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Home My WebLink AboutApplication and WC r :.5.� ~ ,�., �y r � � � ,,t.x o n � v �� " _ � � � �- r t �1 ' _ � � � � � 4 � � � � Q.. � -r � � � � � � �' . � � v� � c�c.� a � �i , � � � �� 4 , - s � � � � � � � � � � � � � I � � � ! � l')-602��30�-l�.-1 5-2338- �2 °� ` TOWN OF YARMOUTH Boardof � � Health = 1146 ROUTE 28, SOLJTH YARMOUTH,MASSACHUSETTS 0266 - - �� Telephone(508) 398-2231, ext. 1241 ��'��' Division Fax(508) 760-3472 Mq� � g ��1T APPLICATION FOR A LICENSE TO CONDUCT A HEALTH DEPT. RECREATIONAL CAMP FOR CHILDREN I (Use back of application if additional space is necessary) FEE: $55.00 ; Name of Camp: j``pi„�„� �.( yCt�rnuc� Rax �nd l�dtren�-u.re Proqrarn SiteAddress: � f 1�u�JOVYf �/2i'1t�.� � Cou-I-vl �/Q,��'Yl�u--�-�� YY�A C��(o� Site Address: , Tax ID Number(FEIN or SSN): E-mail feCXea�-tc�VUtrnot,�.v�n4 •us ' i Type of Camp: Day(less than 24 hrs.)� Residential(24 hrs.) Hours of Operation: �/' 3a�M - �� 3C�PM Dates of Operation: Opening: ��e 28 � 201''7 Closing: Sep}�mf�e.f 1 , 2C�Ir7 Name of Camp Owner: '�c�wn oF Vc�rrr��-I� p�ks rt �eCreC�-i�on Office Address: 4-2� �ou�e �Q� W 2 S� ycu'�►c�u-f�v� , M� t��.to`�3 Office Telephone Number: �- 3q g- a�3 t X I��.� Name of Camp Operator(ifdifferent): I�c��-ir�r�cx. M . l�r�rns}�r�ne► } l�iYtc�-or ' Address: S��rv�e a�s �o�r� c�u,�r��r Telephone Number: Camp Director: f`�lour�ia�, C�h� � � Address: �( �O n� �Y� S Ot1�,t1'1 �C+�r m c�� I�Icx C)�io(a y ' Age: 3(� Telephone Number: 5 c'� - 39 F's� a�.3� h l�j a O ' Coursework in Camping Administration: �(p �_ ��c ��.,�c.t. -+ ACh bl�'PCi�� N�nr�csh��P Previous Camp Administration experience: � \�rs Gts -�iQ�, CQ M� 1�i�eG'�f Health Care Consultant: �� vQ� �ed��t�r�cS �r. Cc�IM�� Type of Medical License: �. �• MA License number: �,� �O��]� Address:7�h �i{�t�'1 PCYe Sbl,l1� 1�Ctl�PYIO�.I'�1 I�A 02�� Telephone: 5D�- 39'�-f� � 'LII(p . 04,30„5 1 of 3 f Hospital for Emergency Services: C0.� ��C'� �6��t-E-+G-� . Health Supervisor:��gr rnUGtYI� -F�I Ct rn rn�n cI � � f Age: Type of Medical License, Registration or Training: (�I�.YStn� �rl-udeYl'� � Swimming Area: Yes �/ No If Yes: Fresh Water ✓ Ocean Pool CPO Specific Onsite Locations: �1 Qk PD�l C� S ii191►�YITVI�Yla � �Ch �''�0. • Water Quality Testing Performed By:�Ou�Y1 C}E �/QTYYipu�'h 80UYC.) O� �eQ�-�-�1 . � Aquatics Director: Name: �re,l� \(O r o5 _ Age: 29 i Lifeguard Certificate issued by: ��1 cr055 Exp. Date: fv (8 � American Red Cross CPR Certificate: Rcd �rc�SS Exp. Date: (� 1 American First Aid Certificate: ��.� �rOSS Exp. Date: � I ; I i Previous aquatics supervisory experience: �� t�.�rvtsarl Hec� Ca+�i.rGl �1 �trs E� E � Watercraft/Boating Activities: Yes y� No Describe: ( �Ts�n kctyct,k� Compliant with Christian's Law: Yes r/ No Food Service: Is food handles served r prepared? Yes J No j F To what extent? Snacks Cooked and Served by Staff Dy �o oC`.1 Ser v c ct , t3�:�c�i I t.t�'�Ch�r' (c�R"s i�e p rcP) If cooked onsite, Food Manager(submit copy of ServSafe) Catered ,,/ If So, by whom? �r�rvS S/AX�Ylp�i_��t1Q.� SC h001 F od► Ser v►�cs Is refrigeration available for perishable foods? Yes � No i � Fire Arms Instructor: Name: �1�� National Rifle Assn. Instructor's Card(or equivalent) Date certified: Expiration Date: 04,30„5 2 of 3 Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and volunteer who may have contact with a camper? Yes�� No ' IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1) WEEK PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. By signing this application, I acknowledge that I have submitted all required documentation and I am in compliance with the State's minimum standards for Recreational Camps for Children, State Sanitary Code Ch � V, 5 MR 430.000. ' , SIGNED: PRINTED: P 1�� DATED:TI�I`�1 , See the next page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the process. oai3on5 3 of 3 �I?-b0 Z B o��-�s-233�-02 °� r T4WN OF Y � RMOUTH Boardof � � Health = 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 ' '�� Telephone(508)398-2231,ext. 1241 Health _niviaion Fa�c(508)760-3472 ��6�� APPLICATION FOR A LICENSE TO CONDUCT A ,q �; j � 3., � �:l.