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HomeMy WebLinkAboutMansfield Arts & Ed. Center 7/3/2017qk , Commonwealth of Massachusetts Town of Mansfield rh5xfr° �h Board of Health License to Operate a Recreational Camp This is to certify that: HOCKOMOCK AREA YMCA 300 ELMWOOD STREET NORTH ATTLEBORO MA 02760 Town of Mansfield 6 Park Row Mansfield, MA 02048 Is hereby granted a MANSFIELD ARTS & EDUCATION CENTER permit for at 40 BALCOM STREET 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 3, 2017 - JULY 14, 2017 Hours of operation: 9 AM - 4 PM MONDAY -FRIDAY Date Approved. ;r J BOARD OF HEALTH MichaeCMCCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Operate a Recreational Camp This is to certify that: HOCKOMOCK AREA YMCA 300 ELMWOOD STREET NORTH ATTLEBORO MA 02760 Is hereby granted a MANSFIELD ARTS & EDUCATION CENTER permit for: at 40 BALCOM STREET 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 24, 2017 -AUGUST 11, 2017 Hours of Operation: 9 AM - 4 PM MONDAY -FRIDAY Date Approved: ( _ 0 i BOARD OF HEALTH NichaecNcCCean, Chairman SANS j) q , Town of ATansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Application for a License to Conduct a Recreational Camp for Children -- - - _ Application must be submitted at least 14 (fourteen) business days prior to the start of camp. Name of camp: MANSFIELD ARTS & EDUCATION CENTER Type of camp: i./!, Day I _ Residential Site address: 40 BALCOM STREET Site telephone: 508-339-3066 Name of camp owner: HOCKOMOCK AREA YMCA Office address: 300 ELMWOOD STREET Owner's telephone: 508-695-7001 Owner's email TONYC@HOCKYMCA.ORG Name of camp operator: HEATHER UTSLER-SMITH Operator's address: 40 BALCOM STREET, MANSFIELD, MA 02048 Hours of operation: 9 AM -4 PM MONDAY -FRIDAY Date(s) of operation: 2-94017 ro 7--i 1-1"17 JUN 2 7 2017 . °- Operator's telephone: (508) 339-3066 I-1.Swimming po �';— Pool permit number Name of health care consultant: KELL-Y OREAVE.S /pJn044 evlvl,4 ,' 44'el 1(d yr/ !Bathing beach Address: 1 Meals provided 02,q / /tCQa iv Xd/ 0,14 ft i> ,, fZ� U�?n b'I Food permit number: Telephone: (508) 593-2206 Date: Signature of Applicant: Fee: $150.00 Official Title: See below for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the license process. Required documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Cock the guidance documents issued by the Department of Public Health, Division of Community Sanitation for the following documents. Staff information form (see attached) Procedures for the background review of staff (105 CMR 430.090) [-'.I Disaster Copy of promotional literature (105 CMR 430.190 (C)) Lost car Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) F_11 Lost swi Health care policy (105 CMR 430.159(B)) Traffic Traffic c Discipline policy (105 CMR 430.191) i.0-� Day car Fire evacuation plan - approved by local fire department (105 CMR 430.210(A)) Current certificate of occupancy from local building inspector (105 CMR 430.451) Written statement of compliance from local fire department (105 CMR 430.215) 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 (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 his 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 Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Camp Director Name: ASHLI PHILLIPS Age: 32 Coursework in camping administration: SEE ATTACHED Previous camp administration experience: 9 YEARS YMCA CAMP EXPERIENCE Health Care Consultant Name: l(F66*G FAVFa6 10#v10 eL21t 110611,i/`f - T1V/'14tN Fsf✓tkYd#W-e MA License Number: 232426 Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): NURSE Health Supervisor Name: SARAH MIHALY Age: 25 Type of Medical License Registration, or Training (See 105 CMR 430.159 C): TRAINING - EEC MEDICATION ADMIN., CPR, FIRST AID Aquatics Director Name: Age: Lifeguard Certificate issued by: Expiration date: American Red Cross CPR Certificate: American First Aid Certificate: Expiration date: Previous aquatics supervisory experience: Firearms Instructor Name: Date Certified: Expiration date: National