doors self-closi . .373 Adequate#of sinks: Day Camp: 1 per every 30 people Residential Cam : 1 r eve 30 .374 Adequate#of showers(residential camp): 1 shower/tub r 20 e .378/.380 Speaal needs campers provided facilities that meet their needs .301 Plumbin in ood workin order .453 L' htin rovided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks,showers/tubs not moroe than 112°F. .377 Sanitary facilities maintained in dean condition. Shower room floors washed dai . Laund .162 Residential Cam : laund facilities rovided .472 Bedding and towels launderred; no cammon towels Grounds• .30Q Potable water rovided. .300J.304 Adequate and centralized drinking water facilities. No common drinkin cu . .209 Telephone readily available with#s of HGC, local hospitals, police,fire,ambulance. Da and Residential Cam nl .213 Emer en cammunication s tem. .165 Tobacco use restricted to designated areas not ��- accessible to cam ers. .350/.355 Pro er stor e and dis I of solid waste .207 Proper storage and aperation ofi power e ui ment. .214 Flammable and hazardous materials labeled and stored in bcked unoccu ied buildin . .400 Rodent and insect control. .401 Weed and noxious lant control. .450 Site location does not cause undue traffic hazards and is accessibfe at all fimes. �'� � , , , ._ . _ :i:.,. Food Service .320 Food service in compliance with 105 CMR 590.000,Minimum Standards for Faod Establishments.Permit posted in food service facili . .330 Nutritious meals that indude a variety of faods served. Menus ted. .331 Residential camps—Provide at least three nutrikious meals. Foods must meet Recommended Dieta Allowances RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA r uirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eatin nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a ba lunch. .452 Screening provided for food preparation and food service areas. Sa-een doors must be self- closi .453 L' htin rovided in kitchen and dinin area. .471 Slee in rohibited in food areas. REGULATION NO. THE SPACE BELOVY DE3Ct�BES VIOLATIONS MARKED ABOVE r � � YARA�UTN HEAI.TH DEi�'1`. 11�d ROUTE 28 ' BQ.YIIRAAOUTH.I�IA p�� NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND S�FETY STANDARDS FOR RECRE/�T�t7NAL CAMP� €�OR CHILDREN, 105 CMR 430.000 - ..4 ,�� .. � b� �- � � a.�c � �•"� @,. �, � � � �.:g�' "�.�r ,�; ^ :«, . � . --, " -+,� �,� .-. :� � `�� r . � � � - 3��'�'+.� � �" � a �v�. : ...,: �, - . �� NAME OF CAMP � � `� ADDRESS � / *y- � f �N °G� OWNER OFF SEASON �c _ �t �� O UT/ � ADDRESS �'r�.- CAMP DIRECTOR s ��e INSPECTED BY , CAPACITY WATER SOURCE DATE OF / � INSPECTION (� D L Regulation 105.CMR 430.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 430.000. Items marked with a°✓"are satisfactory. t. �� °' � z, E �� . �s � ,. ,,. .: �. _� _:. ��`� '� �' ��' O�Q �_ Written procedures avaiiable fo�the review of ~: background of staff. Prior work history,references, � � _� and CORI and SORI information. Documents _ �� ''', verifying background dieck being maintained. �::_ ,,. � ;. ' ��` ti�� Staff have no unsupervised contact with campers ��, :- until background check is approved,unless staff member whose badcground chedc is approved is � present. �=:_ ��;� ._ ' 'A ��;^ All persons and staff receive orientation before �� workin with children. Orientation lan in writin . ��'.�.��. . �� " Written procedures for reporting suspected �� incidents of child abuse and neglect. �� : u:.�;�� . s9� �ounselors have required training and experience. ;� �' Adequate ratio of counselors to campers. � r�- � t�:::.; ��1�#�� Camp Diredor is on premises at all times. Staff 9e� t�; s aware of person who is responsible for the � Training: �-°��'� administration of the cam . � -, Specialized or high risk activities supervised by �� `` experience and ce�rtification Counselors present at �e� % �� ge: 9�2 Aquatics activities supervised b an aquatic � � � x director with proper current cert�cations. Certificatiqn: G r��r v�.-� C'�� S'T�� 1 =r Adequate ratio of properly certified counselors to : campers to supervise swimming. • �Q y�� Adequate ratio of certi�ied counselors to cam ers Names: l�v rZ+vJ � �.