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Home My WebLink AboutApplication and WC : • MrD-C9P�!loaP,SUinoc, � l 5-00,� � °� `� TOWN OF YARMOUTH $oazdof -.��- Health = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACH[JSETTS 02664-24 - o•.�� Telephone(508)398-2231,eXt. izai �� Fas(508) 760-3472 Division JUN O i 2015 APPLICATION FOR A LICENSE TO CONDUCT A HEALTH DEPT. RECREATIONAL CAMP FOR CHiLDREN (Use back of application if additionai space is necessary) �E'E:�$�� ' ` ' � �T� Name of Camp: /�l� - �'�JQE 7`f6L'r/ c�[s�,//L� Site Address: l��i�/N/J-�.C/l�l� ��lo. lf'r/6eS/ ,�Cfj/p�L Site Address: q�/O c�A70.� �l1E CTfi1�!?i/ �� •�/ � ��ilr Q��p�jf� - - _ . Tas ID Number(FEIN or SSI�: �� -� E-mail /'Ljl�f.<ril7� �jyJ,Y�j,� Type of Camp: Day(less than 24 hrsJ ✓ Residential (24 hrs.)_ Hours of Opention: �:��Q y 7p oj 30 p� DatesofOperation: Opening ��y /��,r Closing: �!lL��f��,J= Name of Camp Owner: �ZUT�iQT S' �.4,K/G�i�,.� Office Address:_ � Lfi✓��'/��-� i� li/FJT ��i�.�X�d� �.� t'.Z 6�� Office Telephone Number: �DB 39��0��' Name of Camp Operator(if different): Address: Telephone Number: Camp Director: /�j�E12T .s �.QGy/Clm..� - Address: S�O .S�ffFi�/EC/J 24 �J� �r/��_�i,¢��,j ,� Age:�� Telephone Number: ,�G�-��{- y0�' Coursework in Camping Administration:��fjFi?1 �J ��..t�'/�J ��j�j! ��"' �. /lEC/IF-�a✓. .�{E.Q / .�f ,jJcirr. G ac • s�/�s / , Previous Camp Administration experience: �j�(� �'/?EyO..�� g( '•�Ej�� 3/y/�f, �ot.�rrcrr �ow.✓ Q.�' Y.�•�to.rr� r1E�F.14�Eva,c. Health Care Consultant: !�/1. KG�y ��py� Type of Medical License:��/rQG'/�(/TE+/1,,�,lQL /�;►7MA License number: 7�3� Z�o�ISFiT�? OiPI�V Address:��lE7.�LQ �J J C1�✓t s ,� ��Telephone: ,�� onsna 1 Of 2 � � Hospital for Emergency Services:��E �/J �J��i/AL Health Supervisor: /�i�iQ'/ �Ej'� �!//liti/�y Age:�_ Type of Medical License, Registration or Training:�C'6. /y(f�Qfr, ��G� Swimming Area: Yes_ No ✓� If Yes: Fresh Water Ocean Pool CPO Specific Onsite Locations: Water Quality Testing PerFormed By: Aquatics Director. Submit Certifications: CPR First Aid_ Water Safety_ _ - ----_ _ Other Lifeguazds and Credentials: . Watercraft/Boating Activities: YesT No_ Describe: Food Service: � Is food handles, served or prepazed? Yes_ No � To what eartent? Sn�cks Cooked and Served by Staff If cooked onsite,Food Manager(submit copy of ServSafe) _ Catered_ If so, by whom2 Is refrigeration available for perishable foods? Yes_ No_ 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_ IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS P$IOR TO OPENING TQ SCHED'ULE AN INSPECTION! THIS IS MANDATORY! OVE1tNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WTI'H THE BUII.DING AND FIItE DEPARTMENTS. SIGNED: �h�J � ��.I� PRINTED: /��/�� ..I. ��f/ !/��1 DATED: .T See the next page attac6ed for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete tLese documents as soon as possible and submit t6em in advance. This will eapedite the process. 05��0 2 of 2 Florio, Mary Alice From: Florio, MaryAlice Sent: Tuesday,June 09, 2015 12:15 PM To: Mid-Cape Hoop School (rhamilton08@comcast.net) Subject: Worker's Comp Affidavit Attachments: MA State Workers Compensation Insurance Affidavit Form - General.pdf Good afternoon. Thank you for submitting the 2015 application for the Mid-Cape Hoop School license issued through the Health Department. However, prior to issuing the license to you, we are required under Massachusetts State Law, Chapter 152,Section 25C, Subsection 6, to have you submit a completed State Worker's Compensation Insurence Affidavit form, or to have you submit a Certificate of Insurance from your insurence agency indicating that your State Worker's Compensation is in effect. Please complete the attached affidavit form and return it to our office, or have your insurance agency send us a certificate of insurance showing Worker's Compensation coverage. Even if you do not have employees,the affidavit is still required to be completed and signed. Thank you for your attention to this matter. MaryAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 1 �_\ The Commonwealth of Massaehusetts Print Form � Department of Industrial Accidents _;�. x, `'�= Office ojlnvestigations ��° �, E �� I Congress Street, Suite 100 �)i�� ?��5 �r�``.'�:G .- :�� Boston, MA 02114-2017 www.mass.gov/dia H�/1LT�i 1��P1. Workers' Compensation Insurance Affidavit: Genera usinesses A licant Information Please Print Le ibl Business/Organization Name: � � C/' � % p,J�l� f Address: �(7 �`!/ .��0,��/eC✓ l��i �N�- �`1 l��ts�F Zto S�tatJ{�JE City/State/Zip:_`i/ ,/ .�la.i Phone#: l7�J,9—3 J`��435' Are you an employer?Check the appropriate box:��3 Business Type(required): 5. Retail 1� I a em er with employees(full and/ ❑ part-tune 6. ❑ RestawantBar/Eating Establishment 2.❑ I o e proprietor or par[nership 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 �0.❑ Manufacturing no employees. [No workers'comp. insurance required]' 11.❑Health Care 4.❑ We aze a non-proFit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applican[that checks box#1 mus[also£II out ihe sec[ion below showing their workers'compensation policy infortnation. '"If the corporate o�cers have exempted themselves,bu[[he corpora[ion has o[her employees,a workers'compensa[ion policy is required and such an organization should check box#I. /am an employer that is providing workers'compensation insurance for my empl ees. Below ' the policy information. Insurance Company Name: � ,�i 1��j1 yc �Q/� l/f/ /J/iri��j�fi1'y ��l/Jl, T Insurer's Address: �Q �gC ^�� I � CiTy/State/Zip: ! D�P/' /�!T D�c�� Policy#or Self-ins.Lic.# �� — ��.f — ��/�.� —�� Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secwe coverage as required under Section 25A of MGL a 152 carrlead 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. 7 da hereby eerte ,under the pains and penalties of perjury that the injormation provided above is true and correcG Si a�i_tur�/S/�'l�1• NG.tI��'✓�l Date• �II`�� Phone#: (SOp `,3gy yD,�'j Ojficial use only. Do not wrue in this area,to be comp[eted by ciry or town o�eiaL City or Town: Permit/License# Issuing Authority(circle one): � 1.Board of Health 2.Buildiog Department 3.City/Town Clerk 4.Licensing Board 5.Selectmeds Office 6.Other Contact Person: Phone#: www.mass.gov/dia �