Rifle Association Instructor's Card (or equivalent): Expiration Date: Horseback Riding Instructor Name: License Number: Expiration Date: Stable Location: License in accordance with MGL Ch.111 s. 155, 158: Yes _ No— Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 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. The Colrrtnonrvealth ojMassachusetts Deparinrent Of[itdMir'ial Accidents Ojice of[investigations 600 Nrasltington Street Ulf 11aS(On, MA 02111 "ury K"Mrsgov/dia uatYon Workers' Compensation Insurancees Affidavit: General Business 13ttsiness/OrganiVifion Name: Address: oa U'n City/,Stake/'Lip:�— _ �L a t1Gc� Phone /t: Ar��c,,y,ou an employer'? Check the appropriate box: I • t.7 fan a employer with 750 ` or part-time). * — employees (fill and/ 2• ❑ 1 am a sole proprietor. oi•.par(norship and have no em�rloymv.w4kiti ltir tte(a,mt �y 3. ❑Wo workers' comp, utsurnnco required] We are a corporation ofd its officers have exercised d"oir right of exemption Pero, 152, § 1,(4),, and we have n0 employeas. f.Nodvorkufs' coop: tI7Sl11nnce requiredla 4. ❑ We area non-profit organization, sta(fed by volunteers, with no employees. Mawr k •' '5�-6y3-s.z3 3 Business Type (required_): ---- 5. El Retail 6. [J RestaurantBar/FatingEstablishment 7. U 4Ci oe,and/or $a1e5 (incl. real esiatc,:auto;.ctc.) 3. [ Non-profit 9. [] Entettairunent 10.0 Mnnufachuing 11.❑ Health Care, Any pplicoul lhnt checks L r ers comp• insurance req.] j I f2,❑ Other 'aozp( most also ml ad the scdtan below shnwiag their workers' cowpcosalim, policy.inComwliou. 'If the corporntad ellocs have exempteJ themselves, bid the mrpomtion Iws alherempinyees, awalkers' compensaliro policy is «quimd and such an o'6ani"afionslmuld Nrcck hoz p(. ! arrr an ernptayer 1!, - _ Insurance Company Insurer's City/State/Zip: ^• e• "rung "porker."' comyrens0do" insurance for ory ekrptoyees. Below is die !tc cora:_ 41. Jul �. fir. t e. _ :1, ... _ _.- po y Grfo'llmuorc Policy k or Self -ins, I.,ic. # yt}g "7a+j (D / Attach a copy of the workers' compeosatiou colic • de Expiration pater 7 1 1 1 age owing er and expiration date). Failure to secure coverage as required under Section 25A ofMtGL c 152 Darn lead totttho hnposit oney bof rim nal penalties of a Gfu up to $ I,S00.00 and/or One-year ituprisomnent, as welt as civil penalties in the fano of a STOP WORK ORDER ando fine of es to $250.00 a day against the violotol'. 13e advised that a copy of this statement may he fSTOP W to dte RDE a hwest� i ati_ons of the DIA for insurance cove rage ! do lu reby ceraly, under tGepatas and eaalues on (•)r � _ , p Pfperjrvy tlrn! the above Jr true and correct. Official ure only. Do kat write!"! !itis area, fo be completed. city 0r 1011,11 offlelal City or Town: !suing Authority (circle one): Permit/Liccasc H_ L Board of FCcafth 2. Butkiing pepartment 3. City(i'own 6. Other • Clerk . Licensing Board S. Selectmen's Office Contact Person: Phone 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. `�J _ I lac.,,, k '9' yrn"A Signature Jf Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable) "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. Department of Public Health - Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 NAME OF CAMP: ADDRESS: OWNER/OPERATOR: OFF SEASON ADDRESS: CAMP DIRECTOR: DATE/TIME OF INSPECTION: PHONE #: TYPE OF CAMP: WATER SOURCE: INSPECTED BY: Day Residential Sport / Non -Sport CAMPER CAPACITY: Trip Primitive Travel "No" column = ✓ marked below indicates a violation of 430.000. "Yes" column = ✓ marked below indicates compliance with provision of 430.000. "N/A" column = ✓ marked below indicates that the provision of 430.000 is not applicable to this camp. EASM Current Certificate(s) of Occupancy from .451 local building inspector for sleepinglassembly areas / .215 Written compliance from local fire dept. .300(A)(2) Private water supply (a) DEP approval (>25 people, >60 days/yr)W tr� t t tti u .300(A)(2) Private water supply (b) BOH approval, chemical & bacterial analyses <25 le, <60da s/ r goBOOM �� _ ckground Review