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HomeMy WebLinkAboutMansfield Summer Camp 6/21/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Operate a Recreational Camp l This is to certify that: TOWN OF MANSFIELD -RECREATION DEPARTMENT . 'dCX ►• 1 MANSFIELD MA 02048 Is hereby granted a TOWN OF MANSFIELD- SUMMER CAMP permit for: at 111 HOPE STREET- MEMORIAL PARK 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 25, 2018 -AUGUST 24, 2018 Hours of Operation: 8:00 AM to 4:00 PM Date Approved. BOARD OF HEALTH MichaeCMcCCean, Chairman Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Application for a License to Conduct a Recreational Camp for Children [_ - Application must be submitted at least 90 (ninety) days__prior to the start of camp. Name of camp: TOWN OF MANSFIELD- SUMMER CAMP Type of camp: ❑./ Day ❑ Residential Site address: 111 HOPE STREET - MEMORIAL PARK Site telephone: (508) 261-7383 Name of camp owner: TOWN OF MANSFIELD -RECREATION DEPARTMENT Office address: SIX PARK ROW Owner's telephone: (508) 851-6458 Owner's email A 02t 1�CIh�Y(illb Name of camp operator: 09FFR{WESVEP}ft, CAMP DIRECTOR Operator's address: 111 HOPE STREET, MANSFIELD, MA 02048 Operator's telephone: (508) 261-7383 TOWN HALL(508) 851-6458 Operator's email. S9UYn6n 0 M0r,5jlgd#)& ,111» # volunteers: ID # staff: If campers: 8 Date: Fee: $150.00 Signature of Applicant: Official Title: Hours of operation: 8:00 AM to 4:00 PM Dates) of operation: J 25 • hool 24 ❑ Swimming pool Pool permit number N/A ❑ Bathing beach W Meals provided Food permit number: FS -93 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. PLEASE NOTE THERE ARE NEW REGULATIONS AS OF MARCH 2018. Staff information form (see attached) Procedures for the background review of staff (105 CMR 430.090) ❑ Disaster plan (105 CMR 430.210(8)) 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) ❑ 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) 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 x,❑ Works for disposal or sewage and waste water Town of Town of Mansfield - Board of Health 6 Pak ROMvansfield Mansfield, MA 02048 Camp Director Alan WollywIt, Name: �, CAMP DIRECTOR Coursework in camping administration: NONE Previous camp administration experience: SEE APPLICATION Director email: Health Care Consultant Name: DR. JOHN SHAVER Type of Medical License (430.159(A)): GP Address: 20000PELAND DRIVE, MANSFIELD, MA 02048 Age: -03 G - MA License Number: 37294 Health Care Consultant Phone number: (508) 339-4144 Health Care Consultant email ❑ Health Care Consultant signed Agreement - Please use DPH issued form located at https://www.mass.gov/lists/recreational-camps-for- ch ild ren -community -sanitation Health Care Supervisor Name: G"RRtttlf MENA Na Age Type of Medical License Registration, or Training (See 105 CMR 430.159 C): FIRSTAID AND CPR CERTIFIED AND EPI -PEN CPR/First Aid expiration dates, if applicable: 'I;: ❑ Appropriate training documentation for Health Care Supervisor by Health Care Consultant Aquatics Director , I Name:R Age: �+AtF�-- ..... - — ..... Previous aquatics supup rvisory experience: Lifeguard Certificate issued by: American Red Cross CPR Certificate: Expiration date: American First Aid Certificate: Expiration date: Firearms Instructor Name: R _ _ _-. __..........__ ___.........__._- Date Certified: Horseback Riding Instructor Name: 91 A Stable Location: ❑ License in accordance with MGL Ch.111 s. 155, 158: Expiration date: National Rifle Association Instructor's Card (or equivalent): Expiration Date: License Number: Expiration Date: PLEASE NOTE: MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV - 105 CMR 430.000 have changed as of March 2018. There is additional documentation necessary. Please see the DPH Community Sanitation website for applications, forms, and guidelines. https://www.mass.govilists/recreational-camps-for-children-community-sanitation. Additionally, the website provides a Recreational Camp Operator Checklist PLEASE ATTACH: The names, ages, applicable current certifications (if any), such as First Aid, and the anticipated role at the camp of all staff. Use as many pages as necessary to complete