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HomeMy WebLinkAboutMansfield Parks & Rec Summer Camp - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 License to Operate a Recreational Camp l This is to certify that: TOWN OF MANSFIELD SIX PARK ROW J MA 02048 Is hereby granted a MANSFIELD PARKS AND RECREATION SUMMER CAMP permit for at 111 HOPE STREET -MEMORIAL PARK MANSFIELD MA 02048 This permit is granted in conformity with 105 CMR 430.000, Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV, Department of Public Health, and expires on closing date of each session unless sooner suspended or Date(s) of Operation: JUNE 24, 2019 - AUGUST 23, 2019 Hours of Operation: 8:00 AM to 4:00 PM Date Approved. BOARD OF HEALTH _ 1ichaeCHeaCey, Chairman Town of Mansfield -Board of Health 6 Park Row, Mansfield, Massaclntsetts 02048 Application for a License to Conduct a Recreational Camp for Children Camp Name: , ans LC) 0.YK5J UVICI GLi�afii d ♦7 �.immo- cofr) Location where camp operates: �-I () L City: ManJi,IJ IState:M A ZIPCode: 612j,48 Phone: Email: rCU'CCL @ CQV15/e 0.. m Website/Social Media address: _ (mac _ d a GLI im I Pa r K 5 Owner/Organization Name: W • b ClY1S )c Primary Mailing address: City: Mah sfi4)jQ Slate: M A ZIP Code: 2 60 S Phone(year-round): C•5 U 5S Fax: 368, Z 1,'42 Email: �` f I (license will be sent to this email address) S� OX (l of 0 f • M I all,5 I i L !d a L 0 O'l_ Director/Operator Name: A CI•I 1 r f-V Primary Mailing address: S I a-)` IG Rb W City: Or, h9f�e 1 State: MA ZIP Code: 61-6 h Phone(year-round): 50$ �)51 L-458 I Fax: Email: �ccvza /b) (Y)an )e1dMCc. Lo If the camp previously operated in Massachusetts provide: year(s) the camp operated and the name(s) the camp operated under: El From: J"e ("f G() To: re 5O 114 Name(,): I I tr�nS �� L I� J �,/�(i'�m� {^ `Olft N/A Has the camp's license ever been suspended or revoked:(check): Day or Residential Camp: Suspended a Day Revoked Residential Neither Seasonal or Year -Round Camp: Seasonal camp only: Seasonal +f V� q Opening Date for camp: 1IL L eX Year -Round Tt pp)b�-r Closing Date for camp: PqLtsI.i 4 Hours of O eratiom ` : %b Swimming Pool(s): Pool Permit Number: 0Off-site Off -Site Pools (if applicable): ®Yes No Total Number of Pool(s): Bathing Beach(s): Names of lake or river located at camp (if applicable): Yes ElOff-site X No Off -Site beaches (if applicable) Meals Provided: ❑ Food Permit Number: Yes No Camp Capacity (per Session): 2 Campers: 00VC Staff: o Total Number for the Year: May 2019 Page 1 of 3 Name: DY. John 5haLV- MA License Number: Phone (to reach during camp operations): SL;C� 3�144 Type of Medical License: ® Physician 8 Physician Assistant NOTE: Attach documentation ❑ Other: Nurse Practitioner of pediatric training if a PA) Name: 4 e Icy - MA License Number: Age: Type of Medical License, Registration or Training 105 CMR 430.159(C): 8 Physician 8 Physician Assistant M Other: Please attach Nurse Nurse Practitioner documentation of current First Aid / CPR Training ♦ X Name: Age: Lifeguard Certificate issued by: American Red Cross CPR Certificate: Expiration date: Expiration date: American First Aid Certificate: Previous aquatics supervisory experience: =RifleAssociation on Instructors card (or equivalent): Expiration date: • • X Name: License Number: Expiration date: Stable Location: Licensed in accordance with MGL c.111 §155, 158: ❑ ❑ Yes No ♦ Is the camp a Public Water System (PWS) or connected to a town water supply? PWS Town water supply Other: Is the camp connected to a municipal sewer or other community, off -site sewage disposal system or is it served by on -site sewage disposal system(s)? Municipal/Off-Site On -Site (if on -site, Date of most recent septic tank pumping and inspection: ) Other: If ALL of the above information was previously submitted and has not changed, please note: © INFORMATION ON FILE from previous years May 2019 Page 2 of 3 May 2019 Page 3 of 3 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scou's DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lelribly Business/Organization Name: Address: (�ix Fwrk Row City/State/Zip: 11 Phone #: -568-B,. t+4 Are you an employer? Check the appropriate box: Business Type (required): 1. W I am a employer with 2(/ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership 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• [X] 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 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I .❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ^,nization should check box #1. ram an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 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. I do hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct. Ofjicial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/cim Town of Mansfield, Board of Health APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name: Town of Mansfield — Summer Camp — Memorial Park. Site Address: 111 Hope Street, Mansfield, MA 02048 Site Phone: 508.261.7383 Name of Camp Owner: Town of Mansfield — Recreation Department Operator Office Address: Six Park Row, Mansfield, MA 02048 Telephone number: 508.851.6458 Name of Camp Operator: Alan Weintraub, Summer Camp Director Address: I I I Hope Street, Mansfield Telephone number: 508.261.7383, Town Hall: 508,851.6458 Type of Camp: Day Hours of Operation: 8:OOam to 4:OOpm Dates of Operation: Opening: June 24, 2019; Closing: August 23, 2019 Swimming Pool: No Bathing Beach: No Meals Provided: Yes Food Permit Number: Signature of Applicant: Official Title: Sherri H. Gurnon, Director Parks and Recreation Continued: Required Documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Codes, Chapter IV — 105 CMR 430.000 and the guidance documents issued by the De- partment of Public Health, Division of Community Sanitation for additional assistance with de- veloping the following documents: The following list is for those forms applicable to the Town of Mansfield, Recreation Depart- ment Summer Camp: • Staff information forms • Procedure for the background review ofstaff (105 CMR 430.90) • 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 ) ) • 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) ) • Day Camps —contingency plan (105 CMR 430.211) • 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) • Permit for this summer camp has been held for 15+ years. Water used is bottled from Vermont Pure, 23 Jan Sebastian Dr Sandwich, MA 02563. Children use a fresh cup at each water break or their personal recyclable water containers. Continued: Camp Director Name: Alan Weintraub Age: 60+ Coursework in camping administration: None Health Care Consultant Name: Dr. John Shaver Type of License: GP MA License Number: 37294 Health Supervisor: Name: Alan Weintraub Age: 60+ Medical Training: CPR, First Aid, AED, and Epi-pen Aquatics Director: NA Firearms Instructor: NA Horseback Riding Instructor: NA Stable: NA First Aid and CPR: June 15, 2019 by MEMA. All camp staff will be certified at this time. Camp Director: Alan Weintraub Office Assistant: Nancy Nestor Head Counselors: Courtney Gurnon, Robert Ryan Counselors: Peyton Geddis, Lauren Hurley, Sam Hyland, Molly Keefe, Rebecca Laliberte, Peter Lally, Sarah Lamson, Julia Means, Daniel Medeiros, Nicholas Menz, Dan Rieth, Ailinn Santos, Brendan Sullivan, Emily Vigeant CIT's: Sam Leard, Allison Marchand, Emily Shapiro, Rachel Shapiro, James Tallman, Pranav Tekumalla, Kevin West, Liam West LIT's: Bryan Cavanaugh, Brady Fox, Dexter Harris, Colton Johnson, Ava Karsay, Michael Karsay, Sarah Marchand, Caroline Schlentier