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Home My WebLink AboutRBI Academy-Summer Softball 7/16/2018I� 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: RBI BASEBALL ACADEMY 97 GREEN STREET #2 13e):I 0617�7 MA 02035 Is hereby granted a RBI ACADEMY -SUMMER SOFTBALL CAMP permit for: at MEMORIAL PARK - 194 CHURCH 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 16-20, 2018 Hours of Operation: 9:OOAM - 2:30PM Date Approved. I BOARD OF HEALTH MichaeCMcCCean, Chairman hf Town of Mansfield Town of Mwin field - Boara (f n(-Utfr� �� 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. Name of camp: S U Asti r S Site address: /®r oiet I q q Site telephone: ?7q- 6qos— Name of camp owner: .&,e p, .,.eIt cG Office address: 4?6'P, d/ Q. -4A,5-kov ted. oo j Owner's telephone: °q g ® - j- q Owner's email (-WACk T- t (_ � Name of camp operator:Xi fx W Ci rf _ Operator's address: r? vv! i- *)- 6 Operator's telephone: -9 (7Y6?0-1- Type of camp: V15ay 'I. ',, Residential Hours of operation: d9-)-; 3 0 Date(s) of operation: A,4 I6 L� i- �/� GO I S Swimming pool Ad Pool permit number Name of healthcare consultant: �>rp po va C-Und" r. VtN Address: ,�+«SV ( JY Telephone: Date: d [...; Bathing beach AQ -.., Meals provided NO Fo number: Signature of Applicant: Fee: $1 0.0 Official Title: of A 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. 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)1 1 Disaster plan (105 CMR 430.210(8)) Copy of promotional literature (105 CMR 430.190 (C)) ll 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(8)) Traffic control plan (105 CMR 430210(D)) Da Discipline policy (105 CMR 430.191) '._': -- .. y camp -contingency plan (105 CMR 430211) 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 Works for disposal or sewage and waste water 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. e Signa re of Individual or Corporate Name i B ate Officer Mandatory, if Applicable) ac/) - te�)C��6^7� "Social Security No. (Voluntant) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. CAUsees\sleite\Desktop\Scott's Docmnents\Food Establishments-Temp\TAX CERTIFICATION EORM.doc Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Camp Dir ctor�y Name: _.. � ar� — &Ay ACoursework in camping administration: Previous camp administration experience: C✓ el bid yeniC t�{ / � 6A�'t� p� t"�� -f Health re Con ant Name: ('..—' I MA License Number: 'a\ .-v-.\\r, Type of Medical License (must be a physician, nurse practitioner, or physician zi-,sistant with pediatric training): AV Health Supervisor Name: / .rc �j'" Age: "3/°V 6�✓ Type of Medical License Registration, or arcing (See 105 CMR 430.159 C): _C _I AqDirectoFrst L CF6 uatics Name: v Age: Lifeguard Certificate issued by: Expiration date: American Red Cross CPR Certificate: American First Aid Certificate: Expiration date: Expiration dater Previous aquatics supervisory experience: Firearms Instructor Name: _./f //1111- Date Certified: Horseback Ridiinngg/Instructor Name: ._/---- -- Stable Location: 1.1114 License in accordance with MGL Ch.111 s. 155, 158: _._ National Rifle Association Instructor's Card (or equivalent): Expiration Date: License Number: Expiration Date: Yes No Jane Doucette From: Sent: To: Subject: Just keeping you in the loop.... Amy Donovan -Palmer Tuesday, June 19, 2018 12:37 PM Jane Doucette FW: RBI SOFTBALL Camp From: Amy Donovan -Palmer Sent: Tuesday, June 19, 2018 12:37 PM To: 'Christopher Welch' Subject: RE: RBI SOFTBALL Camp Hi Chris, Yes, you're correct. We'll need a different camp application/fee/etc. Can you let me know when it is? When could you get everything to us? Thanks, Amy From: Christopher Welch[mailto:cwelch(d)rbiacademy.com] Sent: Tuesday, June 19, 2018 8:33 AM To: Amy Donovan -Palmer Subject: RBI SOFTBALL Camp Hi Amy, thank you so much for taking the time to meet with Pat and Joe about the baseball camps. This year we just very last minute added