HomeMy WebLinkAboutApp-License The Commonwealth of Massachusetts Fee
Town of Yarmouth Waived
Lodging License
Number: BOHL-15-2338-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
TOWN OF YARMOUTH PARKS AND RECREATION DEPT. 31 DUPONT AVE
FLAX POND ADVENTURE PROGRAM SOUTH YARMOUTH, MA 02664
424 ROUTE 28
WEST YARMOUTH, MA 02673
IS HEREBY GRANTED A 2022 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 G. urphy, MPH, R.S., CHO
Health Director
4.14\ TOWN OF YARMOUTH Board of
Health
rk 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451
Telephone(508)398-2231, ext. 1241 Health
Division
Fax(508)760-3472
1111FUrUla APPLICATION FOR A LICENSE TO CONDUCT A
t, RECREATIONAL CAMP FOR CHILDREN W�lv
iJ�(.a ® � (Use back of application if additional space is necessary) FF
HEALTH�►j ' amp: Town of Yarmouth Flax Pond Adventure Program
Site Address: 31 Dupont Avenue
Site Address: South Yarmouth, MA 02664
Tax ID Number(FEIN or SSN): # / E-mail recreation@yarmouth.ma.us
Type of Camp: Day(less than 24 hrs.) X Residential(24 hrs.)
Hours of Operation: 7:30am-5:00pm
Dates of Operation: Opening: June 27, 2022 Closing: August 19, 2022
Name of Camp Owner: Town of Yarmouth Recreation Department
Office Address: 424 Route 28, West Yarmouth, MA 02673
Office Telephone Number: (508) 398-2231 x-1520
Name of Camp Operator(if different): Aimee Howell, Recreation Director
Address: 424 Route 28, West Yarmouth, MA 02673
Telephone Number: (508) 398-2231 x-1520
Camp Director: Maria Cobill
Address: 31 Dupont Street, South Yarmouth, MA 02664
Age: 35 Telephone Number: (508) 398-2231 x-1520
Coursework in Camping Administration: 2011 ACA Director Workshop
Previous Camp Administration experience: 12 Years as Camp Director
Health Care Consultant: Dr. Kenneth Colmer, MD
Type of Medical License: Pediatrician MA License number:
Address: 237 Station Avenue, South Yarmouth, MA 02664 (508) 394-2116
Telephone:
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Hospital for Emergency Services: Cape Cod Hospital
Health Supervisor: TBD at rehiring
Age: Type of Medical License, Registration or Training:
Swimming Area: Yes X No _
If Yes: Fresh Water X Ocean Pool CPO
Specific Onsite Locations: Flax Pond Swimming/Beach Area
Water Quality Testing Performed By: Town of Yarmouth Board of Health
Aquatics Director:
Name: TBD at rehiring 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 X No Describe: Kayaking
Compliant with Christian's Law: Yes X No
Food Service:
Is food handlessr prepared? Yes X_ No
To what extent? Snacks Cooked and Served by Staff
If cooked onsite, Food Manager(submit copy of ServSafe)
Catered X If so, by whom? Dennis Yarmouth Food Service- Free Lunch Program
Is refrigeration available for perishable foods? Yes X No
Fire Arms Instructor:
Name: N/A
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 X No
CORI/SORI's done by Town of Yarmouth Human Resource Dept.
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 Sa itary Code ha ter 1V, 105 CMR 430.000.
SIGNED: s
PRINTED: Aimee Howell, Recreation Director DATED: 12-10-2021
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.
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