� : fo�the supervision of watercraft activities. AlPstaff X'�s: and partic�pants wear U.S. Coast Guard approved � �� g �d� �` personal flotation devices. ��`�� Certification: 5 -� Minimum of two counselors each in separate �� watercraft for white water, hazardous saft water or v hazardous fresh water. Campers possess prior ' A, � � ' training certificate before participating in these /�� = watercraft activities. , , .91}2, ' Properly certified individuals provided for scuba Certfication: ; diving actiwties. � ��0:_-� Health Records � �" Required health records maintained for each ::-: camper and staff member. .751 Maintainin medical lo . Lo readil available. ` 153� ` Injury report form completed for each fatality or ,: senous mjury. Copy of repo.rt sent to MOPH. ° 154� Residential Camp• Health history,report of physical exam, and immunization record,prepared r' and signed by licensed health care provider, : fumished to camp by each campe�and staff �� member prior to attending camp. Day Camp: Current medical history signed by ��'` �} Prov derr 9rov d d t�cam licensed health care �/�� ,;., p p p pnor to attending camp. � a. , �� - ._.,. _ _ =;755.= - ___ : MMR 1 Measles 2• �! Measles 2nd dose required Mumps �* i �"' Polio(OPv or e-IP� 3 1 g� 4 doses required if Rubella mixed schedule vaccine Diphtheria and 3 given(IPV and OP� Tetanus Toxoids �' �. Diphtheria and 4 'unless bom before 1957 <. Tetanus Toxoids DTaP/DTP/DTlTd ' - .�� and Pertussis . ;' Booster dose of Tetanus/diphtheria, (td)required : � = if greater than 10 ears since last dose. �;' Hepatitis B:(for 3 , children bom (effective 1-1-99) ��`� "� .� after 1/92) �`' Number of records checked ber of records checked :1� °. Camp health care consultant. Signed written Name: � � .':: orders for use by health care supervisor. �:� : Written camp medical policy. All staff provided with ` � copy of such policy and trained in the program's � infection control procedures and implementation of � :� �` the policy during staff orientation. �� , � = Parents provided with copy of the policy pertaining `� to the care of mUdly ill campers,administration of medication and procedures for emergency care `� Name: :J59 4 Health supervisor provided. rainin : :�6D . Proper starage of inedication. .��0 �' Written approval from health care provider to ';,=. administer medications. .1�9 '� Infirmary provided. Designated area provided for : isolation of child ill with communicable disease separate from the regular living quarters. �' (Residential Camp) ;1��' Laundry facifities. '— c .�� ,' Operator encourages campers and staff to reduce =;: exposure to ultrawolet exposure nom the sun. -.1�,5 Tobacco use, if any, restricted to designated areas , ; not accessible to campers. Desig_na_ te=a�.�� ' �� ;: a pro riat . �90 Program activities and physical environment ;,;: provided to meet needs of campers and does not -� `; pose a hazard to their health and safety. �; r � R YARMOUTH HEALTH DE�T. !14d ROUTE 28 • 8�.YIV�IA01lTH.AAA 02�l+� NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREt.TIONAL CAMP� i OR CHILDREiV, 105 CMR 430.000 — _. RE�RE�,TI�.NAL. CAMP�FOR;CHILDREN INSi�E�TION,; REPORT NAME OF CAMP '}y1,G �Gr��iienrr►t.hd-aJ► c�,ytica��s � ADDRESS l OWNER �irec4ar-n�► e OFF SEASON pt�E�c.w "�38 I �v7•a3�•� ADDRESS (►.CA,n rk M� oM0 CAMP DIRECTOR INSPECTED BY CAPACITY WATER SOURCE DATE OF 4/21/oo- �cc mCcHnq.- INSPECTION �,q- p _ � Regulation 105 CMR 430.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 430.000 Items marked with a "✓" are satisfactory. _ ..w�u , .090 Written procedures available fo�the review of Wri{-�� r�v�ests on �i 1�,� ZO background of staff. Prior work history, references, and CORI and SORI information . Documents verifying background check being maintained. Staff have no unsupervised contact with campers until background check is approved, uniess staff member whose backgrounci check is approved is present. - � .091 All persons and staff receive orientation before workma w�th children . Orientation lan in writin . Db�L. .093 Written procedures for reporting suspected incidents of child abuse and neglect. � .100 Counselors have required training and experience. Adequate ratio of counselors to campers. �:-T ge: �' �F>rc[c�e -la rt�j?rW .101 Camp Director is on premises at all times. Staff Trainin �� rt.sum�on k�Ft�Ju(ta aware of person who is responsible for the �( 2 9' m t, administration of the cam�. �� .102 Specialized or high risk activities supervised by counselors with evidence of appropriate training, experience and certification. Counselors present at •V��S ge: .102 Aquatics activities supervised by an aquatic Certification: director with proper current certifications. .102 Adequate ratio of properly certified counselors to campers to supervise swimmmg. .102 Adequate ratio of certified counselors to campers Names: for the supervision of watercraft activities. All staff and participants wear U.S. Coast Guard approved personal flotation devices. Certification: Minimum of two counseiors each in separate watercraft for white water, hazardous sait water or hazardous fresh water. Campers possess prior training certificate before partiapating in these . watercraft activities. r� .10Z Properly certified individuals provided for scuba Certification: diving activities. .150 Heaith Records Required health records maintained for each camper and staff member. �1L '� .151 Maintainina medical lo . Loa readilv available. � 0� .153 Injury report form completed for each fatality or ,.