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HomeMy WebLinkAboutLITTLE CARPENTERS SHOP - CAMP LITTLE CARPENTERS SHOP }o COMmkc�icaiitx� Wad ; S NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CAMP/LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the ruies and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 St, 2014 unless sooner suspended or revoked. 6/19/2014 Wayne Miller, M. D., Chairman Board Paul J. Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee Renewal Fee By Thomas A. McKean, RS, CHO, Health Agent �' � ��ub ( iC, hvb F" *7V Pell 771 . , Cep erg - s� 7 zoos s°8 077i- S3se 4 orwi V cw, U P 7%. OZ �ON�e rraw7�(1Zp�¢ 1n a.o�E� Jun 19 14 01:29p Carpenters Shop Ministrie 5087715450 p.2 •"•• •`�lUII• 12. LU 16! I .U/I lrl Ivu. 7U4'I r. 1 MALTU CAtitt?CONSFlr IrA MT Ad-nKga1►pwr NA ME 4F CAMP �; !Q � 1 f AnhRPgS OFCAMP t ► "' Thc;MwsaJutrAts neVjrUnonl q l•Pul►1ic Hcatlh rt l r�rilaiie,ru li r rcCt+alsr»al Cam rOr child105 11t5 .•.'�?i. , 4"0.000,mquir�dratW1 r0=41dvnal rol]1 do CMIt r7sponsib1litks Of cps rOt rhiidrr.R hw�;a health ears CeahatJtatht.•lhe reBulationand , ptrson are described below, 4-10.1 i9(A) Tlanith Consultntu A designrtled Mnssootnretrc liexrut:d lrhyaid:th ar�-c -r hyAician a.eistwu With t,odiarrie train'"g as the m ' NaC9l�m+�'or Camp-3 p a hltalth caneconankent.The t:emullant shall: I• Au0r in the developmenr of The earap's health rat policy as deso&W 11t 103 CMR 43D 2. Revim mod a�+mveOr policy initildly and at 1"n turnugl IEteretHrr .159(B}; 3. Approve an in Y , Y des the t>ohtryr: 4. Review oW approvs the first aid!raining of tht:steal S. &availableforoosuukmianat gill limes;and 6. !Develop and sip wrinta Orden 10 be followed by the D J_A,4la ldt supzrvi,or in rho adm:nistruaion or hi.0+mrtclawd dutkm. l{the health supervisor is not a lit Ma'd beatth ICBM professional authorized io:1dmillis1cr p oriplign taedlCtlt(ons,the admiulsrmlion orme4:eadons shal I be tinder ilia protbrsiothl avCtSighT of the ltoAith care ennsulmnt. IAA CMR 430.I'(10(� 430.t 9 D(8) FJUU Cace Pow A wrium inedttaal policy,approved byibe local bonrd Ofbeatth and by the ramp lta drh 0s te'cOnsudtant.SUcJ1 policy shall laelude,but not be litalieed to, daily health supervision,infoelion wntrul,handling cif hrxlllh enrT8rnei`M sud eooidmMs, nvaifablo anbularxx;serviCO.PV irliun for rMwiosl, 11Ur,Ina and'ht W saiyim,the nutme Of the desigmted o .site C=M health supetvisorr the mine,oddness raid plitnto Umberdithe camp health mm toetsntrmtt required by 105 CMR 410.119(A)health supervisor rigs I Ml by 10S CMR 430.154(13%irappllcable. and 11rC name of the 430.160(C) Adeoiois adon ofl4ledlear on The health care coreedlarht sltntl seknnwladge in wr;tinga lire oral! MCWpatiCrtrc adrrti Oahe camp. I meet Il+t:rsquiremeuta of tJhe health cars eRnsvltanr its d"wiWd in M CMK 139159(A).1 have reviewed the mferaeead regnlstiOm and andanesad the nnlxmaihilitim of the I*,",�,and grcc 19 assist dtW camp regardieg the etarn Pwfnt NamC - �l Title VV sipatuft . MALioonss/ltegistration Nambtr. ..-_.._._ Addrw 5ds Trlelh►ione Npmhcar Data: Bass River Pediatric A.SSOC,,P.C. e:trwy ' 237 Stallon Avenue South Yarmouth,MA 02664 (609)394-21 16 s Town of Barnstable Permit Fee: "THE T eo Regulatory Services $75.00 Thomas F. Geiler, Director 6 9. 10� Public Health Division RFD MA'S A Thomas'McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: Si.e Address: c;;�'7® �,� ;s She Telephone: SOT- - 7 7 1— S9 S n Name of Camp Owner: up K Office Address: Telephone Number: 0_-n g - s Name of Camp Operator (if different): Address NO Telephone Number: i Namcry of Healt are Consultant: �q�he_u, & 1daq<2 m1a KK"vq.r Address: Telephone Number: Ong- _ 2//4 - Tyne of Camp:lEa�) Residential W `'' Hours of Operation: `7 Dates of Operation: Opening: 2,c) Closing: 3 1 L Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes N - Meals Provided:Yes No. (If yes: Food Permit Number ) Signature of Applicant• Official Title:6f,�ter-.l[7F Date:/ _/ 4 See the next page for a list of documents that must be completed and submitted,before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance.. This will expedite the licensing process. I el 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. ■ Staff information forms (see attached) (SORI/CORI With Juvenile checks)* ■ Procedures for the background review of staff(105 CMR 430.090) Copy of promotional literature (105 CMR 430.190(C)) Procedures for reporting suspected child abuse or neglect(105 CMR 430.093) ■ Health care policy(105 CMR 430.159(B)) ■ Discipline policy (105 CMR 430.191) Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan (105 CMR 430.210(B)) ■ Lost camper plan (105 CMR 430.210(C)) ■ Lost swimmer plan (105 CMR 430.210(C)) ■ Traffic control plan (105 CMR 430.210(D)) ■ Day Camps—contingency plan(105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) ■ Current certificate of occupancy from local building inspector (105 CMR 430.451) ■ Written statement of compliance from the local fire department (105 CMR 430.215) ■ 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 wastewater New for 2003 Camp Director Name: U�—� Age: '7g Coursework in camping administration: Previous camp administration experience: U Health Care Consultant Name: MA-tke-yy C►��a �a Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): MA License Number: A-2 ?4c4 Health Supervisor Name: &ed tr Age: Type of Medical License, Registration or Training (See 105 CMR 430.159(C): Aquatics Director Name: N 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:— NA National Rifle Association Instructor's card (or equivalent): Date certified:_/ / Expiration date: / / Horseback Riding Instructor Name: N_� License Number: Expiration date: Stable Location: N Q 1 . Licensed in accordance with MGL Ch.I 11 § 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. (file: Q:\Health\Camps\Application.doc) Department of Public Health Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: LAI C."rlaokf r ADDRESS: 2-70 OWNER/OPERATOR: OFFSEASON v e-r l l elX ADDRESS: CAMP DIRECT R: ter( k'oboc& INSPECTED BY: T OF CAMP: (Circle) ATER DATE OF INSPECTION: ay Residential SOURCE:�wn (���1�(i port/NoSport) CAMPER Trip Primitive Travel CAPACITY: "No column = N" marked below indicates a violation of 430.000. "Yes column = N" marked below indicates compliance with provision of 430.000. "N/A column = N" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No N/A Comments Permits .451 Current Certificate(s) of Occupancy from local building ins ector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval V/ >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply - BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. V .090 (C) CORI and SORT, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contin encplans - Day Camp: .211 A Camper doesn't show up for day. B Camper doesn't show up at point of pick up. C Child not registered arrives Contingency plans - Primitive, Travel and Trip: .212 A Itinerary daily - copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 Regulation Yes No N/A Comments Promotional literature/packet contains: .159 (B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background / check, health care, discipline policies and v grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. Required Counselors Ratios .101 (A) Residential and Day Camps: / 1 staff per 10 campers over 6 yrs. 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: / 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. ✓ Vvn, I�e� 1 counselor per 2 severely disabled campers. I9 2 s Regulation Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for / Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health Care Consult n pp U e: Nth � J A GC6 3Rro X - 7�I-S�S D NP PA(w/pediatric training) D �/ eck for Health Care Consultant Agreement 0. .159 (C) Health Supervisor(on ite at all times) RV l Ind P certified OR,RN L .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refrigerated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. .155 Medical log book- bound, pre-numbered pages, ink entries, no skipped lines. .161 (A) Infirmary provided - day and resident camps / Exterior light- resident cams .453 Lighting rovided in infirmary. .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. .150 Health, record for each camper and staff: / -emergency contact info v -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 Regulation Yes No N/A Comments Immunizations: .152 (A) Campers and staff under 18yrs: Number of records checked: MMR: 1st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: i 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability. .204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. .204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 Regulation Yes No N/A Comments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ around it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked / cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked / area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable L/ Cabins/Structures: .457 Day Camp provide shelter for on-going camp / activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Frovide adequate space: / 40 sgft/person in single bed V 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special e ui ment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 Regulation Yes No N/A Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp ,..provided. .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 sgft/person in bunk bed. Toilets/Showers .360 Proper sewage disposal ,�,,, Vver- .301 Plumbing in good working order .370 Adequate# of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. / Screen doors self-closing. .373 Adequate# of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374 Adequate # of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than © 112°F ,„��, f n� c�n.h AAL .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. 472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. 1 .350/.355 Proper storage and disposal of solid waste. 6 i Regulation Yes No N/A Comments .207 groper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food / �T�y1 t'1►� ©vn2. Establishments. Permits posted in food service facility. .330 Nutritious meals that include a variety of foods / served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from / home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food / service areas. Screen doors must be self-closing. .453 1 Lighting rovided in kitchen and dining area. 1 .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE reemei�� ajad A aulv CCMP Imo, Le W�L- PecIC,L'e COPW 0 ei /v IDA (f Camp Director's Signature Date G49114 Health Inspector's Signature I r<0�n Date 1 L� 7 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CAMP/LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 St, 2013 unless sooner suspended orrevoked. 6/13/2013 Wayne Miller, M. D.,Chairman Board Paul J.Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee Renewal Fee By Thomas A. McKean, RS, CHO, Health Agent Town of Barnstable Permit Fee: Regulatory Services $75.00 Thomas F. Geiler, Director + IIARNSTABLE, ' ^ i639, Public Health Division 9• �� . ArEO MAC A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office:. 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: 3.r D r�d-E.�, .,� ram;s�,=,Q Site Address: 476 C�,n. ire;�.ra�; ",D LL Anc,n Site Telephone: k3DR_ 7-7 _ ,3,3� Name of Camp Owner: L e Q-.r� ! OkQdQe-- Office Address: S � Telephone Number: 5-7 54 7 Name of Camp Operator(if different): Address: Telephone Number: Name of Health Care Consultant: m"kQ-'m Address: r-1 Telephone Number: ) Type of Camp: Day4_Residential Hours of Operation: 7,_-3,o Dates of Operation: Opening:jrv'nQ_ Closing: .. Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes No Meals Provided: Yes No (If yes: Food Permit Number ) atureofApPlicantv&,-.-.,,,—e.@ ,e- -.e Ae�eao-'2'a cant Official Title lma- Dater/9 . /Z5 � See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. Q\CAMMApplication 04.doc Department of Public Health Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: A ' k a &-rS ADDRESS: =1) ® OWNER/OPERATOR: I VOFFSEASON Q Te"C- ) P-0 @Ae, ADDRESS: CAMP DIRECTO . � INSPECTED BY: j S TYPE OF CAMP: (Circle) WAT �,�/ / DATE OF INSPECTION: Residential SOURCE: vj- - (Sport/N CAMPER po boh Trip Primitive Travel CAPACITY: "No column = marked below indicates a violation of 430.000. "Yes column = marked below indicates compliance with provision of 430.000. "N/A column = N" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation- Yes No N/A Comments Permits .451 Current Certificate(s) of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply- BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORT, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. 7 .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contingency plans - Day Camp: .211 A Camper doesn't show up for day, B Camper doesn't show up at point of pick up. C Child not registered arrives Contingency plans- Primitive, Travel and Trip: 212 A Itinerary daily- copy to parents B Source of emergency care 190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 .Re ulOtion Yes No' N/A Comments Promotional literature/packet contains: .159 (13)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background check, health care, discipline policies and rievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, r Yo" director, etc. private vehicles may be used. V/>14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of ex erience. .102 (D) Designated substitute when director off-site �� 1 ��� >12 hrs. Sub must meet criteria above �/ l Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 Ali counselors 3 yrs older than campers. Required Counselors Ratios 101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. 1 staff er 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 •Re ulation Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and 9 / First Aid cert. or their equivalents. List names. L/ .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health Care Consultant I�►Y,? � , Name: YYa-vall) NP PA(w/pediatric training) Check for Health Care Consultant Agreement .159 (C) Health Supervisor(on site at all times) Name: 18 s, Fir�t ' n"CPertified OR, MD PA NP RN ZFN .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refri erated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious - in'u . Copy sent to MDPH. on .155 Medical log book- bound, pre-numbered pages, ink entries, no skipped lines. .161 (A) Infirmary provided day and resident camps Exterior light- resident camps .453 Lighting rovided in infirmary, .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 Re ulation Yes No N/A Comments Immunizations: .152 (A) Campers and staff under 18yrs: Number of records checked: MMR: 1 st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: j 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities ..190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety, .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers -"buddy system" .204 C Swim test to classify swimmers by ability, .204 (A) Swimming areas clean and safe, no swimming at VIt undesi nated sites or at night without lighting. .204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 Re ulation Yes No N/A Comments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ V around it, pliable swing seats. Firearms .201 Single shot rifles only, .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going carnp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sgft/person in single bed 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special equipment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 Re ulation Yes No N/A 'Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame �r nearby. .458 35 s fll erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional ✓ toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate#of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374 Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that ✓ meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 112°F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. VO/ No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 Proper storage and disposal of solid waste. r 6 .Regulation Yes No NW Comments .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service v facility. .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closing. .453 1 Lighting rovided in kitchen and dining area. 1 .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Camp Director's Signature ZIP Date Health Inspector's Signature Date 7 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CAMP/LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG.3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 st, 2012 unless sooner suspended or revoked. 6/12/2012 Wayne Miller, M. D.,Chairman Board Paul J.Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee By Renewal Fee Thomas A. McKean, RS, CHO, Health Agent f ` Department of Public Health Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: ' �, ADDRESS: 7 p �D,n „rr,°ca A C OWNER/OPERATOR: 9 OFFSEASON up-r i ADDRESS: CAMP DIRECTOR: ,ter �(�,10e INSPECTED BY: lo,,, l",. S TYPE OF CAMP: (Circle) WATER DATE OF I SPECTION: Da Re ' tial SOURCE: (Sport/ oS CAMPER Trip Primitive Travel CAPACITY: "No column = N" marked below indicates a violation of 430.000. "Yes column = N" marked below indicates compliance with provision of 430.000. "N/A column = N" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No N/A Comments Permits .451 Current Certificate(s)of Occupancy from local l building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply- BOH approval and chemical and bacterial analyses <25 people, <60.da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORI, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting / procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contingency plans - Day Camp: .211 A Camper doesn't show up for day, B Camper doesn't show up at point of pick up. C Child not registered arrives Contingency plans - Primitive, Travel and Trip: .212 A Itinerary daily- copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 Regulation: Yes, I No N/A Comments Promotional literature/packet contains: .159 (13)(2) Copy of policy re: care of mildly ill campers, /01 administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background check, health care, discipline policies and grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. b >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 1 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. Required Counselors Ratios .101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. / 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 Re' ulation Yes No N/A Comments. 103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health Care Consultant Name: Ma 6(46'SGro NP PA(w/pediatric training) -01'ekk for Health Care Consultant Agreement .159 (C) Health Su ervisor(on site at all times) e f �AR n CPR ertified OR, v N .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refri erated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. 155 Medical log book- bound, pre-numbered pages, ink entries, no skipped lines. .161 (A) Infirmary provided -day and resident camps Exterior light- resident camps .453 Lighting rovided in infirmary, .161 B Area for isolation of ill.child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 I Re Ulation .: Yes `} No NIA Comments Immunizations: .152 (A) Campers and staff under 18yrs: Number of records checked: MMR: 1 st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv IV Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DTlTd He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability. 