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HomeMy WebLinkAboutRBI Baseball Camp 7/5/2017i� 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.- PAUL RAPPOLI 97 GREEN STREET, SUITE 2 FOXBOROUGH MA 02035 Is hereby granted a RBI BASEBALL CAMP permit for: at OTIS 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 10, 2017 - JULY 14, 2017 JULY 17 - JULY 21, 2017 Hours of Operation: 9:00 AM - 2:30 PM Date Approved: ?'� BOARD OF HEALTH Nichae[NcCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for a License to Conduct a Recreational Camp for Children Applfcatron must be submitted at 11 least 14 (fourteen) business days prior to the start of camp Name of camp: RBI BASEBALL CAMP Type of camp: fol Day �.,] Residential Site address: OTIS STREET Site telephone: (508) 935-9533 Name of camp owner: PAUL RAPPOLI Office address: 97 GREEN STREET, SUITE 2 Owner's telephone: (508) 543-9595 Owner's email Name of camp operator: PATRICK BOEN Operator's address: 97 GREEN STREET FOXBOROUGH, MA 02035 Operator's telephone: (508) 339-3944 (508) 935-9533 Name of health care consultant: DR. DAVID CUNNINGHAM Address: 21 BRISTOL DRIVE, EASTON, MA 02356 Hours of operation: Date(s) of operation: -./ lr/W y 7 �� ` JUN 0 9 7017 ❑ Swimming pool Pool permit numbele Bathing beach ❑ Meals provided Food permit number: Telephone: (781)344-3555 - 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 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) f Disaster plan (105 CMR 430.210(8)) Copy of promotional literature (105 CMR 430.190 (C)) I:9 Lost camper plan (105 CMR 430.210(C)) Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) [_I Lost swimmer plan (105 CMR 430.210(C)) Health care policy (105 CMR 430.159(6)) 'C.:� Traffic control plan (105 CMR 430.210(D)) Discipline policy (105 CMR 430.191) L:.:1 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) 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) - j 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): __i Buildings, structures, fixtures, and facilities Proposed source of water supply Works for disposal or sewage and waste water Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Camp Director Name: PATRICK BOEN PBOEN@STONEHILL.EDU Age 49 Coursework in camping administration: Previous camp administration experience: 20+ YEARS AS DIRECTOR/CONSULTANT FOR SUMMER CAMPS Health Care Consultant Name: DR. DAVID CUNNINGHAM MA License Number: 218415 Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): MD Health Supervisor Name: PATRICK BOEN Age: 49 Type of Medical License Registration, or Training (See 105 CMR 430.159 C): CPR/FIRST AID Aquatics Director Name: Age: Lifeguard Certificate issued by: Expiration date: American Red Cross CPR Certificate: PATRICK BOEN Expiration date' 5/28/2017 Previous aquatics supervisory experience: Firearms Instructor Name: Date Certified: Horseback Riding Instructor Name: Stable Location: License in accordance with MGL Ch.111 s. 155, 158: American First Aid Certificate: Expiration date: National Rifle Association Instructor's Card (or equivalent): Expiration Date: License Number: Expiration Date: Yes No— CPR & Nursing Consultants 17 Alfred St Attleboro, MA 02703 www.FirstaidCPRconsultants.com Date: (Co To Whom It May Concern Your Employee % 9,9,4E /v n Heart Association's Heartsaver Adult First Aid and CPR ED course /� completed and todayassy.. The cAmerourse completion card should arrive in 10 to 14 days. Sin Ja es Connolly American Heart Association Instructor # 11102102192 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, 6?,19 920 i n ture of Individual or Corporate Name (Mandatory) B e Officer (Mandatory, if applicable) 0/36�6k)l *" Social Security Number (Voluntary) or Federal Identification Number This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803.0970 (800) 876-2765. 'NCCi NO 26158 POLICY NO. qWC-400-7029915.2016A PRIOR NO, AWC-400-7029915.2015A ITEM 1. The Insured Rappoli Baseball Inc DBA: Mailing address: 07 Green Street FEIN: *'•""6959 Foxboro, MA 02035 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 10/2312016 to _ 10/23/2017 12:01 a.m. standard time at the Insured's mailing address. 3. 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 S.A. The limits of liability under Pan Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000;000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 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. Classifications Premium Basis Rates Code Estimated Per $100 Estimated No. Total Annual or Annual Remuneration Remuneration Premium I I INTRA 0341953 INTER SEE CLASS CODE SCHEDU E I Minimum Premium $324 Total Estimated Annual Premium $3,563 GOV r TGeV — Deposit Premium $3,733 I . ISTATE,CLASS MA ! 