HomeMy WebLinkAboutMansfield Arts & Ed. Center 7/2/2018G
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
liTi/a1.&1;11411
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 2, 2018 - AUGUST 10, 2018
Hours of operation: 9 AM - 4 PM MONDAY-FRIDAY
Date Approved. C f ( �:') C',
c t
BOARD OF HEALTH
.Mich.aeCMcCCean, Chairman
',',Town of Mansfield
Town of Mansfield - Board of 4�pglthl 2018 Park Row
F Mansfield, MA 02048
Application for a License to Conduct a Recreational Camp for Children
Appllcatlon must be submitted at least 90 (ninety) days prior to the start of camp,
Name of camp: MANSFIELD ARTS & EDUCATION CENTER Type of camp: [ Day ❑ 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 SALOOM STREET, MANSFIELD, MA 02048
Operator's telephone: (508) 339-3066
# staff:�(�
# volunteers:
Date: 5' 1 N I I
Fee: $150.00
Hours of operation: a AM - 4 PM MONDAY-FRIDAY
Date,(�s)of operation: q
❑ Swimming pool /16 PCB I l P (Q.i11IS'Qj
Pool permit number
❑ Bathing beach (i6
[-]Meals provided )�
Food permit n
Signature of Applicant:
Official Title:
See below for a list of documents that must be completed and submitted before your application fora 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, Slate Sanitary Code, Chapter IV - 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 form (see attached)
Procedures for the background review of staff (105 CMR 430.090) �Dlsaster plan (105 CMR 430.210(B))
Copy of promotional literature (106 CMR 430A90 (C)) V Lost camper plan (105 CMR 430.210(C)) ryy)
Procedures for reporting suspected child abuse or neglect (105 CMR 430,093) �Y osl swimmer plan (105 CMR 430.210(C)) n 0 f-
,�// Health care policy (106 CMR 430.159(B)) l�id/- TrafFlc control plan (105 CMR 430.210(D)) 1
Discipline policy (105 CMR 430.191) L Day camp - contingency plan (105 CMR 430,211)
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)
p{j Written statement of compliance from local fire department (106 CMR 430,215)
I] 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 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):
7�/Buildings. structures, Flxdures, and facilities
Ist Proposed source of water supply
iJ Works for disposal or sewage and waste water
Isa Town of Mansfield
Town of Mansfield - Board of Health
Pant Row
Mansfield, MA 02048
Camp Director
Name: ASHLI PHILLIPS
Age: - ---
Coursework In camping administration: SEE ATTACHED
Previous camp administration experience: 9 YEARS YMCA CAMP EXPERIENCE
Health Care Consultant
Name: DAVID CUNNINGHAM
Type of Medical License (430.159(A)): DOCTOR
Address: 56 LEONARD STREET #7, FOXBORO, MA 02035
Health Care Consultant Phone number: .(.506) 69322.0B--___.__
Health care Consultant signed Agreement
Health Supervisor
Name: SARAH MIHALY
Age l
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 dale:
American Red Cross CPR Certificate
Expiration date:
Previous aquatics supervisory experience:
Firearms Instructor
Name:
Date Certified:
Horseback Riding Instructor
Name:
Stable
Location:
r3 License In accordance with MGL Ch.111 s. 166, 158:
MA License Number: 218415
American First Aid Certificate:
Expiration date:
National Rifle Association Instructor's Card (or equivalent):
Expiration Date:
License Number:
Expiration Date:
Yes _ No
.C"\ The Commonwealth of Massachusetts
Department oflndustrPaMccidenis
1 Congress Street, Suite 100
UIV . Boston, MA 02114-2017
wmumass.gov/dia
Workers' Compensation Insurance Affidavit. General Businesses.
TO BE MILD WITH THE PERAUTTING AUTHORITY.
Applicant Information Please Print Ledbly
Business/Organization Name: HuC{,r;m,,A 4rc- 'ymc/3
Address:. 3w bmw,-„ i 5j.
