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Home My WebLink About2023-05-25 Board of Health Minutes North Andover Board of Health Meeting Minutes Thursday—May 25,2023 7:00 p.m. 120 Main Street,Board of Select Room Live broadcast can be heard on www.northandovercam.org Present: Michelle Davis,Dr.Patrick Scanlon,Jennifer Abou-Ezzi,Jennifer LeBourdais,Brian LaGrasse, Carolyn Lam and Toni K.Wolfenden I. CALL TO ORDER The meeting called to order at 7:03 pm. II. PLEDGE OF ALLEGIANCE III. APPROVAL OF MINUTES A. Meeting Minutes from March 30,2023 presented for signature. MOTION made by Dr.Patrick Scanlon seconded by Jennifer Abou-Ezzi,all in favor,minutes approved.(4-0-0) B. Meeting Minutes from April 27,2023 presented for signature. MOTION made by Dr.Patrick Scanlon seconded by Jennifer Abou-Ezzi,all in favor,minutes approved. (4-0-0) IV. PUBLIC HEARINGS A. Mr.John Schroeder—9 Village Way MOTION made by Jennifer Abou-Ezzi to open the public hearing,seconded by Dr.Patrick Scanlon. (4-0- 0)Brian LaGrasse explains that a tenant at 9 Village Way called the Health Department with a complaint. Stephen Casey Jr. inspected the property. Some violations were found. One of the violations was in issue with a heating unit. Mr. Schroeder appealed the order. A letter was written,(Appendix A.)to explain the situation. The tenant has moved out and the unit will not be re-rented. The property is a single-family dwelling with an in-law apartment. Mr.John Schroeder,9 Village Way,explains that as of March 17, 2023,the unit is no longer rented,he has no intention of it being a rental. The section of the broken heating system has been replaced. Brian explains that if the unit is to be rented,it must be inspected before occupancy. Mr. Schroeder asks for the unit to be inspected to remove the order letter. Dr.Patrick Scanlon, MOTION to take no action or discussion by the Board,seconded by Jennifer LeBourdais. (4-0-0) MOTION by Michelle Davis to close the public hearing,seconded by Jennifer LeBourdais.(4-0-0) B. Mr.and Ms. Scott—39 Hawkins Lane MOTION made by Jennifer Abou-Ezzi to open the public hearing,seconded by Dr.Patrick Scanlon.(4-0- 0)Brian LaGrasse gives an overview of 39 Hawkins Lane septic system. This is a single-family home with 2023 North Andover Board of Health Meeting Note: The Board of Health reserve the right to take items out of order and to discuss and/or vote on items that are not listed on the agenda. Board of Health Members: Michelle Davis,RN,Chairwoman;Dr.Patrick Scanlon Clerk/Town Physician/Member;Jennifer Abou-Ezzi RN,Member;Jennifer LeBourdais,RN,Member;Bral Spight,Member. Department Staff:Brian LaGrasse,Health Director;Stephen Casey,Public Health Inspector;Carolyn Lam,RN,Public Health Nurse;Toni K.Wolfenden,Health Department Assistant. a septic system. The home was added onto years ago. The size of the home exceeded the capacity of existing septic system. Mr.and Ms. Scott entered into an agreement that placed a deed restriction on the property. There were four conditions that the Board of Health included in the deed restriction(Appendix B.) Part of the deed restriction is for the septic system to be inspected every three years to ensure the health of the system and at the time of the sale,the system is to be appropriately upgraded. William Dufresne, Merrimack Engineering Services,66 Park Street Andover,MA 01810 has come before the Board to speak on behalf of the homeowner. Mr.Dufresne explains in 2009,the Scott Family received a building permit to add two rooms onto the existing home. At this time the septic system was functioning and operating properly. Currently,the system is working fine and passed inspection(See Appendix B.) Mr.Dufresne is asking the Board for a modification to the deed restriction with the system to be inspected annually and monitored.Brian asks if the new homeowner is going to do a new deed restriction? Mr.Dufresne explains the septic system is within the 100'buffer zone for conservation and they do not