this. Staff and Volunteer Orientation Attendance records and completion of Concussion Awareness Training documentation is required for all counselors, junior counselors and other staff and volunteer. A current medical history and a certificate of immunization is required for all campers and full time staff person. Town of Mansfield, Board of Health APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name: Town of Mansfield — Summer Camp — Memorial Park. Site Address: 111 Hope Street, Mansfield, MA 02048 Site Phone: 508-261-7383 Name of Camp Owner: Town of Mansfield — Recreation Department Operator Office Address: Six Park Row, Mansfield, MA 02048 Telephone number: 508.851.6458 Name of Camp Operator: Alan Weintraub, Summer Camp Director Address: 111 Hope Street, Mansfield Telephone number: 508.261.7383, Town Hall: 508.851.6458 Type of Camp: Day Hours of Operation: 8:OOam to 4:OOpm Dates of Operation: Opening: June 25, 2018; Closing: August 24, 2018 Swimming Pool: No Bathing Beach: No Meals Provided: Yes Food Permit Number: Signature of Applicant: Official Title: Sherri H. Gurnon, Director Parks and Recreation Continued: DEPARTMENT OF PUBLIC HEALTH — COMMUNITY SANITATION PROGRAM 105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN STATE SANITARY CODE, CHAPTER IV "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. °rr.rr�.,✓.%^"..% , EM s �t -9, '°. X 7 _-' RE �. OWNER/OPERATOR: liDtR OFF SEASONIADDRESS: ', DIRE, CTOR: DATE/TITVIE, OF INSPECTION: • ' OF CAMP: lI .. 1Sport — Non -Sport — Medical Specialty XE I . ,� i CAMPER CA,-ACffV- "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. 430 -Camp Inspection Form 3-27-18 Page I 451 Current Certificate(s) of Inspection from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2) Private water supply: (a) DEP approval (>25 people, >60 days/yr) ✓ Private water supply: (<25 people OR <60days/yr) 300(A)(2) BOH approval, chemical & bacterial analyses, no more ✓ (b) than 45 days prior too enin ',, CAMP Y'OI�TC7ES „ WRiT,N _ , Procedures for Background Review of .090(A) Staff and Volunteers. Staff — CORI and SORT .090(C) Previous Work History (5yrs)-3 Positive Reference Checks Out-of-state/International Criminal Background Checks Volunteer Staff— CORI and SORT .090(D) Previous WorkNolunteer History (5yrs) 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: Orientation Plan & .159(B)(1) Attendance Records, Training on Disaster/Emergency .210 Plans, Health Care Policies, & Concussion Awareness Abuse & Neglect Prevention Policies & Procedures .093 Report procedures in accordance w/ M.G.L. c. 119, § 51 A /r Written notification to MDPH and BOH. Discipline Policy: Appropriate Discipline Methods & Prohibitions: (1) Corporal Punishment, including spanking, is prohibited; (2) No camper shall be .191 subjected to cruel or severe punishment, humiliation, or verbal abuse; (3) No camper shall be denied food, water, or shelter; (4) No child shall be punished for soiling, wetting or not using the toilet 430 -Camp Inspection Form 3-27-18 Page I CAMP PLANS-I+RITT N .210(A) Fire Evacuation Plan and Drills .210(B) Disaster/Emergency Plan .210(C) Lost Camper Plan / Lost Swimmer Plan .210(D) Traffic Control Plan SPECIAL CONTINGENCY PL S =DAY CAMP .211(A) Camper doesn't show up for day. .211(B) Cam er doesn't show Lip at point of pick up. .211(0) Child not registered arrives. Promotional Literature/General Re uirementl Copy of Policy (Parents/Guardians): Care of .159(B)(2) Mildly III Campers, Administration of Meds & Emergency Health Care Provision. .157(C) Meningococcal Disease & Immunization info provided to parents/ ardians annually. .190(B) Camper released only to Parents/Guardians or/ Designated Individual with written authorization. Regulatory Compliance & Licensing Statement: .190(C) "This camp must comply with regulations of the MDPH & be licensed b the LBOH." .190(D) Inform parents of right to review background (at time or check, health care, discipline policies and grievance npplicetion) procedures upon re uest.. .190(1;) Protocol in place to handle unrecognized persons at camp. FIELD TRIPS .212(A) Written itinerary provided to parents/guardians before departure. 