HomeMy WebLinkAbout2022 App-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH
04\ APPLICATION FOR LICENSE/PERMIT - 2022
10
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
Jo 1 - ��'D tvo dv 1 c
ESTABLISHMENT NAME: C (rein o., k TAX ID:
LOCATION ADDRESS: as 7 Plat L. 5+- TEL.#: 5vc 'i -443 12
MAILING ADDRESS: 0 L-1 7 WI U w SI- Yarrn o.) Po 1±
E-MAIL ADDRESS: o- Z-0(lnti ® S COLA-10-5k o r
OWNER NAME: � e- Coco `�T51av�d 5 17.o uh c, l , 'l Q7 S[��-s o- Amen ccs
CORPORATION NAME (1iP APPLICABLE): 0t5 oe13 o /
MANAGER'S NAME: A-rny Zces.n TEL.#: 579Sr 36 a y 3.
MAILING ADDRESS: a i '7 tni1(low S1- Ya imouf-ei. Igor}- ! P'14 Da (r'73
POOL CERTIFICATIONS: �99II
The pool supervisor must be certified as a Pool Operator,as required by State law. s 1 e de ignated
Pool Operator(s) and attach a copy of the certification to this form. 8 NM
1. 2.
HEALTH DEPT.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
years' records. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. Ay Z-0L1/1v 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1.
Ay z 2. Kms,„ }4;I c, 1Q&av,or
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies/"� andmaintain a file at your establishment. IAA
1. vt y 20\ \ 2. u � 1�t A d 6,0 Fcei/) d
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. cNl l r re d v 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55MOTEL $110
_
INN $55 CAMP $55 SWIMMING POOL$110ea.
/LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LI NSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 . NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ �b
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION
Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: -
YES '�N NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to
the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants
must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall
generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days
within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient.
Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as
amended, shall generally be considered Transient.
POOLS
POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the
Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to
opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State
certified lab, and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health
Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health
Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to
the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFÉS:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
TOBACCO PRODUCT PERMIT CAP
A tobacco-permit holder who has failed to renew his order permit within thirty (30)-days of the previous year's
permit expiration date is considered an expired license, and the tobacco license cap is reduced.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PRINT NAME &TITLE:
Rev. 10/15/19
The Commonwealth of Massachusetts Fee
Town of Yarmouth $55.00
Lodging License
Number: BOHL-15-1614-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
CAPE COD & ISLANDS COUNCIL, BSA GREENOUGHS POND
CAMP GREENOUGH YARMOUTH PORT, MA 02675
247 WILLOW STREET
YARMOUTHPORT, MA 02675
IS HEREBY GRANTED A LICENSE
TO OPERATE:
Camp
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey,M.D.,Chairman
Mary Craig, Vice Chairman
Of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce '.Murphy, P , .5., CHO
Health Director
The Commonwealth of Massachusetts Fee
Town of Yarmouth $30.00
Food Establishment License
Number: BOHF-15-1612-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
CAPE COD & ISLANDS COUNCIL, BSA GREENOUGHS POND
CAMP GREENOUGH YARMOUTH PORT. MA 02675
247 WILLOW STREET
YARMOUTHPORT, MA 02675
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Non-Profit
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
Of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce G. Murphy, MP , R.S., (HO
Health Director
TOWN OF YARMOUTH Board of
Health
xa
=i,t 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
MATTACHEESE Health
Telephone(508)398-2231, ext. 1241
Fax(508)760-3472 Division
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: Carv70 Grp°v -1
Site Address: r 7 p,vie, F9i ) MA
Site Address:
Tax ID Number(FEIN or SSN): 0 t.) J Li/8/ E-mail avY1 y<Zc` n 05 Lv L*j�c� tL�
yJ
Type of Camp: Day(less than 24 hrs.) V Residential(24 hrs.)
Hours of Operation: I "I " 'r RSL " o/c-
Dates of Operation: Opening: ,3+J/y I ) Oc Closing: ,/4v t a , Qo
Name of Camp Owner: Ce pe Cod/. 4".1. }onds Co c 13 aCy Sib v 4if/c&
Office Address: a L') '7 e I IO t.,0 f YrLrnw o'ML POI
Office Telephone Number: 3 ! g 36D- Li 3 a
Name of Camp Operator(if different):
Address:
Telephone Number: _
Camp Director: Ayry Zo"v\'1 k'1
Address: . )4"/1-7 VI)f I IOW S•1— *Ur 1 O12 L Por
i.
