HomeMy WebLinkAboutChallenger Sports 6/23/2017Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Operate a Recreational Camp
This is to certify that: DAVID RUSH
94 A JEFFERSON BLVD.
WARWICK
11_
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: JUNE 26, 2017 - JUNE 30, 2017
Hours of Operation: 9 AM - 4 PM
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r
Date Approved: r/r,
BOARD OF HEALTH
%1ichaeCMcCCean, Chairman
Town of Mansfield - Board of Health
1F7
L-0
1 ow�nU i aa�sfield
Park Row
ansfield, MA 02048 m
Application for a License to Conduct a Recreational Camp for Children
Name of camp:(.h cd Ipa) c�&Y-, porfis
Site address: 50 PII iy)&U-fh St, Mam" I21d1
Site telephone: J
Type of camp: 1,4 Day ] Residential
MA 0MI prrours of operation: 61 cLrn _ 4 p m
Name of camp owner Dovld NJ-)
Office address: q 4 A Te K uu6 n e) lYd r N)0-rv) I cK Q I
Owners telephone: 4-0-481-SG44 6,Q%�cc
Owner's email d rus h e r h a I I m er r oo rrts .czyy)
Date(s) of operation:
Name of camp operator: C ho,IIne�r) j �)pQ(tS 11'�� ( '7cc�e
Operators address: q 4 A Tfeff of `jn 61 Y eA, War w� C� 1Z I UMs
Operators telephone: 4 a I -a 13-3) 10� I] Swimming pool
- f Pool permit number
Name of health care consultant: U � I I I M, v a.m al Q M-0 F] Bathing beach
Address:
Meals provided
Telephone: 41,3-5R0 - 1410 Food pe it number:
Date: Signature of Applicant:
Fee: $150.00 Official Title: A U Q 1 A ry T XA A N /1CGE2
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 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) [] Disaster plan (105 CMR 430.210(B))
Copy of promotional literature (105 CMR 430.190 (C)) ] Lost camper plan (105 CMR 430.210(C))
Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ] Lost swimmer plan (105 CMR 430.210(C))
[] Health care policy (105 CMR 430.159(B)) ] Traffic control plan (105 CMR 430.210(D))
❑,' Discipline policy (105 CMR 430.191) U Day camp - contingency plan (105 CMR 430.211)
Fire evacuation plan - approved by local fire department (105 CMR 430.210(A))
El Current cerfficate of occupancy from local building inspector (105 CMR 430.451)
El Written statement of compliance from local fire department (105 CMR 430.215)
E] 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 99 days before your desired opening date (See MGL Ch. 140 s. 32A):
Buildings, structures, fixtures, and facilities
Proposed source of water supply
Ed Works for disposal or sewage and wastewater
aQtpracr t��
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
4 Mansfield, MA 02046
ASK
x..
Camp Director
Name: i i 7 .D
Age:
Coursework in camping administration:
Previous camp administration experience:
Health Care Consultant
Name: _•.....V',wl_Ll
MA License Number: Q
Type of Medical Licenye (must be a physician, nurse practitioner, or physician assistant with pediatric training):
HealthSupervisor
Name: i g�
Age:
Type of Medical License Registration, or Training (See 105 CMR 430.159 C):
Aquatics Director
Name:
Age:
Lifeguard Certificate issu
Expiration date:
American Red Was CPR Certificate:
aquatics supervisory experience:
Firearms Instructor
Name:
Date
American First Aid Certificate:
Expiration dale:
National Rifle Association Instructor's Card (or equivalent):
Expiration Date:
Horseback Riding hsiructor
Name: License Number:
Expiration Date:
Stable
Location:
License in accordance with MGL Ch.111 s. 155, 158: Yes _ No-
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
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 stall who provide supervision to campers without assistance,
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 Officer (Mandatory, if Applicable)
**Social Security No. (Voluntary) or Federal
Identification Namber
*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\sleac\Desktop\Scott's DocumentsWood Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
.Department of Industrial Accidents
Office of Investigations
9 I Congress Street, Suite 100
Boston, MA 0211.4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Challenger Sports Corporation
Address: 8263 Flint St.
