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Home My WebLink AboutRBI Baseball Camp 6/21/2018Commonwealth of Massachusetts Town of Mansfield 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 /6 Town of Mansfield 6 Park Row Mansfield, MA 02048 This permit is granted in conformity with 105 CMR 430.000, Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV, Department of Public Health, and expires on closing date of each session unless sooner suspended or Date(s) of Operation: JULY 9 - JULY 13, 2018 JULY 16 - JULY 20, 2018 JULY 30 - AUGUST 3, 2018 Hours of Operation: 9:00 AM - 2:30 PM Date Approved: BOARD OF HEALTH MichaeC.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 90 (ninety) days prior to the start of camp. Name of camp: RBI BASEBALL CAMP Type of camp: ❑J Day ❑ Residential Site address: OTIS STREET Hours of operation: 9:90 AM -2:30 PM 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 Dates) of operation: ❑ Swimming pool Name of camp operator: PATRICK BOEN Pool permit number Operator's address: 97 GREEN STREET FOXBOROUGH, MA 02035 ❑Bathing beach Operator's telephone: (508) 339-3944 (508) 935-9533 E] Meals provided # staff: L" ' j°l Food permit number: #volunteers: Signature of Applicant: ,f le&� Date: Official Title: Fee: $150.00 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(B)) Copy of promotional literature (105 CMR 430.190 (C)) ❑ Lost camper plan (105 CMR 430.210(C)) [] Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ❑ Lost swimmer plan (105 CMR 430.210(C)) Health care policy (105 CMR 430.159(8)) ❑ Traffic control plan (105 CMR 430.210(D)) Discipline policy (105 CMR 430.191) ❑ Day camp - contingency plan (105 CMR 430.211) El Fire evacuation plan - approved by local foe department (105 CMR 430.210(A)) Current cerfificate 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 Proposed source of water supply Works for disposal or sewage and wastewater 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 Type of Medical License (430.159(A)): MD MA License Number: 21841: Address: 21 BRISTOL DRIVE, EASTON, MA 02356 Health Care Consultant Phone number: (781) 344-3555 Health Care Consultant signed Agreement- Please use DPH issued form located at https://www.mass.gov/lists/recreational-camps-for- child ren-com munity-sanitation 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: American First Aid Certificate: PATRICK BOEN Expiration date: 6/6/2019 Expiration date: 6/6/2019 Previous aquatics supervisory experience: Firearms Instructor Name: Date Certified: Horseback Riding Instructor Name: Stable Location: 1,1 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 Town of Town of Mansfield - Board of Health 6 Pak ROMVansfield Mansfield, MA 02048 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.gov/lists/recreational-camps-for-children-community-sanitation. Additionally, the website provide a Recreational Camp Operator Checklist 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. 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. ,1 Mint�_ Signature of individual or Corporate Name By: Orp&KMOfficer (Mandatory, if Applicable) 2.0- 0/369159 "Sodal Security No. (Voluntary) 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. l�;�USwYVlely=\UCJku)P4yfyt� Y WUNAOWIU• V•UVII nYW bbyllQlCny- 1 COIF\�{� L'L'It I IYII,'q t IUN 1•UItM.511' A.I.M. Mutual insurance Company Insured: 7029915 Producer. 