Age: 7 Telephone Number: ,i5-0g- 36 - Li 3
Coursework in Camping Administration: CJ sC€A. U czy x.tiL Ad immi.S TI c�iioi&
Previous Camp Administration experience: r✓' 5 QS C �J 1 E eciO 1
Health Care Consultant: Cs 0,6 CQ/f -\1\1,00.\\ �>
Type of Medical License: MA License number:
Address: 1-{ a QGt- L0.vrl e C i't—f-V I ifse Telephone: 911 V ld3S- 9)93
1 of 3
04/30/15
Hospital for Emergency Services: Co e, C„,cQ I't- sp 1 ka
Health Supervisor: ICired3e_.
Age: 5-6"-- Type of Medical License,Registration or Training: C PIR hr if,4
Swimming Area: Yes No
/
If Yes: Fresh Water Y Ocean Pool CPO
Specific Onsite Locations: Gt-o c `c V1 'Pon a
Water Quality Testing Performed By: PXAi'n S Wok lyeP'ccj
t
Aquatics Director:
Name: `\f Ly k Age: (p
Lifeguard Certificate issued by: AoY Sc 00+5 O }imerr cam. Exp. Date/3 a IP
American Red Cross CPR Certificate: Exp. Date;14
a 3
American First Aid Certificate: Exp. Date: 3/2,03
3
Previous aquatics supervisoryexperience: �
years f-1"q uCtllc� �vJS 7T"UG-TCS
I
Watercraft/Boating Activities: Yes '"/ No Describe: 'WA 5/ Keyah
Canoe s' S`2 ?
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
Fire Arms Instructor:
`
Name: n 5 )3d Cz�c e�5'� 1
National Rifle Assn. Instructor's Card (or equivalent)
Date certified: I a 0 19 Expiration Date: eL 3/, a 0 a 3
ii
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 No 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: 011 yigy<,e-re--At4A-
PRINTED:
A ; i Art)e-- DATED: cVaa..)
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
k BOY SCOUTS OF AMERICA
CAPE COD&ISLANDS COUNCIL, INC.#224
Scout Oath
On my honor, I will do Camp Greenough Scout Reservation
my best
To do my duty to God Code of Conduct
and my country and to
obey the Scout Law,
To help other people at We strive to provide a safe outdoor experience for all Scouts and families par-
all times, and ticipating in program at Camp Greenough. The Scout Oath and Scout Law are
our guiding principles.Additionally all staff and participants in Cape Cod
To keep myself physical- and Islands Council program are expected to abide by the following:
ly strong, mentally
awake and morally All participants will be respectful of others and their property.
straight. All adults, including leaders and parents accompanying youth participants, are
expected to support camp and program staff by maintaining discipline and activ-
ity-specific rules.
Scout Law Corporal punishment, including spanking, is prohibited.
A Scout is No camper shall be subjected to cruel or severe punishment,humiliation,or ver-
bal abuse from camp staff,participants or visiting parents.
Trustworthy
No camper shall be denied food or shelter as a form of punishment
Loyal
No child shall be punished for soiling,wetting or not using a toilet.
Helpful
The Buddy System is in effect at all times while in camp.No youth may travel
Friendly on his own or leave his group without permission of the group leader.
Courteous In accordance with National BSA policy, use of alcohol, illegal drugs,and to-
Kind bacco products is expressly prohibited on any Council property.
Obedient Violation of any of these policies may result in the individu-
al being removed from the activity or program and possibly
Cheerful sent home.
Thrifty
Brave
Clean
Reverent
247 Willow Street
" —oouth Port MA 02675
I'008)362-4322
F(5{38}362-4323
www,scoutscapecod.org Prepared. For Lifer
BOY SCOUTS OF AMERICA
J. CAPE COD ISLANDS COUNCIL, INC.4224
•
Camp Greenough
Waterfront procedures and Christian Law Compliance:
All Campers and staff must complete a swim assessment immediately upon entering the water on their first day in
attendance. Designations of non-swimmer, beginner,or swimmer will be noted on each camper's buddy tag.Swim-
ming will be limited to the appropriate area depending on their ability.
The buddy system will be used as a safety check during their swim time.Campers must have a buddy having the same
or lesser ability and will be required to stay in the same area at all times while on the waterfront.