204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. .204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 it Re' 'lation Yes No N/A Comments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ around it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked / cabinet. Ammunition locked in separate cabinet. V Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. t/ .453 1 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sgfUperson in single bed 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special equipment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 -Re ulation Yes No N/A Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby, .458 35 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal IL �✓v� .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate#of sinks: / Day camp: 1 per every 30 people �// Residential Camp: 1 per every 30 people .374 Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 112'F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) 213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 1 Proper storage and disposal of solid waste. 6 Re ulation Yes No N/A Comments .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. P. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service facility, .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closin . .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE '2-0 CCIAo Camp Director's Signatu a V�A Date 1(2-/Z1 ; Health Inspector's Signat e Date /Z 7 F .,1 Town of Barnstable Permit Fee: opTF1e ro Regulatory Services $75.00 Thomas F. Geiler, Director `t RARNb'rABLE, ' "As5 Ok 039, 6gq Public Health Division � �ArF° a Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 - Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: - iLe-175, Site Address: Site Telephone: 6,77 7'7/-, - Sin Name of Camp Owner: - Office Address: alb y , a Telephone Number: S S o g' - Name of Camp Operator (if different): Address: Telephone Number: Name of Health Car 'e Co sultant: �� iA M� 1 Address: Telephone Number: CL c� Type of Camp: ay Residential �� �� 12 ►, P P Hours of Operation: 4 Dates of Operation: Opening: 1Z Closing: Swimming Pool: Yes No (If yes: Pool Permit Number Bathing Beach: Yes No Meals Provided: Yes • (If yes: Food Permit Number ) Signature of Applicant: Official Title: See the next page for a list of documents t�atust be completed and submitted before your application for a license can be fully processed.You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. QACAMMApplication 04.doc 4 , r 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 -Dy the Department of Public Health, Division of Community Sanitation for additional assistance with developing the following documents. • Staff information forms (see attached) (SORI/CORI With Juvenile checks)* • Procedures for the background review of staff(105 CMR 430.090) ■ Copy of promotional literature (105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) • Health care policy(105 CMR 430.159(B)) • Discipline policy(105 CMR 430.191) ■ Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan (105 CMR 430.210(B)) ■ Lost camper plan (105 CMR 430.210(C)) ■ Lost swimmer plan (105 CMR 430.210(C)) ■ Traffic control plan (105 CMR 430.210(D)) ■ Day Camps—contingency plan (105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) • Current certificate of occupancy from local building inspector (105 CMR 430.451) ■ Written statement of compliance from the local fire department (105 CMR 430.215) ■ 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 wastewater New, effective 2003 1 QXAMMApplication 04.doc Camp Director Name: j Age: Coursework in camping administration: �p Previous camp administration experience: Health C re Consultant (L Name: �k. 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: QACAMMApplication 04.doc t ' Firearms Instructor Name: National Ri e Association Instructor's card (or equivalent): Date certified: /_/ Expiration date:—/ Horseback Riding Instructor Name: ( � License Number: Expiration date: Stable l A 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,. States Website on Regulations for Recreational Camps for Children (105 CMR 430.000) http://www.state.ma.us/dph/dcs/campre.pdf QACAMMApplication 04.doc of y HEALTH CARE CONSULTANT AGREEINIENT ,Q--r-- ►!}P M NAME OF CAN P ADDRESS OF CAMP The Massachusetts Department of Public Health regulations for recreational camps for children, 105 / CMR 430.000, require that all recreational camps for children have a health care consultant. The regulation and responsibilities of this person are described below. 430.1 59(A) Health Care Consultant A designated Massachusetts licensed physician, nurse practitioner or physician assistant with pediatric training as the camp's health care consultant. The consultant shall: 1. Assist in the development of the camp's health care policy as described in 105 CMR 430.1 59(B); 2. Review and approve the policy initially and at least annually thereafter; 3. Approve any changes in the policy; 4. Review and approve the first aid training of the staff, 5. Be available for consultation at all times; and 6. Develop and sign written orders to be followed by the on-site health supervisor in the administration of his/her related duties. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. 105 CMR 430.160(C) 430.159(B) Health Care Policy A written medical policy,approved by the local board of health and by the camp health care consultant, Such policy shall include, but not be limited to, daily health supervision, infection control,handling of health emergencies and accidents, available ambulance services, provision for medical, nursing and first aid services, the name of the designated on-site camp health supervisor,the name, address and phone number of the camp health care consultant required by 105 CMR 430.159(A) and the name of the health supervisor required by 105 CiviR 430.159(E), if applicable. 430.160(C) Administration of Medication The health care consultant shall acknowledge in writina a list of all medications administered at the camp. I meet the requirements of the health care consultant as described in 105 C1VfR 130.159(_A). I have reviewed theses referenced regulations and understand the responsibilities of the position and agree to assist this camp regarding the same. ANA4(a.3etlLSevro tom• © + Print Name Title Signature MA License/Registration Number Address / Telephone Number Date: l 8112 Bass River Pediatric Assoc.,P.G. 237 Station Avenue South Yarmouth, MA 02664 (508) 394-2116 February 24,2000 I +:7 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS f 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CAMP/LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 St, 2011 unless sooner suspended or revoked. 6/17/2011 Wayne Miller, M. D.,Chairman Board Paul J. Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee Renewal Fee By Thomas A. McKean, RS, CHO, Health Agent a. Town of Barnstable Permit Fee: Regulatory Services $75.00 Thomas F. Geiler, Director sa tasrn�cr MASS Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN 0 CD Name of Camp: Site Address:, ' S it Telephone: — 7 71 0 rr o cu Name of Cam. Owner-0-�- Qv\ - Sk i 0 C Office Address: 0 ,, � ,,r•� o. Telephone Number: �g _ �'3� �- ck 7a Name of Camp Operator(if different): Address: ao �- �S� - ?'l�-y-�'r� L> `ffn— a. Telephone Number: -'' Name of Health Care Consultant: o CD Address: _ c> Telephone Number: o Type of Camp: Days Residential Hours of Operation: Dates of Operation: Opening: 4�—a p // Closing: Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes No / Meals Provided: Yes No (If yes: Food Permit Number ) � p Signature of Applicant: Official Title: JD ����,. ,Y Date: c9e/ See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete those documents as soon as possible and submit them in advance. This will expedite the Camp Director j Name: Age: 75` 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: )'a/L �. 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: 1 1 ` 1 l f Firearms Instructor Name: National Rifle Association Instructor's card (or equivalent): Date certified: / / Expiration date: / / Horseback ,';ding Instructor Name: !� License Number: Expiration date: / / i 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. States Website on Regulations for Recreational Camps for Children (105 CMR 430.000) http://www.state.ma.us/dph/dcs/campre.pdf a (file: QACampsUpplication 04Am) Town of Barnstable. Permit Fee: Regulatory Services $75.00 Thomas F.Geiler,Director IIARNWABM KAM Public Health Division -Th.o4nas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: Site Address: :;� -2 0 0.�rr,,f.,N U rN, C- 111� Site Telephone: 7 7 _ 67 3,g'2) Name of Camp Owner: /p- e-r Office_Address: , Telephone Number: , uj Name of Comp Operator(if different): C0 Address: k Te-lephone"Number: CD �... M lame of Health Care Consultant: :- Address: Telephone Number: Type of Camp: Day Residential Hours of Operation: 'j ` 3 -- S ` 3 Q Dates of Operation: Opening: 6, / Closing: 8 /0 Swimming Pool: Yes No. (If yes: Pool Permit Number ) Bathing Beach: Yes No, Meals Provided: Yes Not (If yes: Food Permit Number ) Signature of Applicant: 1 Official Title;re LDate: G `See the next page for a list of documents that must be completed and submitted before your application fora license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. t ;I A Required Documents See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV - 105 CMR430.000 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 forms (see attached) (SORI/CORI With Juvenile checks)* ■ Procedures for the background review of staff(105 CMR 430.090) ■ Copy of promotional literature (105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect(105 CMR 430.093) ■ Health care policy(105 CMR 430.159(B)) Discipline policy(105 CMR 430.191) ■ Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan(105 CMR 430.210(B)) ■ Lost camper plan (105 CMR 430.210(C)) ■ Lost swimmer plan(105 CMR 430.210(C)) ■ Traffic control plan(105 CMR 430.210(D)) ■ Day Camps—contingency plan (105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) ■ Current certificate of occupancy from local building inspector(105 CMR 430.451) ■ Written statement of compliance from the local fire department(105 CMR 430.215) ■ 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 wastewater "New for 2003 Camp Director Name: Age: Coursework in camping administration: / Previous camp administration experience: Health Car Consultant Name: ' ��� Y:�4d Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training): MA License Number: Health Sup isor Name: xV Age: J Type of Medical License, Registration or Training (See.105 CMR 430.159(C): Aquatics Director t�l 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: i� Firearms Instructor N�� Name: National Rifle Association Instructor's card (or equivalent): Date certified: / / Expiration date:—/ / Horseback Riding Instructor NI 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. (file: Q:\Healfh\Camps\Application.doc) NUMBER - FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CARPENTERS SHOP - FCA 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMP OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31st, 2010 unless sooner suspended or revoked. 6/11/2010 Wayne Miller, M. D., Chairman Board Paul J. Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee \w Renewa_ I Fee By � 3 Thomas A. McKean, RS, CHO, Health Agent Department of Public Health Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONALCAMP FOR CHILDREN.'INSPECTION REPORT NAME OF CAMP: ADDRESS: -'JL e OWNER/OPERATOR: OFFSEASON Q-r y— ADDRESS: CAMP DIRE OR: She INSPECTED BY: �► TYPE OF CAMP: (Circle) WATER DATE OF INSPECTION: a Residential SOURCE (Sport/NoSport) CAMPER / Id 10 Trip Primitive Travel CAPACITY: "No column = N" marked below indicates a violation of 430.000. "Yes column = N" marked below indicates compliance with provision of 430.000. "N/A column = "4" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No N/A [Comments ffi Permits .451 Current Certificate(s) of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply- BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORT, previous work history, 3 references, out of state/international criminal back round checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills V11 .210 B Disaster Plan V00- .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contingency plans- Day Camp: .211 A Camper doesn't show up for day, B Camper doesn't show up at point of pick up. C Child not registered arrives 1/ Contingency plans - Primitive, Travel and Trip: .212 A Itinerary daily - copy to parents B Source of emergency care 190 Camper released only to parents or parent- designated individual in writing. Other plan a roved in writing by BOH. 1 Re elation Yes No N/A Comments Promotional literature/packet contains: .159 (13)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background / check, health care, discipline policies and grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to camp LI-10 Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp ✓' administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 rs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. Required Counselors Ratios .101 (A) Residential and Day Camps: 00, 1 staff per 10 campers over 6 yrs. 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 Regulation Yes No NIA Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health Care Consultant Name: MD 9N PA(w/pediatric training) Chec for Health Care Consultant Agreement .159 (C) Health Su ervisor on site at all times) Name: 18 yrs, First Aida d CPR certified R, MD PA NP RN LPN .159 B Health Care Policy .160 A Medication stored in original containers. ✓ .160 (B) iMeds stored in secured cabinet and if necessary refrigerated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious iniury. Copy sent to MDPH. .155 Medical log book- bound, pre-numbered pages, ink entries, no skipped lines. .161 (A) Infirmary provided - day and resident camps Exterior light- resident camps .453 Lighting rovided in infirmary. .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 Re Oation Yes No NIA Comments Immunizations: .152 (A) Coampers and staff under 18yrs: Number of records checked: MMR: 1 st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td ,persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) #Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) pampers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety, .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability, .204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. 204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 Re-.u ation Yes No N/A Comments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ around it, pliable swing seats. Firearms .201 Sin le shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers (minimum 2 counselors) V .208 A Riders must wear hard hat L/ .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sgft/person in single bed 35 sgfUperson in bunk bed 50 sgfUperson in sleeping area requiring special e ui ment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 `Re ulation Yes No N/A Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats.for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate#of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374. Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 112°F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) ' ,213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 Proper storage and disposal of solid waste. 6 Re` htion Yes No N/A Comments .207 Proper storage and operation of,power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. ' .401 Weed and noxious plant control.. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Q IJ�'l,� l^ Establishments. Permits posted in food service facility. .330 Nutritious meals that include a variety of foods served. Menus posted. 331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closing. .453 Lighting rovided in kitchen and dining area. 1 .471 1 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Camp Director's Signature Date Health Inspector's Signat e Date l 7 Town of Barnstable. Permit Fee: THE T�Qi+ Regulatory Services $75.00 Thomits F. Geiler, Director BAXNSTABL- 163g6 Public Health Division MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 I APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: Site Address: � 70 ;r 3 Site Telephone: Name of Camp Owner: _ / �j P i1 C i �f � ��P�✓ Office Address:. �% .. a Telephone Number: F, Name of Camp Operator(if different): Address: r=' Telephone Number: Name of Health Care Consultant: Address: .�j. Telephone Number: Type cf Camp: Day ) 1_Residential Hours of Operation: -7 e .... �E; 3 L, Dates of Operation: Opening: ; Closing: cd Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes No Meals Provided: Yes No (If yes: Food Permit Number ) Signature of Applicant: Official Title ML - r Da ee 'Seethe-text page for a list of documents that must be completed and submitted before your. applicat_on for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. - f�I Kfl Department of Public Health I�`"'� Division of Community Sanitation ) STATE SANITARY CODE: CHAPTER IV C MINIMUM SANITATION AND S�AF Y STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: ADDRESS: OWN WO ERATOR fjM OFF SEASON L ADDRESS: CAMP DIRECTOR. INSPECTED BY: pOF CAMP: (Circle) WATE ��e / DATE OF INS ECTI N: DayResidential SOURCE: /�NoSport) CAMPER ` / Trip Primitive Travel CAPACITY: � (�J �I "No column = N" marked below indicates a violation of 430.000. "Yes column = N" marked below indicates compliance with provision of 430.000. "N/A column = "4" marked below indicates that the provision of 430.000 is not applicable to this camp. .Regulation Yes No N/A Comments Permits .451 Current Certificate(s) of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply- BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORT, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan 210 D Traffic Control Plan Contin encplans - Day Camp: .211 A Camper doesn't show up for day, B Camper doesn't show up at point of pick up. C Child not registered arrives Contingency plans - Primitive, Travel and Trip: 1.212 A Itinerary daily-copy to parents B Source of emergency care 190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 Re ultition Yes No N/A Comments Promotional literature/packet contains: .159 (13)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background check, health care, discipline policies and grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: PA, <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of ex erience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 .All counselors 3 yrs older than campers. Required Counselors Ratios .101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) 'Special Needs: 1 counselor per 4 mildly disabled campers. kl 1 counselor per 2 severely disabled campers. 2 ate ula'tion Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trn 9 9 9 cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle ' First Aid certified if no other trained staff aboard. Medical Person nel/Records/Faci I qies .159 (A) Health Care Consultant 4 6 m Name OA/S l r6 MD NP PA(w/pediatric training) Check for Health Care Consultant Agreement r Wlb Pwl�' .159 (C) Health S ern site a all times). y� Name: Gol5 fib z� 18 yrs, �, ,A= t Aid and CPR certified OR,MD PA NP RN LPN Ar .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refri erated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. .155 Medical log book- bound, pre-numbered pages, / ink entries, no skipped lines. 1/ .161 (A) Infirmary provided -day and resident camps Exterior light- resident camps .453 Lighting rovided in infirmary. .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health, History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 0 44fs o� 111 l 3 o AK6 oofrz. Re ulation Yes No NIA Comments Immunizations: .152 (A) Campers and staff under 18yrs: Number of records checked: MMR: 1 st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV R J� Diphtheria and Tetanus Toxoids and �'�,/ Q� Pertussis : 4 doses DTaP/DTP/DT or, v 3 doses of Td (persons 7 yrs or older needing additional vaccines"to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td Hep B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to VI health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability. .204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. 