a softball camp to our camp listing.I know it's very late, but it just came together really well really late. For the softball camp, can you let me know what is needed separately from the baseball camp? Shall I bring down a new camp application/fee/etc? Everything will be the same except location and staff on our end, but I am guessing because it's a new camp different location we would need to treat it separately? Whatever I need to do, I'll jump on it asap. Thank you so much! Christopher Welch General Manager RBI Baseball Academy Foxboro: 97 Green St, Foxboro MA 02035 508-543-9595 x300 www.RBIACADEMY.com Twitter: @CoachWelchRBI t, Town of Mansfield To o f Marrs field - 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 staff who provide supervision to campers without assistance. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents 'hr;+ — Office of Investigations ' I Congress Street, Suite 100 Y Boston, MA 02114-2017 �t 5ei'www.mass.govldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information /� Please Print I.etiibly Business/Organization Name: ewa1t q #2 Address: I 6 -r -'-e42 5)1-�u q City/State/Zip: Phone#: Areyouan employer? Check the appropriate box: Business Type (required): 1. G2' t am a employer with employees (full and/ 5. ❑ Retail _Jrd or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. E] Non-profit [No workers' comp. insurance required] ;. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I 1 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12•❑ Other with no employees. [No workers' comp. insurance req.]...I '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" organization should check box 91. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address:'/ -t City/State/Zip: QY liUdz��t �N `YG'kd Y i Policy #or Self -ins. Lie. 9 56C&I0.1135260 Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number find 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. I do hereby cern k� and penalties of perjury that the information provided above is true and correct. 05f- S'N3- 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: Phone #: www.mass.guriuia A`� CERTIFICATE OF LIABILITY INSURANCE 6/12/18 DA7EI�IDDYYYY) 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 CONSTM17E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED EPRESENTA71VE OR PRODUCER, AND THE CERTIFICATE HOLDER. APORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 this certificate does not confer rights to the certificate holder in lieu of such endorsemengs). PRODUCER American Specialty Insurance & Risk Services Inc 7609 W. Jefferson Blvd Ste 100 Fort Wayne, IN 46804 NOANIff Steven M. Shenkel PIWNE 1. (761 455-6664 mircNe: ApDaRE;�sshenkel@bbdedham.com _ INSURE SAFFORDING COVERAGE NAIC0 INSURERA:Arch Insurance Com an INSURED Rappoli Baseball, Inc. 97 Green Street Foxboro, MA 02035 INSURERB:Arbella Protection INSURERc:AIM Mutual Insurance INSURERD:Ae is Security Insurance INSURER IS: INSURER F: RAGES CERTIFICATE NUMBER: MQV10i+""�'^�'-^• COVE IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS 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 OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPEOFINSWTMICE A[D S POUCYNUMBER POLICY EFF M/m1Y PRICY EI(P MMIDdYYYY LIMITS A GENERALLWBBJfY SBCGLO4382DO 11/15/17 11/15/18 EACH OCCURRENCE S 1,000,000 DAMAGETO RENTED $ 1,000,000 X COMNERCUU.GENERALLIABRITY CLAM -MADE OCCUR MED EDP(Ary ore pm m) S PERSONALaADVINJURY $ 1.000.000 X Athletic Particinan coverace included GENERAL AGGREGATEs 5 000 000 GEN'LAGGREGATE LPAITAPPLIES PER PRODUCTS-CONPIOPAGG S 5 OOO OOO Abuse -Mole -9 t $ 100,000. POLICY PRO- 'X] LOC AUTOMOBEELIABI 1020013574 11/16/17 11/16/18 (Exec dart) N L Lwin S 1,000,000 BODILY INJURY(Pw parson) S NYAUTO ALLOW BODILY INJURY(PereWtlenq $ tFD X AUTOSULED NE RIY DAMAGE S PROP. raoudem e AUTOS NON -OWNED X X HIRED AUTOS AUTOS S A ULiBFE0.A LIAR X OCCUR S=S0000500 11/15/17 11/15/18 EACH