PFD's are available for use by any child regardless of their swimming ability.
As part of the aquatics program,all campers will be instructed on the proper usage of the pfds.Campers will be taught
how to wear and properly fit the pfd's.
Campers will be encouraged to experience the pdf by trying one on and floating.This will help children who need to
wear the pdf feel more comfortable about putting one on.
•
All boating activities require the use of PFDs. Boating can only be participated in by campers who have passed the
swimmer test.When campers are boating their buddy tags must be placed on the boating board rather than listed with
those using the swimming area.If they choose to remain in the waterfront after boating,they will need to move their
buddy tags back to the swimming boards.
•
247 Willow Street
Yarmouth Port MA 02675
P(508)362-4322
F(508)362-4323
www,scoulscapecod,ory Prepared, For Lifer'
c►i''u 7
•
- -- BOY SCOUTS OF AMERICA
CAPE COD it ISLANDS COUNCIL,INC. #224
Procedures for reporting suspected child abuse or neglect:
•
Any staff member suspecting that a child has been abused in any manner must
immediately make a report to their supervisor.
Frist Priority will be if the child needs immediate medical treatment,in which case
appropriate treatment will be sought.
Suspected abuse will be immediately reported to the proper authorities:child services
• and/or local police.
The staff member will not engage in"investigating"the abuse.That task is left to the
professionals.The staff's job is to recognize and report the suspected abuse while
keeping the safety of the camper as their primary concern.
•
k
•
•
•
•
•
•
•
247 Willow Street
Yarmouth Poct MA 02675
9)362-4322
d)362-4323
www.scoutscapecod.org Prepared. For Lifer
CAWBOY SCOUTS OF AMERICA
W• CAPE COD&ISLANDS COUNCIL, INC.#224
Traffic Control:
Camp Parking lot is labeled with a one way traffic pattern.
Parents must enter the parking lot,park their car, and walk their child to the check in
• table.
At dismissal,parents/guardians must park their car and walk to check out table at which
time the camper will be brought forward to meet their parent and leave with them.
NO camper is allowed beyond the check in/out tables without being in the care of an
adult
•
•
•
•
•
247 Willow Street
Yarmouth Port MA 02675
3)362-4322
• _J8)362-4323
wuuw.scoutsaapecod.org Prepared.For Life
eta , ,
ti,^ �/
Cape Cod&Islands Council Boy Scouts of America
1;ay Camp Emergency Procedures
All leaders and campers are briefed on emergency procedures shortly after arrival at
camp.
The camp emergency signal is a siren which,will signal for all camp participants and
visitors to assembly on the parade field for roll call.
1 Lightning/Severe Storm out of
a) At the first sign of lightening all waterfront activities stop. All swimmers
the water,all boats beached.Boaters s j�backor to
wate frount1 the stomp subsides.
nt.
b) Everyone in camp seeks shelter in hall and/or pavilion as
i) Program activities will be moved to the dining
appropriate.
ii) Secure camp for high winds and rain
(1) Drop and secure all temporary structures as appropriate
(2) Secure non-essential electrical equipment
2 Missing Camper I Lost I:ether
a) Missing Camper
i) Report missing camper to Camp Director
ii) Sound emergency siren
iii) Assemble all campers,visitors and staff on parade field for roll call.
iv) Commence search as necessary and appropriate.
v) Notify Scout executive if lost camper is not located within fifteen minutes.
•
b) Lost Bather
i) Report lost bather to Camp Director
ii) Sound emergency siren and announce for lost bather divers to report to the
waterfront. grade field for
iii) Assemble all campers,visitors and staff(excluding divers) on p
roll call.
iv) Aquatics staff conduct lost bather search. minutes
v) Notify Scout executive if lost camper is not located within fifteen
3 Major Accident
a) Report all accidents to the Camp Director
b) Camp Director reports to the Scout executive any accident involving
i) Loss of consciousness
ii) Hospital admission
iii) Fatality
c) Execute emergency plan as appropriate
•
Page 1 of 2
Cape Cod&Islands Council Boy Scouts of America
Day Camp Emergency Procedures
4 Hurricane
a) Weather service reports will be monitored throughout the camping season.
b) Communicate status and intent with the Scout executive
c) If camp is in the expected storm track
i) Call all families to cancel program for the following day
ii) Secure camp for high winds and rain
(1) Drop and secure all temporary structures
(2) Secure non-essential electrical equipment
iii)Assemble campers in the dining hall
(1) Call all families for earlypick up
(2) Evacuate to secure shelter if so instructed by emergency services.
