HomeMy WebLinkAbout2005 Summer Camp Permit - Permits - 12/5/2019 Champ Camp Policies and
Procedures
2005 Summer Camp
595 Chickering Rd
North Andover, MA 01845
(978) 683-8493
Health Care Policy
Health Care Consultant:
Dr. Barnett
122 Lancaster 137r rlc�
North Andover, MA 01845
(978) 686-2763
Health Care Supervisor
Tina V. Veth, R.N.
48 Highland Ave
Haverhill, MA 01830
(978) 521-6987
Emergency Phone Numbers:
All general emergencies - 911
Fire - 688-9590
Police - 683-3168
Ambulance - 911
Poison Control Center - 1-800-682-9211
Animal Control - 683-3168
Hospital utilized for emergencies:
Lawrence General Hospital
1 General St.
Lawrence, MA 01841
683-4000
OR
Holy Family
70 East St.
Methuen, MA 01844
(978) 687-0151
Emergency Procedures
In the event of an emergency, the following procedures will be
followed:
1 . Camp Director and Staff members will clear the area away from
the injured person.
2. Health Care Supervisor will assess the condition of the camper.
3. If a head or neck injury is suspected, care will be taken to not
move the camper.
4. Camp Director will get emergency medical help by calling 911 .
5. If camper is not breathing, Health Care Supervisor will begin CPR.
6. Camp Director will try every available contact number to reach the
camper's parent/guardian.
Procedures for Utilizing First Aid Equipment
1 . Location of First Aid Kit
The First Aid Kit will be located in the office.
2. Location of First Aid Manual
The First Aid Manual will also be kept in the office.
3. First Aid is administered by
All first aid will be administered by the Health Care Supervisor, Tina
Veth, R.N.
4. First Aid Kit is maintained by
The First Aid Kit will be maintained by the Camp Director, Brian Veth
5. Contents of First Aid Kit
The First Aid Kit will contain the following:
Band-Aids
Hydrogen Peroxide
Bacitracin
2X2's
Paper Tape
Ace Wraps
Emergency Ice Packs
Plan for Injury Prevention and Management
The gym will be inspected for hazards and dangerous or faulty
equipment each morning by the Camp Director prior to the campers
arrival. Faulty equipment will be repaired or replaced before campers
are allowed to use the equipment. If the faulty equipment cannot be
repaired or replaced, that piece of equipment will have a sign
prohibiting campers from using that equipment.
In addition to the daily inspection for hazards by the Camp Director,
staff members will visually check each piece of equipment to be used
by the campers throughout the day. Any hazards that are found will
be reported to, and handled by the Camp Director.
Procedures for Reporting Serious Iniury, Hospitalization,
and Death of a Camper or Staff Member to Department of
Public Health
In the event of a serious injury, hospitalization or death of a camper
or staff member, the following procedures will be followed:
1 . Camp Director will follow the Emergency Procedures described
elsewhere in this Health Care Policy until the situation is resolved.
2. Camp Director will fill out an injury report form.
3. Camp Director make multiple copies of the injury report form and
mail one copy to the Department of Public Health.
4. Camp Director will keep one copy on file at the location of the
camp.
Procedure for Informing Parents When First Aid is
Administered to Their Child
All first aid administered will be recorded in ink in the medical log
book, to be kept in the office during the day.
At the time of pick up, the Camp Director will have the medical log
book to ensure that all parents are informed of the first aid
administered to their child that day. Parents will be asked to sign the
medical log book as acknowledgement of the fact they were informed
of the first aid administered to their child. The medical log book, as
well as all staff members will be available for parents who may want
more information on the first aid administered to their child that day.
Plan for Infection Control
TREAT ALL INCIDENTS AS IF THERE IS AN INFECTIOUS
DISEASE
Handwashing - Handwashing is the single most effective method in
stopping the transmission of contagious diseases.
Procedure for the Clean Up of Blood Spills
A Blood-Spill Kit will be kept in the office.
The Blood-Spill Kit will contain the following equipment:
Biohazard Red Bags
Disposable gloves
Paper Towels
Fresh Solution of Bleach (1:10)
Bleach: Common household bleach will be diluted 1 :10 (1 part
bleach, 9 parts tap water)
Procedure:
1 . Take equipment to area of spill.
