HomeMy WebLinkAboutApplication ! O06/6OL I 3556
..... ._ TOWN OF YARMOUTH Board of
Health
"6"-',,i, m j 1146 ROUTE 28,SOUTH UTS, CI-I S 02664-24451
TelephoneYARMO(508}3 -H,2231MA,ext.SA1241HUSEHealth
Fax(508)760-3472 Division
APPLICATION FOR A LICENSE TO CONDUCT A r. 0010
RECREATIONAL CAMP FOR CHILDREN
*
(Use back of application if additional space is necessary) IFEE: $55.00'
Name of Camp: Camp Casco a 1-Z- y J J
Site Address: Camp Wingate*Kirkland,79 White Rock Rd.,Yarmouth Port MA 02675 JUN 2 S 2019
Site Address: HEALTH DEPT.
Tax ID Number(FEIN or SSN): 47-2125590 E-mail info@campcasco.org
Type of Camp: Day(less than 24 hrs.) Residential(24 hrs.) X
Hours of Operation: Sunday 8/18 9:00 AM-Saturday 8/24 1:00 PM
Dates of Operation: Opening: Sunday 8/18/19 Closing: Saturday 8/24/19
Name of Camp Owner: Sandy Rubenstein(Camp Wingate*Kirkland)
Office Address: 79 White Rock Rd.,Yarmouth Port MA 02675
Office Telephone Number: 508-362-3798
Name of Camp Operator(if different): Erin Stern
Address: PO Box 330,Sudbury MA 01776
Telephone Number: 857-302-2726
Camp Director: Krystin Whitacre
Address: PO Box 330,Sudbury MA 01776
Age: 31 Telephone Number: 857-302-2726
Coursework in Camping Administration:
Previous Camp Administration experience:11 years total at special needs camps;4 years administration experience
with Camp Casco,3 years with Seany's Camp Reach For The Sky
Health Care Consultant: Christine Duncan
Type of Medical License: MD MA License number: 216427
Address: 450 Brookline Avenue,Boston MA 02215 Telephone: (617)632-6255
04!30/15 1 of 3 " `'i``', 7
Hospital for Emergency Services: Emergency Center at Cape Cod Hospital
Health Supervisor: Kellyann Schmitt
Age: 27 Type of Medical License,Registration or Training: RN
Swimming Area: Yes X No
If Yes: Fresh Water X Ocean Pool CPO
Specific Onsite Locations:
Water Quality Testing Performed By: Please see Camp Wingate*Kirkland's license application
Aquatics Director:
Name: Please see Camp Wingate*Kirkland's license application 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: Please see Camp Wingate*Kirkland's license application
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: N/A
Name:
National Rifle Assn. Instructor's Card (or equivalent)
Date certified: Expiration Date:
o4r30/is 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 X 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: tIM 4k.D---k
-k
PRINTED: Erin Fletcher Stern DATED: 6/18!19
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.
0430/1s 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) x
*Procedures for the background review of staff and volunteers(105 CMR 430.090) x
*Copy of promotional literature(105 CMR 430.190(C)) x
*Procedures for reporting suspected child abuse or neglect(105 CMR 430.093) x
*Health care policy(105 CMR 430.159(B)),including immunization records x
*Discipline policy(105 CMR 430.191) x
*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) N/A
*Primitive, Trip or Travel Camps — Written itinerary, including sources of emergency care
N/A
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