5 Fire
a) All campfires are contained in fire rings and attended per BSA fire guard
procedures.
b) Wild fires and building fires are not fought by campers or leaders.
c) All uncontrolled fires are reported to the camp director
d) All campers and staff report to the parade field for roll call.
6 Earthquake
a) At the first sign of ground tremor
i) exit any building
ii) stay clear of
(1) overhead wires and electrical equipment
(2) buildings,vehicles and tall trees
(3) Propane tanks and flammable liquids. •
b) After tremors stop
i) assemble on parade field for roll call
ii) Staying away from buildings,tall trees and downed wires.
iii) Camp director will ensure main power breakers ore off and check telephone
service.
7 Train Derailment
a) Report derailment to Camp Director
i) Assemble campers for roll call
ii) Call 911 providing as much location information as possible
b) Provide assistance as requested by emergency services.
c) Be prepared to evacuate camp
8 Plane Crash
a) Report crash to Camp Director
i) Assemble campers for roll call
ii) Call 911 providing as much location information as possible
b) Provide rescue assistance as requested by emergency services.
c) Be prepared to evacuate camp.
Page 2 of 2
IMTPOTO
NOTICENOTICE
A
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17117
TO ' TO
EMPLOYEES �I a' EMPLOYEES
dRM �S�e
The Commonwealth of Massachusetts
D F,PARTMENT OF INDUSTRIAL ACCIDENTS
'1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 &30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
A. I. M. Mutual Insurance Company
NAME OF INSURANCE COMPANY
54 3rd Ave Burlington MA 01803
ADDRESS OF INSURANCE COMPANY
VWC-100-6014316-2021A 03/31/2021-03/31/2022
POLICY NUMBER EFFECTIVE DATES
NAME OF INSURANCE AGENT ADDRESS PHONE#
Cape Cod & Islands Council, Inc.#224 BSA 247 Willow St Yarmouth Port MA 02675 508-362-4322
EMPLOYER ADDRESS
03/06/2021
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
Cape Cod Hospital 16 Park St Hyannis MA 02601
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
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BOY SCOUTS OF AMERICA
AWARDS THtWiTtl.Vir8ATE OF TRAINING AWARDS THIS CERTIFICATE OF,I
To:BOY SCOUTS OF AMERICA
AWARDS
ToAquatics Instructor-BSA(CS02)
Barry Lyle
For:
June Norcross Webster f.
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F°ACl2021
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Held at:
April 23-May 2,2021
Held auta:
Date: tiCjSunInesNtorurccrtoossr-WBSebAste(Cr SO2)
Date:
2025
April 23-May 2,
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DEPARTMENT OF PUBLIC HEALTH—COMMUNITY SANITATION PROGRAM
105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN
STATE SANITARY CODE,CHAPTER IV
NAME OF CAMP: ADDRESS:
?a,nio Cceate? PmSi; Ypo 'f
OWNER/OPERATOR: S'eaii OFF SEASON ADDRESS:
:cope 4 2slc-z 5-amu/ a L-7 I/i//07,0 liee
CAMP DIRECTOR:
461y 7-014-7,) DATE/TI OF ,INSPECTION::
PHONE#: COs-- 362 Z- Lt3 /��/l) 7 7/a-0Q-- //. 77;^
TYPE OF CAMP: WATER SOURCE: INSPECTED BY:
Da Residentialtrt"
'6/141/6"tial•
Sport— c —Medical Specialty CAMPER CAPACITY:
Trip— mi ive/Outpost—Travel 0
"No"column= ✓marked below indicates a violation of 430.000.
"Yes"column= V marked below indicates compliance with provision of 430.000.
"N/A"column=V marked below indicates that the rovision of 430.000 is not a licable to this cam .
.451 Current Certificate(s)of Inspection from local
building inspector for sleeping/assembly areas.
.215 Written compliance from local fire department.
.300(A)(2) Private water supply:
(a) DEP approval(>25 people,>60 days/yr)
300(A)(2) Private water supply:(<25 people OR<60days/yr) /
(b) BOH approval,chemical&bacterial analyses,no more 'V
than 45 da s rior to o enin
Procedures for Background Review of
090(A) Staff and Volunteers.