1 .204 Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 'Re ulation Yes No N/A Comments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces 05 free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ / around it, pliable swing seats. V Firearms .201 Single shot rifles only, .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons,, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Liqhting provided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sgfl/person in single bed 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special equipment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 Re y a on , ..i "' { Yes—No MA- Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 1 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearb . .458 135 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate#of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374 Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. /V .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 112°F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 'Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 (Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 1 Proper storage and disposal of solid waste. 6 I "Re u AtiAn w ." Yes No N/ Comments .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service facility. .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closing. .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE MOM �Ee D Camp Director's Signature Date / Health Inspector's Signature Date 7 LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp Program $UItaING OUR f UTURE AC'ABEMICALLY, SOCIALLY AND SPIIZffUAUV Director — Beverly Robedee 270 Communication Way, Building 3C, Hyannis Ma 508-771.5350 csmhyannis.weebly.com r • Camp HandbooK ,A LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp Program WIVAIG OUR FIMRF ACADEHICAuv, WOW AND 5PIRITUAUV Director—Beverly Robedee 270 Communication Way,Building 3C,Hyannis Ma 508-771-5350 csmhyannismeebly.com Little Carpenters Camp will offer your child a summer of fun and excitement. The program is structured in that activities are planned throughout the day, giving time for active and quiet experiences. Qualified instructors provide an atmosphere geared for the age level of your child. Camp is broken down into various groups according to the age of the child. Activities are planned for the pleasure of the individual child at his or her age level. The children remain in their own age group for most activities. Children are always well supervised and the safety, health, and welfare of your child is of the utmost concern to us. We maintain our year round staff offering you quality that cannot come through inexperience. Our teachers are chosen for their concern and love for children as well as meeting State Qualification. Love and kindness is an important part of out daily program being carried out by teacher and student as well. At Little Carpenters Camp, we believe in showing love and respect to one another, care of property, and realizing that God is a very important part of out lives. We ask God to be with us daily, have a time about sharing about His love, as well as thanking Him for our food. Children from all faiths attend Little Carpenters Camp and enjoy having God as a part of their daily lives. We believe in showing respect to each other, to God, and to our country. For your convenience, Camp is open from 7:30a.m. until 5:30 p.m. Your payment schedule will be according to the hours you choose within that time bracket. It is not necessary to attend all of these hours; we will work scheduling for your independent need. Our program is full and exciting. We provide for rainy days as well as sunny. Our facilities are large and accommodating so that weather is not a problem. Beach activities will be provided for children 4 Y2 years old and older. We find that the younger children do not benefit from the beach activities and are much more relaxed in their own setting here at camp. We provide backyard pools for the younger children and they go swimming each day and have an excellent time. Swimming takes place, weather permitting, and if no field trips are planned for that day. Swimming will begin approximately the second week of July. We have to allow this time for beach scheduling. Arts and Crafts are an exciting part of our day. Projects are offered covering all types of skills and materials—according to the age level of the child. You will enjoy seeing the projects as they come home. Amended 6/08 -2 - Field trips will be offered each week. Children over 5 years old will go on at least one field trip and children under 5 years old will go as announced. The field trips will provide exposure to many learning situations as well as nature trips and opportunity to enjoy the rich beauty of the Cape. The Camp has its own qualified drivers for these trips. Each group is well supervised. Stories, active games, sports, quiet games, movies, nature, and much more are included in our camp program at the level of the individual group your child is in. The day is filled with activities that any child would want to be a part of. Desiring to keep your camp high quality, some areas of policy are necessary. These are as follows: The children must be between the ages of 2 years 9 months and 12 years. We also provide an infant-toddler program for children 1 month to 2 years 9 months. Children under the age on 4 'h must bring an extra set of clothing to be left at the camp while the child in enrolled. A sleeping bag or mat must be provided for rest time. An enrollment application must be filled out and on file for each child enrolled, as well as a Massachusetts Health Form signed by the child's physician, as well as a birth Certificate. After the application is on file, it is the parents responsibility to notify the teacher immediately of any change of address, phone number, work changes, emergency number changes, or change in e-mail addresses. This is of great importance. An adult must bring in and pick up all children. Students are not to be brought in by another child or allowed to come in by themselves, unless signed permission by parent and authorization by the director is given. Children will not be passed over the fence to any adult; you must come into the yard to pick up the children. Please do not leave your car running while bringing in children. This could present a serious safety hazard. Please fill out on you application those names of persons who are authorized to pick up your child in your absence. For your protection no one else will be allowed to release your child. Field trips and swimming costs are included in your tuition cost. Field trips will be posted for your information. Please be sure your child has a nutritious lunch including a beverage. Please read the attached sheet on nutrition. If the camp includes lunch, we will notify you. Please do not allow your child to bring any toys or personal articles from home unless it is approved by the teacher in advance. We cannot be responsible for any items brought from home. The following late pick up fee will be in effect as of 5:30 p.m. daily: A late fee will be charged for late pick up after 5:30 p.m. The fee will be $10.00 for the first five(5) minutes or thereof, and $3.00 per minute for each additional minute unless special arrangements have been made with the director in advance. This fee is payable upon picking up your child. It is a lack of Amended 6/08 - 3 - consideration to keep our teachers from their personal schedules. There will be no exceptions unless cleared by the director. If your child is going to be absent, please call us by 9:00 a.m. so that we may make proper plans. No child will be accepted after 9:30 a.m. (unless otherwise approved by the director). Tardiness confuses the scheduling and a child comes too late for a field trip. This could cause you to have to take your child home for the day due to the class having already left. Any returned check will be charged at the rate of$20.00 due to bookkeeping You are responsible for payment of the number of days that your child is enrolled. Payment must be paid if the child is absent. This assures you of a quality program. Tuition is to be paid in advance each Friday for the week that is coming up. Please no exceptions. This is necessary for proper bookkeeping. You will receive a $10.00 prompt payment discount weekly from your tuition for following this procedure. Each child has to bring a bathing suit and towel with their name on it. These remain at camp and will be taken home each weekend to be laundered. Please be sure to return it each Monday so that your child will not miss being able to swim. A sleeping bao for rest time with the child's name is necessary for each child. 44uner itxtra clothes (including a long sleeved shirt) is to be left at the school for any child '/2 for emergency purposes. Water bottle and water shoes should also be brought. Please explain to your child that they are not to share their food with any other children. Many children have allergies, which the other children would not be aware of and it could cause serious difficulties. If medicine is necessary it is a Sate Law that no medicine can be given unless accompanied by a note from your physician. No over the counter can be given —cough syrup, cough drops, or aspirin etc. Any types of medication, prescription or over the counter must be administered by the teacher and given directly to the teacher when the student arrives. No child to keep medication on their person because another child could find it and be allergic if they were to take it. No child is to be brought to camp with a rash— unless accompanied by a physicians note stating the nature of the rash. Children must not be taken from the play yard without the teacher in charge being aware of this. You must be sure your child is signed out by the teacher before you take them. Please do not stand on the outskirts of the play yard and call for your child. This could be dangerous to your child, as well as, it is inconsiderate to the teacher in charge. Please remember that adults are to pick up children. Children cannot be handed over the fence. Amended,6/08 - 4 - i Any child enrolled in the camp is expected to abide by the policies of the camp. Respectful and respectable language must be used at all times. We are concerned with the abundance of violence in our society. We are dedicated to providing a wholesome atmosphere; therefore, NO Power Rangers, Pokemon, Yu-gi-oh!, or any other trendy figures that promote violence are allowed in the school. This includes sleeping bags, backpacks, videos, books, etc. We are sure you agree on this issue as well. Any questions concerning camp or it's policies are to be directed to Mrs. Robedee, Camp Director at 508-771-5350. Many times policies seem long and involved, but we are sure you that you realize that these are all for the welfare of you and your child. We are dedicated to provide an atmosphere of love, concern, safety, and fun for your child. Please try making any phone calls to camp before 4:00 p.m. Many times after this everyone is outside on the playground. We know that your child will enjoy this summer experience with us!!We thank you for sharing your child with us for this happy time. Sincerely, Beverly Robedee, Director We reserve the right to terminate any child for health, safety, discipline, or issues deemed necessary at the discretion of the director or designated staff. The two (2)week termination notice would be waived under these circumstances. Termination would be immediate. Amended 6/08 - 5 - i LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp program $UMMIG OUR f MRE ACADEMICALLY, SOCIAUY AND SPIRffMALIY Director—Beverly Robedee 270 Communication Way,Building 3C,Hyannis Ma 508-771-5350 csmhyannismeebly.com Dear Parents, We would like to WELCOME all of the children who are enrolled in our Summer of Fun Program. There are several items that your child will need. Please bring the following items labeled with your child's name in a backpack: 1. Nutritious lunch and beverage 2. Water bottle 3. Bathing suit—to be taken home at the end of each week 4. Towel—to be taken home at the end of each week 5. Sleeping bag 6. Extra Change of clothes 7. Sun Screen—this can only be applied if you returned and signed the authorization 8. Water shoes 9. Long sleeve sweater or jacket No articles can have characters of violence on them. We are dedicated to provide an atmosphere of love, concern, safety, and fun for each child. We know your child will enjoy this summer experience with us. Sincerely, Beverly Robedee, Camp Director Amended 6/08 - 6 - SOCIAL SERVICE REFERRAL PLAN Procedures for referring parents to appropriate social, mental health, educational and medical services, as well as spiritual guidance for their child should the center staff feel that an assessment for such additional services would benefit the child and the family. (A) The staff is responsible first to notify the director of their concern for the child. (B) The staff member will then be required to observe an d record the child's behavior and present this finding to the director for review by the director before any action is taken. (C) The director will set an appointment with the parents to notify them of the concern for their child. (D) At the meeting the director will present to the parents a list of referral resources in the community. If a referral is needed the following would be done: (A) The director shall provide the parent a written statement including the reason for recommending a referral for additional services, a brief summary of the centers' observations related to the referral and any efforts the center has made to accommodate the child's needs. (B) The director shall offer assistance to the child's parents in making the referral. The director shall have written parental consent before any referral is made. (C) If the child is at least 2 'h years of age, the director shall inform the child's parents the right to appeal under Chapter 766. (D) If a child is under three, the parents will be informed of the services of Early Intervention. (E) The director, with the parents' permission, will follow-up the referral, and contact the agency who evaluated the child for consultation and assistance in meeting the child's needs at the center. If it is determined that the child is not in need of services the director will review the child's progress every three months for determination. The director will maintain a written record of any referrals including the parent conference and results. A child may be suspended because of non-payment, lack of parent cooperation (regarding Policies) and child behavior. The length of suspension will be determined by the Director. The center will do its part in assisting the child to understand in a manner that will be helpful to him/her. If termination is necessary, due to behavior, inability to adjust, needs for which the center is not equipped, inability of the parent to pay, the director will meet with the parent and place in writing the reasons. A two (2)week termination notice may be waived at the discretion of the Director. When a child is terminated from the center, initiated by the center or the parent, the center will do its part in assisting the child to understand in a manner that will be helpful to him. Amended 6/08 - 7 - BEHAVIOR MANAGEMENT The scripture teaches us to "Train up a child in the way he should go and when he is old he will not depart from it."As a Christian Center, we must be aware of our responsibility to train up a child. We must set limits and help the child to realize that he will be responsible for his choice, otherwise, we will not be preparing that child to accept the responsibility for his actions as he grows older. Discipline must be limited to certain specific areas. Children are expected to show respect to the teacher as well as their peers, this is in their actions as well as their words. The child is expected to be honest, kind, and keep a clean mouth. They are not to be disciplined when they are asking questions. Children will be disciplined for: Fighting Hitting Swearing Disobedience Disrespect Defacing property Biting Other areas of distaste will be dealt with to educate the child to handle the matter more tastefully. Parents will be called in to the center for a conference if the teacher and the director feel it necessary. Parents are to be informed if the child is having an abnormally difficult day. No corporal punishment is allowed, including a spanking. A child is not to be shaken, yanked, or physically punished in any way. No child will be put in a corner with his/her face to the wall at any time, neither is the child to be put in the corner with his/her face out of the wall. A child is not to be sent into the hallway to sit alone for punishment, neither is a child to be put into a room or any area by themselves for discipline purposes. No denial of regular meals as punishment. A child is never to be denied his/her meal as a discipline measure. The child is always to be allowed to eat his/her lunch at the proper time. Neither is there to be denial of drink or snack as punishment. No child will be force-fed. No punishment for soiling, wetting, or not using the toilet properly. However, repeated soiling of the bathroom floor will be considered action-needing discipline. The child in the Toddler House is to be carefully and gently toilet trained without undo pressure. Parents must provide additional clothes for each child. If the problem persists after the child is in the three-year-old class, due to health laws, it may be necessary to dismiss the child. Amended 6/08 - 8 - I BEHAVIOR MANAGEMENT (continued) A time out chair is to be used. The time for sitting being no longer than two minutes at one time for children through four years and no longer than five minutes at one time for children over four years old. Never more than one minute for each year of the child's age. The method of discipline is to be used with discretion after the teacher has made every effort to evaluate the situation, being sure she has clearly defined the limits in a manner that the child understands what is expected of him/her. When a child is disciplined, the teacher is always to make the offense clear to the child. Never is a child to be disciplined until the teacher has done her best to see that the child understands why he/she is being corrected. After the discipline has ended the teacher is to spend time with the child reassuring him that he/she is loved, that what he/she did was wrong, that we all make mistakes sometimes, but we work on them so that we don't repeat them. We ask God to forgive uis and ask Him for help to do better next time. Helping the child to realize that he/she is loved, and because we love him/her, we will not allow him/her to disobey. Discipline is a tool to be used to help a child to become a stronger person. Discipline is not to be given because the teacher is older, bigger and in charge. If behavior continues to be an ongoing problem there must be a teacher-parent conference at which time an agreeable plan of action must be drawn up. Discipline is a tool, which if used effectively will produce an inner strength in the child that will give him/her the ability to make proper choices, which will foster health in his/her inner person and bring God the glory through his/her lifetime. i Amended 6/08 - 9 - CHILDREN WITH DISABILITIES In determining whether to accept or serve a child with a disability, the licensee shall, with parental consent and as appropriate, request information related to the child's participation on the center's program from the Local Education Agency. Early Intervention Program or other health or service providers. (A) Based upon available information the licensee shall, with the parent's input, identify in writing the specific accommodations, if any, required to meet the needs of the child at the center, including, but not limited to: 1. Any change or modification of the child's participation in regular center activities. 