2. Put on disposable gloves.
3. Pour or spray disinfectant on area to be decontaminated.
4. Allow one minute.
5. Clean up with damp paper towels.
6. Repeat as necessary.
7. Place everything in Red Biohazard Bag.
8. Remove gloves in such a way as to prevent touching the exterior
of the gloves with your bare hands.
9. Discard the gloves into the Biohazard Bag.
10. Wash hands.
11. Look at area to make sure it is clean.
Emergency Plan for Evacuation of Facility
1 . Evacuation Plans are posted next to each exit.
2. Staff members will lead campers out the safest exit and gather on
the side of the building.
3. The Camp Director will grab the attendance book and check for
any campers that may have been separated from the group.
4. The Camp Director will do a roll call to ensure all campers are safe
and accounted for.
5. Fire drills will be conducted on the first day of each camping week.
6. The Camp Director will keep records of each of the fire drills noting
the date, time and effectiveness of each fire drill.
Plan for Administering Medication
All medications will be kept in a locked safe in the office.
Medications prescribed for campers shall be kept in original
containers bearing the pharmacy label, showing the date of filling,
pharmacist's initials, serial number of the prescription, name of the
patient, name of the prescribing physician, name of prescribed
medication, directions for use, and if tablets or capsules, the number
in the container. All over the counter medications for campers shall
be kept in the original containers containing the original label, which
shall include directions for use.
Medication will only be administered by the parent in the presence of
the Health Care Supervisor.
Medication prescribed for campers brought from home shall only be
administered if it is from the original container, and there is a
parent/guardian to administer it.
Note: As camp is only 3 hours long, we request that parents
administer medications before or after camp. We request that
parents do not bring medication to the gym.
Plan for Returning or Destroying Unused Medication
When no longer needed, or at the end of the campers stay at the
camp, medications shall be returned to a parent/guardian whenever
possible. If the medication cannot be returned, it shall be destroyed
as follows:
Medication shall be destroyed by the Health Care Consultant,
witnessed by a second person and recorded in a log maintained by
the camp for this purpose. The log entry will include the following
information: the name of the camper, the name of the medication, the
quantity of medication destroyed, and the date and method of
destruction. The Health Care Consultant and the witness shall sign
each entry in the medication destruction log.
Note: As stated above, camp is only 3 hours long and medication is
not allowed at the camp.
Plan for the Care of Mildly III Campers
In the event that a camper becomes mildly ill, to the point that the
camper cannot participate in the program, the camper's
parent/guardian shall be notified. All available contact numbers shall
be tried in order to contact the parent/guardian. The parent/guardian
will be asked to bring the child home for the remainder of the day.
Procedures for Identifying and Protecting Campers with
Emergency Medical Information
In the case of a camper with emergency medical information, all staff
members will be made aware of all symptoms, and procedures to
follow in the event of any emergency for that camper.
Exclusion Policy for Serious Illnesses and Contagious
Diseases
Campers may be excluded from camp if any of the following criteria
are not met:
1 . A camper with an elevated temperature must return to a normal
body temperature for at least 24 hours before returning to camp.
2. A camper with a rash must have a note from a doctor regarding the
diagnosis and whether the rash is contagious or not.
3. A camper with head lice must be nit free before returning to camp.
4. A camper with a known medical condition which could affect their
level of consciousness; ie, seizure disorders, CHD must have a note
from their doctor with medical clearance.
Procedures for the Background Review of Staff
MGL c.105 CMR 430.090 Employment Background Information
(A) The operator shall develop and follow written procedures for the review of the
background of each staff person who may have unsupervised contact with a
camper.
The Camp Director will review all staff. This will include checking
former employers, contacting references, conducting a CORI and a
SORI check for each prospective staff member. The Camp Director
will require that all staff members be CPR and First-Aid certified. If
the prospective staff member meets all of the requirements above,
they will be given an interview for employment.
Employees that have been continuously employed at The Champion
Factory since their last CORUSORI check, are exempt.