Staff— CORI and SORT
.090(C) Previous Work History(5yrs)—3 Positive Reference Checks
Out-of-state/International Criminal Background Checks
Volunteer Staff— CORI and SORI
.090(D) Previous Work/Volunteer History(5yrs)
Out-of-state/International Criminal Background Checks
.090(F) All Background Info-Received,reviewed,&made /
determination required pursuant to.090(C&D). '1/
.091 Staff/Volunteer Orientation: Orientation Plan&
.159(B)(1) Attendance Records,Training on Disaster/Emergency .1
.210 Plans,Health Care Policies,&Concussion Awareness
Abuse&Neglect Prevention Policies&Procedures
c .093 Report procedures in accordance w/M.G.L.c. 119,§51A
Written notification to MDPH and BOH.
Discipline Policy:Appropriate Discipline Methods&
Prohibitions: (1)Corporal Punishment,including
spanking,is prohibited;(2)No camper shall be (if
.191 subjected to cruel or severe punishment,humiliation,or
verbal abuse;(3)No camper shall be denied food,water,
or shelter;(4)No child shall be punished for soiling,
wetting or not using the toilet
430-Camp Inspection Form 3-27-18 Page 1
Regulation-105 CMR 430 Yes -
CP PLANS - WRITTENrimajow 411111111111111111112111111
.210(A) Fire Evacuation Plan and Drills _ V
.210(B) Disaster/Emergency Plan Vj
.210(C) Lost Camper Plan / Lost Swimmer Plan
.210(D) Traffic Control Plan
.211(A) Camper doesn't show up for day.
.211(B) Camper doesn't show up at point of pick up.
.211(C) Child not registered arrives.
Promotional Literature/General Requirement
Copy of Policy(Parents/Guardians): Care of
.159(B)(2) Mildly Ill Campers,Administration of Meds&
Emergency Health Care Provision.
.157(C) Meningococcal Disease&Immunization info
provided to parents/guardians annually.
.190(13) Camper released only to Parents/Guardians or
Designated Individual with written authorization.
Regulatory Compliance&Licensing Statement:
.190(C) "This camp must comply with regulations of the MDPH&be
licensed by the LBOH"
.190(D) Inform parents of right to review background
(at time of check,health care,discipline policies and grievance
application) procedures upon request.
.190(E) Protocol in place to handle unrecognized persons at
cam .
.212(A) Written itinerary provided to parents/guardians
before departure.
212(B) Source of emergency care identified;minimum 1 J
health care supervisor accompanying trip.
Health records easily accessible for all
.212(C) campers/staff,medications stored securely and
accessible only by HCS.First aid kit present..
212(D) Written contingency plans brought on all field trips:
(natural disasters.lost camper/swimmer. injuries and illnesses)
Alk TRANS
Vehicle must comply with M.G.L.c.90 §§ 7B& 7D:
<14 passengers&driver is camp coach,director,etc.
.250 camp vehicles may be used
>14 passengers,vehicle must be school bus
All vehicles RMV compliant w/annual safety insp
.253 Proper automobile insurance.
.251(C) Seatbelts must be worn.
1 staff person required when transporting:
.251(D)(E) Campers to the pick-up/drop-off site;or
8+campers under 5 yrs.of age; or
2+campers with physical handicaps.
.251(I) Camper under 7 yrs. are not transported longer than
1 hour non-stop.
Camp vehicle drivers: 18 yrs.+,2yrs.driving
.252 experience,current license for type of vehicle.
First Aid certified if no other trained staff aboard.
430-Camp Inspection Form 3-27-18 Page 2
Regulation—105 CMR 430 Yes No N/A -.
STAFF QUALIFICATIONS
Camp Director: ..�
.102(A) Residential.25 yrs.+,successful completion of Camp v'
Administration Course or 2+seasons experience.
.102(B) Day: 21 yrs.+,successful completion of Camp
Administration Course or 2+seasons experience.
.102(C) Primitive,Travel,Trip: 25 yrs.+and proof of
experience. V
.102(D) Designated Substitute: &.. IIS +'eGSa,
Substitute must meet above criteria.