want to disturb the area until absolutely necessary. Dr. Scanlon asks if the new homeowners are willing to replace the septic system upon failure? Mr.Dufresne explains that the deed restriction was discovered after the house went under contract to be sold. Brian suggests filing a new deed restriction in the new homeowner's name and then the previous restriction can be released. Currently,a new septic system can vary in price,however a system can cost between$30,000 to$40,000. The property is unique,which made the property appealing for the new homeowners. MOTION made by Dr.Patrick Scanlon to CONTINUE to next meeting pending the new deed restriction. Seconded by Jennifer LeBourdais.(4-0-0) MOTION made by Dr.Patrick Scanlon to close public hearing,seconded by Jennifer Abou-Ezzi. (4-0-0) C. Variance—Health Care Supervisor—One School Soccer Camp MOTION made by Jennifer Abou-Ezzi to open the public hearing. Seconded by Jennifer LeBourdais.(4-0- 0). Carolyn Lam is representing One School Soccer Camp. In the Commonwealth of Massachusetts,a licensed summer camp is required to have a healthcare consultant and a healthcare supervisor. The supervisor must remain on site at all times during the operating hours. The supervisor carries out the health policy written by the Healthcare Consultant. The supervisor can be a doctor,physician assistant or a nurse practitioner as well as a Register Nurse,Licensed Practical Nurse or anyone over the age of eighteen who is First Aid Certification or CPR Certified. In 2019,the Town of North Andover,Board of Health required a supervisor to be a nurse;not someone who is over the age of eighteen,who has First Aid Certification and CPR Certification. One School Soccer Camp is having difficulty obtaining the town's qualifications for a healthcare supervisor. The camp has an athletic trainer who can serve as supervisor. The Commonwealth of Massachusetts Camp Regulations require the Healthcare Supervisor to be fully trained by the Healthcare Consultant and has all of the necessary requirements. One School Soccer Camp in asking for a variance which allows Jordan Sliwoski,Athletic Trainer for Millbury Memorial Junior and High School,to serve as the Healthcare Supervisor for One School Soccer Camp. Jordan is CPR,AED and First Aid Certified(See Appendix C.) She will be trained by the Health Care Consultant,Melissa Donais who is the current director of Health and Wellness at Brooks School. Jordan will be signed off on all competencies prior to the start of the camp season. Jordan fits all the criteria for the Commonwealth of Massachusetts. MOTION made by Jennifer Abou-Ezzi to close the public hearing. Seconded by Dr.Patrick Scanlon.(4- 0-0) Dr.Patrick Scanlon,MOTIONS to approve Jordan Sliwoski as the Healthcare Supervisor for One Soccer School pending sign off from Melissa Donais,Healthcare Consultant. Seconded by Jennifer LeBourdais. (4-0-0) D. Variance—Health Care Supervisor—HGR Lacrosse MOTION made by Jennifer Abou-Ezzi to open the public meeting,seconded by Dr.Patrick Scanlon.(4-0- 0) North Andover Board of Health Meeting Minutes Thursday—May 25,2023 7:00 p.m. 120 Main Street,Board of Select Room Live broadcast can be heard on www.northandovercam.org Carolyn Lam is representing Home Grown Lacrosse(HGR). HGR is seeking a variance to have Jordan Mardirossian,LAT,ATC,NREMT serve as the Healthcare Supervisor. Jordan is a Massachusetts board certified Athletic Trainer who is currently employed with Austin Preparatory School and Trinity Ambulance. He will be trained by Ashley Smyth,Nurse Practitioner,Healthcare Consultant,and will be signed off on all competencies prior to the start of the camp season and fits all the criteria for the Commonwealth of Massachusetts. Dr.Patrick Scanlon MOTIONS to close the public hearing. Seconded Jennifer LeBourdais. (4-0-0) Jennifer Abou-Ezzi MOTIONS for Home Grown Lacrosse to have a variance for Jordan Mardirossian to serve as the Healthcare Supervisor under the supervision and training