• , � senous in�ury. Copy of repo.rt sent to MDPH. rIM 0 n .154 Residentiai Camp:.Health history, report of physical exam, and immunization record, prepared and signed by licensed heaith care provider, fumished to camp by each camper and staff member prior to attendmg camp. Day Camp: CuRent medical history signed by parent or guardian, or by licensed health care provider provided to camp pnor to attending camp. a l[„ c '"��.Y�REGtU1RED'IMMUN17AxIONS' ,� `ti��',''�'�``�`... r'�"•2w 5�� `��,�;:=��.��'-`��.��L.«,w�-^��.�"}e-�+`• .155 �.��.k;, -.K�:�� .:ti«�:�_�; -�:k � • ,� �.� = _,,,,�:�_Campers nd:staf�'un��ears�o�,�_,.,��-, s N ,CAMPERS'AND S7AFF 18 YEARS OR OLDER ;: �: .Immonizafion��,'; .�"`��;Dose(s ..��."`�:��X�J .,.t;�- lmmunizado�s: �r x..flose(S -�:a�� X/J ___ _. _. ... ,.. .... MMR � Measles 2' Measies 2nd dose required Mumps 1' Polio(OPv or e-IP� 3 Rubella 1 4 doses required if Diphthena and 3 mixed schedule vaccine Tetanus Toxoids given(IPV and OP� `unless born before 1957 Diphtheria and 4 Tetanus Toxoids DTaP/DTP/DT/Td and Pertussis Booster dose of Tetanus/diphtheria, (td) required if greater than 10 years since last dose. Hepatitis 8:(for 3 children bom (effective 1-1-99) � ��p�,�„ after 1/92) �� ' S��~ Number of records checked v Number of records checked�'��YS�C (,G�! .159 Camp health care consultant. Signed written v Name:�• �hK�^ �/d — hD 514N�0( OYcL¢.�'s. � tb orders for use by health care supervisor. /� .159 Written camp medical policy. All staff provided with copy of such poficy and trained�n the program's infect�on control procedures and impiementation of �jin '�QQI`i�tl+.�' I�l0.hdbdDlL the policy during staff onentation. i n �,� �d� Parents provided with copy of the policy pertaining to the care of mildly ill campers, admmistration of medication and procedures for emergency care � Name: e�� ^� .159 Health supervisor provided. Trainin : .P1. �0►11 S��CCr't7( .160 Proper storage of inedication. ` �� ' .160 Written approval from heaith care provider to � administer medications. .161 Infirmary provided. Designated area provided for isoiation of chtld ill with communicabfe d�sease separate from the regular living quarters. (Residential Camp) .162 Laundry faciiities. r .163 Operator encourages campers and staff to reduce exposure to ultraviolet exposure from the sun. � . .165 Tobacco use, if any, restricted to designated areas not accessible to campers. Designated area � appropriate. .190 Program activities and physicai environment provided to meet needs of campers and does not pose a hazard to their health and safety. � � .190 Campers released oniy to camper's parent or ��1 individual designated in wnting by parent. VW� �,l h� (�S , ,1g1 Written procedures for disciplining campers. Plan provided to parents and to each staff member when empioyed. (� —1 n t((,��(,�S VCS�O�,IXCG �� .201 Riflery program operated in safe manner. Firearms stored�n locked cabinet. Ammunition stored in separate locked facility away from firearms. Shooting range located well away from other activities. .102 Firearm acZivi ies supervised-by prope�ly trained4— — - — — - --�--_ --- - --�-- --_ individual. Proper counselor to camper ratio. .10Z Proper ratio of counseior to campers at the archery .202- Archery range located weil away from other program actrnties and clearly marked. Equipment under lock and ke when not in use. :203 Personal wea ons re tricted. .204 Waterfront and boating programs operated in safe manner. Swimming area in clean and safe condition. Camper's swimming ability determined ' and campers confined to swimming areas consistent with the limits of their skills. "Buddy system"and"lost swimme�'plans established. ;204 Piers and other e ui ment in ood re air. 204 All watercraft equipped with U.S. Coast Guard � ��=' approved flotation devices. �Z04�` Campers possess appropriate swimming certificate ,�: before bemg atlowed to panc�ipate in either white ` water or hazardous saft water boat�ng activi6es. :�� '� �::205: Crafts equipment in good repair and properly installed. �:206 � Playground and athletic equipment in good repair � .