Counselors/Junior Counselors: /
t oo(C)(2) Day Camp,Non-Sport: 3 4 `. Cc S-eic' (
l 00(A) Counselor= 16 yrs.+ Junior Counselor= 15 yrs.+
4+weeks experience&attend orientation and training 1 C ISCec,t %(4"
Residential,Primitive,Sport,Travel,Trip,Medical: V
.100(C)(1) Counselors= 18 yrs.+or graduated from high school
.100(A) Junior Counselors= 16 yrs.+
4+weeks experience&attend orientation and training
.100(C)(3) All counselors 3 yrs. older than campers.
Required Counselor Ratio •
Residential/ a /Sports Camps: G
.101(A) 1 counselor per 0 campers 7 yrs. or above D
1 counselor per 5 campers under 7 yrs.
Primitive/Outpost,Travel,Trip Camps:
.101(B) 1 counselor per 10 campers- 1 counselor at least 21 yrs. /
.159(C) 2 counselor minimum with 1 counselor having First Aid
Certificate or its equivalent
.101(A&B) All Camps:
.103 Staffing plan to supervise campers w/disabilities
during regular and specialized high risk activities.
Aquatics Director:
�/ - `
.020 Lifeguard certification,21 yrs.+,6 weeks previous
.103(A) experience in similar supervisory position.
Lifeguard:
At least 16 years old with [American Red Cross
a
.020 Lifeguard Training Cert/Royal Bronze Medallion/Boy v �,n C (,,5
103(A) Scouts Lifeguard Cert/YMCA Lifeguard Cert]*AND
CPR AND First Aid Certificate
*Or their es uivalent
z , ultant(HCC):
MD/DO NP PA(with doc t ented pediatric training)
.159(A) *Check for Health Care Consultant Agreement*
License#: ) 7 0 s 116
Develop written orders to be followed by HCS,
.159(A)(6) including responsibilities for medication
administration
160(C) Develop a written list of all medication
administered at camp
HCC Provided&Documented Trainings:
.160 HCS required trainings,signs of hypo/hyperglycemia,
(E)(G)(H) diabetic plan management,and administering epi-pen
with evidence of competency
430-Camp Inspection Form 3-27-18 Page 3
Regulation—105 CMR 430 Yes No N/A Comm
MEDICAL, PERSONNEL
Health Care Supervisor(HCS): f its L- � � (
All Cam s must have at least I HCS on site at alt�imes),__�r,
.020 MD PA NP RN L or...
.159(C)(E) 18 .+,First Aid&CPR certified
.159(3) Camp Health Care Policy
.160 ALL Medications stored in Original Containers
(A)(1) and meds properly disposed of with disposal log.
.160(3) Meds stored in secured manner(ACA standards)
Medication refrigerator temp 36°F-46°F
Written Medication Administration Policy:
.160 Medication administered by HCC authorized staff only;
(C)(D) oral/topical medication administration training;and
epi-pen and insulin use.
.163 Sunscreen policy with parent/guardian sign off.
.155 Medical Log:
Readily available and signed by authorized staff person
.154 Injury Report completed for a fatality or serious
injury. Copy sent to MDPH and BOH.
Day/Residential Camps-Infirmary provided I
.161(A) Residential Camps-Easily recognizable and
accessible during the day and night.
.453 Lighting provided in infirmary.
161(B) Residential Camp-Area for isolation of ill child
with ability to provide negative pressure. \/ _
.161(C) First Aid Kit:meet ANSI Z308.1-2015 standards V
Minimum: 1 Class B kit and 1 Class A kit
.140& Medical/Biological waste managed in accordance
.160(F) with 105 CMR 480.000.
Aismiass
Health Record for each Camper&Staff:
.150 Staff/Camper<18 yrs:Emergency Contact Info,
.160(D) Written Parental Permission for Meds,Emergency Care,
.190(A) and Self-Administration of epi-pen or insulin
Camper>18 yrs:Emergency Contact Info
Residential,Travel,Trip,Sports—Medical History&
.151(A)(B) physical within past 18 months ,J
Day—Medical history signed off by Parent/Guardian
IMMUNIZATIONS:
Campers and Staff under 18yrs: Number of records checked:
5 7
.152 .�}- r,�,
J °
r�*r:
Campers and Staff over I8yrs: Numbef recor s clicked:
�'
.152
.153 Exemption Documentation `
430-Camp Inspection Form 3-27-18 Page 4
.190(A) Activities and physical environment meet the needs
of campers; do not pose hazard to health/safety.
