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Home My WebLink AboutHornet Soccer Camp 7/17/2017Commonwealth of Massachusetts U Town of Mansfield Ayl` - R As Board Board ofHealth License to Operate a Recreational Camp This is to certify that: KEVIN SMITH 20 PHEASANT LANE ATTLEBOROUGH MA 02703 Town of Mansfield 6 Park Row Mansfield, MA 02048 Is hereby granted a HORNET SOCCER CAMP permit for: at PLYMOUTH STREET SOCCER FIELDS, PLYMOUTH ST. 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 17, 2017 TO JULY 21, 2017 JULY 26, 2017 TO JULY 28, 2017 Hours of Operation: 9:00 AM - 3:00 PM Date Approved: j BOARD OF HEALTH .MichaeCMcCCean, Chairman APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: Hornets Soccer Camp Site Address: Plymouth Street Soccer Fields Plymouth Street Mansfield MA 02048 Site Telephone: (Director's Cell Phone) 508 369-4980 Name of Camp Owner: Kevin Smith Office Address: 20 Pheasant Lane Attleboro 02703 Telephone Number: 508223-4388 Name of Camp Operator (if different): Address: Telephone Number: Name of Health Care Consultant: Kathryn Forbes -Smith, F.N.P. Address: Bridgewater Pediatrics Pleasant St. Bridgewater, MA 02325 Telephone Number: Office — (508) 697-8116 Type of Camp: Day X Residential Hours of Operation: 9:00am to 3:00pm Dates of Operation: Opening: Monday July 17, 2017 Hours of Operation: 9:00am to 3:00pm Dates of Operation: Opening: Monday July 26, 2017 Swimming Pool: Yes _ No X Bathing Beach: Yes _ No X Meals Provided: Yes No X Signature of Applicant: _ P Official Title: Director Closing: Friday July 21, 2017 Closing: Friday July 28, 2017 Pool Permit Number N/A Food Permit Number N/A Date: 5-13-2017 See the next page for a list of documents that must be completed and submitted before your application for a license can be filly processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. Required Documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter W - 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. • Staff information forms (see attached) • Procedures for the background review of staff (105 CMR 430.090) • 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)) • Traffic control plan (105 CMR 430.210(D)) • Day Camps - contingency plan (105 CMR 430.211) • Primitive, Trip or Travel Camps- Written itinerary, including sources of emergency care, 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 department (105 CMR 430.215) • If applying for initial license after January 1, 2000 -lab analysis of private water supply (if applicable) (105 CMR 430.300, .303). Please note: If you are applying for an original camp license, that is, the original camp license in each community where the camp is located, you must file a plan showing the following with the board of health at least 90 days before your desired opening date (See MGL Ch. 140 s. 32A): • Buildings, structures, fixtures and facilities • Proposed source of water supply • Works for disposal or sewage and waste water Camp Director Name: Kevin Smith Age: 44 Coursework in camping administration: none Previous camp administration experience: Kevin - Director of Hornets Soccer Camp (2000 -present), Director of Living Water Soccer Camp (2000-2003), Director of Hornets Basketball Camp (1999); Director of Essex County United Soccer Camps (2003-2004), First Aid, CPR Health Care Consultant Name: Katherine Forbes -Smith F.N.P. Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): Physician (Pediatrics) MA License Number: # on file Health Supervisor Name: Kevin Smith Age: 44 Type of Medical License, Registration or Training (See 105 CMR 430.159): American Red Cross First Aid Certification (June 2015) and American Red Cross CPR Certification (June 2015) Aquatics Director Name: N/A Age: N/A Lifeguard Certificate issued by: N/A Expiration date: N/A American Red Cross CPR Certificate: N/A Expiration date: N/A American First Aid Certificate: N/A Expiration date: N/A Previous aquatics supervisory experience: N/A Firearms Instructor Name: N/A National Rifle Association Instructor's card (or equivalent): N/A Date certified: N/A Expiration date: N/A Horseback Riding Instructor Name: N/A License Number: N/A Date: N/A Stable Location: N/A Licensed in accordance with MGL Ch.111 § 155, 158: Yes No Attach the names, ages, applicable current certifications (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 to provide direct supervision to camper groups. This may include counselors, junior counselors, general activity leaders or other staff who provide supervision to campers without assistance. Supervisory Staff Director Name: Kevin Smith Age: 44 Certifications: American Red Cross CPR/First