of Ashley Smyth,Healthcare Consultant. Seconded by Jennifer LeBourdais(4-0-0). The Board of Health discuss camp variances. Michelle Davis inquires about the revision of the camp regulations for the summer 2024 season. In the past,a camp was housing medically challenged campers. The camp did not have the appropriate medical personnel. There was a gap with campers that needed more care than an athletic trainer could provide. It was an understanding that camps may need to go in front of board more often. Michelle asks for suggestions from the health department to alter the regulations in the future. V. OLD BUSINESS A. Grants—Update Health Resources in Action(HRiA)is in the process of assessing the community and adopting an improvement plan. They are in the final stages for the reports. Strategies and goals are in planning stage and both are moving forward. Brian LaGrasse is hoping to present the findings within the next couple of months. The Public Health Excellence Grant—Annette Curbow has been hired as the Shared Services Coordinator. The other two positions,currently,have not been advertised. Annette has experience with grants and health departments. Her start date is June 12,2023. The monies for the grant have jumped up from$297,000 to $534,000. A full-time nurse will be hired as well as outside consultants. 2023 North Andover Board of Health Meeting Note: The Board of Health reserve the right to take items out of order and to discuss and/or vote on items that are not listed on the agenda. Board of Health Members: Michelle Davis,RN,Chairwoman;Dr.Patrick Scanlon Clerk/Town Physician/Member;Jennifer Abou-Ezzi RN,Member;Jennifer LeBourdais,RN,Member;Bral Spight,Member. Department Staff:Brian LaGrasse,Health Director;Stephen Casey,Public Health Inspector;Carolyn Lam,RN,Public Health Nurse;Toni K.Wolfenden,Health Department Assistant. i VI. COMMUNICATIONS,ANNOUNCEMENTS,AND DISCUSSION A. Health Inspector—interviews underway with discussions with a candidate to accept the position.A verbal commitment has not been received however,communication has been positive. B. COVID-19—as of May 11,2023 all mandates have ended. Currently,there is one case in a long care facility. Cases are no longer being reported there for positive percentages cannot be calculated. C. Dana Farber Mammogram Van—June 20,2023 from 8:00 am—4:00 pm—Town Hall 120 Main Street VII. ADJOURNMENT MOTION made by Dr.Patrick Scanlon to adjourn the meeting. Seconded by Jennifer Abou-Ezzi,all in favor,MOTION approved.The meeting adjourned at 7:45 pm. Prepared by: Toni K. Wolfenden, Health Dept.Assistant Reviewed bv: All Board of Health Members&Brian LaGrasse, Health Director Si n, ned by: q4h-3 Dr. P Scanlon, Clerk of Board Date Signed Documents Used At Meeting: Agenda 9 Village Way—Packet 39 Hawkins Lane—Packet One Soccer School—Packet Home Grown Lacrosse—Packet i i I i i i i i North Andover Board of Health Meeting Agenda Thursday,May 25, 2023 7:00 pm 120 Main Street Board of Select Room Live broadcast can be heard on www.northandoverma.gov I. CALL TO ORDER II. PLEDGE OF ALLEGIANCE III. APPROVAL OF MEETING MINUTES A. March 30,2023 B. April 27,2023 IV. PUBLIC HEARINGS A. Mr.John Schroeder-9 Village Way B. Mr.and Ms.Scott-39 Hawkins Lane C. Variance-Health Care Supervisor-One School Soccer Camp D. Variance-Health Care Supervisor-HGR Lacrosse V. OLD BUSINESS A. Updates-Grants VI. COMMUNICATIONS,ANNOUNCEMENTS,AND DISCUSSIONS A. COVIDI9-Ending of Mandates 2023 North Andover Board of Health Meeting-Meeting Agenda Page 1 of 1 Note: The Board of Health reserves the right to take items out of order and to discuss and/or vote on items that are not listed on the agenda. Board of Health Members,Michelle Davis,RN,Chairwoman;Dr.Patrick Scanlon Clerk/Town Physician/Member;Jennifer Abou-Ezzi,RN;Member;Jennifer LeBourdais,RN,Member;Bral Spight,Member. Department Staff:Brian LaGrasse,Health Director;Carolyn Lam,RN,Public Health Nurse;Toni K.Wolfenden,Health Department Assistant. North Andover Health