AQUATICS:
Swimming Pool: in compliance with
.430 105 CMR 435.000-Permit Posted
Compliant w/VGB Act&Pool Fence Requirements
Bathing Beach: in compliance with 105 CMR
.432 445.000-weekly water sampling,water clarity,
and ring buoy present
.204(C) All camps in compliance with 105 CMR 432.000
Christian's M.G.L. c. 111 § 127A 1/4
I.aw
.204(C) Swim test to classify swimmers by ability at pools J
.430(B) and beaches(Christian's Law).
Proper supervision at swimming venue:
103 1 lifeguard per 25 campers
.204(D) 1 counselor per 10 campers
Plan to check swimmers-"buddy system"
50+kids in/near water Aquatics Director must be present _
204 Swimming areas clean and safe,no swimming at
undesignated sites or at night without lighting.
.204(F) Piers,floats,and platforms in good repair.
WATERCRAFT 1p , ,iJp � f AKS
.204(1 Watercraft: equipped with USCG approved J � 'cc
.103(B)(4) flotation devices and worn by all campers and staff
engaging in watercraft activities.(paddle boards included)
White water,hazardous salt/fresh water activities:
.204(1) Campers certified with ARC Level 4+Certificate
or equivalent.
White water,hazardous salt/fresh water activities:
.103(B) Minimum 2 counselors in separate watercrafts
1 counselor per 10 campers(counselor must have lifeguard or
small craft safety and basic water rescue cert,or equivalent)
CRAFTS:
.205 Equipment in good repair,safety precautions taken. V
PLAYGROUND/ATHLETIC EQUIPMENT:
.206 Equipment properly maintained, fields/surfaces
(A)(B) free of holes/accident hazards.
.206(0) Playground equipment securely anchored with no
concrete under/around it, and pliable swing seats.
ARCHERY: Names/Certs:
.202(A) Equipment in good condition, stored locked.
Range away from other activity areas,clearly
.202(B) marked danger area with 25 yards clearance behind
each target. Common firing&ready line in place.
.203 Personal weapons allowed with camp operator's
written permission.
.103(E) 1 counselor per 10 campers at range at all times.
430-Camp Inspection Form 3-27-18 Page 5
n )3G►S RRF(S - C 12._4 )
e' lation-105 CMR 430
9•.x � Names Certs: CkieyN tS 1'i /� �P,44i �t
Firearms in good condition, stored in locked V 114/Z-4-71 4'7/.:41 ie..40.e.
.201(A) cabinet.Ammunition locked in separate cabinet. /
.201(B) Shooting range away from other activity areas. V
.201(C) Only non-large capacity,single shot rifles
permitted.
.201(D) Firing line in place,no crossing without instructor's ,
.201(E) permission. �/
Direct Supervisor:NRA Instructor's certification
.103(D) and maintain compliance with applicable M.G.L.'s
1 counselor per 10 campers 2 (44., 5 I 'oZ cr'1
HORSEBACK RIDING: ames/Certs: 1 _
.103(F) Excursions: 1 Certified Instructor per 10 campers
.208(A) Minimum 2 counselors present during excursions
In accordance with M.G.L.c. 128, §2A
.208(A) Riders must wear hard hat at all times.
.208(B) Licensed stable in use.
CHALLENGE COURSES AND CLIMBING WALLS: Operator: lK Gtr I 6e 6t1t o r
.103(G)(1) Licensed and maintained in accordance with
520 CMR 5.00-Amusement Devices
.103(G)(2) Annual inspection with written report
.103(G)(3) 1 counselor per 10 campers at all times
CABINS&STRUCTURES
Day Camp provides shelter for on-going camp
457 activities with certificate of inspection.
.216 Residential-Smoke and carbon monoxide
detectors provided.
.456 Adequate egresses free from obstruction(780 CMR). v _
.453 _ Lighting provided for stairways.
454 All structural and interior elements maintained in
good repair and in a safe and sanitary condition.
SLEEKING ARE ENTIAL CAMPS
Provide adequate space:
.458 Single bed: 40ft2/person;
Bunk bed: 35ft/person;
50ft/person requiring special equipment
Provide separate bed/cot per person with:
.470 6 ft.between individuals heads;and rJ
3 ft. between single beds&4 V2 ft.between bunks
Campers and staff with limited mobility housed on
.459 ground level;egresses leading to grade or ramp
provided.