Contingency Plans
MGL c.105 CMR 430.211 Special Contingency Plans for Day Camps
Day camp operators, shall set forth procedures to be followed in dealing with the
following contingencies.-
(A) Children who are registered and on the camp roll but fail to arrive for a given
day's activities.
(8) Children who fail to arrive at the point of pickup following a given day's
activities.
(C) Children who appear at camp without having registered and without prior
notification.
(A) Camper who is registered and fails to arrive for the day's
activities:
-The Camp Director will double check the attendance and the
camper's registration form to ensure the camper should indeed be in
attendance.
Parents will be contacted using all available contact numbers.
(B) Camper who is missing from the point-of-pickup at the end of the
day:
Camp Director will double check attendance and roll call.
Camp Director will check the office to see if the camper was
picked up early.
-If these aren't successful, we will follow lost camper plan.
(C) Unregistered camper arriving at camp:
Staff will try to get child's parents if still on site. If the parent
has left or cannot be found, staff will try to identify who the child
arrived with.
Staff will call the child's parent if the phone number can be
obtained.
Disaster Plan
MGL c. 105 CMR 430.210(8) Disaster Plan
(8) Each camp shall have a written disaster plan at the campsite. All campers
and staff shall be advised of the procedures contained in the plan.
Arrangements for transporting individuals from the camp to emergency facilities
shall be included in the plan.
In the event of a natural disaster, the following steps will be taken:
1 . A whistle located at the Camp Director's desk will be blown to
notify all campers and staff of an emergency.
2. Staff will bring campers to the middle of the gym floor and the
Camp Director will do an attendance check to ensure all campers are
present.
3. Instructions will be given to staff members at this point.
Tornado
In the event of a tornado, the initial steps will be taken to ensure all
campers are present. Staff members will ask the campers to move to
the back corner of the gym while the Camp Director checks all doors
and windows.
Lightning
In the event of lightning, the initial steps will be taken to ensure that
all campers are inside the building and present. The phone will not
be used except in the event of an emergency.
Fire Evacuation Plan
MGL c. 105 CMR 430.210(A) Fire Drills
(A) Fire drills shall be held within the first 24 hours of the beginning of each
camping session. The fire evacuation plan shall be in writing and approved by
the local fire department. The plan shall indicate the frequency of fire drills to be
held during the camping season.
Fire drills will be conducted on the first day of each camping week.
The maximum number of students will be twelve. There will be three
staff.
There is an exit at each end of the gym. These exits will remain free
of obstructions.
A whistle that is kept at the Camp Director's desk will notify campers
and staff in the event of a fire.
The Fire Department will be called or in the case of an emergency
evacuation, the fire alarm (one at each door) will be pulled on the
way out.
The staff and campers will gather in the grassy area on the side of
the building. An attendance check will be conducted to ensure all
campers are present.
In the event of a fire the Camp Director will sound an alarm and alert
staff of the fire, the gym will be evacuated closing all doors. The Fire
Department will be contacted and given the following info:
Building name and address
Nearest cross street - Salem and Abbott
Location of the fire in the building
Any known info about the fire
Lost Camper Plan
MGL c. 105 CMR 430.210(C) Lost Camper Plan
(C) A written lost camper plan shall be formulated and kept on file. All staff shall
be trained in the procedures contained in these plans.
As soon as it is discovered that a camper is missing the staff will
report the following to the Camp Director:
Camper's name and age
Last place the camper was seen
What the camper was wearing
The staff will then conduct a search of the main gym and bathroom.
The Camp Director will gather the campers in the middle of the floor
and do an accurate head count.
One staff member will go out the front door, and one will go out the
back door in search of the missing camper.
The Camp Director shall check office records to determine if the
camper was picked up by parents or made other such arrangements.
If not, the parents will be contacted to determine if the camper was
picked up without notifying the office.
If not immediately found Police will be notified.
The search will continue until all campers are accounted for.
Protecting Campers from the Sun
The Camp Director and all staff members will encourage the use of
sunscreen with a solar protection factor of 15 or greater. The Camp
Director and all staff members will also encourage the use of hats,
long sleeve shirts and pants should we decide to be in the sun for an
extended period of time.
Procedures for reporting suspected child abuse or
neglect
MGL c.105 CMR 430.093 Prevention of Abuse and Neglect
(A) The operator shall have procedures in place which protect campers from
abuse and neglect while in the camp's care and custody.
(B) The operator shall develop and follow written procedures for reporting of any
suspected incidents of child abuse and neglect in accordance with procedures
described in MGL c. 119 section 51A
In the event that a staff member suspects child abuse or neglect, the
Camp Director will be notified immediately. The Camp Director shall
contact the Massachusetts Department of Social Services. The
Camp Director shall contact the Board of Health if a 51 A report is
filed. The Camp Director will assist in any way possible with an
official investigation.
Telephones Required
MGL c.105 CMR 430.209 Telephones Required
All day camps shall have immediate access to a telephone. The operator shall
maintain and post by each phone a current roster of telephone numbers of the
Health Care Consultant, and all police, EMS and Fire Departments serving the
camp.
Telephones are located at each end of the gym, providing immediate
access.
Egresses Required
MGL c.105 CMR 430.455 Egresses Required
All egresses shall be in compliance with the requirements of the State Building
Code
All egresses in the facility are in compliance with State Building
Code.
Identification of Individuals on Premises - Intruders
The Champion Factory summer camp, "Champ Camp" has a policy
against any unregistered or unknown guests being present at the
facility. Unknown guests or intruders may pose a threat to the safety
of the campers, staff, or the camp itself.
1. Staff is to report any unknown persons to the Camp Director
immediately.
2. Staff will be trained in this policy at the Staff Orientation meeting.
3. Campers will be instructed on the first day of camp on procedures
should they encounter an unknown guest or intruder during camp.
Animal Exposure
Because wild animals, including raccoons, bats and skunks, may
carry rabies, it is important that camps take precautions to minimize
encounters between campers and wild animals.
Camp staff will be informed about the risk of rabies associated with
exposure to wild or stray animals.
Campers will be instructed on the proper procedures if they
encounter a wild or stray animal. Campers will also be instructed not
to handle dead, sick or injured wild animals. Animal control
(978) 683-3168 will be contacted in the case of any wild animal.
Champ Camp will do everything to not attract wild animals. No food
is stored on the property, and the dumpster lid is fastened tightly.
If contact occurs between a person and a stray animal, the wound or
area of skin will be washed immediately with soap and water for at
least 10 minutes. The health care provider and the North Andover
Board of Health will be contacted immediately to determine if the
person should be treated for rabies. Animal control will be contacted
to catch or find the animal that scratched or bit the person. The
animal control and Board of Health will assist with information about
submitting the animal to the MDPH Rabies Laboratory for rabies
testing.
STAFF ORIENTATION
Agenda:
1. Discuss camp philosophy
2. Discuss health care policy
3. Discuss all policies and procedures
4. Discuss parents rights to request copies of background checks,
health care and discipline policies and procedures for filing
grievances.
5. Practice fire drill
6. Review CPR and First-Aid Procedures
7. Review and practice gymnastics spotting skills
8. Discuss Arts & Crafts projects for the summer
Camp Philosophy
To promote health and well-being through gymnastics in a safe, fun,
and engaging environment.
Gymnastics - Skills being taught as well as equipment will be age
appropriate. Skills should be at a level where children can succeed,
but still be challenged.
Arts & Crafts - Projects will be age-appropriate, to be completed with
care and safety. Every camper should get to bring something that he
or she is proud of at the end of the week.
Learning Activity - Activities shall be relevant to the world going on
around them. The general concept is more important than specifics,
as this is not school
Traffic Control Plan
MGL c.105 CMR 430.210(D) Traffic Control
A written plan relating to the control of the movement of vehicular traffic through
the camp shall be on file.
Parents will be reminded to drop off and pick up in the rear of the
building where there is much less traffic. Parents are required to
walk their child into the building thus reducing the number of kids
alone in the parking lot. Parents are also reminded to come into the
building to pick up their child from camp.
Signed on this day ofJ,62-12 2005
Dr. Barnett
i-
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: >`"�v y (JZsz.► �V"'
NER/OPERATOR: OFFSEASON
no ADDRESS:
CAMP DIRECTOR: INSPECTED SY. \ ;" \
E OF CAMP: (Circle) WATER Vy f DATE OF INSPECTION:
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.
Regulation Yes No N/A Comments
Permits
.451 Current Certificate(s) of Occupancy from local
building inspector for sleeping/assembly 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)
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(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:
.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 LZ
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.
Regulation Yes No N/A Comments
Promotional literature/packet contains:
.159(B)(2) Copy of policy re: care of mildly ill campers, ` Y
administration of meds and emergency
health care provision.
190(C) Statement re: regulatory compliance and
licensing.-
.1 90(D) Inform parents of right to review background Nn
check, health care, discipline policies and
grievance procedures upon request.
Trans ortation
.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
cam ers 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
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 i
>12 hrs. Sub must meet criteria above
Counselors/Junior Counselors
.100 Day Camp, non-sport:
Counselor-- 16 yrs. Junior Counselor-- 15 yrs. I�
.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
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 jV
w/mana ement 1�
.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
.159(A) Health Care Consul t
ame.
MD NP PA(w/pediatric training)
heck for Health Care Consultant Agreement
.159(C) Health Supervisor(o(o si 1 times)
Name: \\\A
18yrs, First A#and CPR certified OR,
MD PA NP,,RPJLPN z�
1 59 B Health Care Polic v
160(A) Medication stored in original containers. Z�
.160(B) Meds stored in secured cabinet and if �O
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. 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
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
Yes No N/A Comments
i
Regulation
Immunizations:
.152(A) Campers and staff under 18yrs: Number of records checked:
MMR: 1s' dose = 12 mos or older, +r
Measles: 2Id 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 o
(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) 1
Rubella: 1 dose (exempt if born before 1957) C� 'Xq
Diphtheria and Tetanus Toxoids*: o`Ct�'�'(���5��
3 doses DTaP/DTP/DT/Td
*Booster dose of Td required if more than 10 yrs of } vl� l
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. r'
.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 LI
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.
Regulation Yes No NIA 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 ran a 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 J
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 v
50sgft/person in sleeping area requiring special
equipment
%
.470 Provide bed/cot per person with 6 feet between
sleeper's heads and:
172
3 feet between single beds/4feet between bunks
Regulation, Yes No NIA Comments
Residential Camps/Sleeping Areas:
.459 Campers and staff with limited mobility housed
on ground level; egresses leading to grade or
ram rovided.
.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/
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. osaR
Shower room floors washed daily.
Laundry
.162 Residential Camp: laundry facilities provided L.
.472 Bedding and towels laundered; no common
towels
Grounds:
.300 Potable water provided. L/
.300/.304 Adequate and centralized drinking water
facilities. No common drinking cups. U
.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
Regulation Yes No NIA 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. 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
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
l!!J� • „�
5 �l� \
HEALTH CARE CONSULTANT AGREEMENT
p,n c:n„-� J C1 cJ �� Y.Q r t•o� '` C� C i �I 5
NAME OF CAMP 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.
430.159(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
430.159(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 CMR 430.159(E), if
applicable.
430.160(C) Administration of Medication The health care consultant shall acknowledge in writing a
list of all medications administered at the camp.
I meet the requirements of the health care consultant as described in 105 CMR 130.159(A). I have
reviewed theses referenced regulations and understand the responsibilities of the position and agree to
assist this camp regarding the s_amee.
rC h ��CS Glrn�i1� M b
Print e Title
Sign atwe MA License/Registration Number
Address / v�°r�elephone Number
Date: -0S
February 24,2000
i
i�
i
J
Town of North Andover
F Health Department Date:
Location:
(Indicate Address, if Residential,or Name of Business) j
Check#• �—
Type of Permit or License: (Circle)
E ➢ Animal $
➢ Dumpster $
➢ Food Service-Type: $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal(Septic)Hauler $
*..-Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC)$
❑ Septic Disposal Works Installers(DWI) $
)0- Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
a
➢ TrashlSolid Waste Hauler $
➢ Well Construction $
➢ OTHER(Indicate)
Health Agent Initials ,
r,
' White-Applicant Yellow-Health Pink-Treasurer
s
3
Town of North Andover
Health Department Date: /
f
Location: c_
(Indicate Address,if Residential,or Name of Business
Check#:
Type of Permit or License:(Circle) $
)o, Animal
➢ Dumpster $--—
➢ Food Service-Type: $
➢ Funeral Directors
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal(Septic)Hauler r $
➢ Recreational Camp ` $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Li Septic Disposal Works Construction(DWC)$
❑ Septic Disposal Works Installers(DWI) $
➢ Sun tanning $
a
➢ Swimming Pool $
1
s: ➢ Tobacco
➢ Trash/Solid Waste Hauler $
$
➢ Well Construction
t_
➢ OTHER(Indicate)
Health Agent Initials
F
886
White-Applicant Yellow-Health Pink-Treasurer
NUMBER
,.o•••. BHP-2005-0167
COi.,MONWEALTH OF MASSACHUSEI i S _-
North Andover FEE
• $50.00
. , Board of Health
DATE ISSUED
� "�•...o•�"'
The Champion Factory July 05,2005
------------------
---------------------NAME
595 Chickering Rd.NORTH ANDOVER,MA 01845
------------------------------
ADDRESS
—
IS HEREBY GRANTED A Recreational Camp LICENSE
Recreational Camp
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires August 27,2005 unless sooner suspended or revoked.
RESTRICTIONS:Day Camp;Hours:9 a.m.- 12 p.m.;July
5th-August 26th ---------------------- Board of
-- Health
NOTES: Contact: Brian Veth;978.683.8493 ---- _-_- ----
----------------------------------
--------------------------
APPLICATION FOR A LICENSE TO CONDUCT A
RECREATIONAL CAMP FOR CHILDREN
Name of Camp: `
Site Address: rr. QQ r' �15 hick ,k
Site Telephone: � ;g-- nj
Name of Camp Owner: r-\ Cg")
Office Address: 5 CN k C Q: c
Telephone Number: - 3
Name of Camp Operator(if different):
Address:
Telephone Number:
Name of Health Care Consultant: DT-, K p.7^2- r, •-r�;i
Address: 1 �- �-o�L��� � �� . V y A ),-t 5
Telephone Number: f ?S 6 Q 16 3
Type of Camp: Day
C�_ Residential
Hours of Operation: -1 Carr - r�t�re-
Dates of Operation: Opening: ..) 5 Closing: Aj4. a6
`F'N
Swimming Pool: Yes Pool Permit Number No_
Bathing Beach: Yes No
Meals Provided: Yes Food Permit Number No X —
Signature of Applicant:
Official Title: TvPs\ Q 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.
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)
■ 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 waste water
Camp Director
Name: c-k �Q \
Age: 3
Coursework in camping administration:
Previous camp administration experience: or
Health Care Consultant
Name: r OS' n o�c
Type of Medical License (must be a physician, nurse practitioner, or physician assistant
with pediatric training):
MA License Number:
Health Supervisor \ '
Name: —rk Y)a V� �
Age: aq
Type of Medical License, Registration or Training (See 105 CMR 430.159(C):
Iy
Aquatics Director �, / ) fj
Name: /V 1 1 �
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: / Y / �
National Rifle Association Instructor's card (or equivalent):
Date certified: Expiration date:
Horseback Riding Instructor
Name: N
License Number: Expiration date:
Stable
Location: / V A
Licensed in accordance with MGL Ch.l 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.
■
To all registered campers...
An important note for parents:
According to Massachusetts General Law, all parents have the right to review the policies of
how we conduct background checks, both Criminal Background(CORI) and Sexual Of-
fender Background (SORI),performed on all employees of The Champion Factory Summer
Camp.
Plan for the Care of Mildly Ill Campers
In the event that a camper becomes mildly ill, to the point that the camper cannot participate
in the program, the camper's parent/guardian shall be notified. All available contact num-
bers shall be tried in order to contact the parent/guardian. The parent/guardian will be asked
to bring the child home for the remainder of the day.
Oywn�r►ln F"ff
Circus Arts
595 Chickering Rd
North Andover,MA Ol 845
978.683.8493
www.championfactoty.com