00935.001-001 Rappoii Baseball Inc Brown & Brown of MA LLC dba Richard 97 Green Street 333 Elm at. suite 300 Foxboro, MA 02035 Dedham, MA 02026-6099 Insured FEIN: *""6959 Issue Date: 09/27/2017 Policy Number. AWC-400-7029915-2017A Endorsement Effective Date: 10/23/2017 Policy Period: 10/23/2017 -10/23/2018 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included in this policy: Form No. Form Description Applicable States Policy Effective Date PRIVACY Privacy Notice 10/2312017 POOL - Please Important Notice for Pool Policies 10/23/2017 AIMIMPT AIM - Important Policyholder Notices 10/23/2017 AIM -3 AIM Waiver of Subrogation Notice 10/23/2017 AIM -4 MA Benefits Claim and Aggregate Deductible Program 10/23/2017 AIM -5 AIM Commitment of Service 10/2312017 AIM -61 AIM - Servicing Carrier 10/23/2017 AIMCI AIM - Cl Phone Numbers 10/23/2017 Servonl Services Online Instructions 10=12017 WCRIB WCRIB Circular Letters Notice MA 10/23/2017 Location Location Schedule 10/2312017 Class Code Classification Code Schedule 10/23/2017 Installment Installment Schedule 10/23/2017 Rating Summary Rating Summary by State 10/23/2017 AIM -1A Dividend Classification Endorsement 10/23/2017 AIM -2 MA Workers Compensation Assigned Risk Pool 10/23/2017 WC 00 00 00 C Policy Conditions 10/23/2017 WC 00 04 04 Pending Rate Change End. MA 10123(2017 WC 00 0414 Notification of Change in Ownership 10/23/2017 WC 00 0313 Waiver of Our Right to Recover from Others 10/23/2017 WC 00 04 22 B Terrorism Risk Endorsement 10/23/2017 WC 00 04 25 Experience Rating Modication Factor Revision 10/23/2017 WC 20 03 01 MA Umtts of Uability Endorsement MA 10/23/2017 WC 20 03 02 A MA Assessment Charge MA 10)23/2017 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 10/23/2017 WC 20 03 06 B MA Umtted Other States Insurance Endorsement MA 10/23/2017 WC 20 03 07 MA Assigned Risk Pool Eligibility Endorsement MA 10/23/2017 WC 20 04 05 MA Premium Due Date Endorsement MA 10/23=17 WC 20 04 01 MA Pending Premium Change Endorsement MA 1012302017 WC 20 06 01 A MA Cancellation Endorsement MA 10/23/2017 WC 20 06 04 MA Policy Definition Endorsement MA 10/23/2017 EMPNOTICE MA Notice to Employees MA 10/23/2017 Insured Endorsementach (04111) A.I.M. Mutual Insurance Company Insured: 7029915 Producer. 00935-001-001 Rappoli Baseball Inc Brown & Brown of MA LLC dba Richard 97 Green Street 333 Elm st. suite 300 Foxboro, MA 02035 Dedham, MA 02026-6099 Insured FEIN: "-•"6959 Policy Number. AWC-400-7029915-2017A Issue Date: 09/27/2017 Endorsement Effective Date: 10/23/2017 Policy Period: 10/23/2017 -10/23!2018 Endorsement Number. CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Policy Unit Name: Rappoli Baseball Inc Classification Description Class Payroll Code No. Amount SALESPERSONS, COLLECTORS OR 8742 CLERICAL OFFICE EMPLOYEES NOG 8810 AMUSEMENT PARK OR EXHIBITION 9016 Unit State Code: MA Billing Plan: Annual Rate Estimated Per $100 Premium 150,933 0.16 241 127,381 0.07 89 128,391 2.01 2,581 Manual Premium 2,911 Waiver Endorsement Premium 2 Excess Employers Liability 2.00% 58 EEL Minimum Premium Adjustment 17 Premium Subject to Exp Mod 2,988 Merit Modifier 0.95 (149) Standard Premium 2,839 Expense Constant 338 Terrorism Act Surcharge 122 Total Estimated Premium 3,299 DIA ASSESSMENT 4.58% 126 Total Estimated Premium & Surcharge(s) 3,425 Insured ClassCode&h (04111) NOTICE TO EMPLOYEES NOTICE )10 EMPLOYEES TO 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.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC400-7029915-2017A 10/23/2017 - 10/23/2018 POLICY NUMBER EFFECTIVE DATES 333 Elm st. suite 300 Brown & Brown of MA LLC dba Richard Dedham, MA 02026-6099 (781)455-6664 NAME OF INSURANCE AGENT ADDRESS PHONE Rappoli Baseball Inc 97 Green Street Foxboro, MA 02035 EMPLOYER ADDRESS 09/27/2017 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 Injury must 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 The Commonwealth of Massachusetts Print Form - Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �e Address: City/State/Zip: /pXbaYy//Y%g 0203S Phone#: 5o&3 -, 113, /S 75 Are you an employer? Check the appropriate box: Business Type (required): 1. Lei'out am a employer with _6-0 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. $ F-1 Non-profit [No workers' comp. insurance required] 3. ❑ 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 I ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] °Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 'Alf the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 41 /am an employer that is providing wor�ntkers' compensationsinsuraneefor my employees. Below is the policy information. Insurance Company Name: _ f'! 