.452 Screens&screen doors provided. All doors
//
equipped with a self-closing device.
.454 All structural and interior elements maintained in
good repair and in a safe and sanitary condition.
TENTS
.217 Clearly labeled as fire resistant.No open flame in J
or near tent.
430-Camp Inspection Form 3-27-18 Page 6
TOILETS/HANDWASH SINKS/SHOWERS
.360 Proper sewage disposal. �J
.301 Plumbing maintained in good working order.
Adequate#of toilets:
All Camps: Min.2 toilets/privy seats for each gender
370 Day Camp: >60 of one gender,provide 1 more toilet
for each additional 30 persons of that gender.
Residential: >20 of one gender,provide 1 more
toilet for each additional 10 persons of that gender.
Toilets less than 200 feet from sleeping rooms.
372 Toilet paper provided.
Windows/openings screened. Screen doors self-
closing.
Adequate#of sinks in compliance w/248 CMR:
.373 Day Camp: 1 sink per every 30 people
Residential Camp: 1 sink per every 10 people
.374 Adequate#of showers(no duckboards): J
Residential Camp: 1 shower/tub per 20 people
Campers with special needs provided sanitary
378-380 facilities meeting their needs.
.453 Lighting provided.
g g
Adequate ventilation provided for all bathhouses,
375 dressing rooms, shower rooms,and toilets for
indoor/outdoor pools.
Hot Water in sufficient quantity and pressure:
376 Handwash Sink: 110°F- 130°F 1V/
Shower/Bathtub: 100°F- 112°F
.374(B) Sanitary facilities maintained in clean condition.
.377 Shower room floors washed daily.
LAUNDRY
.162 Residential Camp: Laundry facilities provided.
.472 Bedding and towels laundered;no common towels.
300 Potable water provided.
.300(B) Adequate and centralized drinking water facilities.
.304 No common drinking cups.
.350/.355 Proper storage and disposal of solid waste.
Residential/Day Camps:Immediate access to reliable
.209 phone with posted dialing instructions&
(or have readily accessible)telephone numbers for
HCC,police,emergency medical services,fire dept.
.213 Emergency Communication System
.450 Site location does not cause undue traffic hazards
and is accessible at all times.
430-Camp Inspection Form 3-27-18 Page 7
egulation-105 CMR 430 Yes No N/A Comments
GRO1L'NDS
.165 Tobacco use prohibited at camp.
.166 Alcohol and marijuana use prohibited during camp
operating hours.
.207 Proper storage and operation of power equipment J
Power tools stored in locked place.
.214 Flammable and hazardous materials labeled and
\i/
stored in locked unoccupied building. �//
.400 Rodent and insect control.
.401 Weed and noxious plant control. V
Food service in compliance with 105 CMR
.320 590.000,Minimum Standards for Food
Establishments. Prominently displayed food permit VVV
from BOH.
.320(B) USDA Summer Food Service Program—written A / 1/. ( iOl
`f
documentation of compliance with 105 CMR 590. V b/ ClYttfr-
.330 Nutritious meals that include a variety of foods V
served. Menus posted.
Residential,Travel,Trip camps—Provide at least
.331 3 nutritious meals per day. Foods must meet
recommended dietary guidelines.
332 Day camps—If serving 1 or 2 meals per day food V
must meet recommended dietary guidelines.
Adequately trained staff and equipment to ensure
.334 campers with disabilities are eating nutritious 1/
meals.Meals not denied or forced.
Proper methods for storing meals brought from
335 home. Meals provided to campers who arrive
without a bag lunch.
.452 Screening provided for food preparation and food
service areas. Screen doors must be self-closing.
.453 Lighting provided in kitchen and dining area.
.471 Sleeping prohibited in food areas. I
.145 Operator maintains all records relating to campers,
staff,and volunteers for a minimum of 3 years.
Date and Time of Re-Inspection(if applicable):
430-Camp Inspection Form 3-27-18 Page 8
105Rulation
THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
egCMR 430
Camp Operator:
Name:
Address:
Phone Number: Fax Number:
Email Address:
430-Camp Inspection Form 3-27-18 Page 9
430-Camp Inspection Form 3-27-18 Page 10
430-Camp Inspection Form 3-27-18 Page 13