9016 State Assessments/Surcharges ($$33,031.00 x 5.6000% $170 This policy; including all endorsements, Is hereby countersigned by k _ 09/26/2016_ Authorized Signature Date Service Office: Shenkel Insurance Agency Inc 54 Third Avenue 1017 Turnpike St. 412B Burlington MA 01803 Canton, MA 02021 WC 00 00 01 A (7.11) Included copyrighted material of the National Council on Compensation Insurance, used with its: permission. Minimum Premium $324 Total Estimated Annual Premium $3,563 GOV r TGeV — Deposit Premium $3,733 I . ISTATE,CLASS MA ! 9016 State Assessments/Surcharges ($$33,031.00 x 5.6000% $170 This policy; including all endorsements, Is hereby countersigned by k _ 09/26/2016_ Authorized Signature Date Service Office: Shenkel Insurance Agency Inc 54 Third Avenue 1017 Turnpike St. 412B Burlington MA 01803 Canton, MA 02021 WC 00 00 01 A (7.11) Included copyrighted material of the National Council on Compensation Insurance, used with its: permission. A.I.M. Mutual Insurance Company Insured: 7029915 Rappoli Baseball Inc Producer: 00729.001-001 97 Green Street - Shenkelinsurance Agency Inc Foxboro, MA 02035 1017 Turnpike St. #12B Canton, MA 02021: Insured FEIN: * =***6959 Issue Date: 09/26/2016 Policy Number: AWC-400-7029915-2016A Endorsement Effective Date: 10/23/2016 Policy Period: 10/23/2016-10/23/2017 Endorsement Number: LOCATION SCHEDULE Insured Unit 001 Workplace: 001 Business Type; Corporation Insured Unit: 001 Workplace: 002 Rappoli Baseball Inc Business Type: Corporation 97 Green Street Rappoli Baseball Inc 160 North Main Street Foxboro MA 02035 Carver; MA 02330 TAX ID: 200136959 TAX ID: 200136959 Business Type: Business Type: Business Type: Business Type: Business Type; Business Type: Business Type: Business Types Business Type; Business Type; Insured (11/11) LocationSch ': Iamancap information. iliatis providing ivorkers' compensation insurance for my employees. Below is the paltry and job site Insurance Company Name: /� //Y) Policy # or Self -ins. Lie, #: /7 °J' y� %OU/'� iYCTo�� /� ExptionDate: /f Job site Address: 14 iNG y o 0 ?Ol G!° City/State/Zip:_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of investigations of the IIIA for insurance Cert((y�nder e rzs aHd penallies afperjary that the informallon provided above is trite and correct. 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact The Commonwealth of Massachusetts Depurtment of lndustrialAccidents I Congress Street, Suite 100 ww'orkers' Boston, MA 02114-2017 wwwmass.gov/dia Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO DE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Name (Business/Organizationnndividual):_ /�16 1 13z7JC Liy// A Please Print Leetbiv �y CC�CIIrn t/ Address: 7 r) r c r.✓ d 14?LZ fu. Cit /State/Zi Y P; %aJl�w 1 '�2aJ-Phone #; S S/ Are you an employer? Check the appropriate box: IM I am a employer with 0 employees (full and/or part -time). - Type of project (required): 2,❑Iain a sole proprietor or partnership and have no employees working formem any capacity. [No workers' 7. Q New construction g• ❑ Remodeling comp: insurance required.] 3.❑I am a homeowner doing all workmyself.[Noworkers'comp, t 9• Demolition insurance required.) 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers' compensation insurance or aresole proprietors with nonemployees. Il.❑ Electrical repairs or additions 5 C] I am a general contractor and I have hired the sub -contractors listed on the attached sheet, 12. ❑ Plumbing repairs or additions These sub-contmetors have employees and have workers' comp. insurance.t ' 13.[—_] RR000f repairs 6.❑ We area corporation and its officers have exercised their right of exemption per MGL C. 14, mother 152, §1(4), and we have no employe". [No workers' comp. insurance required.] Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors "lust submit a new affidavit indicating such. 'amractors that check this box most attached an additional sheet showing the name of the sub -contractors and slate nployees. If the sub•connaetorshave employees, they must provide their workers' comp. policy number. whether or not those cmities have Iamancap information. iliatis providing ivorkers' compensation insurance for my employees. Below is the paltry and job site Insurance Company Name: /� //Y) Policy # or Self -ins. Lie, #: /7 °J' y� %OU/'� iYCTo�� /� ExptionDate: /f Job site Address: 14 iNG y o 0 ?Ol G!