Department (ommunity and Economic Development Division May 3, 2023 Mr. John Schroeder 9 Village Way North Andover, MA 01845 RE: Request to Appear before the Board of Health Dear Mr. Schroeder, Your request to appear before the Board of Health to discuss the Order to Correct dated April 11, 2023 has been received. The hearing has been placed on the agenda for the next scheduled Board of Health meeting dated, Thursday,May 25, 2023. The meeting shall take place at the North Andover Town Hall, 120 Main Street; second floor conference room and begins.at 7:00 pm. At the hearing,you shall be given the opportunity to be heard in reference to the inspection and order letter at the above-mentioned resident location on April 10, 2023. If any questions arise before the meeting, please feel free to contact me. Sincerely Brian LB Grasse, CEHT Director of Public Health CC: BOH Page 1 of 1 North Andover Health Department, 120 Main Street North Andover,MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 4/26/23, 1:07 PM Town of North Andover Mail-Board of Health-May 25 2023 -- - ----.------- - NORTH ANDOVER Massachusetts Toni Wolfenden <twolfe n de n@northa n dove rma.gov> r. Board of Health - May 25 2023 1 message Toni Wolfenden <tolfenden@northandoverma.gov> Wed,Apr 26, 2023 at 12:07 PM To:johnschr@aol.com Cc: Brian LaGrasse <blagrasse@northandoverma.gov>, Paul Hutchins<phutchins@northandoverma.gov> Good afternoon Mr. Schroeder, The Health Department has received your request to appear before the Board of Health. Please join the Board at the next meeting to discuss the Order to Correct dated April 11, 2023. Town of North Andover Board of Health 120 Main Street North Andover,MA 01845 Selectboard Room 2nd Floor May 25, 2023 7:00 pm A letter will also be sent to your home address-9 Village Way. If you have any questions or concerns please do not hesitate to contact me. Thank you, Toni K.Wolfenden Toni K. Wolfenden Health Department Assistant 978-688-9540 [;,Icid:image002.jpg@01 CD02A1.85A49B40 image001 Jpg 4K https://mail.google.com/mail/u/0/?ik=aOc6f4e4cf&view=pt&search=all&permthid=thread-a:r-5484555833685949930&simpl=msg-a:r-547629341760252... 1/1 t�EG�`N�o 17 April 2023 TV, To whom it may concern 0� North Andover, Health Department 1000\-\ I received your letter on 15 April regarding Health& Safety issues at 9 village Way. I am requesting a hearing and wish to make you aware of some things. I am fully prepared to correct all valid issues. I cannot make the changes at the present time. I am reluctant to go into the unit alone for fear of my safety. I am a 77 year old 30 year town resident. Ms. Comstock has been verbally abusive, including foul language, and has harassed me on several occasions. I have made Ms. Constock aware that I will be available when my"handyman"is also available. She is hopefully vacating the unit by the end of April although I asked her to vacate in March. I will complete all changes as soon as possible. The unit is no longer a rental unit and has not been since 21 March. In addition, I would like to add that yes there are no CO monitors, I have purchased 2 the issue regarding the heating situation is totally without merit. There are FOUR(4)heating systems in the unit. Two of which both work and are capable of heating the entire unit. A third, also capable of heating the entire unit, is disconnected as discussed below. The fourth is temporary to placate Ms. Constock. At the time your inspector visited the property 128 HVAC had scheduled a complete replacement of the 3rd unit mentioned above at a cost of—$30,000. That is why it is disconnected and not working. That work is approximately half completed. Had your inspector talked to me (I don't know why he was in the unit without my knowledge), I would have shown him the second working unit. It has a thermostat etc. and is the unit used to heat the unit for the past 4 years. Ms. Comstock refuses to use it although she was made aware of it prior to moving in. She choose to