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Home My WebLink AboutApplication and WC � € � 4��C�7�OZ� � °� r TOWN OF YARMOUTH Boardof � �' � = 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 026 4-2�� Health MATTACNEEaE Tele hone 508 398-2231 ext. 1241 � � p Fax(508) 760-3472 `��Ii� � � 2$�Sion APPLICATION FOR A LICENSE TO CONDUCT A ��A!TH DEPT. RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) E ,�.$55.00--. -- << �� p�`� . ��o�SSc�C�J SQ��S �av� So�ce�` M { `�;� =- Name of Camp. �_.. �__� _ . Site Address: � �(7 ��('ca.`Et o r� ��ev�.r�� o v�t" �qrr�o v � � M� Iq Q 2.6 G� Site Address: Tax ID Number(FEIN or SSN): �� E-mail S�l�?q�es(�C�a��Q�Qe('SQoc"�5��o"'+ Type of Camp: Day(less than 24 hrs.) 1� Residential(24 hrs.) Hours of Operation: �0.w� -a'�'��y Dates of Operation: Opening: � � �7 � f� Closing:_T21 � t'� � NameofCampOwner: C.�a��Qv�Ae.�r �ncf�S �(7�5�� ir. _ v VJacv�iC�C Q'' �2.8�8 Office Address: ��QC �Z�t t�5 o r� �� C� � 1 �' Office Telephone Number: L1-01-21�r 0 4-6� � Name of Camp Operator(if different): Address: Telephone Number: Camp Director: `�v � ��i�^^ec� C.1 ose-c' �o ��►�.P ot>er�� • Address: Age: Telephone Number: Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: J�� s�'^�A�`� � Type of 1Vledical License: M� MA License number: �7-� 3�� S �CLrr Q Leho� , M� 0�1-4o Telephone: �1�-s Z-g" ��'�6 Address: �4�i ��c� � �� 1 of 3 04/30/15 Hospital for Emergency Services• ��-� �a d �o�t�a� Health Supervisor: �o b2 Co,� ��,,,,,ec9. �\d�e� 1z, c�..,,�,� o�,�,�,�q Age: Type of Medical License, Registration or Training: � Swimming Area: Yes No ?� If Yes: Fresh Water Ocean Pool CPO Specific Onsite Locations: Water Quality Testing Performed By: Aquatics Director: Name: � �Ia Age: Lifeguard Certificate issued by: Exp. Date: American Red Cross CPR Certificate: Exp. Date: American First Aid Certificate: Exp. Date: Previous aquatics supervisory experience: 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 I� Fire Arms Instructor: Name: � I� National Rifle Assn. Instructar's Card (or equivalent) Date certified: Expiration Date: � 0�'3°"5 2 of 3 � The Commonwealth ofMassachusetts Department of Industrial Accidents Uffice of Investigations � X Congress Street, Suite 1(10 Boston,MA 02114-2017 www.mass.govldaa Workers' Compensation Insurance A .ff'idav�it: General Businesses Auplicant Information Please Print Le�ibly Business/Organization Name:Challenger Sports Corporatian Address:8263 Flint St. Ciiy/State/Zip:Lenexa, KS 66214 Phone#:�13-599-4884 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a ennployer with 418 employees(full and/ 5• ❑Retail or part-#ime).# b. ❑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. g. �Non-profit [No workers' comp.insurance requiredj 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §l(4),and we have 10.�Manufacturing no employees. [No woekers' comp.insurance required]* 11.�]Health Care 4.❑ We axe a non-proft organization�s�affed by volunteers, i 2.� Other Recreational Camps with no ernployees.[No workers cornp.insurance req.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensarion policy information. ' **If the corporate officers have exempted themselves,but tiie corporation has other employees,a workers'compensation policy is required and such an �,,,/ organizafion should check box#1. I am an employer that is providing workers'compensatian insurance for my employees Below is the,poCicy�nformation. Insurance Company Name:Technology Insurance Company Insurer's Address:20 Trafalgar Square City/State/Zip: Nashua, NH 03063 Palicy#or Self-ins.Lic.