�_:` and of a safe design. :�,r.,=.. - :.2D6_ Playground equ�pment designed to prevent injury � '°-:'- and possibility of entrapment of extrem�Ues. �. � ` Equipment securely anchored. Concrete or asphalt - '. surfaces under equipment prohibited. Pliable or ; canvas seats on swings provided. � 7 Pr er stora e and o ratio of ower e ui ment. .1�2 All horseback riding instructors licensed in . accordance with M.G.L.C. 128,S2A. :208 Horseback Riding Program. Licensed instructor, Name: .^ �; ,: hard hats wom, mm�mum of 1 experienced � instructor for every 10 riders. ;:209 = Telephone provided with roster of emergency �. '' numbers inclu m ca 's heatth care consultant. �i d S :_::210 ' Written Contingency Plans. Fire evacuation plan, =: disaster pian, lost camper and swimmer pian,traffic � =' control. :211 ` S ecial contin en lans for da cam s. :292`, Emergency Procedures-Primitive,travel and trip = camps. � �. � ;213 Emergency communicaUon system. �� : 14 aso ine, ammab e substances and other hazardous materials properiy labeled and stored in :' buiiding not occupied by campers. .215. Written statement of compliance from the fire � department � . , moke detectors provi e . - lr .217 Tents fire-retardant and non toxic"USE NO OPEN FLAME"stenciled inside and out of tents if not fire �A , .250 Vehicies for transporting campers in compliance - N�x�I�.s�d� �s c��"�- with M.G.L.c.90, in particular ss. 78 and 7D and �� S�,p,r C((l,p�Q•d• with the appiicable re�uiations of Massachusetts "fCs VO�NS � ' .251 Transportation Safety- seat belts worn. Special needs of campers commurncated to the driver. Age: � V� Y« .252 C2ualifications of driver. Names: p.( i(�Lyt ;ts .300 Potable water suppty provided; adequate quantity Private or municipal well and pressure. b .300 Adequate drinking water facilities provided and centraily located. � .301 Plumbing maintained in good working order. 61L 61L .320 Food Service-Operated in compliance with 105 �� ( �� r.� �- j-�-�r CMR 590.000 Sanitary Code Article X, Minimum Standards for Food Establishments. Required �n �G( p� Q{�fi�0"Y1 .330 Nutritious meals served. Menus posted. Foods ,�h� rnUsk Ir,y2 pds�-�� meet"Recommended Dietary Allowances"of Food and Nutrition Board, National Academy of s/n' V[. .334 Adequately trained staff and equipment provided to � ensure handicapped campers are eating nutritionallv ade uate meals. .335 Operator provides proper methods of storing meals p,(( VYIP�S �1^D�/!�d Q�' '-�'�1�, �'.Ct,WL(/� brought from home at safe temperature and a '�� 1:� protected from contamination. Meai provided to ��,,� �,� cam ers who arrive without a ba lunch. .350 Solid waste disposal. .360 Sewage disposal. #toilets: : .370 Adequate numbers of toilets, sinks and showers #showers: 1 '(� or btt�^G1r provided. (�i #sinks: 1 : tXI•hC.ir .372 Toilets less than 200 feet from sleeping rooms. ,+,�(�,(z�� S�6U�„e� q,y�pt t intGS t/j� Ci,C.C. Toilet paper provided. Windows and other � j nS o enin s screened. .375 Ventilation provided for toilet and shower room to � the outdoors. .376 Hot water at hand sinks, showers and bathtubs x �,� � does not excesd 112°F .377 Sanitary facilities maintained in clean condition. � r .378 Adequate toilet, sink and shower facilities for spec�al needs campers. .400 Rodent and insed control. � .401 Weed and noxious plant control. �j .431 Swimming Pools. Operated in accordance with 105 CMR 435.000, Mirnmum Standards for Swimmin Pools. Pool ermit osted. .432 Bathing Beaches. Bacterial sampling done in Accordance with 105 CMR 445.000. Results of testing avaiiable. .450 Site location. � .451 Current certificate issued by the building inspector. Cert�cation#: �n5�� Structures weathertiaht and watemroof. � r .4 ' c;eernng provi e or s eeping quarters an ood � .453 Lighting provided for each kitchen, dining room, �� infirmary, toilet room and stairway .454 Floors maintained. � S .455 Adequate egresses provided. � 456 E resses free from obstructions. .457 Shelters for day camp. � .458 Shelters for residential camps. Adequate square � . 1„�� feet of floor s ace er erson. V .459 Non-ambulatory campers housed on ground level; egresses leading to grade or ramp prowded. .470 Bed or cot provided for campers and staff. Bunk $dYKa C�YDu�GU n�'�S��Q-- �Gt�� -� : spacing. .471 Sleeping prohibited in food areas. :472. Beddin and towels laundered;common towels not Q,ll �olWlp« � S1�pP� '��d-- allowed9 �� e15 � 4 REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Y r r V � #� — S � � � � - � � 1 a"" 1 SIGNED Date: SIGNED Date: amp irector oar o ea ea t epartment