use the older one although made aware of possible problems. Thank you for your assistance. John Schroeder 9 Village Way North Andover, MA johnschr@aol.com • North Andover Health Department Community and Economic Development Division NORTH ANDOVER BOARD OF HEALTH ORDER TO CORRECT Issued under the provisions set forth in Massachusetts General Laws Chapter 111 Section 123. Date: April 11,2023 To Owner of Record: Property Location: The John Schroeder Trust 9 Village Way 9 Village Way North Andover,MA 01845 North Andover,MA 01845 Dear Owner; The North Andover Health Department personnel conducted an authorized inspection of your property at the above referenced address on 9 Village Way in response to a complaint filed with this Department. The inspection revealed violations of the State Sanitary Code, Chapter II as listed on the attached Violation Form. You are hereby ORDERED to correct the violations within the time allotted on the enclosed form. Failure to comply within the specified time period will result in a fine of up to $500 per day, in accordance with 105 CMR 410.910 of the State Sanitary Code. The fine will continue to accrue until the subject property is brought into compliance with this Order to Correct. Each day or portion thereof during which the violations continue shall constitute a separate offense. You have the right to request a hearing before the Board of Health if you feel this Order to Correct should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven(7) days from receipt of this Order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this Order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect Failure to comply with any order issued pursuant to the provisions of 105 CMR 4 10.000 shall upon conviction be fined not less than S10.00 nor more than$500. Each day's failure to comply with an order shall constitute a separate violation(105 CMR 410.910). Page 1 of 2 North Andover Health Department 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 and copy all records concerning the matter to be heard. You may be represented by an attorney. You have a right to inspect and obtain copies of all relevant records concerning the matter to be heard. If the dwelling unit is vacant or becomes vacant before the violations are corrected, the dwelling unit cannot be re-rented or re-occupied prior to compliance and prior to an inspection by the North Andover Health Department in accordance with 105 CMR 410.010(A). Please call the North Andover Health Department at(978) 688-9540 for a re-inspection. A re-inspection performed by the North Andover Health Department is required. If you have any questions,comments or concerns,please feel free to call me between the hours of 8:00-4:30 on Monday,Wednesday and Thursday,8:00-6:00 on Tuesday and 8:00-12:00 on Friday. Any questions regarding this matter can be answered through the North Andover Health Department. Sincerely, Stephe asey Jr. North Andover Public Health Inspector CC: Brian LaGrasse,North Andover Director of Public Health Board of Health File Sent via: CERTIFIED MAIL# 70=-0 f Q/0 OCOf �7 9� and; Regular First-Class Mail Page 2 of 2 North Andover Health Department 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 �l ,J `1 rZoZ3. 5� LED�w . North Andover Health Department Community Development Division Date: 4/10/23 Time: 10:40 AM BOH Inspector: Stephen Casey Jr. . Tenants Name: Isabel Comstock Phone Number: (603) 937 7345 Location: 9 Village Way,North Andover MA 01845 Owner: The John Schroeder Trust Phone Number: (978) 689 9622 Address: 9 Village Way,North Andover MA 01845 Regulation Findings Violations 105 CMR Deadline Corrected 410.482(A) Smoke detector and carbon monoxide alarm not available on 24 N lower level of dwelling. Provide working smoke detector and Hours carbon monoxide alarm on first level. 