2. The size of the group to which the child may be assigned and the appropriate staff/child ratio; and 3. Any special equipment, material, ramps or aids. (B) If, in the licensee's judgment, the accommodations required by 102CMR 7.07(7)(a)to (b), serve the child would cause an undue burden to the center, the licensee shall provide the parent(s)for written notification within 30 days of receipt of authorized, requested information and the reasons for the decision. In addition, the notification shall inform the parent(s)that they may contact the Department and request that the Department determine if the licensee is in compliance with 102CMR 7.05(2) and 7.07(7). The licensee shall maintain a copy of this notification in its records. The accommodations related to the toileting needs of a child with a disability who is not toilet trained shall not be considered an undue burden. ( C) In determining whether the accommodations required by 102 CMR 7.07(7)(a) are reasonable or would cause an undue burden to the center, the licensee shall consider the following factors which include but are not limited to: 1. The nature and cost of the accommodations needed to provide care for the child at the center. 2. Ability to secure funding or services from other sources. 3. The overall financial resources of the licensee. 4. The number of persons employed by the licensee. 5. The effect on expenses and resources, or the impact otherwise of such action upon the licensee. (D) The licensee shall, with parental permission, participate in the development and review of the child's program plan in cooperation with the LEA. Early Intervention Program and or other health and service providers. (E) The licensee shall, with parents permission, inform the appropriate administrator of special education, in writing, that the licensee is serving a child with a disability. (F) Designation of Center Liaison The licensee shall identify a staff member who is at least teacher qualified to serve as the center liaison for each child with a disability. The center liaison shall be responsible for coordinating care in the program and with service providers and communicating with the child's parents, service providers and center staff. i Amended 16/08 - 10 - CONSENTS FOR ALL CHILDREN ENROLLED Parent Authorization, Consents, Information The licensee shall, in admitting a child, require the parent to provide the following authorizations, consents and information, which shall be made part of the child's record. (1) The child's daily schedule, developmental history, sleeping and play habits, favorite toys, accustomed mode of reassurance and comfort. (2) Procedures for toilet training of the child, if appropriate. (3) Where appropriate, the child's eating schedule and eating preferences, including information on special diets and or allergies; and for infants, a description of formula preparation. (4) Information on where to reach the parent and an alternative - nearest relative or friend in case of an emergency as well as the child's physician or clinic, if any. (5) Parental consents for emergency first aid and any field trips and transportation to a specific hospital in emergency. (6) Identification of any person authorized by the parent to take the child from the center or receive the child at the end of the day and a copy of the written parental authorization. Validity of Consents: A written consent provided under 102 CMR 7.07(9) shall be valid for one year from the date of its execution unless such consent is withdrawn, in writing, prior to that time. Amended 6/08 r ILLNESS No child is to be brought into school with a fever, rash, runny eyes or any known infectious disease. If the child has had a fever, vomiting, or diarrhea during the night, they are not to be brought into school for 24 hours after this has stopped. Any child who becomes sick at school or camp will be kept comfortable until the parent promptly picks up the child. If a child is found to have head lice (either eggs or alive), they will be sent home immediately. Appropriate shampooing of the head and family members, as well as washing all bed linens or stuffed animals, etc. are necessary to be done immediately. The child will not be able to return to their class until they have been first checked by a center representative, and at the discretion of the center, a doctor's note may also be needed. The decision to re-admit the child at that point is at the discretion of the center director or appointed representative. CARE FOR THE MILDLY ILL CHILD The mildly ill child may be admitted into the center if they can basically follow the normal daily schedule. If the illness necessitates needing other routine, normally the parent would be called. While waiting for the parent, the child would be given the opportunity to lie on their sleeping bag in a quiet protected area of the classroom. If the child wasn't interested in resting, some quiet materials would be given to play with and if desired, food or drink would be provided. PLAN FOR DISPENSING MEDICINE If medicine is necessary, it is a State Law that no medicine can be given unless accompanied by a note from the physician. Parents are instructed to personally hand the medication to the teacher upon entering the classroom. No medication is either to be placed in the lunch box, back pack, or given to the child to be responsible for. Prescription Medication must have the child's name, date, be in the original container, labeled with the drug name, and have directions on the label. The medication must be stored properly and returned nightly or when no longer needed. If it is a medication that will be taken regularly then an open yearly note would be given by the physician. Parental authorization must accompany this medication. Non-Prescription Medication must have the permission of a physician for an open time span of not more than one year and a parental permission slip. Parents will be notified in writing whenever medication is given to a child under a blanket authorization from doctor and parent. Each time medication is given, it is logged with the date, the child's name, the time, the amount and the full name of the caregiver. Copies of this log will be placed in the child's folder. Topical Non-Prescription Medication must have written approval from the parent, listing the name of the medication, which is valid for a year. We do not apply eye medication. Suntan lotion. The parent is required to sign a sheet giving permission for the application of the same, if the parent does not want the lotion used then they must sign a sheet stating the same. Amended 6/08 - 12 - I EMERGENCY PROCEDURES Parent is to sign Consent Form upon admission. Director is notified immediately and parent is called. If minor emergency parent will decide whether to come to school. Emergency- Rescue Squad is called - 911 - the parent is also called. If necessary, child is treated by Rescue Squad or transported to Cape Cod Hospital. A staff member will accompany the child in the rescue vehicle if parents cannot be reached in time. Parent will meet child either at school or at the hospital. If the parents cannot be reached, authorized persons on the permission list will be contacted and if hospitalization is not necessary will take the child home. WEATHER EMERGENCY OR OTHER UNSAFE CONDITIONS If it becomes necessary to close school, while school is in operation, due to weather or other unsafe conditions, the parents will be called; if they cannot be reached, an authorized name will be called. It will be the responsibility of whoever is reached to come immediately and pick up the child. If school is closed due to weather or other unsafe conditions, you will hear the report on the local radio stations after 6:30 am. Please listen carefully as some times Faith Christian Academy may be closed but Little Carpenters will be open. OUTDOOR POLICY All children will go out daily. Please dress your child appropriately for the season we are in. If a child is too sick to go outside then they are too sick to come to school. Children will not go out in the rain or weather deemed dangerous. k Amended,6/08 - 13 - PARENTAL RIGHTS Chapter 28A, Section 10 of the General Laws of the Commonwealth of Massachusetts mandates to the Department of Early Education for Children the legal responsibility of promulgating rules and regulations governing the operation of pre-school centers, nursery schools, and day care centers. In accordance with this law, The Department of Early Education for Children published the requirements now in effect on March 3, 1977. These regulations must be complied with by the licensee in order to ensure a minimum level of care for the children serviced by the pre-school center, nursery school or day care. The licensee (center owner) is required to inform all parents of"the rights of parents" as stated in the regulations at the time of admission of their child to the center. These rights are as follows: PARENTINVOLVEMENT 7.05(12) Parental Visits. The licensee shall permit unannounced visits by the parents to the center and their child's room while their child is present. If both parents names are on the application. This applies also to legal guardians whose names are on the application. 7.05(13) Parental Input. The licensee shall have a procedure for allowing parental input in the development of center policy and programs. The licensee shall provide an explanation to the parent(s) when a parent makes suggestions as to the program or policy of a center and the suggestions are not adopted by the licensee. If the parent requests a written response, the licensee shall respond in writing to the parent. 7.05(14) Reports to Parents. The licensee shall, periodically, but at least every six (6) months, prepare a written progress report of the participation of each child in their center's records. The licensee shall provide a copy of each report to the parent(s) or meet with them at least every six (6) months to discuss their child's activities and participation in the center. In addition: (a) For infants and children with disabilities, the licensee shall complete a written progress report of the child's development every three (3) months, and provide it to the parent(s). (b) The licensee shall bring special problems or significant developments, particularly as they regard infants, to the parent's attention as soon as they arise. 7.05 Parent Conferences. The licensee shall make the staff available for individual conferences with parents at parental request. Amended 6/08 - 14 - PARENTAL RIGHTS (continued) 7.05(19) Confidentiality and Distribution of Records. Information contained in a child's record shall be privileged and confidential. The licensee shall not distribute or release information in a child's record to anyone not directly related to implementing the program plan without written consent of the child's parent(s) and the approval of the center director. The licensee shall notify the parent(s) if a child's record is subpoenaed. The child's parent(s) shall, upon request have access to his child's record at reasonable times. In no event shall such access be delayed more than two (2) business days after the initial request without the consent of the child's parent(s). Upon such request for access, the child's entire record regardless of the physical location of its parts shall be made available. The licensee shall establish procedures governing access to, duplication of, and dissemination of such information, and shall maintain a permanent, written log in each child's record indicating any person to whom information contained in a child's record has been released. Each person disseminating or releasing information contained in a child's record, in whole or in part, shall upon each instance of disseminations or release enter into the log the following: his name signature, position, the date, the portions of the record which were disseminated or released, the purpose of such dissemination or release, and the signature of the person to whom the information is disseminated or released. Such log shall be available only to the child's parent(s) and center personnel responsible for record maintenance. 7.05(21) Charge for Copies. The licensee shall not charge an unreasonable fee for copies of any information contained in the child's record. 7.05(21) Amending the Child's Record. (a) A child's parent(s) shall have the right to add information, comments, data or any other relevant materials to the child's record. (b) A child's parent(s) shall have the right to request deletion or amendment of any information contained in the child's record. Such request shall be made in accordance with the procedures described below: 1. If such parent(s) is of the opinion that adding information is not sufficient to explain, clarify or correcting objectionable material in the child's record, he shall have the right to have a conference with the licensee to make his objections known. 2. The licensee shall, within one (1) week after the conference, render to such parent(s) a decision in writing stating the reason or reasons for the decision. If his decision is in favor of the parent(s), he shall immediately take steps as may be necessary to put the decision into effect. 7.05(22) Transfer of Records. Upon written request of the parent(s), the licensee shall transfer the child's record to the parent(s), or any other person the Amended 6/08 - 15 - parent(s) identifies, when the child is no longer in care. 7.05(23) Notification to Parents. The licensee shall notify the parent(s) in writing of the provisions of 7.05(19)through 7.05(22 and 7.05(24) at the time of the child's admission to the center and thereafter, in writing, at least once a year. INFORMATION REQUIRED BY THE DEPARTMENT 7.04(24 Availability of the Information to the Department. Notwithstanding 102 CMR 7.05(19), upon request of an employee, authorized by the Director and involved in the regulatory process, the licensee shall make available to the Department any information required to be kept and maintained under these regulations and any other information reasonably related to the requirements of these regulations. Authorized employees of the Department shall not remove identifying case material from the center's premises and shall maintain the confidentiality of individual records. 7.07(6) Meetinq with Parents. The licensee shall assure that the administrator or his designee shall meet with the parent(s) prior to admitting a child to the center. (a) At the meeting, the licensee shall provide to the parent(s) the center's written statement of purpose, services, procedures for parent conferences, visits and input to center policy, procedures relating to child's records, and procedures for providing emergency health care. (b) The licensee shall provide the opportunity for the parent(s)to visit the center's classrooms at the time of the meeting or prior to the enrollment of the child. In addition, Section 7.03(23) required all licensees to have a copy of the regulations on the premises of the center and the regulations shall be made available to any person upon request. From time to time pictures and names will be published of the students. All parents will receive a permission slip giving permission for the school to take pictures and publish the name of the child. Amended 6/08 - 16 - i PROCEDURES FOR IDENTIFYING AND REPORTING SUSPECTED CHILD ABUSE OR NEGLECT All staff are mandated reporters. Each staff member is trained to be aware of the symptoms of abuse and neglect. This is then to be reported immediately to the Director, who notifies the local DSS intake worker, (508)394-1325, this is done within 24 hours, documented in writing within 48 hours. If possible parents will be notified. In the absence of the Director, the person next in charge will be notified. Any such action is noted in the child's folder. The center works closely with the DSS Department during this procedure. PREVENTION OF ABUSE AND NEGLECT All staff members are mandated reporters. Should a staff member be suspected of abuse or neglect while the child is in the care of the center, the center Director must be notified immediately. In the absence of the Director the person next in charge is to be notified. The report will then be immediately filed with a 51A to DSS and to DEEC. While an investigation is on-going that staff member will be removed from having access with children. A determination will be made at that time whether or not the staff member will be paid during this time. Cooperation will be given to DSS and DEEC. Depending on the outcome of all allegations, determination will be made whether to reinstate or terminate. Amended 6/08 - 17 - LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp 'program FUNDING OUR f U IU AMEMICAUY, SOCIALLY AND SPORIALLY Director— Beverly Robedee 270 Communication Way, Building 3C, Hyannis Ma 508.771-5350 csmhyannis.weebly.com Cp Applicationam LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp Program FUNDING OUR FUME ACADE MAuY, WOW AND SPIRWAuY Director—Beverly Robedee 270 Communication Way,Building 3C,Hyannis Ma 508-771-5350 csmhyannismeebly.com Dear Parents, We would like to WELCOME!! all of the children who are enrolled in our Summer of Fun Program. There are several items that your child will need. Please bring the following items labeled with your child's name in a backpack: 1. Nutritious lunch and beverage 2. Water bottle 3. Bathing suit—to be taken home at the end of each week 4. Towel—to be taken home at the end of each week 5. Sleeping bag 6. Extra Change of clothes 7. Sun Screen—this can only be applied if you returned and signed the authorization 8. Water shoes 9. Long sleeve sweater or jacket No articles can have characters of violence on them. We are dedicated to provide an atmosphere of love, concern, safety, and fun for each child. We know your child will enjoy this summer experience with us. Sincerely,. Beverly Robedee, Camp Director - 2 - Authorization and Consent Form I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child . However, I cannot be reached, I hereby authorize Little Carpenter's Early Childhood Learning Center to transport my child to Cape Cod Hospital (or the nearest hospital)and to secure for my child the necessary medical treatment. I understand the teachers in the Learning Center are trained in the basic of First Aid and I authorize them to give my child first aid when appropriate.When I cannot be reached I authorize Little Carpenters Early Childhood Learning Center to release my child to the following persons as well as the names on the current application. I authorize the use of this procedure for the school premises as well as field trips. Name: Relationship to Child: Address: Phone: Name: Relationship to Child: Address: Phone: Name: Relationship to Child: Address: Phone: Name: Relationship to Child: Address: Phone: Others Authorized To Pick Up Child and Phone Numbers: Child's Physician and Clinic: Child's Physician Address: Physician Phone: Desired Days and Hours Desired for camp: Desired Starting Date: Enclosed Registration Fee of$40.00 (Non-Refundable): I HAVE READ THE CAMP POLICIES, UNDERSTAND THEM,AND WILL ABIDE BY THEM. Parent/Guardian Signature Date Be sure to ask for applications for the Fall enrollment for Infant/Toddler,Pre-school,Pre-Kindergarten, Kindergarten,and Faith Christian Academy.