HomeMy WebLinkAboutChallenger Sports - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Py�``�ns h05S�p� e
Board of Health
License to Operate a Recreational Camp
This is to certify that: DAVID RUSH
94 A JEFFERSON BLVD,
WARWICK
MA 02888
Is hereby granted a CHALLENGER SPORTS
permit for:
at 50 PLYMOUTH STREET
Mansfield
MA 02048
Town of Mansfield
6 Park Row
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: JULY 8, 2019 - JULY 12, 2019
Hours of Operation: 9:00 AM - 4:00 PM
Date Approved.
BOARD OF HEALTH
NichaeCHeaCey, Chairman
Town of Mansfield
Town o f Mansfield - Board of Health 0 Park Row
Mansfield, MA 02048
Application for a License to Conducta Recreational Camp for Children
Application must be submitted at least14 (fourteen) business days prlorto the start of camp.
Nameofcamp: C(/t,QQ•Q,1 jw S;P C�/r�s
7
Site address: w �" fly`"-"
Site telephone: t -
Name of camp owner. r,V¢ IA Qy el
Office address: qf) A- (T at5,�, 'J'L-tv 01
Owner's telephone: t{et_ 213 — 44,KO4; -
Ownerssmall M ✓Y'iV`1-)2-. C4&o .wPiyl.{..QI•p /1� • ow
Name of camp operator. V 1
Operators address:
Operators telephone:
Name of health care consultant: ill t,t/vr ('t iw ° Mv`ao
Address:
Tel hone• C(pI , �'f-- QL(�
Type of camp: YDay 0 Residential
Hoursofoperation: q4A" -(-t ewe
Dates) of opemtlon: o� p h W,
2Swimming pool
Pool permit number
C1 Bathing beach
no Meals provided
Food permit number:
eP
Date: Signature of Applicanr
- Fee: $175.00 Official Title: — a l-LQO�Tii ••___„_-___,,_..._-__.. _ .
See below for a llstofdocuments thatmustbe completed and submitted before your application for a license can be Poly processed. You are
encouraged to complete these documents as soon as possible and submit them in advance. This will expedfle the license process.
See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter Al -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.
Ii Staff information form (see attached)
c� Procedures far the background review of staff (105 CMR 430.090) 0 Disaster plan (105 CMR 430.210(B))
0 Copy of promotional literature (105 CMR 430.190 (Cp E Lost camper plan (105 CMR 430.210(C))
Procedures for reporting suspected child abuse or neglect (105 CMR 430,093) ❑'7 Lostswlmmerplan (105 CMR 430.210(C))
ru Health care policy (105 CMR 430.159(B)) Traffic control plan (105 CMR 430.21D(D))
n Discipline policy (105 CMR 430.191) Daycamp - contingency plan (105 CMR 430.211)
-1 Fire evacuation plan - approved by local fire department (105 CMR 430.210(A))
U Current certificate of occupancyfrom local building inspector (105 CMR 430.451)
M Written statement of compliance from local fire department (105 CMR 43D.215)
E0 Primitive, Trip or Travel Camps - Written itinerary, Including sources of emergency care, and contingency plan (105 CMR 430.212)
[] If applying for Initial license after January 1, 2000 - lab analysis of private water supply Of applicable) (105 CMR 430.300,303)
Please note: Ifyou are applying for an original camp license, that is, the original camp license In each community where life camp Is located, you
must file a plan shaving the following whh the board of health at least 90 days before yourdeshed opening date (See MGL Ch.140 s, 32A):
EJ Buildings, structures, fixtures, and fadlities
El Proposed source of water supply
p Works for disposal or sewage and waste water
Town of Mansfield
Town o f Mansfield - Board o f Health 8 Park Row
Mansfield, MA 02048
Camp Director
Name: -/^✓/1()iL/Iy-IY��1lrV,V\S(d��� 4l� :..__. _....
Age: _r�r r "(.1
Coursework in camping administration:
Previous camp administration experience:
Health Care Consultant (/y,
Name:_-- --. _- -
MA License Number:
Type of Medical License (must be a physiclan, nurse practitioner, Dr pbysiclan assistant with pedlalric training):
Health Supervisor
Supervisor
Name:
Age:
Type of Medical License Registration, or Training (See 105 CMR 430.159 C):
Name:
Age:
Lifeguard Cer Ificate issued by:
Expiration date:
American Red Cross CPR Certificate; American First Aid Certificate:
Expiration date:
Previous aquatics supervisory experience:
Firearms Ins
Name:
Date Certified:
Horseback R
Name:
Stable
Location:
0 License In accordance with MGL Ch.111 S.155,158;
Expiration date:
National Rifle Association Instructor's Card (orequivalent):
Expiration Data;
_ License Number:
Expiration Date:
Yes_ No_
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 of Individual or Corporate Name By: Corporate Officez ( ndatonf, if Applicab e
'_m, I D 5 - 291�?
"Social Security No. (Voluntary) or Federal
Identification Number
*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:\Useis\slelte)Deskmp\Scoh's Docoments\Food Establishments Temp\TAX CERTIFICATION FORM.doc
S I ne 4ommonweatin of ivlassacnusens
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Natne: (U&d"/ �Lt/'��•
Address:114 4- p _� Iran 4yr%
City/State/Zip:Phone hi:
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I 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] 6. ❑ 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]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ 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
organization should check box #1.
I am an employer that is providing workers' compensation insurance^ for m y employees. Below is the policy information.
Insurance Company Name:.' ,MAA',`�.GVPjoll, " • .(/1.�`^Pt4_
Insurer's Address: I$ ��Y��j, caik2 f7J1
City/State/Zip: V�SOL4 � l t Iy �/t� W k.jfY
Policy # or Self -ins. Lic. # SDI• 11:56&1W q ogif - Expiration Dater �n I I
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required trader Section 25A of MG 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 cerd&, under the pains and penalties of perjury that the information provided above is true and correct
Sivnature: /t-'CI Date: E X,4 p't
Official 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):
1. Board of Health 2. Building Department 3. City/rown Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person:_—_.— _ � �� Phone #:—
www.mass.aov/dla