Aid, Massachusetts Professional Teaching Certification, United States Soccer Federation (USSF) National C Coaching license, NSCAA Advanced National Diploma, NSCAA National Diploma Anticipated Role: Lead station work with assistance of a junior counselor, will lead provide lead instruction during games to teams and to individuals, Oversee daily camp activities Co -Director Name: Denis Cutler Age: 49 Certifications: USSF A license, NSCAA Premier License, Anticipated Role: coach, assistant director Name: Simon Shipley Age: 48 Certifications: USSF C License Anticipated Role: coach Department of Public Health - Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CIRLDREN,105 CMR 430.000 NAME OF CAMP: ADDRESS: ,t \AyvvtsCAM Siceu3c 5 OWNER/OPERATOR: Current Certificate(s) of Occupancy from OFF SEASON ADDRESS: CAMP DIRECTOR: `:S 6v� Jor ccn w� DATE/TIME OF INSPECTION: local building inspector for slee in assembl areas PHONE #: TYPE OF CAMP: a Residential Spot /Non -Sport WATER SOURCE: •�Cf.�-"-� INSPECTED BY: CAMPER CAPACITY: Trt rimitive Travel "No" column = ✓ marked below indicates a violation of430.000. "Yes" column = ✓ marked below indicates compliance with provision of 430.000. "N/A" column = ✓ marked below indicates that the revision of 430.000 is not applicable to this camp. r r Itt h ri Y. PERMITS 451 Current Certificate(s) of Occupancy from •� 6v� Jor ccn w� local building inspector for slee in assembl areas .215 Written compliance from local fire dept. .300(A)(2) Private water supply (a) DEP approval >25 people, >60 days/yr) .300(A)(2) Private water supply (b) BOH approval, chemical & bacterial analyses <25 people, <60da s/ r PLANS AND POLICIES- WRITTEN Procedures for Background Review of .090(A) Staff/Volunteers Staff- CORI and SORI .090(C) - Previous Work History -3References - Out-of-state/International Criminal Background Checks Volunteer Staff- CORI and SORI .090(D) -Previous Work History- 3 References- Out-of-state/International Criminal Background Checks All Background Info - Received, reviewed, & made .090(F) determination required pursuant to .090 C&D .091 Staff/Volunteer Orientation Pian & Review .093 Abuse & Neglect Prevention/Report procedures Discipline Policy: Appropriate Discipline Methods & .191 Prohibitions: (1) Corporal Punishment, including spanking, is (B) prohibited; (2) No camper shall be subjected to cruel or severe X (C) punishment, humiliation, or verbal abuse; (3) No camper shall be denied food or shelter as a form of punishment; (4) No child shall be punished for soiling, wetting or not using the toilet .210(A) Fire Evacuation Plan and Drills .210(B)Disaster Plan .210(C) Lost Camper Plan / Lost Swimmer Plan .210(D) Traffic Control Plan 430 -Inspection Sheet 5-10-16.docx Page I ;A it Health Record for each Camper & Staff: Staff/Camper > 18 yrs - Emergency Contact Info 150 Camper < 18 yrs must have Written Parental Permission for Meds/Emergency Care IMMUNIZATIONS Campers and Staff under 18vrs: Number of records checked: MMR: In dose = 12 mos or older, C\) . Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/ OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, .152(A) 3 doses of Td (persons 7 years or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades I 1-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 Campers and Staff over 18vrs: Number of records Measles: 2 doses (exempt born before 1957) checked:. l 0 Mumps: 1 dose (exempt born before 1957) Rubella: I dose r( 152(B) Diphtheria and Tetanus Toxoids*: 3 doses DT/Td *Booster dose of Td required if more than 10 yrs since last dose. ACTIVITIES Activities and physical environment meet the .190 needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all, AQUATICS Swimming Pool: in compliance with 105 CMR .430 435.00 - permit posted **VBG Compliance Letter" Bathing Beach: in compliance with 105 CMR .432 445.00 - weekly water sampling conducted. Proper supervision at swimming venue: 1 lifeguard per 25 campers .103 1 counselor per 10 campers Plan to check swimmers- "buddy system" .204(3) Swim test to classify swimmers by ability. Swimming areas clean and safe, no swimming at .204(A) undesignated sites or at night without lighting. .204(E) Piers and floats in good repair. 