City/State/Zip: N. / rrtaha• tn/- o?-IW Phona#:
Are you an employer? Check the appropriate box:
Business Type (required):
1. ® lama employer wlth fo 0 employees (full and/
5. 0 Retail
orpart-time),*
6. E3RestaurantBar/6aflngEstablishment
2; ® lam a sole proprietor or partnership and have no
?• Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
S• 0 Non-profit
[No workers' comp. insurance required]
3. ❑ We arc a corporation and its officers have exercised
9. [] Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.0 Manufacturing
no employees, [No workers' comp, insurance required]*
11 ❑ Health Cam
. ❑ We are a non-profit organization, staffed by volunteam,
4,E]
with no employees. [No workers' comp, insuranceroq.]
12.0 Other
*Any applioant Net checks box #I nest also fill out No section below ehovriog their workers' cempensedon policy Information.
**If the eerpomte officers have exampled themselves, but the corporation bas other employees, aworkern' oempeosadon policy is required and such an
orgmizationahould cbeckboxWJ.
1 am an employer that is prortding workers' compensation insurance for my employees. Below is the policy tnformatio$.
Insurance
rnsurar's Address: 'Fo"6+ r- [Y'1 5 ; 507 /✓k G� l 1��wD
City/State/zip: Murn)nw,f V7 6-?vl, Z
Policy # or Self -ins. Lio. #• 24 017 Y _ Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fallure to secure ooyerage as required under Section 25A of MGL e. 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 tho violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
do hereby cyrtt,(y, under the pains and penalties of perjury that the information provided above 0 true and correct
)675
Official. use only. Do not write in this area, to be completed by city or town offtdaL
City or Town:
Permit/License
Issuing Authority (circle one).
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6.Other
Contact Person:
'CRUM&FORSTER
INSURER:
UNITED STATES FIRE INSURANCE COMPANY
HOME OFFICE: MORRISTOWN, NJ
A STOCK INSURANCE COMPANY
1. THE INSURED AND MAILING ADDRESS:
HOCKOMOCK YOUNG MEN'S
(SEE NAMED INSURED ENDT)
300 ELMWOOD STREET
NORTH ATTLEBORO MA 02760
WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE POLICY - INFORMATION PAGE
POLICY NO: 4087315908
RENEWAL OF: 4087289349
NCCI CO NO: 12777
INSURED ID
NO(S):
CLIENT NO: 3186440
PRODUCERNO: 89671
PRODUCER NAME AND ADDRESS:
FBINSURE
ONE GEORGE LEVEN DR
NORTH ATTLEBORO
MA 02761-0000
INSURED ENTITY: YMCA
BUSINESS OF INSURED:
OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension of Information Page)
2. POLICY PERIOD: FROM 07-01-2017 TO 07-01-2018
Effective 12:01 A.M. Standard Time at the Insured's Mailing Address.
3. COVERAGE:
A. Workers' Compensation Insurance: Part One of the Policy applies to the Workers' Compensation Law of the
States Listed here:
MA
B. Employers' Liability Insurance: Part Two of the Policy applies to work in each state listed in Item 3A. The Limits
of our liability under Part Two are:
Bodily Injury by Accident:
Bodily Injury by Disease:
Bodily Injury by Disease:
500,000
Each Accident
500,000
Policy Limit
500,000
Each Employee
C. Other States Insurance: Part Three of the Policy applies to All States of the United States, except those listed in
Item 3A above and in: NO, OH, WA, WY and in any additional states listed below:
D. This Policy includes these Endorsements and Schedules:
As per schedule of forms and endorsements.
4. THE PREMIUM for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit. See Extension of Information Page.
AGENCY BILL
Total Estimated
Minimum Premium: $ 483 Annual Cost: $ 86,029
Audit Period: ANNUAL
Issued At: MORRISTOWN NJ Deposit Premium: $ 86,029
Date: 0 6-2 8 -17
DATE Authorized Representative
WC 00 00 01 A (2/90) Copyright 1987 National Council on Compensation Insurance
WC 00 00 01 C (7/97)
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.
(;�w�-� �' +^'1e.�,e,-�z, s�i ✓r Seca
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
c.J-Z13i 7d4
"Social Security No, (Voluntary) or Federal
Identfffcation 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.
0Users\9le1te\Desk1op&o1Ps Documenls\Food Establishments Temp\TAX CERTIFICATION FORM.doc