OCCURRENCE $ 1-,-00-0,000 AGGREGATE 5 1,000,000 X EXCESSLIAB CLAIMS M1MDE DED RETENTIONS WORKERS COMPENSATION AWC400-7029915-2017 10/23/17 10/23/18 S X WCSTATd- 01T" C AND EMPLOYERS' UABILITY YIN EL. EACH ACODENr S 1,000,000 ANY PROPRIETOR/PARTNER,EXECUTNE VI NIA OFFICERIMEMBER EXCLUDED? EL.DISEASE-EA BVLOYE 1 OOO OOO (Mardaa,ry in NH) EL.DISPA.SE-POUCYLIMIT $ 1,000,000 If davafhaunder DESCRIP ION OF OPERATIONS bebw D Accident Medical 7311707283 11/15/17 11/15/1e Accident Med 100,000 DESCRIPTIONOFOPERATIONSILOCATIONS/VEHICLES (Adach ACORDIOI.Adittl nal Remarks Schodule,I/moaapace5mgdMd) The Certificate Holder is included as additional insured with respect to liability caused by the negligence of teh Named Insured only as per Form 00 SGL0026 00 Additional Insured - Certi£icate Holders with respect to baseball games. Militia Park 184R Lincoln Street North Easton, MA 02356 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROWSIONS. AUTIORBUD All ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@shenkel.com ACOORLIP CERTIFICATE OF LIABILITY INSURANCE DA'E' '4�° '1B 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(S), AUTHORIZED EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. AIPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(es) 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 this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER American Specialty Insurance 6 NOAH T Steven M. Shenkel PHONE 781 455-6664 rAx Nd: iat:dlisshenkel@bbdedham.com Risk Services Inc 7609 W. Jefferson Blvd Ste 100 INSURERS) AFFORDING COVERAGE NAIC# Fort Wayne, IN 46804 INSURERA:Arch Insurance Company INSURED INSURER B:Arbella Protection Mutual Insurance Rappoli Baseball, Inc. D:Ae is Securi Insurance 97 Green Street rREERcAIM E: Foxboro, MA 02035 RER F- rill 3lildlaL'11l_X: L1W-7X:F THIS IS TO CERTIFY THAT THE POLICES 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. INBR LTR TYPEOFINSURANCE Am SU POLICY NUMBER POLICY EFF MIDD PIXICY D9 MMMO'YYYY UNITS A GENERALUAINUTY SBCGL0438200 11/15/17 11/15/18 EACHOCCURRENCE $ 1.000,000 DAMAGETO RENTED $ 1,000,000 Om X COMdERCW. GENERAL LIABILITY MED EXP (AM ore man) $ CIAINSMADE O OCCUR PERSONALaaoVINIURY $ 1 000 000 X Athletic particivan coverage included GENERAL AGGREGATE S 5.000.000 GEN'LAGGREGATE LNTAPPLIES PER PRODUCTS -COhWIOP AGG $ 5,000,000 Abuse-Molestat s 100,000 Poucv PRD- }( LDC ALITOMOmLE LIABILITY 1020013574 11/16/17 11/16/18 , d. INGL LDAR S 1,000,000 BODILY INJURY(Per parson) $ ANYAUTO BODILY INJURY(Par accident) 5 X SCHEDULED AUTOS�D AUTOS NON -OWNED PROPERNYDMMGE S erecddaM X HIREDAUTOS X AUTOS S AUMBRELLALIAB X OCCUR SJFXSOOOO500 11/15/17 11/15/18 EACH OCCURRENCE S 1,000"000 AGGREGATE $ 1.000,000 HX EXCESS LIAR CLAIMS -MADE Om RETENTION $S WORKERS COMPENSATION WC STATU- OTH- X Tn C AWC400-7029915-2017 10/23/17 10/23/10 EL. EACH ACtl�Nr $ 1,000,000 AND EMPLOYERS' LIABIUTY ANY PROPRIETOR/PARTNEREXECUTNE YIN EL.OISFJISE-EAEMLOYE S 1 000,000 OFFICERMEMBER EXCLUDED? aI NIA (Mandatory In NH) EL.DISFASE-POLICYLIMB S 1 000 000 I dasvibaunder DESCRIPTION CF OPERATIONS below D Accident Medical 7311707283 11/15/17 11/15/10 Accident Med 100,000 DESCRIPTIONOFOPERARONSILOCARONSIVEOCLES (Atach ACORD 101, Additional R-Mrks SdMM9!Un%a,e spam islagdred) The Certificate Holder is included as additional insured with respect to liability caused by the negligence of teh Named Insured only as per Form 00 SGL0026 00 Additional Insured - Certificate Holders with respect to baseball games. Otis Street Field Complex 260 Otis Street Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 7HE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE F'111 reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@sheakel.com 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. AAWP40-7002991152A WC07PRIOR NO. ti-2016A ITEM 1. The Insured: Rappoli Baseball Inc DBA: - Mailing address: 97 Green Street FEIN: "-"'6959 Foxboro, MA 02035 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2 The policy period is from 10/23/2017 to 101=018 1201 am. 