City/State/Zip: Lenexa, KS 66214 Phone #: 913-599-4884
Are you an employer? Check the appropriate box: I I Business Type (required):
1. ❑✓ I am a employer with 418 employees (full and/ I I S. ❑ Retail
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no emolovees, rNo workers' coma. insurance reo.l
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
ILEI Health Care
12.❑✓ Other Recreational Camps
*Any applicant that checks box 41 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 #l.
lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:Technology Insurance Company
Insurer's Address: 20 Trafalgar Square .
City/State/Zip: Nashua, NH 03063
Policy # or Self -ins. Lic. #TWC3601036 Expiration Date: 01/01/2018
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.
Ido hereby cerci , under the ' :d penalties ofperjury that the information provided above is true and correct
06/13/2017
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/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
www.mass.gov/dia
Phone
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:
V `Avha .A
OWNER/OPERATOR: \ OFF SEASON ADDRESS:
CAMP DIRECTOR:
DATE/TIME OF INSPECTION:
PHONE #:
TYPE OF CAMP: WATER SOURCE: INSPECTED BY:
Day Residential 10tilec)--
Sport / Non -Sport CAMPER CAPACITY:
Trip Primitive Travel t
"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 annlicable to this camn.
430 -Inspection Sheet 5-10-16.docx Page 1
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)
.300(A)(2)
Private water supply
(b)
BOH approval, chemical & bacterial analyses
<25eo le, <60da s/ )
.S.f1ND"'IC
M
m
Procedures for Background Review of
090( A)
Staff/Volunteers
Staff— CORI and SORI
.090(C)
— Previous Work History — 3 References —
t �\ c� V\
Out-of-state/International Criminal Background Checks
Volunteer Staff— CORI and SORI
.090(D)
— Previous Work History — 3 References —
\ v" \ \ C ^
Out-of-state/Intemational Criminal Background Checks
All Background Info - Received, reviewed, & made
.0900
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
(B)
Prohibitions: (1) Corporal Punishment, including spanking, is
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
X
.210(C)
Lost Camper Plan / Lost Swimmer Plan
.210(D)
Traffic Control Plan
430 -Inspection Sheet 5-10-16.docx Page 1
_E _
.211(A) Camper doesn't show up for day
.211(B)
Cam er doesn't show up at point of pick u
.211(C)
Child not registered arrives
-,.,
- PromottonalI iterature/G'enerOl'te_
urrement
-
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 or
check, health care, discipline policies and
application)
'evance rocedures upon reuest
Pi W
Daily Itinera - Copy to Parents
--
.212(A)
.212(B)
Source of Emergency Care
Contingency Plans (natural disasters, missing campers,
.212(C)
lost swimmers, illness and injury) shall Travel with
Campers & Staff
�� -
Wn
-
Vehicle must comply with MGLc.90 s7B&7D:
<14 passengers & driver is camp coach, director, etc. private
.250 vehicles may be used
>14 passengers, vehicle must be school bus
All vehicles must be RMV compliant
.253
Proper automobile insurance
.251(C)
Seatbelts must be worn
Camper <7yrs not transported longer than 1 hr to
.251(11) -
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 Direetoz•
- -
Residential Camp: 25 yrs, completed course mi
\,
.102(A)
cam administration or at least 2 seasons ex erience
j
Day Camp: 21 yrs, completed camp administration
.102(B)
course or 2 seasons ex erience
Primitive, Travel, Trip: 21 yrs & proof of
102(C)
experience.
gnafgd 5ubstttute
.102(D)
when director off-site >12 hrS. (Sub must meet cnteriaabove)
Counselors/Juniok,Counselors
=
.100
Day Camp, Non -Sport:
Counselor= 16 yrs. Junior Counselor- 15 yrs.