(Grades 1-12) For Office Use Only Director's Signature Rate$ Start Date Amt. rec. Cash or Check# Date -4 - I LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp Program $U WNG OUR F MRE ACADEMIeAuY, WOW AND SPfR1NUAUV Director—Beverly Robedee 270 Communication Way,Building 3C,Hyannis Ma 508-771-5350 csmhyannismeebly.com From time to time the children of Little Carpenters Early Childhood Learning Center will The photographed or video taped and their name published. Please sign below either giving permission or not giving permission for us to photograph or video tape your child. This is for school use only. I give permission for to be photographed or video taped. I DO NOT give permission for to be photographed or video taped Child's Name Parent/Guardian's Signature Today's Date . i - 5 - ,p a, LITTLE CARPENTERS EARLY CHILDHOOD LEARNING CENTER Camp 'Program $UI MIQ OUR f=RF A044DEWALLY, SOCIALLY AND SPRITUALLY Director—Beverly Robedee 270 Communication Way,Building 3C,Hyannis Ma 508-771-5350 csmhyannismeebly.com That wonderful time of year is here again!! It is time for each child to bring in a summer change of clothes, bathing suit,towel, and sunscreen. Because the weather on Cape Cod tends to be changeable, it is also advisable to bring a lightweight jacket. Please label al items that you bring in. IMPORTANT!!! Attached you will find a permission form giving us permission to put sunscreen to your child.Without this form being returned,we CANNOT apply sunscreen to your child. If you do not want sunscreen to be used on your child,then it is necessary to state that you Do Not want your child using sunscreen. I am looking forward to a fun filled summer with your child. Sincerely, Beverly Robedee Director Please check the appropriate box: I want Little Carpenters Early Childhood Learning Center Camp Program to apply sunscreen to my child I DO NOT want Little Carpenters Early Childhood Learning Center Camp Program to apply sunscreen to my child Child's Name Parent/Guardian Signature - 6 - Termination and Late Fee Policy We reserve the right to terminate any child for health, safety, discipline or issues deemed necessary at the discretion of the Director or designated staff. The 2 (two)week termination notice would be waived under these circumstances. Termination would be immediate. The following late pick up fee will be in effect as of 5:30 p.m. daily: A late fee will be charged for late pick up after 5:30 p.m. The fee will be $10.00 for the first 5 (five) minutes or thereof, and $3.00 per minute for each additional minute per child unless special arrangements have been made with the Director in advance. This fee is payable on picking up your child. It is a lack of consideration to keep our teachers from their personal schedules. There will be no exceptions unless cleared by the Director. By signing below you will agree to the above statements. Signature Date - 7 - NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee DBA CAMP LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG. 3,.HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS,MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as t adopted by the Board of Health,and expires December 31 St, 2017 unless sooner suspended or revoked. JANUARY 1, 2017 Paul J.Canniff, D.M.D,Chairman Board Junichi Sawayanagi of Donald A.Guadagnoli, M.D Health Original License Fee (� Renewal Fee By Thomas A. McKean, RS,CHO, Health Agent r Town of Barnstable Permit Fee: .°�THE ri0�,,� Regulatory Services $75.00 Thomas F. Geiler, Director-BARNSTABM 1 MASS Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Officer 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp:, '4,--, Site Address: pi,� ; S Site Telephone: ��%�— 7-2 f — 1 3 S� a Name of Camp Owner: &41e r_4e Office Address: Ste, Telephone Number: E . r Name of Camp Operator (if different): Address: Telephone Number: Name of Health Care Consultant:,, Address: Telephone Number: Ty pe of Camp: Da Residential Hours of Operation: Dates of Operation: Opening: G 24 Closing: 9 /v "7 Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes (907 Meals Provided: Yes o (If yes: Food Permit Number ) Signature of Applicant: Official'Title: AL Date: 6 <7 See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing process. f � 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. ■ Staff information forms (see attached) (SORI/CORI With Juvenile checks)* ■ Procedures for the background review of staff(105 CMR 430.090) ■ Copy of promotional literature(105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ■ Health care policy(105 CMR 430.159(B)) ■ Discipline policy (105 CMR 430.191) ■ Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan(105 CMR 430.210(B)) ■ Lost camper plan (105 CMR 430.210(C)) ■ Lost swimmer plan (.105 CMR 430.210(C)) ■ Traffic control plan (105 CMR 430.210(D)) ■ Day Camps—contingency plan(105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) ■ Current certificate of occupancy from local building inspector(105 CMR 430.451) ■ Written statement of compliance from the local fire department (105.CMR 430.215) ■ 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 Cl . 140 s. 32A): ■ Buildings, structures, fixtures and facilities ■ Proposed source of water supply ■ Works for disposal or sewage and wastewater i New.for'2003 'F Camp Director Name: - Age: Coursework in camping administration: Previous camp administration experience: Health Care Consultant Name: el Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training)A (d ; 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: i t� Firearms.Instructor Name: National Rifle Association Instructor's card (or equivalent): Date certified: / / Expiration date:_/ / Horseback Riding Instructor Name: 1A 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. (file: Q:\Health\Camps\Application.doc) Town of Barnstable Permit Fee: Regulatory Services $75.00 c=p . Thomas F. Geiler, Director-"(RARNSrA 1 a� a��� Public Health Division 7�Y �fb MA'S Thomas McKean Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp:� �, Site Address: -;�- �7(-> _,�yr-1 v,r. .r1 ; �� rv, w�a Q— r��z:fh,n n Site Telephone: 77 ! Name of Camp Owner: 1L� ,f �. Office Address: Ste_,-,• : . Telephone Number: ,Name of Camp Operator (if different): Address: Telephone Number: Name of Health Care Consultant: Address: Telephone Number: Type of Camp: Da Residential Hours of Operation: Dates of Operation: Opening: 6 2-e� 7 Closing: i� ? Swimming Pool: Yes No (If yes: Pool Permit Number ) Bathing Beach: Yes 1N Meals Provided: Yes o (If yes: Food Permit Number ) Signature of Applicant: Official Title: AL 'ea Date: //Z//: See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing 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. ■ Staff information forms.(see attached) (SORI/CORI With Juvenile checks)* ■ Procedures for the background review of staff(105 CMR 430.090) ■ Copy of promotional literature (105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ■ Health care policy(105 CMR 430;159(B)) ■ Discipline policy (105 CMR 430.191) ■ Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan(105 CMR 430.210(B)) ■ Lost camper plan(105 CMR 430.210(C)) ■ Lost swimmer plan(105 CMR 430.210(C)) ■ Traffic control plan(105 CMR 430.210(D)) ■ Day Camps—contingency plan(105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) i ■ Current certificate of occupancy from local building inspector (105 CMR 430.451) ■ Written statement of compliance from the local fire department (105 CMR 430.215) ■ If applying for initial license after January 1, 2000—lab analysis of private water i 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 wastewater r I New for 2003 I Camp Director Name: Age: Coursework in camping administration: Previous camp administration experience: Health Care Consultant r Name: ,r+� -401 r Type of Medical License (must be a physician, nurse practitioner, or physician assistant with pediatric training)A aSs Qve-f- , 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: F American First Aid Certificate: Expiration date: ri Previous aquatics supervisory experience: . Firearms Instructor Name: National Rifle Association Instructor's card(or equivalent): Date certified: / / Expiration date: / / Horseback Riding Instructor Name: A License Number: Expiration date: Stable Location: I 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. • i (file: Q:\Health\Camps\Application.doc) t . j Jun. 2'8, 2017 8:21AM No. 8608 P, 2 Jun 271 y 03:18p kim 5087715450 p.2 THE COMMONWEALTH OF MASSACHUSETTS Department of Early Education and Care Health Care Consultant Agreement Name of Program: r Address of Program'. 15, The Department of Early Education and Care Standards for the Licensure or Approval of Large Group and School Age Child Care Programs, 606 CMR 7.11(19)(b') require that each licensee designate a Massachusetts licensed physician, registered nurse, nurse practitioner or physician's assistant with pediatric or family health training andfor experience. In accordance with the regulations, the Health Care Consultant shall approve the program's health care policy initially and at least upon renewal of the regular license, shall approve changes in the health care policy, shall approve first aid training and training in medication administration for staff and shall be available for corsultation as needed. Regulation 7.11(19)(a) require that the Health Care Policy include: . The name, address and telephone number of the health care consultant and local health care authority; the telephone number of the fire department, police, ambulance, nearest health care facility, and the Poison Control Center; the name and telephone number of the emergency back-up person, if applicable; and the telephone and address of the program, including where applicable, the location of the program in the facility; method of 2. fhe procedures to be followed in case of illness, injury or emergency, transportation, notification of parents, and procedures where parent(s) cannot be reached including procedures to be followed when on field trips; 3. A list defining mild symptoms which'ill children may remain in care, and more severe symptoms that require notification of the parents or back-up contact to pick up the child; 4. A plan for caring for mildly ill children who remain in care; 5. A plan for administering medication, including: a. Annual evaluation of the ability of any staff authorized to administer medication to follow the medication administration procedures specified at 606.*CMR .7.11(2), and above;' b. A requirement that parents provide written authorization by a licensed health care practitioner for administration of any non-topical, non-prescription medication to their child. Such authorization shall be valid for one year unless earlier revoked; Page 1 of 2 1.G/SAHealthCaTeConsultent20loOl22 Jun. 28. 2017 8,22AM No, 8608 P. 3 Jun 27 17 03:18p kim 5087715450 P,3. 6. A plan for meeting individual.childten's specific health care needs, including the procedure for identifying children with allergies and protecting children from that to which they are allergic; 7. A plan to allow parents, with the written permission of the child's health care practitioner, to train staff in implementation of their child's individual health care plan; 8. A plan to ensure that all appropriate specific measures will be taken to ensure that the health requirements of children with disabilities are met, when children with disabilities are enrolled; 9. A plan to ensure that all children twelve months of age or younger are placed on their backs for sleeping, -unless the child's. health care professional orders othervvise in writing; on to parents that educators are mandated reporters and must, by law, 10.Noti rwis report suspected child abuse or neglect to the Department of Children and Families. I certify by my signature below that I meet the requirements of the health care consultant as described above. I have reviewed and understand the regulations referenced above and have agreed to assist this program regarding the same. Health Care Consultant a 0 Titl Telephone 5 o Lill to MA Certification/Registrtion Number d� Expiration Date of MA Certification Signature Date of Agreement I Please refer to A Guide to Developing sample Health Care Policies for Assistance I Page 2 of 2 LG/SA14ealthCareConsultant201oo122 a. 10 Department of Public Health `Ql VRDS Division of Community Sanitation STATE SANITARY ODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STA RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREAT!PN4,CAPPJEOR CAj JILDREN IN§PggTJPN REP NAME OF CAMP: DDRESS: ; OWNER/OPERATOR: OFF SEASON L, o ADDRESS: CAMP DIRECTOR' INSPECTED BY: ' F CAMP: (Circle) W ER J DATE OF INSPECTION 'Fport/oNoS Residential SOURCE: port) CAMPER �drf A Primitive Travel CAPACITY: "No column = N" marked below indicates a violation of 430.000. "Yes column = "�" marked below indicates compliance with provision of 430.000. "N/A column = N" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No N/A Comments Permits .451 Current Certificate(s) of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply - BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORI, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contingency plans - Day Camp: .211 A Camper doesn't show up for day. B Camper doesn't show up at point of pick up. C Child not registered arrives Contingency plans - Primitive, Travel and Trip: .212 A Itinerary daily - copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 I Regulation Yes No N/A Comments Promotional literature/packet contains: .159 (B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. 01 190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background check, health care, discipline policies and grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above) V Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. Required Counselors Ratios .101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 r Regulation Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving 01 experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities 159 (A) Health Care oi. I n Name: '3A A MD NP PA(w/pediatric training) Check for Health Care Consultant Agreement .159 (C) Health Su ervi or(on siteat al�ir�es Name: �✓ �` V 18 yrs, rstAid and R certified OR,MD PA RNLPN !•�c✓ MOM .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refrigerated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. .155 Medical log book- bound, pre-numbered pages, 771 ink entries; no skipped lines. .161 (A) Infirmary provided -day and resident camps Exterior light - resident camps .453 Lighting rovided in infirmary. .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR I W1 , mask, tweezers, cold pack, gloves. CW .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for meds and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 Regulation Yes No N/A Comments Immunizations: .152 (A) Campers and staff under 18yrs: Number of records checked: MMR: 1st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Poljio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) "Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the NO POISON P needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability. .204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. .204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 Regulation Aquatics (cont'd Yes No N/A Comments .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts ol .205 Equipment in good repair, safety precautions taken. Pla. round/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. V .206 Playground equipment secure, no concrete under/ arcund it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery 202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sqft/person in single bed 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special equipment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 Regulation Yes No N/A Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate# of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate# of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374 Adequate# of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 1'2°F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 1 Proper storage and disposal of solid waste. 6 Regulation Yes No N/A Comments .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. V if .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service facilit . .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances (RDA) .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided ' to ensure handicapped campers are eating nutritious meals. o .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closing. .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE a Camp Director's Signature A Date Health Inspector's Signature o Dat /'� 7 Old �D�partment of Public Health Division of Community Sanitation STATE SANITAR��ODE: CHAPTER IV MINIMU M SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECR ATIONAL AMP FOR qHILDREN INSP C ION REPOR NAME OF CAMP: DDRESS: OWNER/OP T �)) OFF SEASON �p ADDRESS: CAMP DIRECTOR: INSPECTED BY: r T OF CAMP: (Circle) WAT DATE OF INSPECTION: ay Residential SOURCEa)-Vport/NoSport) CAMPER d TripPrimitive Travel CAPACITY: � IY "No column = "J" marked below indicates a violation of 430.000. "Yes column = marked below indicates compliance with provision of 430.000. "N/A column = " " marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No NIA Comments Permits .451 Current Certificate(s) of Occupancy from local building ins ector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 eo le, >60 da s/ r . .300(A)(2)(b) Private water supply - BOH approval and chemical and bacterial analyses <25 people, <60 da s/ Plans and Policie - Written .090 (A) Procedures for backgro staff and volunteers. .090 (C) CORI and SORT, previous work history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contin ency plans - Day Camp: .211 A Camper doesn't show up for day. B Camper doesn't show up at point of pick up. C Child not registered arrives Conn encplans - Primitive, Travel and Trip: .212 A Itinerary daily - copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. Regulation . Yes No N/A Comments Promotional literature/packet contains: .159 (B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. 190 (C) Statement re: regulatory compliance and licensing. .190 (D) Inform parents of right to review background check, health care, discipline policies and grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D:' <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons IV experience. .102 (B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. Required Counselors Ratios ',� .101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. S 1 staff per 5 campers 6 yrs and under. .101 (B) Primitive, Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 f Regulation Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health CareIAa(=ric Ita Name: B/I WA�x j MD NP training) Check for Health Care Consultant Agreement .159 (C) Health Su rvis r ( n it a Name: � i �; 18 yrs, First Aid a CP certified OR, 459 P— 0! MD PN RN LPN .159 B Health Care Policy .160 A Medication stored in original containers. .160 (B) Meds stored in secured cabinet and if necessary refrigerated in affixed box. .160 C Medication administered by Health Supervisor. V ex-Y 4: .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. ;+ .155 Medical log book- bound, pre-numbered pages,- `4 ink entries, no skipped lines. .161 (A) Infirmary provided -day and resident camps Exterior light - resident camps .453 Lighting rovided in infirmary. .161 B Area for isolation of ill child .161 (C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask, tweezers, cold pack, gloves. - .150 Health, record for each camper and staff: -emergency contact info 1 -camper<18 yrs must have written parental per- l 1� mission for meds and emergency care. Residential, Sport, Travel/Trip: �V Q Health History, Physical Exam (<2 yrs) V I Record of Immunizations (noted below) Day Camp Non-Sport: �` l Health History, Record of Immunizations (noted below 3 Regulation Yes No N/A Comments Immunizations: .152 (A) Campers and staff under 18yrs: Num J r of records checked: MMR: 1st dose = 12 mos or older, 119 Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Number of records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers - "buddy system" .204 C Swim test to classify swimmers by ability. .204 (A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. .204E Piers and floats in good repair .204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. 