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 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each acpidenl Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other Slates 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, Rales 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 Of Annual CLASS Remuneration Remuneration Premium INTRA 0341953 9016 $2,765.00 x 45600% INTER SEE CLASS CODE SCHEDU Minimum Premium $324 Total Estimated Annual Premium $3,299 GOV Deposit Premium $3,425 T STATAT E CLASS Slate Assessmants/Suroharges MA 9016 $2,765.00 x 45600% $126 This policy, including all endorsements, is hereby countersigned by � �`'�` 09!2712017 AuUwdmd SlgnFtu Date Service Office: 54 Third Avenue Burlington MA01803 WC 00 00 01 A (7-11) Includes copyrighted material or the National Cosncll on Compenseeon insurance, used with Its permiselon. Brown & Brown of MA LLC dba Richard Endlar Ins 333 Elm st. suite 300 Dedham, MA 02026-6099 430 -Camp Inspection Form 3-27-18 Page 2 .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 r SP CT i Il G 1 S SPT x: G. . , .211(A) Camper doesn't show up for day. .211(B) Camper doesn't show up at point of pick up. .211(C) Child not registered arrives. Promotional LiteraturefGeneralRe uirement Copy of Policy (Parents/Guardians): Care of .159(B)(2) Mildly Ill Campers, Administration of Meds & Emergency Health Care Provision. (� Meningococcal Disease & Immunization info V\ .157 provided to parents/guardians annually. Camper released only to Parents/Guardians or .190(B) Designated Individual with written authorization. Regulatory Compliance & Licensing Statement: .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 application) procedures upon request. Protocol in place to handle unrecognized persons at .190(E) camp. Written itinerary provided to parents/guardians .212(A) before departure. Source of emergency care identified; minimum 1 212(B) 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. Written contingency plans brought on all field trips: 212(D) (natural disasters, lost camper/swimmer, injuries and illnesses) .,- Vehicle must comply with M.G.L. c. 90 §§ 7B & 7D: <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(C) Seatbelts must be worn. 1 staff person required when transporting: Campers to the pick-up/drop-off site; or .251(D)(E) 8+ campers under 5 yrs. of age; or 2+ campers with physical handicaps. Camper under 7 yrs. are not transported longer than .251(1) 1 hour non-stop. Camp vehicle drivers: 18 yrs +, 2yrs. driving ; .252 experience, current license for type of vehicle. j First Aid certified if no other trained staff aboard. 430 -Camp Inspection Form 3-27-18 Page 2 DEPARTMENT OF PUBLIC HEALTH = COMMUNITY SANITATION PROGRAM 105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN STATE SANITARY CODE, CHAPTER IV AME OF CAMP: ADDRESS: 1V�CvvvU C�ctiL. ?nr�c � 1�1� C�ct:,u�c.i �1 OWNER/OPERATOR: OFF SEASON ADDRESS: 6�� a, u0 n 5' a. -_a CAMP DIRECTOR: ��,t1�c o Yh P, OD -c -6- \_\e C -\ aw%\_\ec-\ C C,(, _ DATE/TIME OF INSPECTION: PHONE #: '1 I'1 U L \ 'C� `O `. v�-,o TYPE OF CAMP: WATER SOURCE: INSPECTED BY: Day - Residential r \V, poi on-Sport—Medical Specialty CAMPER CAPACITY: Tri Primitive/Outpost — Travel G&J "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 .. v "'" x41? x 1�'��'fe._,�h:� "_ ._ .._�.:c-..`s�.m.➢.�, .a.... --.v r. _.. Current Certificate(s) of Inspection from local .451 building inspector for sleeping/assembly areas. .215 Written compliance from local fire depart tent. .