212(B) Source of emergency care identified; minimum 1 health care supervisor accompanying trip. Health records easily accessible for all .212(0) campers/staff, medications stored securely and accessible only by HCS. Fist aid kit present. .212(D) Written contingency plans brought on all field trips: (natural disasters, lost camper/swimmer, injuries and illnesses) TRANSPORTATION Vehicle must comply with M.G.L. c. 90 §§ 7B & 713:- <14 passengers & driver is camp coach, director, etc. .250 camp vehicles may be used >14 passengers, vehicle must be school bus All vehicles RMV compliant w/ annual safety ins .253 Proper automobile insurance. .251(0) Seatbelts must be worn. _ Qv C', �Lc. 1 staff person required when transporting: .251(D)(E) Campers to the pick-up/drop-off site; or 8+ campers under 5 yrs. of age; or 2+ campers with physical handicaps. .251(1) Camper under 7 yrs. are not transported longer than 1 hour non-stop. Camp vehicle drivers: 18 yrs.+, 2yrs. driving .252 experience, current license for type of vehicle. First Aid certified if no other trained staff aboard. 430 -Camp Inspection Form 3-27-18 Page 2 °r'-r'sr " :"'�.%�. ✓l r .fr '" t,�,�L��'�.-.. �.E�.tl)i,��[,�1.���,rr r '" %^ _ '+ * rte. �: Camp Director: Residential: 25 yrs +, successful completion of Camp 102(A) Administration Course or 2+ seasons experience. Day: 21 yrs.+, successful completion of Camp / .102(B) Administration Course or 2+ seasons experience. Primitive, Travel, Trip: 25 yrs.+ and proof of .102(C) experience. Designated Substitute: .102(D) Substitute must meet above criteria. Counselors/Junior lCounselors: Day Camp, Non-Sport: .100(C)(2) Counselor = 16 yrs .+ Junior Counselor =15 yrs.+ .100(A) 4+ weeks experience & attend orientation and training Residential, Primitive, Sport, Travel, Trip, Medical: .100(C)(1) Counselors = 18 yrs.+ or graduated from high school .100(A) Junior Counselors = 16 yrs.+ 4+ weeks ex erience & attend orientation and training 100(0)(3) All counselors 3 am s. older than cers. ✓ Required Counselor Ratios: Residential / Day / Sports Camps: .101(A) I counselor per 10 campers 7 yrs. or above y' I counselor per 5 cam ers under 7 yrs. Primitive/Outpost, Travel, Trip Camps: .101(B) I counselor per 10 campers - 1 counselor at least 21 yrs. .159(C) 2 counselor minimum with 1 counselor having First Aid Certificate or its equivalent All Camps: .101(A&B) Staffing plan to supervise campers w/ disabilities p / .103 d6uring( regular and specialized high risk activities. }:c.,,. .020 Lifeguard certification, 21 yrs.+, 6 weeks previous .103(A) experience in similar supervisory position. � sx1`d 1 71 At least 16 years old with [American Red Cross .020 Lifeguard Training Cert/Royal Bronze Medallion/Boy Scouts Lifeguard Cert/YMCA Lifeguard Cert]* AND 103 A O CPR AND First Aid Certificate* *Or their equivalent 010I WIN-0111 M-1101 0100111 "NOW WIN MD/DO NP PA (with documented pediatric training) .159(A) *Check for Health Care Consultant Agreement* License #: Develop written orders to be followed by HCS, .159(A)(6) including responsibilities for medication o administration Develop a written list of all medication Q N4�� .160(0) administered at camp HCC Provided & Documented Trainings: .160 HCS required hainings, signs of hypo/hyperglycemia, (1;)(G)(Ii) diabetic plan management, and administering epi-pen with evidence of competency 430 -Camp Inspection Form 3-27-18 Page 3 Ago MD %rsr--Rr_t 59(C)(E) C�r—s.+, Firsyrrst Aid &CPR certified .159(B) Camp Health Care Policy .160 ALL Medications stored in Original Containers (A)(1) and meds properly disposed of with disposal log. .160(B) Meds stored in secured manner (ACA standards) Medication refiigerator temp 36°F - 46°F Written Medication Administration Policy: .160 Medication administered by HCC authorized staff only; (C)(D) oral/topical medication administration training; and epi -pen and insulin use. .163 Sunscreen polic with arent/guardian sign off. .155 Medical Log: .154 Injury Report completed for a fatality or serious injury. Copy sent to MDPH and BOH. V Day / Residential Camps - Infirmary provided / .161(A) Residential Camps - Easily recognizable and J accessible during the da and ni ht. .453 Lighting provided in infirmary. 161(B) Residential Camp - Area for isolation of ill child with ability to provide negative pressure. .161(C) First Aid Kit: meet ANSI Z308.1-2015 standards ✓ Minimum: 1 Class B kit and 1 Class A kit .140 & Medical/Biological waste managed in accordance .160(1) I with 105 CMR 480.000. Health Record for each Camper & Staff: .150 Staff/Camper < 18 yrs: Emergency Contact Info, .160(D) Written Parental Permission for Meds, Emergency Care, .190(A) and Self -Administration of epi -pen or insulin .151(A)(B) I physical within past 18 Dav—Medical hktnro .152 Campers and Staff over 18vrs: .152 1 .153 1 Exemption Documentation Parent/Guardian 6±1 Num ,ber of records `\1-3 Number ofrecr /- \C' 430 -Camp Inspection Form 3-27-18 Page 4 430 -Camp Inspection Form 3-27-18 Page 5 EMEMEM Activities and physical environment meet the needs .190(A) of campers; do not pose hazard to health/safety. ". Swimming Pool: in compliance with .430 105 CMR 435.000 - Permit Posted Compliant w/ VGB Act & Pool Fence Requirements Bathing Beach: in compliance with 105 CMR .432 445.000 - weekly water sampling, water clarity, and ring buoy present .204(C) All camps in compliance with 105 CMR 432.000 ✓ Sin\c% ail UrC Christian's Law M.G.L. c. 111 § 127A %2 c.c�y2.cer7 UOQ .204(C) Swim test to classify swimmers by ability at pools .430(B) and beaches (Christian's Law). Proper supervision at swimming venue: .103 1 lifeguard per 25 campers .204(D) 1 counselor per 10 campers Plan to check swimmers - "buddy system" 50+ kids in/near water Aquatics Director must be present Swimming areas clean and safe, no swimming at .204 undesignated sites or at night without lighting. .204(F) Piers, floats, and platforms in good repair. ._ v_. ,, �ItIt , r Watercraft: equipped with USCG approved ,204 .204(F!) flotation devices and worn b all campers and staff (4) engaging in watercraft activities.(paddle boards included) White water, hazardous saltifresh water activities: .204(1) Campers certified with ARC Level 4+ Certificate or equivalent. White water, hazardous salt/fresh water activities: .103(B) Minimum 2 counselors in separate watercrafts IV 1 counselor per 10 campers (counselor must have lifeguard or small craft safety and basic water rescue cert, orequivalent ) CRAFTS: .205 Equipment in good repair, safety precautions taken. .206 Equipment properly maintained, fields/surfaces (A)(B) free of holes/accident hazards. Playground equipment securely anchored with no .206(C) concrete under/around it, and pliable swing seats. ARCHERY'Names/Certs: .202(A) Equipment in good condition, stored locked. n y Range away from other activity areas, clearly .202(B) marked danger area with 25 yards clearance behind each target. Common firing & ready line in place. Personal weapons allowed with camp operator's .203. written permission. .103(E) 1 counselor per 10 campers at range at all times. 430 -Camp Inspection Form 3-27-18 Page 5 430 -Camp Inspection Form 3-27-18 Page 6 mum Names/Certs: Firearms in good condition, stored in locked .201(A) cabinet. Ammunition locked in separate cabinet. .201(B) Shooting range away from other activity areas. Only non -large capacity, single shot rifles .201(C) permitted. .201(D) Firing line in place, no crossing without instructor's .201(E) permission. Direct Supervisor: NRA Instructor's certification .103(D) and maintain compliance with applicable M.G.L.'s 1 counselor er 10 cam ers f 1T,_-125eID71(> F, amen/Certs: Excursions: 1 Certified Instructor per 10 campers .103(E) .208(A) Minimum 2 counselors present during excursions �r1 In accordance with M.G.L. c. 128, § 2A .208(A) Riders must wear hard hat at all times. .208(B) Licensed stable in use. CIRC LEI�TGE COI7S'S Al�iD CLINIBINtr WALI SS ,' `' Operator: .103(G)(1) Licensed and maintained in accordance with nI 520 CMR 5.00 — Amusement Devices .103(G)(2) Annual inspection with written report .103(G)(3) 1 counselor per 10 campers at all times CABINS & STRUCTURES Day Camp provides shelter for on-going camp .457 activities with certificate of inspection. Residential - Smoke and carbon monoxide .216 detectors provided. .456 Adequate egresses free from obstruction (780 CMR). .453 Lighting provided for stairways. All structural and interior elements maintained in .454 good repair and in a safe and sanitary condition. SLEEPING AREAS - RESIDENTIAL CAMPS Provide adequate space: Single bed: 40fl /person; ^h .458 Bunk bed: 3511?/Person; 501f/person requhing special equipment Provide separate bed/cot per person with: .470 6 ft. between individuals heads; and 3 ft. between single beds & 4 `/2 ft. between bunks Campers and staff with limited mobility housed on .459 ground level; egresses leading to grade or ramp provided. Screens & screen doors provided. All doors .452 equipped with a self-closing device. All structural and interior elements maintained in .454 good repair and in a safe and sanitary condition. TENTS Clearly labeled as fire resistant. No open flame in 217 or near tent. 430 -Camp Inspection Form 3-27-18 Page 6 TOH.ETS/HANDWASH SINKS/SHOWERS .360 Proper sewage disposal. .301 Plumbing maintained in good working order. Adequate # of toilets: All Camps: Min. 2 toilets/privy seats for each gender .370 Day Camp: >60 of one gender, provide 1 more toilet for each additional 30 persons of that gender. Residential: >20 of one gender, provide I more toilet for each additional 10 persons of that gender. Toilets less than 200 feet from sleeping rooms. Toilet paper provided. 372 Windows/ openings screened. Screen doors self- closing. Adequate # of sinks in compliance w/ 248 CMR: .373 Day Camp: I sink per every 30 people Residential Camp: 1 sink per every 10 people Adequate # of showers (no duckboards): .374 Residential Camp: l shower/tub per 20 people Campers with special needs provided sanitary .378-.380 facilities meeting their needs. .453 Lighting provided. Adequate ventilation provided for all bathhouses, .375 dressing rooms, shower rooms, and toilets for indoor/outdoor pools. Hot Water in sufficient quantity and pressure: .376 Handwash Sink: 110°F - 130°F Shower/Bathtub: 100°F - 112°F .374(B) Sanitary facilities maintained in clean condition. .377 Shower room floors washed daily. LAUNDRY .162 Residential Camp: Laundry facilities provided. n) q .472 Bedding and towels laundered; no common towels. GROUNI)a .300 Potable water provided. .300(B) Adequate and centralized drinking water facilities. .304 No common drinking cups. .350/.355 Proper storage and disposal of solid waste. Residential/Day Camps: Immediate access to reliable 209 phone with posted dialing instructions & (or have readily accessible) telephone numbers for HCC, police, emergency medical services, fire dept. .213 Emergency Communication System 1 i^ \ . Site location does not cause undue traffic hazards .450 and is accessible at all times. 430 -Camp Inspection Form 3-27-18 Page 7 430 -Camp Inspection Form 3-27-18 Page 8 GROUNDS .165 Tobacco use prohibited at camp. Alcohol and marijuana use prohibited during camp .166 operating hours. 207 Proper storage and operation of power equipment Power in locked tools stored place. 214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. FOOD SERVICE. Food service in compliance with 105 CMR 590.000, Minimum Standards for Food \�� � ,N,� •, ,� a ur_� .320 Establishments. Prominently displayed food permit from BOH. USDA Summer Food Service Program—written 320(3) documentation of compliance with 105 CMR 590. Nutritious meals that include a variety of foods .330 served. Menus posted. Residential, Travel, Trip camps — Provide at least .331 3 nutritious meals per day. Foods must meet recommended dietary guidelines. 332 Day camps —If serving 1 or 2 meals per day food must meet recommended dietary guidelines. Adequately trained staff and equipment to ensure .334 campers with disabilities are eating nutritious meals. Meals not denied or forced. Proper methods for storing meals brought from iv) .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. MAINTENANCE OF RECORDS Operator maintains all records relating to campers, .145 staff, and volunteers for a minimum of 3 years. Date and Time of Re -Inspection (if applicable): 430 -Camp Inspection Form 3-27-18 Page 8 430 -Camp Inspecrion Form 3-27-18 Page 10