100
Other camps: Counselors= 18 yrs or graduated
from hi school. Junior Counselors- 16 yrs
��
.100
All counselors 3 yrs older than campers
430 -Inspection Sheet 5-10-16.docx Page 2
Residential /Day Camps:
.101(A) I staff per 10 kids over 6 yrs
I 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 severelv disabled campers
American Red Cross Lifeguard Tmg cert., CPR
.103 for Professional Rescuer & First Aid Cert. or their
equivalents.
if sunervisine 2+ staff must be 21v & experience w/ management
American Red Cross / Lifeguard Ting cert. / CPR
.103 for Professional Rescuer cert. & First Aid Cert, or
their eauivalents.
MD NP PA(w/pediatric training)
.159(A) *Check for Health Care Consultant Agreement*
Lincense #:
.159(C)
.159(B) Health Care olic
160(A) ALL Medications stored in Original Containers --
Meds stored in Secured Cabinet
.160(B) & if necessary refrigerated in box affixed in W -
First Aid Kit: non -perfumed soap, sterile gauze dx d' �evS
161(0) 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
Injury Reports completed for fatality or serious
.154
injury. Copy sent to MDPH.
Medication administered by Health Supervisor or
160(0)
Licensed Health Care Professional
.160(C)
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
X
First Aid Kit: non -perfumed soap, sterile gauze dx d' �evS
161(0) 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 -Inspection Sheet5-10-16.docx Page 4
Health Record for each Camper & Staff:
Staff/Camper > 18 yrs - Emergency Contact Info
150
Camper < 18 yrs must have Written Parental
Permission for Mods/Emergency Care
Campers and Staff under 18yrs:
Number of records checked:
MMR: l t dose = 12 mos or older,
Measles: 2"d dose = grades K-12 or age equiv
_
Polio: 3 doses 1PV or OPV, or
4 doses mix IPV/ OPV
Diphtheria and Tetanus Toxoids and
Pertussis*:
4 doses DTaP/DTP/DT or,
Cctr.'
.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 11-12 need booster if more than 10 yrs
since last dose of DTaP/DTP/DT/Td
Hop B: 3 doses if born on or after 1/1/92
Campers and Staff over 18yrs:
Number of records
Measles: 2 doses (exempt born before 1957)
checked:(
Mumps: 1 dose (exempt born before 1957)
Rubella: I 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.
t Q\C.
Swimming Pool: in 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
1 counselor per 10 campers
Plan to check swimmers- "buddy system"
.204(B)
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 Sheet5-10-16.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(11) 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 1
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
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 vards clearance behind each tareet.
.203 I Personal weapons, bows, rifles allowed w/camp
.103(G) 1 Certified Instructor per 10 campers
minimal 2 counselors)
.103(G) I 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 Sheet5-10-16.docx Page 6
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/
4'n 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.
Fire-retardant and non-toxic. No open flame
217
nearby.
't OTLETS/ST30RS
.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: I 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
AlUN
.162
Residential Camp: Laundry facilities provided
.472
Bedding and towels laundered; no common towels
430 -Inspection Sheet5-10-16.docx Page 6
^�.,,'�-..'�„`r^ ra��:
rte:'" --'r^ '' ✓` �r� a=ori*-�'�'^�'*^.,-y'' '" ';-.c-,. x
.., ztta�
-µ§��-"��„
./, � 'tea" ^� *'�:
.300
Potable water provided
Adequate and centralized drinking water facilities
.300/.304
- No common drinking cups
\h
Day / Residential Camps: Telephone readily
.209
available with #s of HCC, Local Hospitals, Police,
Fire, Ambulance
.213
Emergency Communication System/Procedure
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
10
M ��.���a._��i��N
`-
�.....:n, r�.
^'S 4-zs✓�"-F,. _.r='�''�. ;�.
;„�"`�?��^,:s���ryF-m�-�”`-.
,�.
Food service in compliance with 105 CMR
590.000, Minimum Standards for Food
.320
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)
Day camps —Each meal provided must meet 1/3
.332
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
i
without a bag lunch.
.452
Screening provided for food preparation and food
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