410.482(A) Bedroom upstairs missing carbon monoxide alarm. Provide 24 working carbon monoxide alarm in this area. Hours 410.100(A) No oven unit is available in the dwelling. Cooktop is present 5 N but unit lacks oven. Provide oven unit with at least 1.7 cubic Days feet of oven area. 410.201 Heat was not working in lower portion of the unit. Upper floor 24 N had heat that worked and temperature was ay 70 degrees Hours Fahrenheit. Lower floor had temperature measured at 65.8 degrees Fahrenheit. When thermostat was adjusted;no heat was produced from vents in the floor. Repair heat to maintain at least 68 degrees between the hours of TOOAM and 11:OOPM, and to maintain 64 degrees between 11:01PM and 6:59AM every day other than during the period from June 151h to September 151h Questions were raised about the habitability of the unit due to the angled ceilings in the upper floor. Based on calculations from measuring the room and ceiling heights,the room appears to meet habitability requirements as defined in 410.400 and 410.401. Inspectors Signature: Date: 4/10/23 Page Iof1 North Andover Health Department 120 Main Street North Andover,MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 North Andover Health Department Community and Economic Development Division NORTH ANDOVER BOARD OF HEALTH ORDER TO CORRECT Issued under the provisions set forth in Massachusetts General Laws Chapter 111 Section 123. Date: April 11,2023 To Owner of Record: Property Location: g Village Way The John Schroeder Trust 9 Village Way North Andover,MA 01845 North Andover,MA 01845 Dear Owner; The North Andover Health Department personnel caoed�uc �dan authorized a complaint of your property at the above referenced address on 9 Village yresponse filed with this Department. The inspection revealed violations of the State Sanitary Code, Chapter II as listed on the attached Violation Form. You are hereby ORDERED to correct the violations within the time allotted on the eriod will resultfine of up to, enclosed form. Failure to comply within the specified time pCode.aThe fine will $500 per days in accordance with 105 CMR 410.910 of the State Sanitary continue to accrue until the subject property is brought vi lationsto pontinu hall. constitute liance with this Order to. Correct. Each day or portion thereof during which separate offense. before the Board of Health if you feel this Order You have the right to request a hearing to Correct should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven(7).days from receipt of this Order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this Order sould be he hearing of theied or r withdrawn.toAil affected parties will be informed of the date,time and placeg i Failure to comply with any order issued pursuant to the yfe provisionsai to complyCAR 10 order salt upon onst conviction be. fined not less than$10.00 nor more than$5.00. Each a separate violation(105 CPR 410.910). Page 1 of 2 North Andover Health Department 120 Main Street North Andover,MA 01845 gam: 978.688.9542 Phone: 978.688.9540 and copy all records concerning the matter to be heard. You may be represented by an attorney. You have a right to inspect and obtain copies of all relevant records concerning the matter to be heard. If the dwelling unit is vacant or becomes vacant before the violations are corrected,the dwelling unit cannot be re-rented or re-occupied prior to compliance and prior to an inspection by the North Andover Health Department in accordance with 105 CMR 410.010(A). Please call the North.Andover Health Department at(978) 688-9540 for a re-inspection. A re-inspection performed by the North Andover Health Department is required. If you have any questions,comments or concerns,please feel free to call me between the hours of 8:00-4:30 on Monday,Wednesday and Thursday,8:00-6:00 on Tuesday and 8:00-12:00 on Friday.Any questions regarding this matter can be answered through the North Andover Health Department. Sincerely, Stephe asey Jr. North Andover Public Health Inspector CC: Brian LaGrasse,North Andover Director of Public Health Board of Health File Sent via: CERTIFIED MAIL# 70 Z,0/9/O b OC '/722c/3- 499(e