HomeMy WebLinkAboutApplication ��s— oo�
� °� `� TOWN OF YARMOUTH Bo�dof
Health
= 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 266���N/C����
�..e• Telephone(508)398-2231,ext. 1241 ��5�
F�(508)760-3472 MAY 'l 9 201.�i
APPLICATION FOR A LICENSE TO CONDUCT HEALTH DEP7
RECREATIONAL CAMP FOR CHILDREN
(Use back of applicatiou if additional space is necessary) FEE: $55.00
Name of Camp: �IL1.X, Por,d Adve.ntur� Prao�a.rn
SiteAddress:_� ��poYt-F /�U�
SiteAddress:SOIL�"�/l y0.YYVIlT1/l/l'n'1 � Mlq 0210(0�{
Tax ID Number(FEIN or SSI�: E-mail�r�sG h[j Ye!'rl4+io✓1� arrnokth.
us
Type of Camp: Day(less than 24 hrs.) ✓ Residenrial(24 hrs.)_
Hours of Operation: �� 30 — 5' 3 O
Dates of Operation: Opening: SW`1 c Cbsing: �tAp Us-f'
Name of Camp Owner:T u�rt DF y!]YYVLUU'ti'l� �1 Y kS l�nrl �eCf'eCti'F"r a v')
Office Address: q-2 4 IZOI.I�e ��' 11VeS F �(�('� o u 3'f�t � Yy►(k O 2�-T 3
Office Telephone Number: 'J�g' -�� -aa3� X-� 153-b
Name of Camp Operator(if different): f l,�Y�U�, � • �((blStlOYya ��1 Y��V
Address: SQYYIC
Telephone Number:
Camp Director• (�QYIQ, CUbi �l
Address: (p C�press I`Zoc•d SO �n�'1�S , 11'�f� 02(e4- O
Age:� TelephoneNumber: 'rJC14 - �S ' S3�I o1 .
CourseworkinCampingAdministration: �3 �/� 2X�Y1PX1C� Y ACh Direc#vr Y�IOf���
Previous Camp Administration experience: ��fs CQpy�p �1 reC�pr
Health Care Consultant: 13Ass k�1V`?!2 �eC�ta�}- �Gs L�r. �� YYI�{/
Type of Medical License: M , D MA License number. �{�(o�21' 3
Address: 23r1 ��f'[6h �1f2 S �L1J(Mbldl'`1��t D2We�Telephone: � -3q�-2(( (o ,
����5 1 of 3
Hospital for Emergency Services:�Pz � �f9r-�-Li�
Health Supervisor: SQf`/1R-✓�'�'�/�Q (�(�C�1'�e-�
Age: Type of Medical License,Registration or Training: K� �XOSS ����Pt �tA�+
Cer.liFied pluxs�ny Ikss�s+-rtini , Phlcb��urin.�s�, �I�t� Tec� , �Cl�ed !-Fec:._fi�r Chilct .
Swimming Area: Yes ✓ No_
IfYes: Fresh Water ✓ Ocean Pool CPO
SpecificOnsiteLocations: SW lrnM�v1-q t�2C.�<<'1 -
Water Quality Testing Performed By:�Qj'ry��7y�.� �pClyC{ O� �-{Q0.,L�7
Aquatics Director:
Name: �'A lL�e�r1 G,CXK'rt1�S Age: a'-I-
Lifeguard Certificate issued by: �� �'XOSS Exp. Date: �L11 �
American Red Cross CPR Certificate: �� �OSS Exp. Date: �5 s'
American First Aid Certificate: �-CC� CF'�� Exp. Date: c�01£j g
Previous aquatics supervisory experience: I}�d l.t 'Fe�ua ycI —T0�/ aOl I — I'�F
Watercraft/Boating Activities: Yes ✓ No Describe:
Compliant with Christian's Law: Yes ✓ No
Food Service:
Is food handle serv r prepared? Yes ✓ No
Av �od
To what extent? Servic.e Snacks Cooked and Se ed by Staff
aE bag �uv�chcs �afF s:+e. p�rep�
If cooked onsite, Food Manager(submit copy of ServSafe)
Catered ✓ If so,by whom? ��/ �SD �ood SeVv�ce
Is refrigeration available for perishable foods? Yes ✓ No
Fire Arms Instructor:
Name: �(i I�
National Rifle Assn. Instructor's Cazd(or equivalent)
Date certified: Expirafion Date:
����s 2 of 3
Background Checks:
Has the Camp Owner or Director obtained and reviewed the CORI and SO�ach staff
person and volunteer who may have contact with a camper? Yes t/ No
IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS
PRIOR TO OPENING TO SCHEDULE AN INSPECTION! TffiS IS MANDATORY!
OVEI2NIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE
BUII.DING AND FIRE DE NTS.
SIGNED•
PRINTED: �e��/�: w ��.�s�✓iivi a DATED: Q � I
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.
arowu 3 of 3
i a���oe�o
MAY L 9 '1U15
', HEALTH DEPT.
� Required Documents
See the MA Regulations for Minimum Standazds for Recreafional 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.
� Staffinformation forms (see attached) .� 8 of
➢ Procedures for the backround review of staff and volunteers (105 CMR 430.090)�Ma,,���
➢ Copy of promotional literature (105 CMR 430.190 (C))
➢ Procedures for re ortin sus ected child abuse or ne lect 105 CMR 430.093 3� + 3 2
P S P S � ) a�n.�ori��-.c
➢ Health caze policy (105 CMR 430:159 (B)) 4��r� i5�4 b.F Mo.��o.Q
➢ Discipline policy(105 CMR430.191)�`� ''3 — 3'� of rti,���,.o_A
➢ Fire evacuation plan—approved by local fire department (105 CMR 430.210 (A)) �G `",,,�,�
➢ Disaster plan (105 CMR 430.210 (B))P�q� 23�t-24 o� �n�,�(
➢ Lost camper plan(105 CMR 430.210 (C))P49� 2` ` 22 0� +�r�
➢ Lost swimmer plan (105 CMR 430.210 (C))p�'je �� • ►4 oF +v�-•-���
� Traffic control plan(105 CMR 430.210 (D))
�Ra Day Catnps—contingency plan(105 CMR 430.211)
�g Primitive, Trip or Travel Camps — Written itinerary, including sources of
emergency caze 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 de arhnent (105 CMR
430.215) APP+ Mond ar� Ti.�� 1`� �or �nsPec-k�or� ��•Qf of �t�skk ►rsp��F�on
➢ Lab analysis of private water supply(if applicable) (105 CMR 430.300, .303) N�1< .
Toux� v.�t¢2 .
Please: If you aze applying for an original camp license for a camp based in Yannouth,
you must file a plan showing the following with the boazd of health at least 90 days
before your desired opening date (See MGL Ch. 140 § 32A):
➢ Buildings, struchues, faciliries and fi�tures
➢ Proposed source of water supply
➢ Works for disposal or sewage and waste water
✓Attach the names, ages, applicable current ceritifcations (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.
✓ Supervisory staff means those persons with the responsibility, authority and training tq
provide direct supervision to camper groups. This may include counselors, juniar`.
counselors, general activity leaders or other staff who provide supervision to campers
without assistance.
oaro9ns