° City/State/Zip:_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of investigations of the IIIA for insurance Cert((y�nder e rzs aHd penallies afperjary that the informallon provided above is trite and correct. 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727.4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with:' A.W. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O; Box 4070 Burlington, MA 01803.0970 ADDRESS OF INSURANCE COMPANY AWC-400-7029915.2016A 10/23/2016 - 10/23/2017 POLICY NUMBER EFFECTIVE DATES 1017 Turnpike St. #12B Shenkel Insurance Agency Inc Canton, MA 02021 (781)871-6050 NAME OF INSURANCE AGENT ADDRESS PHONE Rappoli Baseball Inc 160 North Main Street Carver, MA 02330 EMPLOYER ADDRESS 09/26/2016 DATE MEDICAL TREATMENT The above named Insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injurymust be given to the. injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by: the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER' ,L (EES I NOTICE I TO EMPLOYEES -- --- — -- -- ; I'd -'s _ J 'M T , DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC-400-7029915-2016A 10/23/2016 -10/23/2017 POLICY NUMBER EFFECTIVE DATES 1017 Turnpike St. #12B Shenkeilnsurance Agency Inc Canton, MA 02021 (781)871.5050 NAME OF INSURANCE AGENT ADDRESS PHONE Rappoli Baseball Inc97 Green Street Foxboro MA 02035 EMPLOYER ADDRESS 09/26/2016 DATE MEDICAL TREATMENT reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAI3EST'AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER; ACCO, Ra® CERTIFICATE OF LIABILITY INSURANCE CATE(NM/D6%/)17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(los) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on thi s certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). PRODUCER Shenkel Insurance Agency, Inc. 1017 Turnpike Street Suite 1-2B Canton, MA 02021 CONTACT NAME: PHONE781 575-9111 FAX IAJC.Re: (781) 401-9995 EMAIL ADDRESS: INSURE 3 AFFORDING COVERAGE NAIC If INSURERA:US FIRE INSURANCE EACH OCCURRENCE $ 1._ QOQ,,_Q_O0 INSURED _ INSURERB:A.I.M. INSURANCE GROUP PERSONALBADVINJURY $ 1,000,000 INSURER c:ARBELLA PROTECTION _ Rappoli Baseball, Inc. 97 Green Street INSURERD:US FIRE INSRUANCE C Foxboro, MA 02035 INSURER E: INSURER F: 12/4/16 - 12/4/17 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSIR LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF M/OD/Y POLICY EXP MMDDIYYYY UMTS A GENERALLMRRITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X Athletic Participan Steven M. Shenkel SRPGPM-101-0716 11/15/16 11/15/17 EACH OCCURRENCE $ 1._ QOQ,,_Q_O0 DAMAGE TO RENTED $ 300 ,000 _ 36EMLSES_(Ea WDEXP(Anyompasoa) $ 5,000 PERSONALBADVINJURY $ 1,000,000 coverage included__ AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIESPER PDucv PRO, CT X LOC _GENERAL PRODUCE-COMPIOP AGO $ 2,000,000 Abuse-Molestat $ 100,000 C AUTOMOBILE LIAMUTY ANYAUTO ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS 46255400003 12/4/16 - 12/4/17 COMBINED SINGLE LIMIT arrmidem $ 1,000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ _ PROPERLY DAMAGE Peramideno $ $ A X UNBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE USX102502 11/15/16 11/15/17 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED RETENTION $ $ H WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTNE OFFICER?AEMBER EXCLUDED? (Mandamry In NH) Dyes, describe under DE SCRIPTIONCFOPERATIONS below N/A AWC400-7029915-2016 10/23/16 10/23/17 X WCSTATU- OTH- Mu FR--- EL.EACH ACq CEM $ 1,000,000 E.L. DISEASE-EAEMPLOYEE $ 1 000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 D Accident Medical US504869 11/15/16 11/15/17 Accident Med 25,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Romfics Schedule, if more space Is regU red) Certificate Holder is added as additional insured with respect to liability arising out of operations of the named insured CERTIFICATE HOLDER CANCELLATION © 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@shenkel,com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Otis Street Complex ACCORDANCE WITH THE POLICY PROVISIONS. 250 Otis Street AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Steven M. Shenkel © 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@shenkel,com Department of Public Health - Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS I LII �M NAME OF CAMP: r CAMP DIRECTOR: c�.Lk_ �jFr�v\ PHONE#: — �1-3�rktwv\ � \�5-`"iS3� TYPE MP: ATER SOURCE: ( Day esidential I UIVILK 4.3U.nlln ADDRESS: '�X;ay - O(F�FF SEASON ADDRESS: DATE/TIME OF INSPECTED BY: I Lo%v r' �m "Nn" column = ✓ marked below indicates a "Yes" column = ✓ marked below indicates compliance with provision of 430.000. 