5 � 149M Insurer's Address: /� `� �•_,1e'6LLP1?9_ & SOi4'L' /Po City/State/Zip: ILI 4 Y7N y6 �d y !� i' Policy # or Self -ins. Lic. # 04V3 S Zbd Expiration Date: // rJ a Attach a copy of the workers' compensation policy declaration page (showing the policy number And expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern and penalties ofperlury that the miormatimt provtaea rmove is true aria correct. 1: --- i -'I rlata !'J�// h;, 3, q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): t. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone Av �® CERTIFICATE OF LIABILITY INSURANCE `�m"Y""' 6/12/18 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 CERrincATE HOLDER. , APORTANR 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 endorsement(s). PRODUCER American Specialty Insurance & COMET Steven M. Shenkel P NE781 955-6664 TAX N ADDRESS: sshenkel@bbdedham.com Risk Services Inc 7609 W. Jefferson Blvd Ste 100 INSURE a AFFORDING COVERAGE NAIC0 INSURERA:Arch Insurance Company Fort Wayne, IN 46804 INSURED msuR :Arbella Protection INSURERc:AIM Mutual Insurance Rappoli Baseball, Inc. RERD:Ae is SecurityInsurance 97 Green Street R E: Foxboro, MA 02035 INSURER F: MED 8W(A,Vore anon) E COVERAGES CERTIFICATE NUMBER: REV1310H 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 ANDCONCITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OFINSURANCE AOO POLICY NUMBER PMIDDIYW MWDDIYYYY LIM73 A GENMALLMOILITY cOMMERCIALGENERALLWBILITY SBCGL0438200 11/15/17 11/15/18 EACH OCCURRENCE S 1,000,000 DAMAX PREMI ETORENTED E 1,000,000. CLAMS�MADE OCCUR MED 8W(A,Vore anon) E PERSONALSADVINRIRY E 1,000,000 Athletic Participan COV@race included GENERAL AGGREGATE E 5 DDD DDD GEN'LAGGREGATE LNITAPPUES PER PRODUCTS -COMPIOP AGG E 5,000,000 Abuse—Mole tat E 100,000 POLICY ECrPRO- X LOC AUTOMOBILE LIABILITY 1020013574 11/16/17 11/16/18 CaSWOON) NGLEL_ WIT S 1,000,000 BODILY INJURY(Pa parson) E ANYAUM BODILY INJURY(Pawddenl $ ALLOWNED X SCHEDULED AUTOS NUTOS ON -OWNED X HIREOAUTOS !� AUTOS PROP ER�Y DAMAGE E ere rJ en1 E AUMBREUAUAB X OCCUR SJFXS0000500 11/15/17 11/15/18 EACH OCCURRENCE E 1 DOD DDD AGGREGATE E 1 '000,000 X EXCESSLIAB CLAIMS-MOE OED RETENTION E L. WORKERS COMPENSATION AND EMPLOYERT LIABILITY �� EPIE%ECUTNE = (Ma,da6a,yin NH) NIA AWC400-7029915-2017 10/23/17 10/23/16 X WC STATU- DTH - L. EACH ACOCEM' 1,000,000 EL -01 FASE-EARAPLOYEE $ 1, 00,000 EL.OISEASE-POUCY1 [MIT $ 1,000,000 Uvyeea desaWeunder DESG2IPTION OF OPEMTIONS below D Accident Medical 7311707283 11/15/17 11/15/18 Accident Med 100,000 DESCRIPTIONOFOPERATONSILOCATIONS IVEHICLES (=ACORD TSI,AMgond RomrM Scho&da,Nnwrospace IzragLAmd) 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. Militia Park 184R Lincoln Street North Easton, MA 02356 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIM n ACORD 25 (2010/06) The ACORD dame and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: Steven@shenkel.com reserved. ,acv v® CERTIFICATE OF LIABILITY INSURANCE DATE`si 9'le 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 ,rd PORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(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 In the certificate holder in lieu of such endorsemengs). PRODUCER American Specialty Insurance S Risk Services Inc 7609 W. Jefferson Blvd Ste 100 Fort Wayne, IN 46804 AME: Steven M. Shenkel PHONE 781 455-6664 rMA x 106s: ashenkel@bbdedham.com INSURE 8 AFFORDING COVERAGE NAIC0 INSUREtA:Arch Insurance Company INSURED INSUREte:Arbella Protection c:AIMMutual Insurance Rappoli Baseball, Inc. 97 Green Street NSURERD:Ae is Securit Insurance [ISURERREM NSURER E: Foxboro, MA 02035 NF: 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. IITR TYPE OFINSURPNCE AIRUIR DD SU POLICY NUMBER FF PMIM E POLICY EXP MM/Ont UMTS A GENERALLIABKITY SBCGL0438200 11/15/17 11/15/18 EACH OCCURRENCE $ 1 OQO,000 X CONSIERCIALGENEPALLIABILITY DANIAGETORENTED $ 1,000,D00 CLAIMSMADE Fx� OCCUR MEO EYP N ore sem S PERSONALSADVINIIIRY $ 1.000.000 X Athletic Particivan COyeracre included GENERAL AGGREGATE S 5,000,000 GEN'LAGGREGATE LaDTAPPLES PER PRODUCTS -COMPIOP AGG S 5 000 000 Abuse-Molestat $ 100,000 POLICY PRa FX1 LOC AUTOMOBILE LIABILITY 1020013574 11/16/17 11/16/18 lecddBDINDr1 IN L LIMB S 1 000 000 BOOILYINJURY(Perpeoo) $ ANYAUM BODILY INJURY(Per accident) $ WNED X SCHEDULED AUTOS NON -OWNED X HIREDAUTOS R AUTOS PROPERTY DAMAGE S efacdderd S A UMBREUALIAB X OCCUR SJFXS0000500 11/15/17 11/15/18 EACH OCCURRENCE S 1,000,000 AGGREGATE $ 1,000,000 X I EXCESS LIAR CLAIMS -MADE DEO RETENTION S $ C.+ WDRKERS COMPENSATIONAWC400 AND EMPLOYERS' LIABILITY AN Y PROPRIETDRIPARTNER)EXCCUTNE YIN OFFICERIMEMBER EXCLUDED? IN I adandamryl"NH) MIA -7029915-2017 10/23/17 10/23/18 X WC STAN• OTH- EL.EACHACODENT 1,000,000 FL DISEAS BA DYE 1 000,000 EL. DISEASE -POLIO L 1.000.000 ffryes, dwaibeunder 0 8CRIPTION OF OPERATIONS below D Accident Medical 7311707283 11/15/17 11/15/18 Accident Med 100,000 DESCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLES (Adech ACORDIOI.AdSSona)Romft Schadda,UmwespamismgdMd) 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 POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1988-2010 ACORD ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@shenkel.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. AWC-400-7029915-2017 PRIOR NO. AWC-000-7029915-2016, 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 11123/2018 1201 a.m. standard time at the Insureds 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 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 Of Annual CLASS Remuneration Remuneration Premium INTRA 0341953 9016 State Assessments/Surcharges INTER SE CLASS CODE SCHEDUX Minimum Premium $324 Total Estimated Annual Premium $3,299 GOVGOV Deposit Premium $3,425 STATE CLASS MA 9016 State Assessments/Surcharges $2,765.00 x 4.6600% $126 Q%� f' &P This policy, Including ell endorsements, is hereby countersigned by ea 09/27/2017 Aullmixed Signature Date Service Office: 54 Third Avenue Burlington MA 01803 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insumnee, used with its permission. Brown & Brown of MA LLC dba Richard Endlar Ins 333 Elm at. suite 300 Dedham, MA 02026-6099 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: rp e Officer (Mandatory, if Applicable) .40-0134!0,59 "Social Security No. (Voluntary) 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. CAUsem\sleite\Desktop\Swa's DoeumentsWood Establishments- TempVI AX CERTIFICATION FORM.doc 0 DEPARTMENT OF PUBLIC HEALTH — COMMUNITY SANITATION PROGRAM 105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN JIAIU�A1N11AKY NAME OF CAMP: OWNER/OPERATOR: CAMP DIRECTOR: PHONE TYPE OF CAMP: WATER SOURCE: Day — Residential r` poil�Non-Sport—Medical Specialty CAMPERCAPACITY: l , Primitive/Ou ost—Ti vel 1aA1' 1 11111L I v ADDRESS: OFF SEASON ADDRESS: INSPECTED BY: "Nn" rnh�mn= ✓marked below indicates a vied inn nf430 (1nn "Yes" column = ✓ marked below indicates compliance with provision of 430.000. "N/A" column = ✓ marked below indicates that the nrovision of 430.000 is not annlicable to this camp. 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 1 Current Certificate(s) of Inspection from local 451 building inspector for sleepiqLassern ly areas. .215 Written compliance from local fire department. .300(A)(2) Private water supply: (a) DEP approval (>25 people, >60 da s/ r Private water supply: (<25 people OR <60days/yr) 300(A)(2) BOH approval, chemical & bacterial analyses, no more (b) than 45 days prior toopening wNA _.... 4 ,. 19'?�„.,. ' a �' 090(A) Procedures for Background Review of Staff and Volunteers. Staff— CORI and SORT .090(C) Previous Work History (Syis)-3 Positive Reference Checks ,% lv\ vk. � v1 Out-of-slate/International Criminal Background Checks Volunteer Staff— CORI and SORI .090(1)) Previous WorldVolunteer History (5yrs) Out-of-state/hiternationat Criminal Background Checks All Background Into - Received, reviewed, & made .090(N) determination re uii d pursuant to .090 (C&D). .091 Staff/Volunteer Orientation: Orientation Plan & O vt 7\ .159(B)(1) Attendance Records, Training on Disaster/Emergency k.,✓ .210 Plans, Health Care Policies, & Concussion Awareness Abuse & Neglect Prevention Policies & Procedures .093 Report procedures in accordance w/ M.G.L. c. It 9, § 5 1 A 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 with highlighted updates Page 1 CAM[p V, .210(A) Fire Evacuation Plan and Drills .210(B) Disaster/Emergency Plan .210(C) Lost Camper Plan / Lost Swinmter Plan .210(D) Traffic Control Plan SPECIAL CONTINGENCY PL - DAY CAMP .211(A) Camper doesn't show up for day. - » s .211(B) Camper doesn't show up at point of pick up. .211(C) Child not registered arrives. U Promotional Literature/General Requirement Copy of Policy (Parents/Guardians): Care of .159(B)(2) Mildly Ill Campers, Administration of Meds & it �3�- Emergency Health Care Provision. Meningococcal Disease & Immunization nrfo 157 CO rovided to parents/guardians amorally. N ` 190(B) Camper released only to Parents/Guardians or Designated hrdividual 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) hrform parents of right to review background tat tmue or check, health care, discipline policies and grievance apphcatioa) procedures upon request. Protocol in place to handle unrecognized persons at 190(E) camp.�o> t✓' v FTELD'I'f2IPS Written itinerary provided to patents/guardians .212(A) before departure. Source of emergency care identified; minimum l 212�) 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/swinvuer, injuries and illnesses) TRANSPORTAVON Vehicle must comply with M.G.L. c. 90 §§ 7B & 71): .250 <14 passengers & driver is camp coach, director, etc. camp vehicles may be used 0 >14 passengers, vehicle must be school bus 1 All vehicles RMV com liantw/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-rip/drop-off site; or g+ campers under 5 yrs. of age; or 2+ campers with physical handicaps. _ Camper under 7 yrs. are not transported longer than 251(1) I 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-I8 with highlighted updates Page 2 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 3 ,Lor: 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. Designated Substitute., 102(D) Substitute must meet above criteria.- Counselors/Junior Counselors: Day Camp, Non -Sport: .1 Counselor = 16 yrs.+ Junior Counselor = 15 yrs.+ `� c� 1 10000(A)(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(C)(3) All counselors 3 yrs. older than campers. Required 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(B) I counselor per 10 campers - l counselor at least 2l yrs. .159(C) 2 counselor minimum with 1 counselor having First Aid Certificate or its eq uivalent All Camps: .10l(A&B) Staffing plan to supervise campers w/ disabilities .103 during regular and specialized high risk activities. ` Aires '7777077tl t 7' M fr ggav g r Lifeguard certification, 21 yrs.+, 6 weeks previous r` jq .020 .103(A) experience in similar supervisory position. At least 16 years old with [American Red Cross n Lifeguard Training Cert/Royal Bronze Medallion/Boy \\�/ .020 Scouts Lifeguard Cert/YMCA Lifeguard Cert]* AND .103(A) CPR AND First Aid Certificate* *Or their equivalent mom T1exlthGare. < t�nt�... �MD/DgO 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 administration Develop a written list of all medication .160(C) administered at camp kl� HCC Provided '& Documented Trainings: .160 HCS required ttainings, signs of hypo/hyperglycemia, f (E)(G)(H) diabetic plan management, and administering epi -pen v with evidence of competency 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 3 .020 MD P RN LPN or... 9(C)(G) 8 vis.+. Fust Aid &CPR certified .160 ALL Medications stored in Original Containers (A)(I) and meds properly disposed of with dis osal log. .160(B) Meds stored in secured manner (ACA standards) Medication refrigerator tern` 36T - 46T / t Written Medication Administration Poky: .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 parenttguardian sign off. .155 Medical Log: i Readil available and sigpedb authorized staff person Injury Report completed for a fatality or serious .154 in'ur . Coov sent to MDPH and BOH. V t Day / Residential Camps - Infirmary provided .161(A) Residential Camps - Easily recognizable and accessible during the da and night, .453 Lighting provided in infirmary. Residential Camp - Area for isolation of ill child .161(B) with ability to provide negative pressure. 161(C) First Aid Vit: meet ANSI Z308.1-2015 standards Minimum: I Class B kit and t 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 Into, .160(D) Written Parental Permission for Meds, Emergency Care, f .190(A) and Self -Administration of epi -pen or insulin Camper > 18yrs: Emergency Contact Info Residential, Travel, Trip, Sports—Medical History & .151(A)(B) physical within past 18 months Dav—Medical history sieved off by Parent/Guardian .152 Number of records checked: .152 .153 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 4 /'/t .. J�� ,, .��, � � y'"M �" u -J,. y^L"r✓Ru--0,vl' r P, ' _ ,`•u�'.`�i �. M�.�+N r-r"VJ'_/+' �Uµ.. 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 rI H Com liant w/ VGB Act & Pool Fence Requirements Bathing Beach: in compliance with 105 CMR .432 445.000 - weeldy water sampling, water clarity, and ring buoy resent .204(C) All camps in compliance with 105 CMR 432.000 cbria M.G.L. c, 111 § 127A %z.. Lao'w .204(C) Swim test to classify swituners by ability at pools .430(B) and beaches (Christian's Law). Proper supervision at swimming venue: .103 1 lifeguard per 25 campers .204(D) I counselor per 10 campers Plan to check swimmers - "buddy system" 50+kids ht/near water Aquatics Dnector must be present Swimming areas clean and safe, no swimming at .204 undesignated sites or at night without lighting. .204(1i) Piers, floats, and platforms in good repair, �.gv: Watercraft: equipped with USCG approved .2040 flotation devices and worn by all campers and staff 10303)(4) engaging in watercraft activities.(paddle boards included) NI IIU White water, hazardous salt/fiesh water activities: .204(1) Campers certified with ARC Level 4+ Certificate or equivalent. White water, hazardous salt/fiesh water activities: .103(13) Minimum 2 counselors in separate watercrafts I counselor per 10 campers (counselor must have lifeguard or U small craft safety and basic water rescue cert, or equivalent) CRAFTS: .205 Equipment in good repair, safety precautions taken. h q PCAYGROUNll/ATHGETIC FQMTVMI T: .206 Equipment properly maintained, fields/surfaces / (A)(B) free of holes/accident hazards. 206 C Playground equipment securely anchored with no O concrete under/around it, and pliable swing seats. ARCHERY:Names/Certs: .202(A) Equipment in good condition, stored locked. 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 permission. .103(;) 1 counselor per 10 campers at range at all times. 430 -Camp Inspection Form 3-27-I8 with highlighted updates Page 5 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 6 Names/Certs: Firearms in good condition, stored in locked 201(A) cabinet. Ammunition locked in separate cabinet. w+'I .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(0) permission. Direct Supervisor: NRA Instructor's certification .103(D) and maintain compliance with applicable M.G.L.'s 1 counselorpet- 10 campers HORSE BACK RIDING: `: ames/Certs: Excursions: 1 Certified Instructor per 10 campers w�h .208(A) Mininnum 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(13) Licensed stable in use. V CUALLENGE COURSES AND CLIMBING WALLS: operator: Licensed and maintained in accordance with .103(G)(1) 520 CMR 5.00 -Amusement Devices Y4 Y .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. All structural and interior elements maintained in l .454 good repair and in a safe and sanitary condition. V SM, PING AREA-AESIDENTIAL.CAI VS; :..: Provide adequate space: Single bed: 40112 /person; Yv`.cj 458 Bunk bed: 350person ; 50112/person requiring special equipment Provide separate bed/cot per person with: .470 6 ft. between individuals heads; and 3 ft. between single beds & 4'/z 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 maintaine din .454 good repair and in a safe and sanitary condition. TENTS Clearly labeled as fire resistant. No open flame in / 217 or near tent. v 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 6 TOI LETS/HANDWASH smrxs/S OWERS .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 1 more toilet for each additional 10 persons of that gender. Toilets less than 200feet from sleeping rooms. 372 Toilet paper provided. 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: I sink per every 10 people Adequate # of showers (no duckboards): .374 Residential Camp: 1 shower/tub per 20 people .378-.380 Campers with special needs provided sanitary facilities meeting their needs. .453 Lighting provided. Adequate ventilation provided for all bathhouses, .375 dressing rooms, shower rooms, and toilets for indoor/ontdoor vols. Hot Water insufficient quantity and pressuiei .376 Handwash Sink: 110°F -130°F ShowerMattimb: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. ry(5 .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. Residential/Day Camps: Immediate access to reliable phone with posted dialing instructions & s .209 (or have readily accessible) telephone numbers for HCC, police, emergency medical services, fire dept. .213 Emergency Communication System Site location does not cause undue traffic hazards .450 and is accessible at all times. 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 7 - C�Rtxt1ND5 y OEM .165 Tobacco use prohibited at camp. Alcohol and marijuana use prohibited during camp .166 operating hours. Proper storage and operation of power equipment / 207 Power tools stored in locked place. / Flatnmiable and hazardous materials labeled and .214 stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. V FOODARVECE- Food service in compliance with 105 CMR 590.000, Minunnun Standards for Food .320 Establishments. Prominently displayed food permit from BOH. USDA Summer Food Service Program written ✓ .320(B) documentation ofcompliance 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 nvast 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 fiom .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. � IJ .453 Lighting provided in kitchen and dining area. V .471 Sleeping prohibited in food areas. MAIN`I'ENANCP Off' RECO S . 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 with highlighted updates rage 8 430 -Camp Inspection Form 3-27-18 with highlighted updates Page 9