of Procedures for Background �� � .090(A) StatUVolunteers Staff— CORI and SORT .090(C) —Previous Work History -3 References — Out-of-state/Intemational Criminal Background Checks Volunteer Staff— CORI and SORI .090(D) — Previous Work History — 3 References — Out-of-state/Intemational Criminal Background Checks .090(F) All Background Info - Received, reviewed, & made determination required pursuant to .090 C&D .091 Staff/Volunteer Orientation Plan & 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 (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(0) Lost Cam er Plan / Lost Swimmer Plan X .210(1)) 1 Traffic Control Plan 430 -Inspection Sheet 5-10-16.docx Page 1 i 430 -Inspection Sheet 5-10-16.doex Page 2 .:A �3 MEMOMM -- - T .211(A) Camper doesn't show up for day XW .211(B) Camper doesn't show up at point of pick u .211(0) Child not registered arrives _, .. . PYomutionxliiEerature/G_ettei�l.Re nirement . .- Copy of Policy (Parents/Staff): Care of Mildly ill .159(B)(2) Campers, Administration of Meds & Emergency Health Care Provision Camper released only to Parents or Parent- .190(B) Designated Individual in writing Statement: Regulatory Compliance & Licensing .190(C) "This camp must comply with regs of the MDPH & be licensed by the LBOH" .190(D) Inform parents of right to review background (at time of check, health care, discipline policies and application) grievance procedures upon request _ .212(A) Daily Itiner - Copy to Parents .212(B) Source of Emergency Care Contingency Plans (natural disasters, missing campers, 7—e So .212(C) lost swimmers, illness and injury) shall Travel with�a',e> Campers & Staff> ' Q v Vehicle must comply with MGLe.90 s7B&7D: �� <14 passengers & driver is camp coach, director, etc. private �. .250 vehicles may be used \ '`— >14assen ers, vehicle must be school bus P All vehicles must be RMV compliant ora liant.253 .253 Proper automobile insurance .251(C) Seatbelts must be worn Camper <7yrs not transported longer than 1 hr to 251(F)) cam Camp vehicle drivers: 18yrs, 2yrs driving experience, .252 current license for type of vehicle First Aid certified if no other trained staff aboard. - Camp Director _ Residential Camp: 25 yrs, completed course in .102(A) camp administration or at least 2 seasons experience Day Camp: 21 yrs, completed camp administration .102(B) course or 2 seasons experience Primitive, Travel, Trip: 21 yrs & proof of 102(C) experience. esnated5ubstitufe ; 102(D) when director off -Site >12 firs (Sub must meet criteria above) -C4unsel6rs/Junior Corinselors .100 Day Camp, Non-Sport: Counselor— 16 yrs. Junior Counselor= 15 yrs. Other camps: Counselors= 18 yrs or graduated .100 from high school. Junior Counselors= 16 yrs .100 All counselors 3 yrs older than campers 430 -Inspection Sheet 5-10-16.doex Page 2 edwred bunselt rRatios? Residential / Day Camps: .101(A) 1 staff per 10 kids over 6 yrs 1 staff per 5 campers 6 yrs and under .101(B) Primitive,Travel, Trip: 1 counselor per 10 campers. 2 counselor min. Special Needs: .101(C) 1 counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled cam ers i American Red Cross Lifeguard Ting cert., CPR .103 for Professional Rescuer & First Aid Cert. or their equivalents. ifsupervising 2+staff, mmt be 21 & exggrience w/ ramagement American Red Cross /Lifeguard Tmg cert. /CPR .103 for Professional Rescuer cert. &First Aid Cert. or �, their e uivalents. NP PA(w/pediatric training) 159(A) *Check for Health Care Consultant Agreement* R Lincense #: P- .159(C) MD PA NP RN LPN or... ` y w e\ 18yrs, First Aid & CPR certified m .159(B) Health Care PolicyX .160(A) ALL Medications stored in Original Containers Meds stored in Secured Cabinet .160(B) & if necessary refrigerated in box affixed in refrigerator (if no secondary lock) 1 ' .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. 