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 ening — t �„ Procedures for Background Review of / c .090(A) Staff and Volunteers. V/ Staff - CORI and SORI .090(C) Previous Work History (5yrs)— 3 Positive Reference Checks ✓ '��` \ Out-of-state/Intemational Criminal Background Checks Volunteer Staff — CORI and SORI .090(D) Previous Work/Volunteer History (5yrs) Out-of-state/International Criminal Background Checks All Background Info - Received, reviewed, & made s V"N a .090(F) S determination re uired pursuant to .090 (C&D). .091 StaffNolunteer Orientation: Orientation Plan & y� .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, § 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 1 430 -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. 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. esignated Substitute: , 102(D) Substitute must meet above criteria. Counselors/Junior Counselors:' 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 experience & attend orientation and training .100(C)(3) All counselors 3 yrs. older than campers. Re aired Counselor Ratios: Residential / Day / Sports Camps: .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(13) 1 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 / .103 during regular and specialized high risk activities. uaie eefor":gin - 1r 020 Lifeguard certification, 21 yrs.+, 6 weeks previous .103(A) experience in similar supervisory position. Lile aid At least 16 years old with [American Red Cross 020 Lifeguard Training Cert/Royal Bronze Medallion/Boy Scouts Lifeguard Cer"CA Lifeguard Cert]* AND .103(A) CPR AND First Aid Certificate* *Or their e uivalent elt 1ti7iS .W <as,} MD/DO NP PA (with documented pediatric training) .159(A) eck for Health Care Consultant Agreement* License #: .159(A)(6) Develop written orders to be followed by HCS, including responsibilities for medication administration Develop a written list of all medication .160(C) administered at camp HCC Provided & Documented Trainings: .160 HCS required tainings, signs of hypo/hyperglycemia, / (E)(G)(R) diabetic plan management, and administering epi-pen with evidence of competency 430 -Camp Inspection Form 3-27-18 Page 3 430 -Camp Inspection Form 3-27-18 Page 4 SM .020 MD PA NP RN LPN or... .159(C)(E) 18 yrs.+, First 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(3) Meds stored in secured manner (ACA standards) / Medication refrigerator 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 policy with parent/guardian sign off. Medical Log: .155 available and signed by authorized staff person >/ --Readily Injury Report completed for a fatality or serious / .154 try. Copy sent to MDPH and BOH. ✓ Day / Residential Camps - Infirmary provided .161(A) Residential Camps - Easily recognizable and accessible during the day and night. .453 Lighting provided in infirmary. Residential Camp - Area for isolation of ill child .161(3) 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(F) with 105 CMR 480.000. moolsommonommmmm Health Record for each Camper & Staff: .150 StafVCamper < 18 yrs: Emergency Contact Into, w\ .160(1)) Written Parental Permission for Meds, Emergency Care, .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 Day—Medical histoi gnedoff byParent/Guardian "z Campers and Staff under 18yrs: Number of records checked: N� .152 Campers and Staff over 18yrs: Number of records checked: .152 J .153 Exemption Documentation 430 -Camp Inspection Form 3-27-18 Page 4 430 -Camp Inspection Form 3-27-18 Page 5 Activities and physical environment meet the needs .190(A) of campers; do not pose hazard to health/safety. V1 I Swimming Pool: in compliance with .430 105 CMR 435.000 - Pen -nit 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 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. 'llil', .4+s"�f=..ix"M`"'x^r Watercraft: equipped with USCG approved .204(13) 103(B)(4) flotation devices and wom by all campers and staff engaging in watercraft activities.(paddle boards included) White water, hazardous salt/fresh water activities: .2040) Campers certified with ARC Level 4+ Certificate or equivalent. White water, hazardous salt/fresh water activities: .103(B) Minimum 2 counselors in separate watercrafts 1 counselor per 10 campers (counselor must have lifeguard or small craft safety and basic water rescue cert, orequivalent ) .205 Equipment in good repair, safety precautions taken. t\l q > s .