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of Page APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN
Name of Camp: _____________________________________________________________________________
Site Address: _______________________________________________________________________________
Site Telephone: ______________________________________________________________________
Name of Camp Owner: _______________________________________________________________________
Office Address: _____________________________________________________________________________
Telephone Number: ___________________________________________________________________
Name of Camp Operator (if different): ___________________________________________________________
Address: ___________________________________________________________________________________
Telephone Number: ___________________________________________________________________
Name of Health Care Consultant: ________________________________________________________________
Address: ____________________________________________________________________________________
Telephone Number: ____________________________________________________________________
Type of Camp: Day _______ Residential _________
Hours of Operation: _________________________________________________
Dates of Operation: Opening: ____________________ Closing: _________________________
Swimming Pool: Yes ____ Pool Permit Number __________ No ____
Bathing Beach: Yes ____ No ____
Meals Provided: Yes ____ Food Permit Number __________ No ____
Signature of App1icant: ______________________________________________________
Title: ____________________________________________Date: _____________________
See the application checklist 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.
09.20.01
Recreation Camp for Children Application Checklist
Required Documents
See the Massachusetts 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),
¨ 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 applying for an original license, you must file a plan showing the following with the Board of Health at least 90 days before your desired opening date (See 105 CMR 430.631):
¨ Buildings, structures, fixtures and facilities,
¨ Proposed source of water supply,
¨ Works for disposal of sewage and wastewater.
Camp Director
Name: _______________________________________________________________________________
Age: _________________________
Coursework in camping administration: ____________________________________________________
______________________________________________________________________________
Previous camp administration experience: __________________________________________________
_____________________________________________________________________________________
Health Care Consultant
Name: _______________________________________________________________________________
Type of Medical License (must be a physician, nurse practitioner, or physician’s assistant with pediatric training): ____________________________________________________________________________
MA License Number: __________________________________
Health Supervisor
Name: _______________________________________________________________________________
Age: ______________________
Type of Medical License, Registration or Training (See 105 CMR 430.159(C)): ____________________
_____________________________________________________________________________________
Aquatics Director
Name: _______________________________________________________________________________
Age: ______________________________________
Lifeguard Certificate issued by: __________________________________________________________
Expiration date: __________________________
American Red Cross CPR Certificate: ______________________________________________________
Expiration date: __________________________
American First Aid Certificate: ___________________________________________________________
Expiration date: _________________________
Previous Aquatics supervisory experience: __________________________________________________
_____________________________________________________________________________________
Firearms Instructor
Name: _______________________________________________________________________________
National Rifle Association Instructor's card (or equivalent): _____________________________________
Date certified: ________________ Expiration date:__________________
Horseback Riding Instructor
Name: _______________________________________________________________________________
License Number. ___________________________ Expiration date: ___________________
Stable
Location: ____________________________________________________________________________
Licensed in accordance with MGL Ch. 111 § 155, 158: Yes _______ No_______
Attach the names, ages, applicable current certifications (if any), such as First Aid, and the anticipated role at the camp of all supervisory staff (see below). Use as many pages as necessary to complete this.
“Supervisory Staff” means those persons with the responsibility, authority, and training to provide direct supervision to camper groups. This may include counselors, junior counselors, general activity leaders or other staff who provide supervision to campers without assistance.