160(C) Medication administered by Health Supervisor or Licensed Health Care Professional .160(0) Written list of all meds administered at camp (if H.S. not a L.H.C.P. auth'd to admin Rx, meds) .160(B) Refrigerator temperature 38 to 42 Medical Log Book .155 bound, pre -numbered pages, ink entries, no skipped lines. ^� .161(A) Day / Residential Camps - Infirmary provided Residential Camps - Exterior light .453 Lighting provided in infirmary h .161(B) Residential Camp - Area for isolation of ill child First Aid Kit: non -perfumed soap, sterile gauze .161(C) squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. 430 -Inspection Sheet 5-10-16.docx Page 3 430-hispection Sheet 5-10-16.docx Page 4 IMMINNEWOMMIN Health Record for each Camper & Staff: (-etv;a ov\ Staff/Camper > 18 yrs - Emergency Contact Info 150 Camper < 18 yrs must have Written Parental Permission for Meds/Emergency Care Campers and Staff under 18yrs: Number of records checked: MMR: 1" dose = 12 mos or older, J �� Measles: 2nd dose= grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/ OPV z 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 _ '2> 5 comply with above, Td is to be used) �, ti 2c�� o �-<_ '`' *Booster dose of Td:.- -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades 11-12 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: Mumps: 1 dose (exempt born before 1957) Rubella: 1 dose .152(B) Diphtheria and Tetanus Toxoids 3 doses DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities and physical environment meet the .190 needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. 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: .103 1 lifeguard per 25 campers j 1 counselor per 10 campers f Plan to check swimmers- "buddy system" .204(B) Swim test to classify swimmers by ability. j 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-hispection Sheet 5-10-16.docx Page 4 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(II) 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. 205 Equipment in good repair, safety precautions taken. .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete } under/around it, pliable swing seats. .201 Single shot rifles only .201 Shooting range away from other activity areas 201 Firearms in good condition, stored in locked t cabinet. Ammunition locked in separate cabinet 103 Certifications for other high-risk activities, eg: NRA Instructor Certification for Firearms .202 Equipment in good condition, stored locked Range away from other activity areas, clearly .202 marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 Personal weapons, bows, rifles allowed w/camp operator's written permission .103(G) 1 Certified Instructor per 10 campers minimal 2 counselors .103(G) Riders must wear hard hat .103(G) Licensed stable .457 Day Camp provides shelter for on-going camp 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.docx Page 5 430 -Inspection Sheet 5-10-16.docx Page 6 -- MIMMMMIMIMNMI�,0 - - �� 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/ 41r2 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. TENS Fire -retardant and non-toxic. No open flame 217 nearby. TOII,E'PS/SH©VERS .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 1 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 .162 Residential Camp: Laundry facilities provided .472 Bedding and towels laundered; no common towels 430 -Inspection Sheet 5-10-16.docx Page 6 Balm .300 Potable water provided Adequate and centralized drinking water facilities .300/.304 No common drinking cups f Day / Residential Camps: Telephone readily .209 available with #s of HCC, Local Hospitals, Police, Fire, Ambulance .213 Emergency Communication System/Procedure `ji Cn_A^\ t'vi Tobacco use restricted to designated areas not 165 accessible to campers. .350/.355 Proper storage and disposal of solid waste f .207 Proper storage and operation of power equipment tt .214 Flammable and hazardous materials labeled and, 1 stored in locked unoccupied building. ' .400 Rodent and insect control .401 Weed and noxious plant control = Site location does not cause undue traffic hazards y .450 and is accessible at all times 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.docx Page 7 430-Inspection Sheet 5-10-16.docx Page 8