44M/A"-1...." _ ✓ mnArad helnm iMirarec that the nrnvisinn n1`410 000 i.c not annlicahle to this canon. 430 -Inspection Sheet5-10-16.doex Page I Current Certificate(s) of Occupancy from rs$ .451 local building inspector for sleepinglassembly areas .215 Written compliance from local fire dept. w\ .300(A)(2) Private water supply (a) DEP approval (>25 people, >60 days/yr) Private water supply .300(A)(2) BOH approval, chemical & bacterial analyses (b) <25 people, <60da s/ r Procedures for Background Review of .090(A) Staff/Volunteers Staff— CORI and SORI .090(C) —Previous Work History -3 References— Out-of-state/International Crhuinal Background Checks Volunteer Staff— CORI and SORI .090(D) —Previous WorkHistoty— 3 References— X Out-of-state/International Criminal Background Checks All Background Info - Received, reviewed, & made y 090(I� 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 (�) prohibited; (2) No camper shall be subjected to cruel or severe punishment, humiliation, or verbal abuse; (3) No camper shall be >� (C) denied food or shelter as a form of punishment; (4) No child shall be unshed for soiling, wetting or not using the toilet .210(A) Fire Evacuation Plan and Drills .210(B) Disaster Plan .210(C) Lost Cam er Plan / Lost Swimmer Plan .210(p) Traffic Control Plan 430 -Inspection Sheet5-10-16.doex Page I CONTINGENCY PLANS - DAY CAMP: .211(A) Camper doesn't show up for day .211(13) 1 Camper doesn't show up at point of pick ti .211(C) I Child not registered arrives Promotional Literature/General Re uirement Copy of Policy (Parents/Staff): Care of Mildly ill .159(B)(2) Campers, Administration of Meds & Emergency Health Care Provision .190(B) Camper released only to Parents or Parent- arent-Desi Designated nated Individual in writing Statement: Regulatory Compliance & Licensing v ov. .190(C) "This camp must comply with regs ofthe MDPH & be licensed by theLBOH" .190(D) Inform parents of right to review background tv rev-l4,- r - (at time of check, health care, discipline policies and �( application) grievance procedures upon request l� CONTINGENCY PLANS - PRI RT[VE, TRAVEL AND TRIP: .212(A) Daily Itiner - Copy to Parents .212(11) Source of Emergency Care Contingency Plans (natural disasters, missing campers, .212(C) lost swimmers, illness and injury) shall Travel with Campers & Staff TRANSPORTATION 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 .251(11) Camper <7yrs not transported longer than 1 hr to cam Camp vehicle drivers: 18yrs, 2yrs driving experience, .252 current license for type of vehicle First Aid certified if no other pained staff aboard. STAFF UALIFICATIONS Camp Director: ' .102(A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience .102(B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience .102(C) Primitive, Travel, Trip: 21 yrs & proof of experience. .102(D) Designated Substitute; when director off-site > 121us. (sub most meet enteria above) Connselors/Junior Counselors .100 Day Camp, Non -Sport: Counselor= 16 yrs. Junior Counselor -15 yrs. .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counselors= 16 yrs .100 All counselors 3 yrs older than campers 430 -Inspection Sheet 5-10-16.doex Page Required Counselor Ratios MEN= MEMMEAME Masawss Residential / Day Camps: .101(A) I staff per 10 kids over 6 yrs I staff per 5 campers 6 yrs and under Primitive,Travel, Trip: 0 I I B) 1 counselor per 10 campers. 2 counselor min. Special Needs: .101(C) I counselor per 4 mildly disabled campers I counselor per 2 severely disabled campers w Ct e 'pr: American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer & First Aid Cert. or their .103 equivalents. if supervisina 2+ staff, inust L� 21Xm&aerie=Nv/Inma9eIIieIn American Red Cross / Lifeguard Trng cert. / CPR .103 for Professional Rescuer cert. & First Aid Cert. or their e uivalents. M MIN M NT PA(w/pediatric training) .159(A) *Cliecl-ror Health Care Consultant Agreement* Lincense "I I Itu—NIS-4 WOMEN Ilk MD PA LPN or... NP �- .159(C) C8yrs, Eirst Aid & CE .159(B) Health Care Polig 2X .160(A) ALL Medications stored in Original Containers *V\C" S Meds stored in Secured Cabinet .160(B) & if necessary refrigerated in box affixed in reftigerator (if no secondary lock) Injury Reports completed for fatality or serious .154 iniurv. Coov sent to MDPH. Medication