HomeMy WebLinkAboutApplication �
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°� TOWN QF YARMOU �LTH
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Health
1146 ROUTE 28,SOUT'H YARMOUTH,MASSACHIJSETTS 02664-24 ' � � c����
� Telephone(508)398-2231,ext. 1241 � ith�4 � -
� Fax�(508)760-3472 �, � . 1O��y�
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is necessary) —"�"'^---
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Name of Camp: ��������� �Lj��
Site Address: l � • � • �
' Site Address: Q � � �
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Tax ID Number(FEIN or SSN):_ �� E-mail�j(r����,� (L��j��.l�:
T e of Cam Da less than 24 hrs. �� ��f
YP P� Y� ) Residential(24 hrs.)
Hours of Operation: �'�� Q,y � a�'�� ��,�,�
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Dates of Operation: Opening: ��rj �� ZO/� Closing:__ �� 2/� 2 0/�
j Name of Camp Owner: /�l��/� f �►'�,�y,'��
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Office Address: yO ����j f�C < ,���/ � �Z6i?3
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Office Telephone Number: .s�� -.�j�� �j�3!�
Name of Camp Operator(if different}: �.st.L
Address:
Telephone Number.
Camp Director: � c�
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Address: � �%//�l� l �rr� /..�vj4'� � ��v 7�'.f �
Age:__�_ Telephone Number: ,5��' 3�� � „3 j!�
Coursework in Camping Administration:���j,r� �� �g/vC9��� , ��� /L �/�/��`i�`�
/lK r��i
Previo amp Admi istratio�n ,x�erience: Q'�✓C���, � � �j�ru�(L,
/����'��%� // lv��` s��' /s��' �' � .i� ��- �L/✓�
HeaIth Care ConsWtant: �� �
Type of Medical License:�i��� `t,�j Mp License number: ��J �6 9
Address: •�/ � /�.y Telephone: S� -��j O- 2�� �
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Hospital for Emergency Services: � �j/f�/��,/
Health Supervisor: /�4� �/'
-�- 2�/ .� 9 6
Age:�_ Type of Medical License,Registration or Training: � � 3 �
; Swimming Area: Yes No v
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If Yes: Fresh Water Ocean Pool CPO
Specific Onsite Locations:
! Water Quality Testing Performed By:
Aqaatics Director:
I Name: Age:
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Lifeguard Certificate issued by: Exp. Date:
American Red Cross CPR Certificate: Exp. Date:
American First Aid Certificate: Exp. Date:
i Previous aqua.tics supervisory ex�rience:
Watercraft/Boating Activities: Yes No Describe:
Compliant with Christian's Law: Yes No
Food Service:
Is food handles, served or prepared? Yes No �
To what extent? Snacks Cooked and Served by Staff
If cooked onsite,Food Manager(submit copy of ServSafe)
Catered if so,by whom?
Is refrigeration available for perishable foods? Yes No
Fire Arms Instructor:
Name:
National Rifle Assn. Instructor's Card(or equivalent}
Date certified: Expiration Date:
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Background Checks:
Has the Camp Owner or Director obta.ined and reviewed the CORI and SORI f each staff
person and volunteer who rnay have contact with a camper? Yes � No
; IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1)
' WEEK PRIOR TO OPEI�TING 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 documeatation
and I am in compliance with the State's minimum standards for Recreationad Camps for
Children,State 'ary Code Chapter Ii;l0 CMR 430.000.
SIGNED• � ' s,,�.
PRINTED: f�j►J'�S������,�,� DATED: S ' Z� ' /�
See the next page attached for a list of documents that must be completed and submitted
before your applic�tion can be fully processed. You are strongly encouraged to complete
these documents as soon as possible and snbmit them in advance. This will expedite the
process.
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