#�C3601036 Expira#ion Date:Q11Q1/2018 Attach a copy of the workers' compensatian poticy declaration page(showing the policy nunnber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fne up ta$1,500.00 and/or one-year imprisonment,as well as civil penalties in ths form of a STOP WORK ORDER and a fine of up to$254.00 a day against the violator. Be advised that a copy of this statement rnay be farwarded to the Office of Investigations of the DIA for insurance coverage verif cation. I da here6y cert' ,under the �nnd penalties ofperjury that the infarmation pravided above ts true and correct Si ature. Date:a6/13/2017 Phone �l� `�`��' 4�� O�cial use only. Do not write in this area,to be completed by city or town official. City or Town• PerRnit/License# Issui�g Authority(circle one): � l..Board of Health 2.Bnitding Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's 4ffice 6.Other Contact Person• Phone#• www.mass.gov/dia � i Florio, Mary Alice ' From: Steven Hughes <shughes@challengersports.com> Sent: Wednesday,June 21, 2017 5:37 PM � To: Florio, Mary Alice ��: Renaud, Philip � Subject: Re: Recreation Camp Application Thank you for confirming receipt of our information packet. I am waiting on the check to be sent by our head � office in Kansas. As soon as that arrives I will forward it on. If I do not receive it by the end of this week then I will send a personal check. Regards, � �,,, Steve � "� � �� .� �f�� `, ��;,�'" __ , Steve Hughes—Regional Director Challenger Sports: Camps�Training�Tours�Tournaments �Teamwear Tel: 401-213-0463 Fax: 401-228-6548 94A Jefferson Blvd,Warwick RI 02888 www.challen e�rsports.com On Wed, Jun 21, 2017 at 8:39 AM,Florio, Mary Alice <MFlorio(a�yarmouth.ma.us>wrote: Good morning. Thank you for submitting the recreational camp application packet for Challenger Sports' Massachusetts Youth ' Soccer Camp to be conducted in Yarmouth. However,there was no check enclosed for the license fee. The recreational camp license fee is $55.00, and checks should be made out to the Town of Yarmouth. As soon as we receive the payment for the license, we will be able to process the application. Thank you for your attention to this matter. MaryAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231. ext. 1241 1 I �apin�aoinaag x3Pa� ;ua��n�aas's�wi�awi��ou�s uiy�nn pa�y aq;snw swie��ua��/�/��apm�aoin�ag ano ui pa�si�suaa�i aay;o pue s�uawn��sui a�qeilo6au`s�e�aw snoioaad '�(a�aMaf•6•a`000`6$si an�en�(�euipaoea�xa�o swa}��o�wnwixeW�sso�pa�uawn�op�en�oe paaoxa;ouueo�(�ano�a��an�en paae�oap paziaoy;ne ay�ao pp�$�o�a;ea�6 ay�o�pa�iwi�si�eioads ao`�ei�uanbasuo�`�e�uapi�ui'}oaaip aay;aynn a6ewep}o sua�o�aay�o pue`s�so�`saa;s,�tauao�e '}��o�d`�sa�a;ui awo�ui'sa�es;o sso�`a6e��ed ay�;o an�en oisuia�ui Buipn�oui'sso��(ue�o��pa�woa;aano�aa o�;y6ia ano��(�dde apin�aoin�ag �pa�;ua�mo ay�u�puno;suoge�iwi�•wie��(�awi;e a�y pue sso��en�oe�no�(;uawn�op'a6�eyo�euoi�ippe ue�(ed'an�en�ayBiy e a�e�oap no�(ssa�un `uogew�o;uisiw�o'i(aaN�apsiw'iGangap-uou`�(e�ap`a6euaep'sso��o�nsaa ay;aay;aynn'a6e��ed�ad pp�$;o ssa�xa ui uaiep�tue ao�a�qisuodsa�aq �ou��inn x3Pa��woo�xapa;uo a�qe�iene`apm�aoin.rag x3pa��ua�mo ay;ui suoi�ipuo�aoinaas ay�o;�uawaaaBe�no�(sa�n}��suo�uaa�s�(s siy��o as� •aaqwnu�uno��e�pa��no/(;o uoi�e��aoue�ay�y�M 6uo�e`sa6�eyo 6ug�iq�euogippe w�nsaa p�noo pue�ua�npnea;si sasodand 6wddiys�o;�aqe�siy�}o�(do�o�oyd e 6ws��6uiddiys�o��aqe��eui6uo pa�uud ay��Guo as�:BuiweM •pauue�s pue pea�aq ue��aqe�ay�;o uoi;�od apo�aeq ay;�ey;os;uawdiys ano�(o;u x�}e pue y�nod Bwddiys ui�aqe�aoeld'£ •aw��e;uoz��oy ay;6uo�e a6ed pa�uud ay;p�o j�Z ��a�uud�af�w�o aase�ano�(o;�aqe�ano�(�wad o�a6ed siy�uo uo}}nq,;ui�d,ay}as�•� :�aqe�siy;Bui;uud�ai;t/ � ti H ��6�£�16r91Ia�1 ^^u►�:ecuu�r � � � ev d H �� = w W � � �o o � ;..