430 -Inspection Sheet 5-10-16.docx Page 4 1 ACTIVITIES AQUATICS Watercraft: equipped with USCG approved .204(G) flotation devices and worn by all campers and staff participating in watercraft activities. Campers must be certified by ARC level 3 .204(H) swimmers or equivalent for white water, hazardous salt or fresh water activities. Minimum 2 counselors in separate watercraft .103(C) supervising white water, hazardous salt or fresh water activities. CRAFTS Equipment in good repair, safety precautions 205 taken. PLAYGROUNINATHLETICEQUI WENT Equipment properly maintained, fields/surfaces .206 fi•ee of holes/accident hazards Playground equipment secure, no concrete .206 under/around it, pliable swing seats. FIREARMSNames/Certs: .201 Single shot rifles only .201 Shooting range away from other activity areas Firearms in good condition, stored in locked .201 cabinet. Ammunition locked in separate cabinet Certifications for other high-risk activities, eg: .103 NRA Instructor Certification for Firearms ARCHERY ames/Certs: .202 Equipment in good condition, stored locked Range away fiom other activity areas, clearly .202 marked as danger area. Must have common firing line and 25 yards clearance behind each target. Personal weapons, bows, rifles allowed w/camp .203 o erator's written ermission HORSEBACKRIDINGNames/Certs: .103(G) 1 Certified Instructor per 10 campers minimal 2 counselors .103(G) Riders must wear hard hat .103(G) Licensed stable CABINS/STRUCTURES Day Camp provides shelter for on-going camp .457 activities .216 Residential - Smoke detectors provided .456 Adequate egresses free from obstruction .453 Lighting provided for stairways .454 Floors maintained. 430 -Inspection Sheet 5-10-16.doex Page 5 430 -Inspection Sheet 5-10-16.docx Page 6 RESIDENTIAL CAMPS/SLEEPING AREAS Provide adequate space: 40sgft/person in single bed; 35sgft/person in .458 bunk bed; 50sgft/person in sleeping area requiring special equipment Provide bed/cot per person with 6 feet between .470 sleeper's heads and: 3 feet between single beds/ 4112 feet between bunks Campers and staff with limited mobility housed on .459 ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen door self-closing. .454 Floors maintained. TENTS Fire -retardant and non-toxic. No open flame 1 217 nearby. I TOILETS/SHOWERS .360 Proper sewage disposal .301 Plumbing in good working order Adequate # of toilets: All camps: 2 toilets/privy seats for each sex .370 Day Camp: >60 of one sex, provide I additional toilet per every 30 people of that sex Residential: >20 of one sex, provide additional toilet per every 10 people of that sex. Toilet less than 200 feet from sleeping rooms. .372 Toilet paper provided. Windows/ openings �( screened. Screen doors self-closing. Adequate # of sinks: .373 Day / Residential Camp: 1 per every 30 people Adequate # of showers: .374 Residential Camp: 1 shower/tub per 20 people Special needs campers provided facilities that .378/.380 meet their needs .453 Lighting provided .375 Toilets and Shower rooms ventilated to outdoors Hot water at sinks, showers/tubs not more than .376 112°F Sanitary facilities maintained in clean condition 377 Shower room floors washed daily LAUNDRY .162 Residential Camp: Laundry facilities provided .472 Bedding and towels laundered; no common towels 430 -Inspection Sheet 5-10-16.docx Page 6 . .,•JO.,, _ , r.�nr^= y ,fir-=r,r,Y-v^v"-�''✓,..:�' .��n,�a *., ..r 1'"-'^'--'--rr GROUNDS .300 Potable water provided Adequate and centralized drinking water facilities .300/.304 - No common drinking cups Day / Residential Camps: Telephone readily .209 available with #s of HCC, Local Hospitals, Police, Fire, Ambulance .213 Fnrergesary Cotnynnniea9iobs Sy�tena/b"o•ocvdnae Tobacco use restricted to designated areas not .165 accessible to campers. .350/.355 Proper storage and disposal of solid waste .207 Proper storage and operation of power equipment Flammable and hazardous materials labeled and .214 stored in locked unoccupied building. .400 Rodent and insect control .401 Weed and noxious plant control Site location does not cause undue traffic hazards .450 and is accessible at all times FOOD SERVICE Food service in compliance with 105 CMR .320 590.000, Minimum Standards for Food Establishments. Permit posted in food service facility. Nutritious meals that include a variety of foods .330 served. Menus posted. Residential camps — Provide at least three .331 nutritious meals. Foods must meet Recommended Dietary Allowances (RDA) .332 Day camps — Each meal provided must meet 1/3 of the RDA requirements. Adequately trained staff and equipment provided .334 to ensure handicapped campers are eating nutritious meals. Proper methods for storing meals brought from .335 home. Meals provided to campers who arrive without a bag lunch. Screening provided for food preparation and food .452 service areas. Screen doors must be self-closing. .453 Lighting provided in kitchen and dining area. .471 Sleeping prohibited in food areas. 430 -Inspection Sheet 5-10-16.doex Page 7 430-Inspection Sheet 5-10-16.docx Page 8