administered by Health Supervisor or 160(C) Licensed Health Care Professional Written list of a I meds administered at camp .160(C) if H.S. not a L.H.. . P. auth'd to admin Rx, meds) .160(B) Reftigerator temperature 38 to 42uF Medical Lou Book .155 bound, pre -numbered pages, ink entries, no skipped lines. Day / Residential Camps - Infirmary provided .161(A) Residential Camp - Exterior light .453 Lighting provided in infirmary .161(B) Residential Camp - Area for isolation of ill child Mrst Aid Kit: non -perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage .161(C) scissors, triangular and rolled bandages, CPR mask� tweezers, cold pack, gloves. I I 430 -Inspection Sheet 5-10-16,docx Page 3 430 -Inspection Sheet 5-10-16.doex 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 Meds/Emergency Care Campers and Staff render 18vrs: Number of records checked: MMR: V dose = 12 mos or older, Measles: 2"d 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 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 IBvrs: Number of records Measles: 2 doses (exempt born before 1957) checked: Mumps: 1 dose (exempt born before 1957) .152(B) Rubella: 1 dose 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" .432 Bathing Beach: in compliance with 105 CMR 445.00 - weekly water sampling conducted, Proper supervision at swimming venue: .103 1 lifeguard per 25 campers I counselor per 10 campers Plan to check swimtners- "buddy system" .204(B) Swim test to classify swimmers by ability. .204(A) Swimming areas clean and safe, no swimming at undesignated sites or at night without lighting. .204(E) Piers and floats in good repair. 430 -Inspection Sheet 5-10-16.doex Page 4 r 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(13) 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 y TT .205 taken. n PIA G �%lal li Ai I 1 a' LO f Equipment properly maintained, fields/surfaces 206 free of holes/accident hazards Playground equipment secure, no concrete .206 under/around it, pliable swing seats. FIREARMS aures/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 anies/Certs: .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. Personal weapons, bows, rifles allowed w/camp 203 operator's written ermission _Names/Certs: 1 Certified Inshuctor per 10 campers .103(G) minimal 2 counselors .103(G) Riders must wear hard hat .103(G) Licensed stable ' • , CA�S7S'T1LU�`TUI2T..S� � ` _ :: <,.., Day Camp provides shelter for on-going camp .457 activities .216 Residential - Smoke detectors provided .456 Adequate egresses flee from obstruction .453 Lighting provided for stairways .454 Floors maintained. 430 -Inspection Sheet 5-10-16.docx Page 5 RESIDENTIAL CAMPS/SLEEPING AREAS Provide adequate space: .458 40sgft /person in single bed; 35sgft/person in 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/ 41/2 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 .217 nearby. TOILETS/SHOWERS .360 Proper sewage disposal x .301 Plumbing in good working order Adequate # of toilets: clsw ` 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. .373 Adequate # of sinks: Day / Residential Camp: 1 per every 30 people .374 Adequate # of showers: Residential Camp: 1 shower/tub per 20 people 378/.380 Special needs campers provided facilities that meet their needs .453 Lighting provided .375 Toilets and Shower rooms ventilated to outdoors .376 Hot water at sinks, showers/tubs not more than 112°F 377 Sanitary facilities maintained in clean condition 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 .300 Potable water provided Adequate and centralized drinking water facilities .300/.304 - No corm -non drinking cups Day/ Residential Cainps: Telephone readily .209 available with #s of HCC, Local Hospitals, Police, -- nn nn t 4� pw Fire, Ambulance .213 Emergency Communication System/Procedure 165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 Proper storage and disposal of solid waste .207 I Proper storage and operation of power equipment I I I V .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control .401 Weed and noxious plant control .450 Site location does not cause undue traffic hazards and is accessible at all times ie Food service in compliance with 105 CMR .320 590.000, Minimum Standards for Food Establishments. Permit posted in food service facility. .330 Nutritious meals that include a variety of foods 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. .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.doex Page 7 430-Inspection Sheet 5-10-16.docx Page 8