and, Regular First-Class Mail North Andover Health Department Page 2 of 2 120 Main Street North Andover,MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 North Andover Health Department Community Development Division Date: 4/10/23 Time: 10:40 AM BOH Inspector: Stephen casey Jr. Phone Number: 603 937 7345 Tenants Name: Isabel Comstock Location: 9 Village Way,North Andover MA 01845 ` Owner: The John Schroeder Trust Phone Number: 978 689 9622 Address: 9 Village way,North Andover MA 01845 Violations Regulation Findings Deadline Corrected 105 CMR24 N 410.482(A) Smoke detector and car bo on monoxide wo alarm Smoke detectorl and Hours lower level of dwelling. Pr carbon monoxide alarm on first level. 24 410.482(A) Bedroom upstairs missing carbon monoxide alarm.Provide Hours working carbon monoxide alarm in this area. 5 N 410.100(A) No oven unit is available in the dwelling. Cooktop is present but unit lacks oven. Provide oven unit with at least 1.7 cubic Days feet of oven area. Upper floor 24 N 410.201 Heat was not working in lower portion of the un i t. Hours had heat that worked and temperature was ay 70 degrees Fahrenheit. Lower floor had temperature measured at 65.8 degrees Fahrenheit. When thermostat was ad ust d o maintain no heat was produced from vents in the floor. Repair at least 68 degrees between the hours of 7:OOAM and 11:OOPM, and to maintain 64 degrees between I I:O1PM and 6:59AM every day other than during the period from June 15th to Se tember 15tn Questions were raised about the habitability of the unit due to o the angled ceilings in the upper floor. Basedo from measuring the room and ceiling heights,the room appears to meet habitability requirements as defined in 410.400 and 410.401. Date: 4/10/23 Inspectors Signature: Page 1 of 1 North Andover Health Department 120 Main Street North Andover,MA 01845 Fax: 978.688.8476 Phone: 978.688.9540 a 1 North Andover Town Hall Health 120 Main Street Phone:(978)688-9540 North Andover, MA 01845 Fax:(978)688-9542 www.northandoverma.gov NORTH AND VER HEALTH DIVISION COMPLAINT INTAKE FORM Nature of Complaint Case Number: ❑ Food Service ❑ Nuisance Time: ❑ Pool 0 Housing ❑ No Permit ❑ Septic Date: ❑ Other Complainant: Location of Property Name: :S-a�i Ccm45�ccl Name: ,kl,cae. lcv,t Address: q V(/l Address: Email: Contact Person: Telephone: Telephone: 6SIA igVu Anonymous: I ❑ Owner: Description: n ��aW.i`c7Di�s CiiJ�LSMrC.�\ate.!Gf.1�\+.�Yt21q�5�1+L 1.3�n"t-�gt2.aS in n e\ 41 CIO '�SSL� 1n�.J dM1Si� 5 �' ,�145.`�'��fl �w3�1 UxJu SW sl Vize Inspector: Complainant: ` 4/13/23,8:22 AM Town of North Andover Mail-North Andover Health Issues/Concerns,NA-6760-Reportlt,${rep_add)has been Submitted or Upd... NORTH MIDOVER Massachusetts Toni Wolfenden <twolfenden@northandoverma.gov> North Andover Health Issues / Concerns , NA-6760-Repo rtlt, ${rep_add) has been Submitted or Updated 1 message do not_reply@peoplegis.com <do_not_reply@peoplegis.com> Mon, Mar 20, 2023 at 8:58 AM To: healthdept@northandoverma.gov Someone has submitted or updated a service request. Please use the link below to sign in and update the status. You may need to expand the bottom of the message to see the link if this message is part of a chain. The current status of the request is: Health Issues / Concerns Isabel Comstock 603-937-7345 isabelar83@gmail.com Currently under 6 month lease at 9 Village Way. The property does not meet the requirements for a rental property by the state of MA. There is not stove or oven, no closets in the listed as "bedrooms" areas. There is not doors, the square footage listed is not actual livable space, due to the inclination angle of the roof. The landlord only cleans snow on one entry (the one he uses) and leaves the second entry with snow. There has been several issues with the power outlets not been able to withstand all the electronics and we have lost power many times, I have records of these instances. In addition, one of the Hot force air units broke down last week, and they provided me