�. � r z o m M �� u� � � � � w � �' _ � j � � z � 0 �t � ?m�`o o � oo� � �J� � � . . . Q�o W Z �� . � � —� O � �, f�AQq m � .� � �c � � H- e}w G� � � C�U � �J� a N� o a �� w Qm = _ �� =F��•� o N _� � Mo o a � _ - c� � w oo O _ -- - —=-- �„� �z a = N =_- —�-- /�"' = w o�C� - - � � �om o�o� � � � �X = -_- � °-o ��' O —� � �ww� �Q � � � �cM.� � — - ti oZZ� Y� J � � �m a = --a. �' 1`� ZJJW "o = Q � OM � _ � �==4 aZ a � � �o�o = �N ODUrn �� a � - �� o � _ ACO� DATE(MMlOD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 1�6�201� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS — CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Paul BTOIISSdTCI NAME: Risk & Insurance Consultants� II1C PHONE E (404)459-5975 F� No:(404)459-5976 5416 6lenridge Drive ADDR�Ess:Pbroussard@riskinsuranceco.com INSURER(S)AFFORDING COVERAGE NAIC# Atlanta GA 30342 INSURERA:SCO'ttSCid1E Insurance Co an 41297 INSURED INSURER B Ndt10IIW].dE MU't11d1 insurance CO 23787 Challenger Sports Corp INSURERC:TAChI3010 Insurance Com an 42376 8263 Flint St INSURERD. BE IIIS CO 392],7 INSURER E: Lenexa KS 66214 INSURER F: COVERAGES CERTIFICATE NUMBER:17-18 rev MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH i'HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' I�TR TYPE OF INSUR.4NCE ADDL�BD POLICV NUMBER MMlDDY� MM/DDIYY�YPY LIMITS � X COMMERCIAI.GENERAL LIABILITY 1,000 EACH OCCURRENCE $ ,000 A CLAIMS-MADE a OCCUR DAMAGE O RENTED 300 -PREMISES Ea occurrence 8 ,000 iLi¢(S0000006678900 1/1/2017 1/1/2018 MED IXP(Anyoneperson) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ None X POLIGY❑PRO- ❑LOC J . � . JECT PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Employee Benefits Liability $ 1,000,000 AUTOMOBILE LIABILITY Ea eoc deDtSiNGLE LIMIT $ 1,000,000 � X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED 1LXKS0000006679000 1/1/2017 1/1/2018 BODILYINJURY Peraccident $ AUTOS AUTOS ( � X HIREDAUTOS X NONAWNE� PROPERTI:-DAMAGE $ AUTOS Per accident � Uninsured Motortst $ 1,000,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5 000 000 A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5 000 000 DED X RETENTION$ 0 1LKK50000006678900 1/1/2017 1/1/2018 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER � ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000 000 OFFICEWMEMBER EXCLUDE�7 N❑N�A C (Mandatory in NH) TWC3601036 1/1/2017 1/1/2018 E.l.DISEASE-EA EMPLOYE $ 1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 D Participant Accident AgH006104 1/1/2017 1/1/2018 Accident/Medical $25,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 107,Additlonai Remarks Schedule,may be attached ff more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ***PROOF OF INSURANCE*** THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Steve Molina/BECKY ��- ---=�� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r�man�i � Additional Named Insureds —� Other Named Insureds I. � Camsie Leasing LLC Challenger Sports Canada Challenger Sports Corp �i Challenger Sports Teamwear LLC i`. �' Complete Players Program LLC ii � �; �f DBA Challenger Teamwear I' � SMG Enterprises, LLC � SoccerPlus Camps, Inc Tetra Brazil Soccer LLC i � i V I � i � � � � I � V��:,� OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC