HomeMy WebLinkAboutChallenger Sports 8/6/2018Commonwealth 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: DAVID RUSH
94 A JEFFERSON BLVD.
WARWICK
MA 02888
Is hereby granted a CHALLENGER SPORTS
permit for:
at 50 PLYMOUTH 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: AUGUST 6, 2018 - AUGUST 10, 2018
Hours of Operation. 8:00 AM - 4:00 PM
Date Approved: _ _ a 1 C)c"/&'
BOARD OF HEALTH
Michaet'McCCean, 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
Application must be submitted at least 14 (fourteen) business days prior to the start of camp. 1
Name of camp: a Type of camp: gDay Q Residential
Site address: 50 PI,�rn cf?dY� St, Mcu�fiei A. MA 02OL4 urs of operation: 6 arn— -T" m
Site telephone: 1`)� '"� (
Name of camp owner:
(����ri ij/,'�1� �� 1Push ' ` 1 rf'
Office address: �IUA J 0_ U aSon b'UAB 6U -w ice} �i
Owner's telephone: t � 0 I' 213 _3 ko2 Q
Owners email y{ r us
lr` e c In A I,o y� O r� c (fib its . Lzm
Name of camp operator: A 1rn VtalUOperator's address:ir'�gD( O A V fi ' I
Operators telephone: UA U 1. CAJ V n BI 0, lJ I
U012 3-3102
Date(s) of operation:
Swimming pool
Pool permit number
Name of health care consultant: l , l uyrn p� E] Bathing beach
Address: �U 4 --'vi l cn "" "'�'
�f C r e` t O.) S 0 � Meals provided
V1 1 J ^W Foodyea it number:
Telephone: t A O I m
Date: iV II 1 00 Signature of AYL
p�pinicant:
Fee: $151 C
0.00 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.
Repaired 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)
Copy of promotional literature (105 CMR 430.190 (C))FJ
11 Disaster plan (105 CMR 430.210(B))
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(9)) ❑ 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 430.21G A))
Current ceKficate 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):
El Buildings, structures, fixtures, and facilities
El Proposed source of water supply
El 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:
Age:
Coursework in camping administration:
Previous camp administration experience:
Health Care
Consultant .
Name: I l rni a y - (A c 1
MA License Number:
a -
Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training):
v
Health Supervisor
Name: 7-0, Y-)
Age:
Type of Medical License Registration, or Training (See 105 CMR 430.159 C)
Aquatics Director
Name:
Age:
Lifeguard Certificate issued by:
Expiration date:
American Red Cross CPR Certificate
Expiration date:
Previous aquatics supervisory experience:
Firearms Instructor
Name: n )
Date Certified:
Horseback Riding Instructor
Name: n I ,
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
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Attach
The names, ages, applicable current certifications (it 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.
DEPARTMENT OF PUBLIC HEALTH - Commiti w SANITA'T`ION PROGRAM
105 CMR 430.000: MINIMUM STANDARDSI FOR RECREATIONAL CAMPS FOR CHILDREN
STATE SANITARY CODE. CHAPTER IV
NAME OF CAMP:
CAMP DIRECTOR:
PHONE #:
TYPE OF CAMP:
Day — Residential
Sport — Non -Sport — Medical Specialty
Trip — Primitive/Outpost — Travel
WATER SOURCE:
ADDRESS:
OFF SEASON ADDRESS:
DATE/TIME OF INSPECTION:
INSPECTED BY:
"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 1
Current Certificate(s) of Inspection from local
.451
building inspector for sleepinglassembly areas.
.215
Written compliance from local fie 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 toopening
y
x
VOW"LICIE -
WR1 FTEN
Procedures for Background Review of
090(A)
Staff and Volunteers.
Staff— CORI and SORI
.090(0)
Previous Work History (5yrs) — 3 Positive Reference Checks
\'
l
Out-of-state/International Criminal Background Checks
Volunteer Staff— CORI and SORI
.090(D)
Previous Work(VolunteerHistory (5yrs)
t
Out-of-state/International Criminal Background Checks
All Background Info - Received, reviewed, & made
.090M
determination required pursuant to .090 (C&D).
.091
StaffNolunteer Orientation: Orientation Plan &
A\"()'c'•.� c� . <,e < e �c c
.159(B)(1)
Attendance Records, Training on Disaster/Emergency
V
.210
Plans, Health Care Policies, & Concussion Awareness
Abuse & Neglect Prevention Policies & Procedures
.093
Report procedures in accordance w/ M.G.L. c. 119, § 51A
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 1
CAMP PLANS - WRITTEN
.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 PLANS-- DAY CAMP /
.211(A)
Camper doesn't show up for day. `
.211(B)
Camper doesn't show up at point of pick up. s
.211(0)
Child not registered arrives.
Promotional Literature/General Re uirement
Copy of Policy (Parents/Guardians): Care of
.159(B)(2)
Mildly Ill Campers, Administration of Meds &/
v e 4 r,,NV
Emergency Health Care Provision.
V
Meningococcal Disease & immunization info
.157(C)
provided to parents/guardians annually.
.190(B)
Camper released only to Parents/Guardians or
Designated Individual with written authorization.
Regulatory Compliance & Licensing Statement:
IPAk
.190(C)
This camp must comply with regulations 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 grievance
\'Jvo6Aut a i
application)
procedures upon request.
r)cv\,�
.190(E)
Protocol in place to handle unrecognized persons at
/
camp.
FIELD TRIPS
.212(A)
Written itinerary provided to parents/guardians
X
before departure.
212(B)
Source of emergency care identified; minimum 1
health care supervisor accompanying trip.
Health records easily accessible for all
.212(C)
campers/staff, medications stored securely and
accessible only by HCS. First 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 §§ 9B & 7D:
<14 passengers & driver is camp coach, director, etc.
.250
camp vehicles may be used
V/
>14 passengers, vehicle must be school bus
All vehicles RMV compliant w/ annual safety ins
.253
Proper automobile insurance.
.251(C)
Seatbelts must be worn.
I 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 pained staff aboard.
430 -Camp Inspection Form 3-27-18 Page 2
430 -Camp Inspection Form 3-27-18 Page 3
Camp Director:
.102(A)
Residential: 25 yrs.+, successful completion of Camp
Administration Course or 2+ seasons experience.
102(13)
Day: 21 yrs.+, successful completion of Camp
�7 Rr —ckvu�rrLS
Administration Course or 2+ seasons experience.
Cc%n e
102(C)
Primitive, Travel, Trip: 25 yrs.+ and proof of
+Q
p\
experience.
Designated Substitute:
.102(D)
Substitute must meet above criteria.,
Counselors/Junior
Counselors:
o
Day Camp, Non-Sport-I
OO
t100(A)
on-Sport:
Counselor =l6 rs.+Junior Counlrelor-15 yr s.+
.100(A)
4+ weeks experience & attend orientation and training
Residential, Primitive, Sport, Travel, Trip, Medical:
7J
.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(C)(3)
All counselors 3 yrs. older than campers.
Required Counselor Ratios:
Residential / Day / Sports Camps:
sn�� �� ��c�� a _cam r�
.101(A)
1 counselor per 10 campers 7 yrs. or above
1 counselor per 5 campers under 7 yrs.
Primitive/Outpost, Travel, Trip Camps:
.101(B)
1 counselor per 10 campers - 1 counselor at least 21 yrs.
.159(0)
2 counselor minimum with 1 counselor having First Aid
IIA.
Certificate or its equ valent
All Camps:
nUv� 4
.t0 l0&B)
(
Staffing plan to supervise campers w/ disabilities
during regular and specialized big risk activities.
.020
Lifeguard certification, 21 yrs.+, 6 weeks previous
,
.103(A)
experience in similar supervisory position.
At least 16 years old with [American Red Cross
Lifeguard Training Cert/Royal Bronze Medallion/Boy
.020
.103(A)
Scouts Lifeguard Cert/YMCA Lifeguard Cert]* AND
CPR AND First Aid Certificate*
*Or their equivalent
A D%DO NP PA (with documented pediatric training)
01
.159(A)
-'---*Check for Health Care Consultant Agreement*
License
Develop written orders to be followed by HCS,
.159(A)(6)
including responsibilities for medication
administration
Develop a written list of all medication
160(C)
administered at camp
HCC Provided & Documented Trainings
.160
HCS required trainings, signs of hypo/hyperglycemia,
S`
(1✓)(G)(H)
diabetic plan management, and administering epi -pen
with evidence of competency
430 -Camp Inspection Form 3-27-18 Page 3
.020I MD PA NP RN LPN or...
9(CI(E) 18 vrs.+_ First Aid & CPR certified
.159(B) I Camp Health Care Policy ;v
.160 ALL Medications stored in Original Containers
(A)(1) and meds properly disposed of with disposal log.
.160(3) Meds stored in secured manner (ACA standards)
Medication refrigerator temp 36°F - 46°F
Written Medication Administration Policy: ,j �� c v�
.160 Medication administered by_HCC authorized staff only;
(C)(D) oral/topical medication administration training; and
.163
Sunscreen policy withparent/guardian sign off.,
.155
Medical Log:
Readily available and signed by authorized staff person
Injury Report completed for a fatality or serious
.154
injury. Copy sent to MDPH and BOH.
Day / Residential Camps - Infirmary provided
.161(A)
Residential Camps - Easily recognizable and
accessible during the dayandnight.
.453
Lighting provided in infirmary.
x
Residential Camp - Area for isolation of ill child
.161(B)
with ability to provide negative pressure.
.161(0)
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(F)
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,
C7
.190(A)
and Self -Administration of epi -pen or insulin
Camper > 18 yrs: Emergency Contact Info
Residential, Travel, Trip, Sports—Medical History
.151(A)(B)
physical within past 18 months
Da —Medical history signed off by ParentIGuardian
Campers and Staff under 18vrs:
Number of records checked:
� Ih
.152
„
3)kjA vy�' t
,Q� J�
.152 1 cN"R evG D- U^
.153
430 -Camp Inspection Form 3-27-18 Page 4
430 -Camp Inspection Form 3-27-18 r �, �� Page 5
i
Activitiesenvironmentmeet the needs
O U�
190 A of do not pose hazard to
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
Christian's
M.G.L. c. 111 § 127A %2
LAW
.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.
Watercraft: equipped with USCG approved
.204(1)
flotation devices and womb all campers and staff
.103(B)(4)
engaging in watercraft activitieS.(paddle boards included)
White water, hazardous salt/fresh water activities:
.204(l)
Campers certified with ARC Level 4+ Certificate
or equivalent.
White water, hazardous salt/fresh water activities:
103(B)
Minimum 2 counselors in separate watercrafts
I 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.,
;,,
"' ;,_.,,.
,..AIi0i3Nb/ATFI�,`LGQIa
.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.
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 r �, �� Page 5
i
430 -Camp Inspection Form 3-27-18 1 Page 6
Names/Certs:
Firearms in good condition, stored in locked
201(A)
cabinet. Ammunition locked in separate cabinet.
.201(B)
Shooting range away fiom 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 per 10 campers
aures/Certs:
Excursions: I Certified Instructor per 10 campers
.103(F)
.208(A)
Minimum 2 counselors present during excursions
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.
/
C.Ci I LEItiGE
0, Ir T25ES ALAI , I1V1BIN t SAL) S
Operator:
.103(G)(1)
Licensed and maintained in accordance with
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
.457
Day Camp provides shelter for on-going camp
activities with certificate of inspection.
.216
Residential - Smoke and carbon monoxide
detectors provided.
.456
Adequate egresses free from obstruction (780 CMR).
.453
Lighting provided for stairways.
.454
All structural and interior elements maintained in
/
good repair and in a safe and sanitary condition.
SLEEPING AREAS . RESIDENTIAL
CAMPS,
Provide adequate space:
Single bed: 400person-
.458
Bunk bed: 35f /person ;
5W/person erson re uiring special equipment
Provide separate bed/cot per person with:
.470
6 ft. between individuals heads; and
3 ft. between single beds & 4 3/2 ft. between bunks
Campers and staff with limited mobility housed on
.459
ground level; egresses leading to grade or ramp
provided.
.452
Screens & screen doors provided. All doors
equipped with a self-closing device.
.454
All structural and interior elements maintained in
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 1 Page 6
TOILETS/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
Day Camp: >60 of one gender, provide 1 more toilet
.370
for each additional 30 persons of that gender.
Residential: >20 of one gender, provide 1 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: 1 sink per every 30 people
Residential Camp: 1 sink per every 10 people
Adequate # of showers (no duckboards):
ti
.374
Residential Camp: 1 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.
7
.472
Bedding and towels laundered; no common towels.
.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.
v\ J\ '�'\"
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
V� f�\ t", � _t
Site location does not cause undue traffic hazards
.450
and is accessible at all times.
430 -Camp Inspection Form 3-27-18 Page 7
GROUNDS
.165
Tobacco use prohibited at camp.
.166
Alcohol and marijuana use prohibited during camp
operating hours.
207
Proper storage and operation of power equipment
\ /
Power tools stored in locked place.
Y\
Flammable and hazardous materials labeled and
.214
stored in locked unoccupied building.
.400
Rodent and insect control.
.401
Weed and noxious plant control.
i
FOOD SERVICE
-
Food service in compliance with 105 CMR
.320
590.000, Minimum Standards for Food
\ /
Establishments. Prominently displayed food permit
r\
from BOH.
USDA Summer Food Service Program — written
.320(B)
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.
Day camps — If serving 1 or 2 meals per day food
.332
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
.335
home. Meals provided to campers who arrive
e en
without a bag lunch.
.452
Screening provided for food preparation and food
^f
service areas. Screen doors must be self-closing.
.453
Lighting provided in kitchen and dining area.
.471
Sleeping prohibited in food areas.
k
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 Inspection Form 3-27-18 Page 10