4 I Regulation Yes No N/A Pornments Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces 01 free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ around it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sqft/person in single bed 35 sgft/person in bunk bed 50 sgft/person in sleeping area requiring special e ui ment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 h Regulation Yes No N/A Comments Residential Camps/Sleeping Areas .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. 1 .452 Screens provided. Screen doors self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate# of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people .374 Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 11.2'F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. or .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. V 11" 1 (A .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 Emergency communications system. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 Proper storage and disposal of solid waste. 6 Regulation Yes No N/ Comments .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. 400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service facilit . Y)fA .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 ofthe RDA requirements. .334 Adequately trained staff and equipment provided V • to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self-closing. .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 0— Me v O (' -04 An Camp Director's Signature Date o 1 . p 9 Health Inspector's Signature ate 7 t , W NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee DBA CAMP LITTLE CARPENTERS SHOP 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS OR CABINS, MOTELS AND TRAILER COACH PARKS `{ l This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 St, 2016 unless sooner suspended orrevoked. JANUARY 1, 2016 Wayne Miller, M.D.,Chairman Board Paul J.Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee By Renewal Fee Thomas A. McKean, RS, CHO, Health Agent t V • TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 MAIN STREET HYANNIS,MA 02601 508-8624644 RECREATIONAL CAMPS FOR CHILDREN REPORTING FORM s N N C* co MANDATORY Please complete entire form below, as well as camp application and mail with payment. Thank you. Camp Nam : RECRE TIONAL CAMP INFORMATION Tel#: Email: rem_r Owner's Name/ Director's Na e: 76 ? <aL In-Season Address City: Sta e: Zip: (No PO Boxes): Off-Season Address: City: State: Zip: Type of Camp: O Residential Day O Sports O Other(specify): #Staff per season: #Volunteers per season: # Campers per season: o� 430-LBOH Rec Camp-Reporting Form- Rev 8-2012 (partial) ENCLOSURE Z Town of Barnstable Permit Fee: • �TM'o Regulatory Services $15.00 Thomas F. Geiler, Director BAMSTABM 659. Public Health Division i6;q ,fig` Thomas McKean, Director 'y 200 Main Street, Hyannis, MA 02601 CM r � Office: 508-862-4644 Fax: 508-790-6304 N q X APPLICATION FOR A LICENSE TO CONDUCT A °D RECREATIONAL CAMP FOR CHILDREN Name of Camp: 4 SA Site Address: o�7� �a C.2 rl S Site Telephone: J`��S — —7'7/ , S ? sew Name of Camp Owner: Office Address: its on V 3C WL� S Telephone Number: Name of Camp Operator (if different): Address: Telephone Number: Name of Health Care Consultant: � ,� Address: 20 45S Telephone Number: Type of Camp: Da Residential Hours of Operation: `7,'go--- S 30 Dates of Operation: Opening: 2a Closing: Swimming Pool: Yes (If yes: Pool Permit Number ) Bathing Beach: Yes No Meals Provided:Yes o (If yes: Food Permit Number ) Signature of Applicant: A-e-C-1 Official Title Date: • See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing.process. i 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. v Staff information forms (see attached) (SORI/CORI With Juvenile checks)* ■ Procedures for the background review of staff(105 CMR 430.090) r ■ Copy of promotional literature (105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ■ Health care policy(105 CMR 430.159(B)) ■ Discipline policy (105 CMR 430.191) Fire evacuation plan—approved by local fire department (105 CMR 430.210(A)) ■ Disaster plan (105 CMR 430.210(B)) • ■ Lost camper plan (105 CMR 430.210(C)) ■ Lost swimmer plan (105 CMR 430.210(C)) ■ Traffic control plan (105 CMR 430.210(D)) ■ Day Camps—contingency plan(105 CMR 430.211) ■ Frimitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) ■ Current certificate of occupancy from local building inspector (105 CMR 430.451) Written statement of compliance from the local fire department(105 CMR 430.215) ■ If applying for initial license after January 1, 2000—lab analysis of private water supply (if applicable) (105 CMR 43 0.3 005 .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 wastewater • New for 2003 • Camp Director Name: Age: Coursework in camping administration: Previous camp administration experience: Health Care Consultant 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: ni �T 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: 1 National Rifle Association Instructor's card (or equivalent): Date certified:_/ / Expiration date: / / Horseback Riding Instructor Name: License Number: Expiration date: Stable Location: W 9 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. (file: QAHealth\Camps\Appl ication.doc) I 4 - Department of Public Health Dvision'of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: 1 ,eVlo ADDRESS: �7Q C ,; OWNER/OPE TOR: \_ OFFSEASON . Jc��. ADDRESS: CAMP DIRECTOR: j INSPECTED BY: TYPE OF CAMP: (Circle) WATER �.--, DATE OF INSPECTION: Residential SOURCE. (SporkttjoSpo CAMPER I Il Trip Primitive Travel CAPACITY: "No column = "4" marked below indicates a violation of 430.000. "Yes column = '1' marked below indicates compliance with provision of 430.000. "N/A column = "4" marked below indicates that the provision of 430.000 is not applicable to this camp. Regulation Yes No N/A Comments Permits .451 Current Certificate(s) of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire department. .300(A)(2)(a) Private water supply- DEP approval >25 people, >60 da s/ r . .300(A)(2)(b) Private water supply- BOH approval and chemical and bacterial analyses <25 people, <60 da s/ r . Plans and Policies - Written .090 (A) Procedures for background review of staff and volunteers. .090 (C) CORI and SORT, previous work"history, 3 references, out of state/international criminal background checks for staff and volunteers. .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures. .191 (B)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan .210 D Traffic Control Plan Contingency plans - Day Camp: .211 A Camper doesn't show up for day. B Camper doesn't show,up at point of pick up. C Child not registered arrives Contingency plans - Primitive, Travel and Trip: 12 (A)__ Itinerary daily-copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan japproved in writing by BOH. 1 Re ulaton Yes No N/A Comments Promotional literature/packet contains: .159 (13)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. .190 (C) Statement re: regulatory compliance and / �a licensing. V 1n��1�� ,1 V .190 (D) Inform parents of right to review background check, health care, discipline policies and / grievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90s7B&7D: <14 passengers AND driver is camp coach, director, etc. private vehicles may be used. >14 passengers, vehicle must be school bus. All vehicles must be RMV compliant .253 1 Proper automobile insurance .251 Seatbelts must be worn and special needs of campers communicated to driver. V .251 Campers <7 yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102 (A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons experience. OF02 (B) Day Camp: 21 yrs, completed camp �� (� administration course or 2 seasons experience. p� 102 (C) Primitive, Travel, Trip: 21 yrs and proof of experience. .102 (D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp. non-sport: Counselor= 16 yrs. Junior Counselor= 15 yrs. .100 Other camps: Counselors = 18 yrs or graduated from high school. Junior Counselors = 16 yrs. .100 All counselors 3 yrs older than campers. 101 (A) Residential and Day Camps: 1 staff per 10 campers over 6 yrs. 1 staff per 5 campers 6 yrs and under. S 101 , 1 counselor per 10 campers. 2 counselor min. .101 (C) Special Needs: 1 counselor per 4 mildly disabled campers. 1 counselor per 2 severely disabled campers. 2 Re' ulation Yes No N/A Comments .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert. CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21 yrs and experience w/mana ement. .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18 yrs, 2 yrs driving experience, current license for type of vehicle CN./ First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities .159 (A) Health Care Consultant- Name: /Yl.y NP PA(w/pediatric training) �d Check for Health Care Consultant Agreement .159 (C) Health Supervisor(on ego at. I times) N 8 yr First Aida CPR certi id R, A 59 B Health Care Polic 1 60 A Medication stored in original containers. .160 (B) Mods stored in secured cabinet and if necessary refri erated in affixed box. .160 C Medication administered by Health Supervisor. .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. .155 Medical log book- bound, pre-numbered pages, ink entries, no skipped lines. .161 (A) Infirmary provided -day and resident camps Exterior light- resident camps .453 Li htin rovided in infirmary, .161 B Area for isolation of ill child .161 (C) First Aid Kit:. &aap,.�erkr-pNize uare , press s, g e ss riangular and Hotted-banTlages 6PR--1 .150 Health, record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental per- mission for mods and emergency care. Residential, Sport, Travel/Trip: Health History, Physical Exam (<2 yrs) Record of Immunizations (noted below) Day Camp Non-Sport: Health History, Record of Immunizations (noted below 3 Re ulation Yes No N/A Comments immunizations: .152 (A) Campers and staff under 18yrs: Nu of records checked: MMR: 1st dose = 12 mos or older, Measles: 2nd dose = grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7-10 need booster if>5 yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td He B: 3 doses if born on or after 1/1/92 .152 (B) Campers and staff 18 yrs. or older: Numbrer records checked: Measles: 2 doses (exempt if born before 1957) Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxiods*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety, .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00 - permit posted. .204 (B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers -"buddy system" .204 C Swim test to classify swimmers by ability. .204 (A) Swimming areas clean and safe, no swimming at uindesi nated sites or at night without lighting. .204E Piers and floats in good repair 204 (G) Watercraft: equipped with US Coast Guard ap- proved flotation devices and worn by all campers and staff participating in watercraft activities. • 4 Re ulation Yes No. N/A Comments_ Aquatics cont'd .204 (H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103 (C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards. .206 Playground equipment secure, no concrete under/ around it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas. .201 Firearms in good condition, stored in locked cabinet. Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing 16 line and 25 yards clearance behind each target. 203 No personal weapons, bows, rifles allowed. Horseback Riding .208 (A) 1 certified instructor per 10 campers minimum 2 counselors .208 A Riders must wear hard hat .208 B Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Building Code and are free from obstruction. v .453 Lighting rovided for stairways .454 Ploors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40 sgfUperson in single bed 35 sgft/person in bunk bed 50 sgfb'person in sleeping area requiring special e uli ment. .470 Provide bed/cot per person with 6 feet between sleepers' heads and: 3 feet between single beds/4 1/2 feet between bunks 5 Re ulation Yes No NIA Comments Residential Cam s/Slee i Areas 459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen doors self-closing. 454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 s ft/ erson in bunk bed. Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order .370 Adequate#of toilets: All Camps: 2 toilets/privy seats for each sex. Day Camp: >60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp: >20 of one sex, provide 1 additional toilet per every 10 people of that sex .372 Toilet less than 200 feet from sleeping rooms. Toilet paper provided. Windows/opening screened. Screen doors self-closing. .373 Adequate#of sinks: Day camp: 1 per every 30 people Residential Camp: 1 per every 30 people 74 Adequate#of showers (residential camp): 1 shower/tub per 20 people. .378/.380 Special needs campers provided facilities that meet their needs. .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors. .376 Hot water at sinks, showers/tubs not more than 112°F .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily Laundry .162 Residential Camp: laundry facilities provided. .472 Bedding and towels laundered; no common towels. Grounds .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with #s of HCC, EMS, police, fire. (Day and Residential Camps only) .213 Emergency communications system. 65 Tobacco use restricted to designated areas not accessible to campers. .350055 Proper storage and disposal of solid waste. 6 I Re ulation Yes No . N/A Comments 207 Proper storage and o eration•of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permits posted in food service facility, .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps - Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day Camps - Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. 52 Screening provided for food preparation and food v service areas. Screen doors must be self-closing. .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. Regulation No. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Camp Director's Signature Date I� Health Inspector's Signature N Date 7 Jun201jun; 20. 20161 2: 15PM 5087715450 No. 4446 �P._ 2 ' IMALT11 C&UCOJMSULTANT AGYtr,,FMENT 1 NAME OF'CAMP ��: f'i' ��,� PCI� tS Af)nRFS3 OF CAMP !4 f ib-N I'he Mm.%a:hwolts 1)upurtmuntof Puhlit:Health rugulations for rccrulinnal Camps for children.105 CMlt 4301000,requite that all 1'MoUtionul camps for ehildrian httvc o health wTe consultant.ThO wgularlon and responsibilities of this person are described below. 410.159(A) Heoldt Care Consoltaot A designated massy chuFettc licensed physician,nurse practitiAner or phyaici3n atisistant with pediatric training 0 the calltp's health care consultant.The consultant MIME I, Assiut in the development of the vamp`s healtlicare policy as described iit 105.CMA 430.159(B); 2. Review and grove dye policy;nitially and at least annually shereaRzr; 3, Approve any chartges in the policy; 4. Review;uid approve die first rid training of the staff; 5. Be available for consultarioll at all times;and 6. Develop and sign wrinell tndeas to be followed by tiro arsito hoold►suporvlsor bi the Wininisvoon of his/her rclatM dutium If tho heolth supervisor is not a licensed hCalih care professional authorized to administer prescription medicntions,the administration of rtiedlcatlons shall be underilte pnottsional oversight ofthe health care eonxulsant. 1n5 CMR 4.10,11Go(Q 430.159(3) Ilealtb Csre_EWjV A written medleal policy,approved by the local board of lterttth and by the cutn;p health care gonsuftam.Such policy shall include,but not be limited to,daily health super-Yision,infection uuntrul,handling of health enwrgcnci=and nocidcnts,avuilabh:dmlxrlunuc durv;cus'proviviun for medival, nursing pnd tint aid scrv'tcss,the name of the dtssibnmd on-site camp health supervisor,Alit mime,address • tmd pli000 number of the comp health care consultant requ iced by 105 CMR 430.159(A)end llte namt of the health supervisor required by 105 CMR 430,159(C),if appl ioahle- 430,160(C) Admiu tratlon of Medication The health care consultant shall aeknuwludflu in writing a list of all mctticationa administered ru the camp. 1 meet tharelluirelnents of the health we cotwulrtnt as descf Ued In 105 C;MK 430.159(A).I have reviewed thoses referenced regulations end undmiand thu rosponsihilitio of the pnaition and x6rcc to assist this camp regarding the same. l3a�dNs.0.ea a' �...0_ ' Print Namc Title Sil;rutsre MALieartsc/ cgistrationNumher Address Te(ephorie Numhor Bass River Pediatric Assoc.,P.C. Date; 237 Station Avenue South Yarmouth, MA 02664 (508)394-2116. l NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CARPENTERS SHOP -FCA 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMP OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 st, 2009 unless sooner suspended or revoked. 6/22/2009 Wayne Miller, M. D., Chairman Board Paul J. Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee By Renewal Fee y� Thomas A. McKean, RS, CHO, Health Agent r- Town of Barnstable - Peru Fee: , SHE A�o Regulatory Services $75.00 h Thomas F. Geiler,Director BA[tT'jS'F'AB1A MAC Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: 4Q r e, o /;�p � a- n Site Address: 76 3 � CD Site Telephone: -7 7 w o cn Name of Camp Owner: �� ��; r g i L+ o CD� Office Address: A-T0 /_-��,- �, M�j P-; Telephone Number: :j0,P- Name of Camp Operator(if different): i t' �s Address: Telephone Number: - 3G `- \Z ~ �71 � � a Name of Health Care Consultant: t' � C' CD Address: <a l �� ,� �ia�` °R T �V � Telephone Number: ~'^' rt• Type of Camp: Day Residential Hours of Operation: .7;3c) --- Dates of Operation: Opening: 6 Closing: ' Swimming Pool: Yes No _(If yes: Pool Permit Number �7 Bathing Beach: Yes No Meals Provided: Yes No (If yes: Food Permit Number =z Signature of Applicant: Official Title: Date: / / 9 U- p , `l See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete �Y these documents as soon as possible and submit them in advance. This will expedite the process.- -- --- Camp Director Name: Liz r-e- Age: Coursework in camping administration: Previous camp administration experience: e 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 I Name: NIP, I P, 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: KA4 —r, 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. States Website on Regulations for Recreational Camps for Children (105 CMR 430.000) http://www.state.ma.us/dph/dcs/campre.pdf (file: QXampsUpplication 04.doc) I Gf S Department of Public Health Division of Community Sanitation STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 ����, R�E���R�E�A`T ®fi`Ik �� DAM FOR.C� `ILDRE IINSPEC�TIONI�E��RTs,, NAME OF CAMP: ADDRESS: oG OWNERIOPERATOR: OFFSEASON ADDRESS: CAMP DIRECTOR. k1 INSPECTED BY: JYJ�EOF CAMP: (Circle) WATER DATE OF INSPECTION: a Residential SOURCE: �� (Sport/NoSport) CAMPER ' Trip Primitive Travel CAPACITY: "No"column marked below indicates a violation of 430.000. "Yes"column= marked below indicates compliance with provision of 430.000. "N/A"column = marked below indicates that the provision of 430.000 is not applicable to this camp. Permits .451 Current Certificate(s)of Occupancy from local building inspector for sleeping/assembly areas. .215 Written compliance from local fire dept. .300(A)(2i(a) Private water supply- DEP approval(>25 people, >60 da s/ r .300(A)(2;n(b) Private water supply-BOH approval and chemical and bacterial analyses <25 peopie, <60da s/ r Plans and Policies-Written .090(A) Procedures for background review of staff and volunteers. .090(C) CORI and SORI , previous work history, 3 references, out of state/international criminal back round checks for staff and volunteers .091 Staff and volunteer orientation plan and review. l0 .093 Abuse and neglect prevention/reporting rocedures. .191(13)(C) Discipline Policy with: appropriate discipline methods and prohibitions. .210 A Fire evacuation plan and drills l/ 210 B Disaster Plan 210 C Lost Camper Plan 210 C Lost Swimmer Plan 210 D Traffic Control Plan Contingency plans- Day Camp: .211 (A) Camper doesn't show up for day B Camper doesn't show up at point of pick u C Child not registered arrives Contingency plans- Primitive,Travel and Trip: .212 (A) Itinerary daily-copy to parents it (B) Source of emergency care I! .