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:_ .' aures/Cei .202(A) Equipment in good condition, stored locked. h q 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 pertnission. .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 Names/Certs: Firearms in good condition, stored in locked .201(A) cabinet. Ammunition locked in separate cabinet. tca 1 .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 .1030)) and maintain compliance with applicable M.G.L.'s 1 counselor per 10 cam ers ,1-- :' aures/Certs: Excursions: 1 Certified Instructor per 10 campers .103(F) Mnumum 2 counselors present during excursions + t� .208(A) In accordance with M.G.L. c. 128, § 2A .208(A) Riders must wear hard hat at all times. .208(3) Licensed stable in use. A11Vt)COIII2iJv.AkYk 7BII.,dTi : Operator: Licensed and maintained in accordance with .103(G)(1) 520 CMR 5.00 — Amusement Devices .103(G)(2) Annual inspection with written report .103(G)(3) 1 counselor per 10 campers at alltimes V pp� my Day Camp provides shelter for on-going camp ry .457 activities with certificate of inspection. Residential - Smoke and carbon monoxide hI .216 detectors provided. .456 Adequate egresses free from obstruction (780 CMR). .453 Lighting provided for stairways. v All structural and interior elements maintained in .454 good repair and in a safe and �ysanitary [condition. Provide adequate space: Single bed: 4011/person; 458 Bunk bed: 35f z/person ; 5W/person requiring special equipment Provide separate bed/cot per person with: .470 6 ft. between individuals heads; and 3 ft. between single beds & 411/2 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. 217 Clearly labeled as fire resistant. No open flame in / or near tent. v 430 -Camp Inspection Form 3-27-18 Page 6 TOILETS/HANDWASH SINKS/SHOWERS .360 Proper sewage disposal. .301 Plumbing maintained in good working order. v 5 s 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): .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 ShowerBathtub: 100°F -112°F .374(B) Sanitary facilities maintained in clean condition. T— .377 Shower room floors washed daily. LAUNDRY .162 Residential Camp: Laundry facilities provided. .472 Bedding and towels laundered; no common towels. \ , gi .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 .450 Site location does not cause undue traffic hazards and is accessible at all times. V 430 -Camp Inspection Form 3-27-18 Page 7 ,.�s ..s., ti u � ,��-`e`x �- �» �?s___.�'-.cc.. ,�-�y+a..t ,h .-"`c-:� `` vi.c•�•{ � �-�-��'� .=)_"'�„'--� •' .165 Tobacco use prohibited at camp. ✓ i h �7\ cvw Alcohol and marijuana use prohibited during camp ^` 166 operating hours. Proper storage and operation of power equipment 207 Power tools stored in locked place. Flammable and hazardous materials labeled and .214 stored in locked unoccupied building. .400 Rodent and insect control. lr� �Qk laki5( .401 Weed and noxious plant control. ✓ � '� `�� Food service in compliance with 105 CMR 590.000, Minimum Standards for Food .320 Establishments. Prominently displayed food permit 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. V Residential, Travel, Trip camps — Provide at least .331 3 nutritious meals per day. Foods must meet recommended dietary guidelines. 332 or Day camps — If serving 1 or 2 meals per day food / must meet recommended 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 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. Operator maintains all records relating to campers, .145 staff, and volunteers for a minimum of 3 years. Date anti']I'iimte ¢f Re-In�pechon (�f applicable}, t,Y s 430 -Camp Inspection Form 3-27-18 Page 8 430 -Camp Inspection Form 3-27-18 Page 9 430 -Camp Inspection Form 3-27-18 Page 10