HomeMy WebLinkAboutApplication and WCJ4ep-CAI pr. *60P
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
Telephone (508) 398-2231, ext. 241
Fax (508) 760-3472 j
Name of Camp:
Site Address:
Site Address:
Board of
Health
APPLICATION FOR A LICENSE TO CONDUCT A ! {'
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is necessary) HE _
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Tax ID Number (FEIN or SSN): 61 7 Y".?,c ?6 FS
Type of Camp: Day (less than 24 hrs.) L/ Residential (24 hrs.)
Hours of Operation: 9.'30 q.,.-s , 71) o? : 1d e.,a.,r
Dates of Operation: Opening: Vk 3 Zeq l2. closing: Air. t 20/ L
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Name of Camp Owner: /? o Ike., / .i,
Office Address: 7 0 j i�/e� , lt�l��' ,1� A,&' a4ec"? i'
Office Telephone Number: 5�59-3p5/- 41V X F
Name of Camp Operator (if different):
Address:
Telephone Number:
Camp Director: � ,l,� f 41.' hii tt / 7ef!
Address: �O -�-% !lJoe OA�L
Age:_ �0. Telephone Number:
Coursework in Camp Administration: 6fP /;6---r T_/�glj%
Previous Camp Administration experience.,
Health Care Consultant:
Type of Medical License:
c,`
ise nu. ber:
0Z 4,C,-/
,SDI- r�(Qo -Zoe y`
Hospital for Emergency Services:
—�
Health Supervisor: sr
Age: Type of Medical License, Registration or Training:i�ir.,/ �trLe
Swimming Area: Yes No /W /
If Yes: Fresh Water Ocean Pool CPO
Speck Onsite Locations:
Water Quality Testing Performed By:
Aquatics Director:
Submit Certifications: CPR
Other Lifeguards and Credentials:_
WatercraWBoating Activities: Yes,
Food Service:
First Aid Water Safety
No Describe:
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
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 48 HOURS PRIOR
TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT
CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE
DEPARTMENTS.
SIGNED:
PRINTED:
See the neat 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.
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