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. Re ufatipn dux „ „, r„,. y,...,,, �Yes MIN. ;Comments - Promotional literature/packet contains: .159(B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision. 190(C) Statement re: regulatory compliance and licensing. .190(D) Inform parents of right to review background check, health care,discipline policies and rievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers AND driver is camp coach, director,etc. private vehicles may be used. >14 passengers,vehicle must be school bus All vehicles must be RMV compliant .253 Proper automobile insurance .251 Seatbelts must be worn and special needs of v campers communicated to driver .251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102(A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons ex erience. .102(B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of ,/ experience. .102(D) Designated substitute when director off-site >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: Counselo ­ 16 yrs. Junior Counselor- 15 yrs. .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counselors= 16 yrs .100 All counselors 3 yrs older than campers Required Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs 1 staff per 5 campers 6 yrs and under .101(B) Primitive,Travel,Trip: 1 counselor per 10 campers.2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled campers I .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid Cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs, 2yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. Medical Personnel/Records/Facilities on .159(A) Health Care Consultant f, q Name- MD PA(w/pediatric training) Check for Health Care Consultant A reement .159(C) Health Supervisor(o site at all ti es) Name: R@1&r' 18yrs, First Aid and CPR certified OR, j MD PA NP RN LPN .159(B) Health Care Policyw` .160(A) Medication stored in original containers. .160(B) Meds stored in secured cabinet and if necessary refrigerated in affixed box. .1 60 C Medication administered by Health Supervisor .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH. .155 Medical log book-bound, pre-numbered pages, ink entries, no skipped lines. .161(A) Infirmary provided-day and resident.camps Exterior light-resident. camps .453 Lighting rovided in infirmarytf .161(B) Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap, sterile gauze squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask,tweezers, cold pack, gloves. .150 Health record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental permission for meds and emergency care. Residential,Sport,Travel/Trip: Health History, Physical Exam(<2yrs) Record of Immunizations(noted below) Day Camp Non-Sport: Health History, Record of Immunizations(noted below f Re ulafion , Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: MMR: 1 n dose = 12 mos or older, Measles: 2"d dose=grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be used) *Booster dose of Td: -grades 7=10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td Hep B: 3 doses if born on or after 1/1/92 .152(B) Campers and staff 18 yrs.or older: Number of records Measles: 2 doses(exempt if born before 1957) checked: Mumps: 1 dose (exempt if born before 1957) Rubella: 1 dose (exempt if born before 1957) Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers; do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics .430 Swimming Pool: in compliance with 105 CMR 435.00-permit posted. .204(B) Bathing Beach: in compliance with 105 CMR 445.00-weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers-"buddy system" .204(C) Swim test to classify swimmers by ability. .204(A) Swimming areas clean and safe, no swimming at undesi nated sites or at night without lighting. .204E Piers and floats in good repair. .204(G) Watercraft: equipped with US Coast Guard approved flotation devices and worn by all campers and staff participating in watercraft activities. Iwo l,y � ✓-- 3at3 f q sue..✓,,v� /l f'. " ON, Aquatics cont'd .204(H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. .103(C) Minimum 2 counselors in separate watercraft supervising white water, hazardous salt or fresh water activities. Crafts .205 Equipment in good repair, safety precautions taken. Playground/Athletic Equipment .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure, no concrete under/around it, pliable swing seats. Firearms .201 Single shot rifles only. .201 Shooting range away from other activity areas .201 Firearms in good condition, stored in locked cabinet.Ammunition locked in separate cabinet. Archery .202 Equipment in good condition, stored in locked area. .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding .208(A) 1 certified instructor per 10 campers(Min.2 counselors .208(A) Riders must wear hard hat 208(B) Licensed stable Cabins/Structures: .457 Day Camp provide shelter for on-going camp activities. .216 Smoke detectors provided. .455/.456 Egresses comply with Bldg.Code and are free / from obstruction .453 Lighting rovided for stairways .454 Floors maintained. Residential Camps/Sleeping Areas: .458 Provide adequate space: 40sgft/person in single bed 35sgft/person in bunk bed 50sgft/person in sleeping area requiring special e ui ment .470 Provide bed/cot per person with 6 feet between sleeper's heads and: 3'feet between single beds/4112 feet between bunks �' I" rlflt f J133 �� Rye u£lati©n a� es N,o :�N/�► Comments 3 (r - Residential Camps/Sleeping Areas: .459 Campers and staff with limited mobility housed on ground level; egresses leading to grade or ramp provided. .452 Screens provided. Screen door self-closing. .454 Floors maintained. Tents: .217 Fire-retardant and non-toxic. No open flame nearby. .458 35 s ft/ erson in bunk bed Toilets/Showers .360 Proper sewage disposal .301 Plumbing in good working order 370 Adequate#of toilets: All camps: 2 toilets/privy seats for each sex Day Camp:>60 of one sex, provide 1 additional toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex,provide 1 additional toilet per every 10 people of that sex. .372 Toilet less than 200 feet from sleeping / rooms.Toilet paper provided.Windows/ V openings screened. Screen doors self-closing. .373 Adequate#of sinks: Day Camp: 1 per every 30 people Residential Camp: 1 per every 30 .374 Adequate#of showers(residential camp): 1 shower/tub per 20 people .378/.380 Special needs campers provided facilities that meet their needs y .453 Lighting provided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks, showers/tubs not more than V, 112°F. .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily. Laundry .162 Residential Camp: laundry facilities provided .472 Bedding and towels laundered; no common towels Grounds: .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with#s of HCC, EMS, police,fire. (Day and Residential Camps only) .213 Emergency communications stem. .165 Tobacco use restricted to designated areas not accessible to campers. .350/.355 Proper storage and disposal of solid waste Fl .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied building. .400 Rodent and insect control. .401- Weed and noxious plant control. t/I .450 Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permit posted in food service facility. .330 Nutritious meals that include a variety of foods served. Menus posted. .331 Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day camps—Each meal provided must meet �� ram,,,,, t 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are r eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self- closing. .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 51 75.00 TOWN of BARNSTABLE This is to Certify that Beverly Robdee D/B/A CARPENTERS SHOP - FCA 270 COMMUNICATIONS WAY, BLDG. 3, HYANNIS HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMP OR CABINS, MOTELS AND TRAILER COACH PARKS This License is issued in conformity with the authority granted to the Board of Health, by Chapter 140, Sections 32A, 32B, 32C, 32D, and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to said Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31 st, 2008 unless sooner suspended or revoked. June 26, 2008 Wayne Miller, M. D., Chairman Board Paul J. Canniff, D.M.D. of Junichi Sawayanagi Health Original License Fee Renewal Fee By Thomas A. McKean, RS, CHO, Health Agent z Of e NAP O� ' TOWN OF BARNSTABLE �b .00 200 MAIN STREET .�,n�,� • HYANNIS, MA 02601 �f0 MAC� STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 -.� ��C/�M� ��R �:11_ �x� _ DNS ;G.��O1 �:PQ_ NAME OF CAMP: ' -- C)or ADDRESS: 70 n7,,"I"C* O. NER/OPERAT R. OFFSEASON 03 GJhd-mac- fofu, AEI b�� ADDRESS: pc963e 56,?—C1a$—f6 S 3 CAMP DIRE TOR: INSPECTED BY: - Srn-4ee f]5. TYPE OF CAMP: (Circle) WATER DATE OF INSPECTION: 1!7; Residential SOURCE: Sport/NoSport) CAMPER Trip Primitive Travel CAPACITY: "No"column= `4" marked below indicates a violation of 430.000. "Yes"column = 'I' 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. c aax N;oN/A �Gom_rnertts � � Permits .451 Current Certificate(s)of Occupancy from local -building inspector for sleeping/assembly areas. .215 Written compliance from local fire dept. .300(A)(2)(a) Private water supply-DEP approval (>25 people, >60 da s/ r .300(A)(2)(b) Private water supply-BOH approval and / chemical and bacterial analyses / <25 people, <60da s/ r VVV Plans and Policies- Written .090(A) Procedures for background review of staff and volunteers. .090(C) CORI and SORT , previous work history, 3 references,out of state/international criminal background checks for staff and volunteers .091 Staff and volunteer orientation plan and review. .093 Abuse and neglect prevention/reporting procedures. .191(13)(C) Discipline Policy with:appropriate discipline methods and prohibitions. 210 A Fire evacuation plan and drills .210 B Disaster Plan .210 C Lost Camper Plan .210 C Lost Swimmer Plan 210 D Traffic Control Plan -Contingency plans-Day Camp: Vol .211 A Camper doesn't show up for day B Camper doesn't show up at point of pick u C Child not registered arrives Contingency plans-Primitive,Travel and Trip: .212 A Itinerary daily-copy to parents B Source of emergency care .190 Camper released only to parents or parent- designated individual in writing. Other plan approved in writing by BOH. 1 f Relat�oii nE � � s;§n r w� v' E f uN. r,. .; w a Promotional literature/packet contains: .159(B)(2) Copy of policy re:care of mildly ill campers, administration of meds and emergency health care provision. .190(C) Statement re: regulatory compliance and ( rrw*z licensing. ;ks .190(D) Inform parents of right to review background check, health care,discipline policies and rievance procedures upon request. Transportation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers AND driver is camp coach, director,etc. private vehicles may be used. >14 passengers,vehicle must be school bus All vehicles must be RMV compliant .253 Proper automobile insurance 251 Seatbelts must be worn and special needs of �. campers communicated to driver 251 Camper<7yrs not transported longer than 1 hr to cam Staff Qualifications Camp Director .102(A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons ex erience. .102(B) Day Camp: 21 yrs, completed camp administration course or 2 seasons experience. .102(C) Primitive,Travel,Trip: 21 yrs and proof of experience. .102(D) Designated substitute when director off-site 04- >12 hrs. Sub must meet criteria above Counselors/Junior Counselors .100 Day Camp, non-sport: Counselor- 16 yrs. Junior Counselo ­ 15 yrs. .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counselors= 16 yrs .100 All counselors 3 yrs older than campers Required Counselor Ratios .101(A) Residential and Day Camps: 1 staff per 10 kids over 6 yrs 1 staff er 5 campers 6 yrs and under .101(8) Primitive,Travel, Trip: 1 counselor per 10 campers. 2 counselor min. .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled campers Re ulat�on . ,,s 3 f Ye10� N/A =�Gornments :. .103 Aquatics Director: Name: None American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer and First Aid Cert. or their equivalents. If supervise 2 staff, 21yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Trng cert., CPR for Professional Rescuer cert. and First Aid Cert. or their equivalents. List names. .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. List Names and Certifications: .252 Camp vehicle drivers: 18yrs, 2yrs driving experience, current license for type of vehicle First Aid certified if no other trained staff aboard. e Medical Personnel/Records/Facilities J �- lybk .159(A) Health Care Consultant �j�a S Name: MD g) PA(w/pediatric training) Q ( 44/!�� Check for Health Care Consultant Agreement Gu'rrt1 .159(C) Health SURE rvisor(on site at all times) Name: - cQVVA-/ .18yrs, First Aid and 04R certified OR, MD PA NP RN LPN .159(B) Health Care Policy .1 60 A. Medication stored in original containers. .160(B) Meds stored in secured cabinet and if necessary refrigerated in affixed box. .1 60 C Medication administered by Health Supervisor .154 Injury Reports completed for fatality or serious injury. Co sent to MDPH. .155 Medical log book-bound, pre-numbered pages, ink entries, no skipped lines. .161(A) Infirmary provided-day and resident.camps Exterior light-resident. camps '453 Lighting rovided in infirmary .161(B) Area for isolation of ill child .161(C) First Aid Kit: non-perfumed soap, sterile gauze VJ squares, compresses, adhesive tape, bandage scissors, triangular and rolled bandages, CPR mask,tweezers, cold pack, gloves. .150 Health record for each camper and staff: -emergency contact info -camper<18 yrs must have written parental permission for meds and emergency care. Residential,Sport,Travel/Trip: Health History, Physical Exam(<2yrs) Record of Immunizations(noted below) Day Camp Non-Sport: Health History, Record of Immunizations(noted below � �r`'� I �4 x k i rtu3 1�,' � � ek >;� c 5�. � R � ��, ,�'; � �'3 3, Y s 'tNo r Nl Co. rnOr�ts L�p rs ,4 'F'"�a "5 �� 3,N Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: MMR: 1�t dose = 12 mos or older, Measles: 2"d dose=grades K-12 or age equiv Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV Diphtheria and Tetanus Toxoids and Pertussis*: 4 doses DTaP/DTP/DT or, 3 doses of Td (persons 7 yrs or older needing additional vaccines to comply with above, Td is to be 1 ' used) *Booster dose of Td: -grades 7-10 need booster if>5yrs since.last dose of iDTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs since last dose of DTaP/DTP/DT/Td Hep B: 3 doses if born on or after 1/1/92 .152(B) Campers and staff 18 yrs.or older: Number of records Meeasles: 2 doses(exempt if born before 1957) checked: _ ,clumps: 1 dose (exempt if born before 1957) Rubella: 1. dose (exempt if born before 1957) 'V Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td *Booster dose of Td required if more than 10 yrs since last dose. Activities .190 Activities and physical environment meet the needs of campers;do not pose hazard to health/safety. .163 Operator encourages sun protection for all. Aquatics 430— Sturimming Pool: in compliance with 105 CMR 435.00- permit posted. _ .204(B) Bathing Beach: in compliance with 105 CMR 445.00-weekly water sampling conducted. .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers Plan to check swimmers-"buddy system" .204(C) Swim test to classify sv,/immers by ability. 204(A) Swimming areas clean and safe, no swi iming — --_ at undesi nated sites or at night>AMIIout figh ing.- — _ -- _ ---^--- — -_ .204(EL Pi; rs and floats in good repairer. __ — --- --- — ----- .204(G) Watercraft: equirped with US Coast Guard approved flotation devices and-,,vorn by a;l carnper s ai id!sta'-I I"articipLitirlG activities. I Aquatics Cont'd .204(H) Campers must be certified by American Red Cross or equivalent for white water, hazardous salt or fresh water activities. 103(C) Minimum 2 counselors in separate watercraft supeRnsing white water, hazardous salt or fresh water activities. Craft: .205 Equipment in good repair, safety precautions — taken. Plav-round/Athletic Equipment__ 206— Equipment properly maintained, fields/surfaces — 'rree of l-soles/accident hazards :206 Playground equipment secure, no concrete Linder/around it, pliable swing seats. Firearms — .201 Sina„le shot rifles only. _ .201 Shootinq range away from other activity areas .201 Firearms in good condition, stored in locked cabinet.Airmunition locked in separate cabinet. Archery 202 Equipment in good condition„ stored in locked area. _ .202 Range away from other activity areas, clearly marked as danger area. Must have common firing line and 25 yards clearance behind each target. .203 No personal weapons, bows, rifles allowed. Horseback Riding — -- — .208(H) 1 certified instructor per 10 campers(Min.2 counselors 208 A Riders must wear hard hat .203(B) _ Licensed stable .457 Day Camp provide shelter for on-going camp _ activities. _ .216 Smoke detectors provided. .455/.456 Egresses comply with Bldg.Code and are free from obstruction .453 Li hting.provided for stairways — .454 Floors maintained. Residenfiai Cam s/Slee-ping Areas: .458 Pr wide adequate space: 40sgft/person in single bed 35sgrUperson in bunk bed 50sctfl/person in sleeping area requiring special e ui^r+ent 470 Provide h:,vivot fen person with G fret betw ri ----- _- s!ee-per's i;eads and: 3 feet between single beds/41/2 feet between bunks a£, � aw"3 a k s3t Reulafiot „ r r MIN. Ar. , .,k..._ Residential Camps/Sleeping Areas: .459 Campers and staff with limited mobility housed on ground level;egresses leading to grade or ramp provided. .452 Screens provided. Screen door self-closin . .454 Floors maintained. _ Vents: .217 Fire-retardant and non-toxic. No open flame nearby. .453 35 sgft/person in bunk bed Toi;e;:s/Showers �•, — ----- .360 Proper sewage disposal 301 Plumbing in good working order .370 Adequate#of toilets: All camps: 2 toilets/privy seats for each sex Day Camp:>60 of one sex,provide 1 additional toilet per every 30 people of that sex. Non-Day Camp:>20 of one sex, provide 1 . additional toilet per every 10 people of that sex. .372 ,Toilet less than 200 feet from sleeping rooms.Toilet paper provided.Windows/ openings screened. Screen doors self-closing. .373 Adequate#of sinks: Day Camp: 1 per every 30 people Residential Camp: 1 per every 30 .374 Adequate#of showers(residential camp): 1 shower/tub per 20 people .378/.380 Special needs campers provided facilities that meet their needs .453 Lighting rovided. .375 Toilets and shower rooms ventilated to outdoors .376 Hot water at sinks, showers/tubs not more than ��� 112°F. .377 Sanitary facilities maintained in clean condition. Shower room floors washed daily. Laundry .162 Residential Camp: laundry facilities provided .472 Bedding and towels laundered; no common towels Grounds: .300 Potable water provided. .300/.304 Adequate and centralized drinking water facilities. No common drinking cups. .209 Telephone readily available with#s of HCC, EMS, police,fire. (Day and Residential Camps only) _ 213 Fr+nergn ommunicatior;system.—__ _ �- -- — .165 Tobacco use restricted to designated areas not --- accessible to campers. .350/.355 Proper storage and disposal of solid waste 1 � .207, Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked unoccupied buildin . .400 Rodent and insect control. .401 Weed and noxious plant control. .450 Site location does not cause undue traffic _ hazards and is accessible at all times. Food. SemLlce .320 Food service in compliance with 105 CMR 590.000, Minimum Standard's for Food Establishments. Permit posted in food service facility. .330 Nutritious meals that include a variety of foods n served. Menus posted. .331 Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances (RDA) .332 Day camps—Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are ,eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self- closing. .453 Lighting provided in kitchen and dining area. .471 Sleeping rohibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 1 i .207 Proper storage and operation of power equipment. .214 Flammable and hazardous materials labeled and stored in locked,unoccupied building. .400 Rodent and insect control. 401 Weed and noxious plant control. 450 € Site location does not cause undue traffic hazards and is accessible at all times. Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permit posted in food service facility. .330, Nutritious meals that include a variety of foods served. Menus posted. n s .331 j Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances RDA .332 Day camps—Each meal provided must meet 1/3 of the RDA requirements. .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals. .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive 1� without a bag lunch. .452 Screening provided for food preparation and food service areas. Screen doors must be self- closin . .453 Lighting rovided in kitchen and dining area. .471 Sleeping rohibited in food areas. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE HeA th Care [Poky, ditt0e Carpenters Early ChiRdhoo i Learning Center . . , 270 d®mmunl6a, ti®ns Way,,s uiudine 39 59r6nnis Na • + 508-367-2705 Emergency Numbers. Fire-Rescue 1-508-775-1300 Police 1-508-775-0387 911- Poison Prevention Center, 1-800-222-1222 1-617-232-2120 Cape Cod Hospital 1-508-771-1800 27 Park St. Hyannis , , Health Care Consultant 1-508-771-8350 Pauline Designated adult for first and last hour contact: Beverly 1-508-367-2705 1-508-428-1658 Location of allergy postings: On every clipboard as well as: Infants: On wall by door Toddlers: On wall by door 3's: On wall by door 4's: , On wall,by door ,. Kindergarten: On wall by door School Age: On wall by door Location of Health Care Policy: Main Office Location of First Aid Kit: Main Office 1 Procedures To Be Followed In Case Of Illness Of Emergency I understand that every effort will be made to contact me in`the.event of an emergency requiring medical attention for my child While I am being reached, if necessary, Little Carpenters has my permission to call the Rescue Squad and to secure for my child the necessay medical treatment: If necessary my child may be transported to Cape Cod Hospital where the necessary medical-treatment,can be given. I understand that the teachers at Little Carpenters and Faith Christian Academy are trained in the basics of first aid and I authorize them to give'my child first aid when appropriate. I will be notified upon picking up my child by an accident report. When I cannot be reached I authorize Little Carpenters to release my child to the following persons as well as the names on the current application: Name: Relationship: Address:r Telephone#: Name: - Relationship: . Address: ,s , ;; ` ' Telephone#: Name: Relationship: Address: ; u - Telephone#' Name: ry Relationship: Address: Telephone#: Name: ` ` ''"`' Relationship: Address: Telephone#: Name: ,, , : Relationship: Address: Telephone#: I authorize this same procedure for school premises as well as field trips. 2 r r ,+ Emergency Procedures, Parent is to sign the Consent Form upon admission!,,, Director is to be notified immediately and parent is to be called. If it is a minor emergency; the. parent will decide whether to come to the school. Emergency—Rescue Squad is to be called—911- parent is also to be called. If necessary, the child is treated by the Rescue Squad or transported to Cape Cod Hospital, a staff member will accompany the child in the rescue vehicle of the parents cannot be reached'in time. The parents will meet the child at either the school or the hospital. If the parents cannot be reached, authorized persons on the permission list will be-contacted— and if hospitalization is not necessary take the child home. 3 r,.• y Procedures For Using And Maintaining First Aid Equipment All staff will be given approved first aid training. First aid care will•be given by the school staff. _ . Parents or authorized adult will be notified immediately if situation requires more thean minor first aid. c - s' ► • : The proper_first aid procedure will,be followed, according to first.aid training;.in relationship to. the injury r If minor first aid ;is given,(,the parent is notified..upon picking up, the child,and is given an accident report to read and sign. If the injury is more than minor, the parent will be called., The Health Care Consultant along with the director is responsible for maintaining adequate supplies for the first aid kit. The supplies include the following: Adhesive tape Band-aids Compress Gauze pads Roller bandage Disposable gloves Instant cold packs Scissors Tweezers Thermometer The first aid kit is located in the main office. A fist aid manual is located in each classroom as well as the main office. First aid is administered by the Director, teachers, nurse, rescue squad, or person on staff trained in first aid. A central log of injuries is maintained by the Director and is in the main office. Fire drills are held every other month and documented. This log is kept in the main office. There are four(4)non-coined operated telephones on the premises. 4 i Procedures For.Evacuation Of Center,In An Emergency Above each classroom door is an evacuation route to be used in the even of an evacuation.The , t route is discussed with the teachers and-practice drills are maintained. - _ ;• • . Each teacher has a separate attendance sheet weekly which each child is signed in and out immediately upon arriving and leaving for the day.,If the child-is,dismissed for a short period of;•t time the child is signed out and back in when he/she-returns.l These attendance sheets-are in a , sturdy clipboard along with emergency information and applications for each child. The emergency and:application material,is,in a manila envelop:and the,attendance.sheet°is on the top. A pen is,also,attached to the clipboard. The clipboard travels with the teacher wherever the class goes. Each teacher will lead the children out of the building during the evacuation and the assistant will follow at the end. The teacher will be responsible for taking the attendance sheet and checking that each child is accounted for when they reach outside;as well as again when they F=, return to the building. An appointed staff member, usually the Director, is responsible for.,checking for stragglers in the.. building. Each bathroom, lunchroom, gym, or vacant room is checked. In the infant department, there is a crib that is marked clearly - for evacuation.. Each'teacher is aware of this crib and can place the infants in it for evacuation. In the toddler department, the children are taken into the backyard which is all,fenced in., Additional staff and senior students from our school immediately, go to specified areas in+the infant and toddler areas to assist the teachers. , A log is kept of the fire drills that are conducted. The time of day, date, weather, and time needed to evacuate is noted. The, local fire department also conducts designated drills. Ve have automatic alarms that are hooked up to the fire department, so that if there is a malfunction in an, alarm and it goes off immediately at the fires department is here. We normally are totally evacuated totally in less then 45 seconds. !: The teacher will be personally responsible to see that any handicapped child is individually taken out. 5 tlPlan.For-Iiijury.Prevention�,, The•Injury,Log isrlocated in the main'office who is responsible-for charting the,injuries.'This log is setup by classroom -with area tfor.date,-time; teacher,on duty,`child's name, and nature of .• injury. The original fled into the individual child's folder. r The teacher present at the time of injury.will'completely fill out the-accident report and,have it,,'t signed by.the.parent or.giardian.,All forms are to be signed by the Director. : .., `I s � .. .. F r,r• r !':f+}, �:� ,!� i'+ r 1_ � t✓ r r tA, Each teacher monitors their own classroom for items:that could be hazardous to the children. r c Broken.toys or equipment are iemoved from the room. The equipment=that.has been removed-is wither repaired or discarded. The equipment that needs repairing the teacher should place a note _ in the Director's mailbox. If there is a building needs that needs repairing the teacher is to place a note in Pastor's mailbox;`t.i r„_ _.-14 ;-+, , , ,i ' • . .4. Daily checklist would include among other things: Cobwebs Broken or sharp objects Dust, or toys that need;cleaning or repairing , .. if t;• ,, ,. . Electrical plugs Burned out lights Any-adult belonging put out of reach of children That all shelves are secure IVJ ' Chairs and tables are in good repair Soap and paper towels are•in:available Gates are in proper place Floors are clean and free of clutter i Refrigerators are clean Playarea is free from sharp objects, brushes, and broken toys J Medications-are stored'either in the refrigerator or'on a high shelf in the kitchen, where the, children do not'go, 1,. , 1 ') ,. 1 !i', i "', , .t= I• � .t., +`7 5 iJY � is e} ... 1• ,i Sharp objects, toxic substances would likely not be in the center. If there ware, they would be . . placed out of the reach of the children, in an area that they would not have access to. There are no poisonous plants in the center. There are no matches in the center, if there were they would be stored in a water tight container on a high shelf in the kitchen. 6 _ J Plan For Management Of Infectious-Diseases The precautions used to,minimize the spread of infectious,diseases is.for each staff member to. use great caution to wash their hands with dial soap regularly.-That children be instructed to do ; the same. That good supply of tissues are available and that hand washing is done after using tissues. That all waste baskets are.emptied and sanitized daily. Cleaning agents such as Lysol , and/or,bleach is used in cleaning and disinfecting,daily... Children are taught to cover their mouths.when coughing, to use tissues, to wash their hands, , etc. 1 1. 1 _ , . ; No child is to remain at the center if they exhibit fever, an undetermined rash, eye infection,. repeated diarrhea, or vomiting. The parent,or authorized person is to be contacted and the child is taken home. After the child is on a penicillin type of medication for 24 hours,they-may return to.., the center. While the child is waiting to be taken home, they will be given,an area,away from the other children and made comfortable until someone arrives. If communicable disease is noted in the center;.a•notice is sent home to the parents. We also request the parents to notify us of any communicable disease that maybe in their home. , 7 Plan For-Infection Control. The following plari,is taught to each new staff,member. The Director, in conjunction•with the Health Care Consultant will monitor this activity. Liquid dial soap and,disposable totiwels are•provided in'each classroom and bathrooms,.,Children are instructed by the staff to was and dry their-hands before lunch or when handling food, after using the bathroom, after painting or other activities that would necessitate this. Cleanliness is a unit that is'taught' each classroom andreviewed as needed. Teachers-will wash their hands for above reasons, as well as after cleaning, or taking care of a wound on a child. After each use=potty chairs-are"emptied and sanitized'as well'as the adult toilets that they are ' emptied inio: Each time a•child is changed the diapering area is washed with disinfectant, teachers hand sate washed, and clean disposable towel•is•placed under the child. All diapers aie placed in a container that has a'liner and a lid.'These containers are emptied after each diaper change and place outside in a proper area and container. , . �r '" . - ' .1 1 r Non-disposable items, such as: bottles, training cups and feeding spoons are washed and then rinsed'in a bleach solution, again rinsed in a clear solution. Bibs and toys are-washed and ' sanitized. ,. .. Dail all rooms are vacuumed—Lysol or bleach is used to clean the bathrooms—unca eted Y Y rP floors are mopped with Lysol or bleach—garbage containers have new liner put in them after the container has been disinfected, The drinking fountain is disinfected—tables are washed down after each use—mops are rinsed after use—washcloths are machine washed with bleach—crib sheets are machine washed with bleach- all bibs are machine washed with bleach. All cribs are sanitized nightly, as well as all washable toys and books. Sleeping bags are sent home monthly, or less if needed. Immediately if soiled. All cleaning materials are stored in kitchen areas, far out of the reach of any child. 8 • ,tea t -Care Fo.r'The Mildly; Tll'Child At The Center! The mildly ill.child may be admitted into the center if they can basically follow,the normal daily schedule.Ythe illness necessitated needing other routine, normally the parent would bey called.. While waiting for the parent,the child would be given the opportunity.to lie on,their sleeping.bag . in a quiet protected area of the classroom. If the child wasn't interested in sleeping some quiet materials would be given to.play with and if desired,-food or drink.would be provided. If a child is.found to have head lice-(either eggs or alive),-they will be sent homerimmediately. The child will,not be able to.return to the center until,they have been first checkedlby a center r representative and t the discretion of the center, a doctor's note may also be needed. The decision to re-admit the child at that point is at the discretion of the center. 9' q ' Plan For Dispensing.Medication At The Center If medication is necessary, it is a State;Law.that no medicine can be given unless it accompanied by a,note.froni the physician.,Parentss rare,instructed to.personally hand,the medication"to the. .' , teacher upon entering the classroom. No medication to be placed in either the lunch box or given to�the,child.to be responsible,for. . • r-,« E. _ ., r =.�. 1� i trJ s1 �T •I�c . 4rt � t � a•; • � '. . , .. ..> F 'r., r Prescription Medication'must have the,child's name;,date, be in original container,labeled,with.� the drug name, and have directions on the label. The medication must be stored properly and returned nightly or,.when no.longer needed df,it is a medication that,will be taken regularly,then an open yearly.note'would be given;by=the physician. Parental'authorization,must accompany. this medication:_ _oc. . . Ij Non-prescriptions Medication must have.a physicians permission for an open time span of not more than a year and a parental permission slip. Parents will be notified in writing whenever medication is given to a child under a blanket authorization from doctor and parent. Each time medication is given, it is logged with the date the child's name, the time, the amount and the name of the caregiver. Copies of this log will be placed in the child's folder. Suntan lotion The parent is required to sign a sheet giving permission for the application of the same, if the parent does not want the lotion used then they must sign a sheet stating the same. 10 Plan For Meeting Individual.Children's Specific Health Care Needs On the application presented to the parent upon admission to e center is an area to cussed so that there is ast allergies or any other medical needs. During the initial interview this s clear understanding between the center and parent. f the application is'highlighted on the application that the teacher receives. She also This area opp writes this information on the manila envelope that contains the chVed she s l which is oes, A list is al`so attached to the attendance sheet. This goes with the teacher where g placed in each classroom. Each teacher and staff member is made aware of the individual child's allergies so that the child will be protected if such substance or food would be present. 11 Procedures For Identifying and Reporting Suspected ' Child Abuse Or Neglect All staff are mandated reporters. Each staff member is trained to be aware of the symptoms of abuse or neglect. This is then to be reported immediately to the Director, who"notified the local DSS intake worker 508-34 325,this is'done within-24 hours, documented in writing within 48 hours. If possible parent will be notified. In the absence of the.Director,:the riext'person in charge will be notified. Any such action is noted in the child's folder. The center works closely with the DSS Department during this procedure' ` Prevention Of Abuse And Neglect All staff members are mandated reporters. Should a staff member be suspected of abuse or neglect while the child is in the care of the center, the center Director must be notified immediately. In the absence of the Director the next person in charge is to be notified. The report will then be immediately filed with a 5IA to DSS and to EEC. While an investigation is on- going that staff member will be removed from having access with children. A determination will be made at that time whether or not the staff member will be paid during this time. Cooperation will be given to DSS and EEC. Depending on the outcome of the allegations, determination will be made whether to reinstate or terminate. I2 ° Town of Barnstable Permit Fee: ., Regulatory Services $75.00 Thomas F. Geiler,Director • sr�RrrsrnAi�. +MAS& Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN Name of Camp: Site Address: -!� 7U Site Telephone: 3 7 76 C, � c Name of Camp Owner: J ��., �, V d n,'s �tiS2 o Office Address: 8 h )�, - �� , , ; � 62< ,/ o �d Telephone Number: CD 1-3 0 . Name of Camp Operator(if different): ¢' Address: °u Telephone Number: C o Name of Health re Consultant: Pf-,) v + n .e— Address: /62) 4 rn 3 e l L l l e+ Q-- )cam 73 , Telephone Number: Sn - `7'7 Type of Camp: Day Residential 0' Hours of Operation: — S 3 0 Dates of Operation: Opening: Z/6 Closing: Swimming Pool: Yes No_)<_(If yes: Pool Permit Number ) Bathing Beach: Yes No K Meals Provided: Yes No (If yes: Food Permit Number ) Signature of Applicant: Official Title: Z2e i e oAe c, Date:/An 1 169, See the next page for a list of documents that must be completed and submitted before your application for a license can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the licensing 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. ■ Staff information forms (see attached) (SORI/CORI With Juvenile checks) ■ Procedures for the background review of staff(105 CMR 430.090) ■ Copy of promotional literature(105 CMR 430.190(C)) ■ Procedures for reporting suspected child abuse or neglect (105 CMR 430.093) ■ Health care policy(105 CMR 430.159(B)) ■ Discipline policy(105 CMR 430.191) ■ Fire evacuation plan—approved by local fire department(105 CMR 430.210(A)) ■ Disaster plan(105. CMR 430.210(B)) ■ Lost camper plan(105 CMR 430.210(C)) f. ■ Lost swimmer plan(105 CMR 430.210(C)) ■ Traffic control plan(105 CMR 430.210(D)) ■ Day Camps—contingency plan(105 CMR 430.211) ■ Primitive, Trip or Travel Camps—Written itinerary, including sources of emergency care, and contingency plans (105 CMR 430.212) ■ Current certificate of occupancy from local building inspector(105 CMR 430.451) ■ Written statement of compliance from the local fire department (105 CMR 430.215) ■ 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 wastewater Camp Director Name: y erl✓ Age: Coursework in camping administration: Previous camp administration experience: le s- q'O �)r - Health Care Consultant � Name: 1 /�y I i r 1� I``�e) 4ze-- r, Type of Medical License(must be a phsician,nurse practitioner, or physician assistant with pediatric training): r,4 u-r54�— MA License Number: Health Supervisor Name: IZ.V<-- c►- Age: 7 Type of Medical License, Registration or Training(See 105 CMR 430.159(C): Aquatics Director Name: l I 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 �In�ttructor Name: �`( /' National Rifle Association Instructor's card(or equivalent): Date certified: / / Expiration date: / / Horseback Riding Instructor Name: I"L"N 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. �iA n x ®6 ems. 2,A 1 �s (file: Q:\Health\Camps\Application.doc)