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if-4005 0.0 .-15--Z37 8-4A
JUN 0 5 2019
CTOWN OF YARMOUTH H �o�
pr. , al 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24 , +s i A .Telephone(508)398-2231,ext. 1241 4. I ' is Fax(508) 760-3472
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APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
(Use back of application if additional space is necessary) FEE: $55.00
Name of Camp: 14;(/c/ (4, 4046a'/
Site Address: ��472,.:5 — ,Q/1Dvi /cz,Z//4/2.4Co44oa/
Site Address: .. , (5-74,4i/ i ., _ L r� A.1‘. o70"? / 97
Tax ID Number(FEIN or SSN): 627. ? Q7 E-mail/' '-f,'-4,O/®�,, :
Type of Camp: Day(less than 24 hrs.) le Residential(24 hrs.)
Hours of Operation: grip , i,."J �j 0,2'J ', .t
Dates of Operation: Opening: 1,4 g. 2O 9 Closing: V4 5. / 020/9
Name of Camp Owner: /CO b,,,11 A4's /44
Office Address: 79 (.5-4,0///llcilk Lie/jilam®(. Y14. Q, &76P2
Office Telephone Number: MSOg- ..3}% (70.57
Name of Camp Operator(if different):
Address:
Telephone Number:
Camp Director: 2 4,f 14_,e /pj/
Address: 170( 5-4.,Ml/a .44/. L 1)4(.16r ddigAiii o Wil ® 4?&7�3
Age: ?/ Telephone Number: ,Seal-3,474-4937
Coursework in Camping A inistration: ,//,f �' /4 / _Li A. 4 _/ ye- .
3 lei41J L C.: fid `�l�4ilr Pe i Y = . .
Previous Camp Administre"experience: �.� �/
3q 1/,Q�✓ om, ®uJ../VC1'` 4C1
Healt Care Consultan P/1
Type of Medical License: �,s//47/1449 Co%/MA License number: V.' . '9
Address: / p ' J /. 1 Pill •i-lephone: V
04/30/15 1 of 3
Hospital for Emergency Services: dpe od
/O�jl*/
Health Supervisor: /14,-.7 3•A Pc/eWey
Age:___42__ Type of Medical License, Registration or Training: ,2j(r (f37
Swimming Area: Yes No ld
If Yes: Fresh Water Ocean Pool CPO
Specific Onsite Locations:
Water Quality Testing Performed By:
Aquatics Director:
Name: 7/4 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: v/?C� QO' ®s/'G41� ✓" ���f
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) #4,1C44.60/®r?al; e
Catered If so, by whom?
Is refrigeration available for perishable foods? Yes IC No 4" cI
Fire Arms Instructor: 7,0b."-a04-
Name: /469.
National Rifle Assn. Instructor's Card (or equivalent)
Date certified: Expiration Date:
04/30/15 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 1 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 Chapter IV, 105 CMR 430.000.
SIGNED: j
PRINTED:i��� e T �� G%� /cL-7ax. DATED: 14/4,6: 204'
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
Required Documents
See the MA Regulations for Minimum Standards for Recreational Camps for Children,
State Sanitary Code, Chapter IV-105 CMR 430.000 and the guidance documents issued
by the Department of Public Health, Division of Community Sanitation for additional
assistance with developing the following documents.
Check
Documents
Submitted
*Staff information forms(see attached)
*Procedures for the background review of staff and volunteers(105 CMR 430.090)
*Copy of promotional literature(105 CMR 430.190(C))
*Procedures for reporting suspected child abuse or neglect(105 CMR 430.093)
*Health care policy(105 CMR 430.159(B)),including immunization records
*Discipline policy(105 CMR 430.191)
*Fire evacuation plan—approved by local fire department(105 CMR 430.210(A))
*Disaster plan(105 CMR 430.210 (B))
*Lost camper plan(105 CMR 430.210(C))
*Lost swimmer plan(105 CMR 430.210(C))
*Traffic control plan(105 CMR 430.210(D))
*Day Camps—contingency plan(105 CMR 430.211)
*Primitive, Trip or Travel Camps — Written itinerary, including sources of emergency care
and contingency plans(105 CMR 430.212)
*Current certificate of occupancy from local building inspector(105 CMR 430.451)
*Written statement of compliance from the local fire department(105 CMR 430.215)
*Aquatic plan, including Christian Law, PFD fitting tests,water testing and swim tests
Attach the names, ages, applicable current certifications (if any), such as First Aid, and
the anticipated role at the camp of all supervisory staff(see below). Use as many pages
as necessary to complete this.
Please: If you are applying for an original camp license for a camp based in Yarmouth,
you must file a plan showing the following with the board of health at least 90 days
before your desired opening date (See MGL Ch. 140 § 32A):
> Buildings, structures, facilities and fixtures
> Proposed source of water supply
> Works for disposal or sewage and waste water
Supervisory staff means those persons with the responsibility, authority and training to
provide direct supervision to camper groups. This may include counselors, junior
counselors, general activity leaders or other staff who provide supervision to campers
without assistance.
04/30/15
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 'r Office of Investigations
s _= � 1 Congress Street, Suite 100
« = Boston, MA 02114-2017
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. El Retail
or part-time).* 6. El Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ 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 10.El 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.❑ Other
*My 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 an
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:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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 Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia