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Board Members Chairman Christopher M. Montiverdi Vice-Chairman Debra Rigiero Member Robin Wood Director of Public Health Darlene M. O’Connor BOARD OF HEALTH |
Phone: 508-892-7008 FAX: 508-892-7500
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
Name of Camp: ________________________________________________________
Site Address: ________________________________________________________
Site Telephone: ________________________________________________________
Name of
Office Address: ________________________________________________________
Telephone Number: _____________________________________________________
Name of
Address: ______________________________________________________________
Telephone Number: _____________________________________________________
Name of Health Care Consultant: __________________________________________
Address: ______________________________________________________________
Telephone Number: _____________________________________________________
Type of Camp: Day ____ Residential ____
Hours of Operation _____________________________________________________
Dates of Operation: Opening ____ Closing ____
Swimming Pool: Yes ___ Pool Permit Number ________ No ___
Meals Provided: Yes ___ Food Permit Number ________ No ___
Signature of Applicant: __________________________________________________
Official Title: ________________________________ Date: ____________
THIS DOCUMENT IS MEANT TO BE USED AS A GUIDE AND SHOULD NOT BE USED AS A SUBSTITUTE FOR INSPECTION. ALL CAMPS SHALL HAVE A COPY OF 105 CMR 430
Check List for Recreation Camps For Children Application (105 CMR 430)
Name of Camp: ________________________________________________
Application & Fee Received in Health Department Office
Occupancy Permit (if Applicable) (.451)
Water Quality Report (if Applicable) (.303)
Policies & Procedures On Background Review Of Staff & Volunteers (.090)
Orientation Plan For Staff & volunteers (Roles & Responsibilities) (.091)
Policy On Reporting Of Suspected Child Abuse (.093)
Discipline Policy (“Time-Out”) Or Similar, Must List Prohibitions) (.191)
Fire Evacuation Plan (Drill W/In First 24 Hours) (.210) (A)
Disaster Plan (Transportation Resources, Emergency Shelter, Etc.) (.210) (B)
Lost Camper Plan (Explain Procedure, Include Calling 911) (.210) (C)
Lost Swimmer Plan (Lifeguard Procedure For Shallow/Deep Areas) (.210) (C)
Traffic Control Plan (Methods For Reducing Hazardous, Drop Off/Up) (.210) (D)
Contingency Plans (No-Show Camper, “Last Minute” Camper) (.211)
Camper Release Policy (Written Designee To Pick Up) (0190) (B)
Promotional Literature (0190)
CORI/SORI Reviewed For All Staff & Volunteers!
Medical Forms & Immunizations for Campers/Staff
First Aid Kit
Health Policies/Consultant/Supervisor
Site Inspection
Full Compliance With All Parts of 105 CMR 430 as applicable
Water Source (Well Test Results)
Sewerage Disposal (Title V Inspection/Town Sewer)
Health Care Consultant Agreement
Name: __________________________________________________________________
Age: ___________________________________________________________________
Coursework in Camping Administration: ______________________________________
Previous camp administration experience: _____________________________________
Health Care
Consultant
Name: _________________________________________________________________
Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): ____________________________________________________
MA License Number: _____________________________________________________
Health Supervisor
Name: __________________________________________________________________
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: __________________________________________________________
American First Aid Certificate: ______________________________________________
Expiration date: __________________________________________________________
Previous aquatics supervisory experience: _____________________________________
________________________________________________________________________
Firearms Instructor
Name: __________________________________________________________________
National Rifle Association Instructor’s card (or equivalent): _______________________
Date Certified: ________________________ Expiration Date: ________________
Horseback Riding
Instructor
Name: __________________________________________________________________
License Number: ____________________ Expiration Date: ________________
Stable
Location: _______________________________________________________________
Licensed in accordance with MGL Ch. 111 § 155, 158: Yes ____ No ____
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.
Note: Applications are subject to a 45 day review.