�f� +:..: F i f.i i� RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) �-{EqLTH DEPT. Town of Yarmouth Parks & Recreation Department Name of Camp: Flax Pond Adventure Program Site Address: 31 Dupont Avenue, South Yarmouth, MA 02664 Site Address: Taac ID Number(FEIN or SSN): E-mail recreation@yarmouth.ma.us Type of Camp: Day(less than 24 hrs.) � Residential(24 hrs.) Hours of Operation: 7:30AM-5:30PM Dates of operation: Opening: June 26, 2017 Closing: September 1, 2017 Name of Camp Owner: Town of Yarmouth Parks& Recreation Off'ice Address: 424 Route 28,West Yarmouth, Massachusetts 02673 Office Telephone Number: (508)398-2231 x-1520 Name of Camp Operator(if different): Patricia M.Armstrong, Director Address: 424 Route 28,West Yarmouth, Massachusetts 02673 Telephone Number: (508)398-2231 x-1520 Camp DirectOr: Maria Cobil Address: 31 Dupont Street, South Yarmouth, Massachusetts 02664 Age: 28 yrs. old Telephone Number: (508)398-2231 x-1520 Coursework in Camping Administration: 14 years experience&ACA Director workshop Previous Camp Administration experience: 6 years as Flax Camp Director Health Care Consultant: Bass River Pediatrics, Dr.Colmer Type ofMedical License: M.D. MA License number: MA60273 Address: 237 Station Avenue,South Yarmouth, Massachusetts 02664 Telephone: 508-394-2116 oa�3o�,5 1 of 3 � Hospital for Emergency Services: Cape Cod Hospital Health Supervisor: Charmagne Fiammond Age: Type of Medical License,Registratian or Trainin�: Nursing Student, CPR/FA Adult&Child, Red Cross Certified Swimming Area: Yes�/ No If Yes: Fresh Water �/ Ocean Pool CPO Specific Onsite Locations: Flax Pond swimminglbeach area Water Quality Testing Performed By: Town of Yarmouth Board of Health Aquatics Director: Nan1e: Andrew Voros Age: 2g Lifeguard Certificate issued by: Red cross Exp. Date: �une 2018 American Red Cross CPR Certificate: Red Cross Exp. Date: �une 2o1s American First Aid Certificate: Red cross Exp.Date: June 2o�s Previous aquatics supervisory experience: Beach Supervisor/Head Guard, 6 years experience WatercraftBoatingActivities: Yes� No Describe: 2-man& 1-man kayaks Compliant with Christian's Law: Yes_� No Food Service: Is food handles served r prepared? Yes � No To what extent? DY Food Service Si1c1CICS Cooked and Served by Staff Bagged Lunches(off-site prep) If cooked onsite,Food Manager(submit copy of ServSafe) N1A Catered�_ If so, by whom? Dennis Yarmouth Regionai School District Food Services Is refrigeration available for perishable foods? Yes �/ No Fire Arms Instructor: Name: w,a National Rifle Assn. Instructor's Card(or equivalent) Date certified: Expiration Date: °"3°"5 2 of 3 , Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and volunteer who may have contact with a camper? Yes� No IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1) WEEK PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. i , By signing this application, I acknox�ledge that I have submitted all required documentation and I am in compliance with the State's minimum standards for Recreational Camps for � Children,State Sanit i �e ha •IV CMR 430.000. i SIGNE . PRINTED: Patricia M.Armstrong,Director DATED• to as lb See the next page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the process. oaiaais 3 of 3 �y The Commonwealth of Massachusetts Department of Industrial Accidents O�ce of Investigations ' 1 Congress Street, Suite 100 Boston,N�9 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: Town of Yarmouth Parks&Recreation Address: 424 Route 28 City/State/Zip; West Yarmouth,Massachusetts 02673 Phone#: 1-508-398-2231 x-1520 Are you an employer? Check the appropriate boa: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment ; 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] $• [�Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have �0.�Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i *'If the cotporate officers have exempted themselves,but the corporation has oiher employees,a workers'compensation policy is required and such an j organization should check box#1. � I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: MUA Property&cas�aity crouP i��. Insurer'S Add1'ess: One Winthrop Square Clty/State/ZiP: eoston,Massachusetts 02110 Policy!#or Self-ins.Lic.# Contract#15-210 Expiration Date: 7-�-2o�s Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civi] penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificafion. I do hereby certify,un li ins a perjury that the information provided abov is true and correct. Si at Date: Z d Ph n #' {508)398-2231 x-1520 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Oftice 6.Other Contact Person• Phone#• www.mass.gov/dia