HomeMy WebLinkAboutApplication and WC fI t-6116/ e'o L-I S-2.338-0t/
C TOWN OF YARMOUTH_ Board of
Lgi UVI hh
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-244 A h
Telephone(508)398-2231,ext. 1241 AAFT 0 Division
Fax(508) 760-3472 HEALTH DEPT.
APPLICATION FOR A LICENSE TO CONDUCT A WA I a
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is necessary) FEE: O
/—
Name of Camp: '3,6111 G VCUYI1c dir - nal._., Poiv ci M V,ltLD P('CJirk_1-1 )
'3
Site Address: _ 1 I-)14P0m-r crla , SOLATH \ wWI I } ( 2_leL.,y
Site Address:
Tax ID Number(FEIN or SSN): E-mail (CC rettl"1cy10(ojwttttl Vl.Atka uls
Type of Camp: Day(less than 24 hrs.) V Residential(24 hrs.)
Hours of Operation: r i : 3D AM - S. 3b PM MOM 1..)A-1 tic)e u FrL.i DA-Li
Dates of Operation: Opening: Jane(n 2L 20 i C( Closing: 1:1/419 CA c -- 30 , 2-0 I c1
Name of Camp Owner: ll\ ( Yarn)l LI't R etreckh un
Office Address: 4 24 ?O 20 tAJ yr tYlo ut ( , M( 0 2 0 (2,
Office Telephone Number: 50R 361? - d1-I X`f 152 D
Name of Camp Operator(if different): Da} knyisftryli] Di reu (if' UT emu .. Eery1Cec
Address: .1..}' ee C.rtr f 0 vU fP ' acare5s.
Telephone Number: Sed OvJ()Lr p heti/ .
Camp Director: Mar Ia. e_Dh1 I I
Address: i LtpohA (Vi. S0 ili h 'cLrIY u t.d ' 1
Age: 5Z Telephone Number: 5Dr. - ']bb- L81 5 - 1 rl SeasO-Vl
Coursework in Camping Administration: ASC A. t)r-eck& Wo-rkShop 2.6 I i
iC' s C'&rwp DI rec.-Fete-
Previous
eciz cPrevious Camp Administration experience: 2.
5 Nu -Directly
Health Care Consultant: 1?w'6( -Ped Icth1cs -- Ns. Ken u Iv11cr
Type of Medical License: M . b MA License number: MA Le 0 L-13
Address: 23'1 Sit hon Ave SOUf1 liati` tOtkiV1,MA Telephone: 344 - 2-04,, .
Q z irisi
04/30/15 1 of 3
Hospital for Emergency Services: CCCOL £ od RDSPI+CJ
311t.0 -T
Health Sueor:
Age: Type of Medical License, Registration or Training:
Swimming Area: Yes `/ No
If Yes: Fresh Water v' Ocean Pool CPO
Specific Onsite Locations: OXChirvi krea
Water Quality Testing Performed By: O113r1 p t Urryl -Iv1 6e-pi-
Aquatics Director:
Name: PcfkA t (7 Age:
Lifeguard Certificate issued by: Anikeiriczcin KC (Y'p�S • Exp. Date:
American Red Cross CPR Certificate: I-t - Exp. Date:
American First Aid Certificate: '-' s Exp. Date:
Lifars Head Li"'cc ��-
Previous aquatics supervisory experience: / Lkwu tuu 1 ey f vcr f bi re- C SL✓
Watercraft/Boating Activities: Yes Y No Describe: x.vl k.S •
Compliant with Christian's Law: Yes No
Food Service:
Is food handles served or prepared? Yes v/ No
To what extent? Snacks Cooked and Served by Staff
If cooked onsite, Food Manager (submit copy of ServSafe)
Fob v i Fw th Prr ram
Catered If so, by whom?Off" 51-Ve rep- eaorrej Lu CSS
Is refrigeration available for perishable foods? Yes No
Fire Arms Instructor:
Name: frcN
National Rifle Assn. Instructor's Card (or equivalent)
Date certified: Expiration Date:
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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 mu,imum standards for Recreational Camps for
Children,State • ' , ' i de C ;y l • CMR 430.000.
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SIG 1 : �%�
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PRINTED: -PA M . A-rw., DATED: 41 al I9
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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.
04/30/15 3 of 3
The Commonwealth of Massachusetts
Department of Industrial Accidents
la ELAM* ;111111111111111
Office of Investigations
1 Congress Street,Suite 100
Boston, MA 02114-2017
Vt1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A, licant Information Please Print Legibly
Business/Organization Name: Town of Yarmouth Parks and Recreation
Address: 424 Route 28
City/State/Zip: West Yarmouth, MA 02673 Phone #: 1-508-398-2231 x-1520
Are you an employer? Check the appropriate box: Business Type(required):
1. I am a employer
with employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7. 0 Office arid/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
'2
[No workers' comp. insurance required] 8. Non-profit
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
11.u Health Care
4.0 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.
"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such en
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: MIIA Property and Casualty Group Inc
Insurer's Address: One Winthrop Square
air •
City/State/Zip: Boston, MA 02110 4
Policy#or Self-ins.Lie. # Contract# 15-210 Expiration Date: 7-1-2016
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 civil 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 verification.
I do hereby certify,under ' 'ins •nd's of perjury that the information provided above is true and correct.
Si Nt u.,e: ,41Date: :3 / .76)/q
hope#: ' - 3 - 2Z51
•
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Pertnit/License
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.govidia
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