with space heaters and asked me to use a fan to blow heat from the second level to the first one. The owner of the property John acts like he is doing me a favor with pretty much anything I ask, the snow was clean only one time and I was told it wont be cleaned again and i have to use the second door. I facilitate them two days per week to show the property to future tenants, as a result of that John sent me an email which seems passive aggressive, mentioning the cost of the HVAC repair for the hot air force unit, mentioning my departure going "smoothly" if I collaborate, etc. Please contact me to coordinate an inspection to this property before you contact the landlord. I have more pictures and texts to show the interaction has been abusive towards me. In Process Left message requesting date and time for inspection. The record can be viewed at the following LIRL: https://www.mapsonline.net/northandoverma/forms/template_ select.php?id=828365189&jump=d 104b4a9657017dcdfa7b4e55a24c673 https://mail.google.com/mail/u/0/?ik=aOc6f4e4cf&view=pt&search=all&permthid=thread-f:1760891623045591244&simpl=msg-f:1760891623045591244 1/1 �u 13. 91AC01 LAW PROVIDENCE • BOSTON • WESTERLY April 26,2023 VIA V CLASS MAIL&ELECTRONIC TRANSMISSION (blasrasse a northandoverma.2ov) Mr.Brian LaGrasse,Director Town of North Andover Board of Health 120 Main Street North Andover,MA 01845 Atten: Ms.Toni Wolfenden,Department Assistant RE: 39 Hawkins Lane, North Andover,MA Our File No.04029.057 Dear Director LaGrasse and Ms.Wolfenden, I am writing on behalf of my clients, Mr.Thomas Scott,and Ms.Maureen Scott,to request to be included on the Board of Health Agenda for the upcoming meeting scheduled for May 25,2023. The purpose of my request is to discuss and modify an existing deed restriction encumbering 39 Hawkins Lane,North Andover,MA(the"Property"). The deed restriction in question is dated April 8`h 2009 and pertains to the existing Sub Surface Disposal Septic System and is recorded at Essex County Registry of Deeds at Book 11551,Page 235. (The"Deed Restriction,"see Exhibit A attached herewith.) The modification of the Deed Restriction is necessitated at this time because,among other things, the existing Sub Surface Disposal Septic System is functioning perfectly and has been regularly maintained and serviced as evidenced by the Title V Certificate of Approval(the"Title V"Certificate of Approval,"see Exhibit B attached herewith). It appears the Deed Restriction is intended to address a future improvement to the dwelling along with an upgrade to the existing Sub Surface Disposal Septic System based on the actual number of rooms and bedrooms in the existing dwelling which is not the situation in this case. Given that the capacity of the existing Sub Surface Disposal Septic System is adequate and given the fact that the Sub Surface Disposal Septic System is functioning perfectly and given that neither an upgrade nor new design is required at this time,we believe it is appropriate to modify the Deed Restriction. PROVIDENCE ( Administrative Office 1 171 Broadway Providence,RI 02903 1 P 401.331.21911 F 401.331.2991 BOSTON I Lewis Wharfs Ba 228 Boston,MA 02110 1 P 617.723.3777 1 F 617.723.7876 WESTERLY 15 Grove Avenue,Westerly,RI 02891 1 P 401.265.3183 1 F 401.679.0280 Mr. Brian LaGrasse,Director Ms. Toni Wolfenden,Department Assistant Town of North Andover Board of Health April 26,2023 Page 2 Moreover, since there is no negative impact to the Property or the Community's health and well- being;to require the homeowner to"dig up"the Property,at this time, for no reason would be economically unfeasible. I understand that the process of modifying a deed restriction can be complex and time- consuming,but I am willing to work with the Board to ensure that this matter is handled in a timely and efficient manner whereby we can find a mutually beneficial solution. In an effort to advance the process, attached is a proposed modified deed restriction for review(the"Proposed Septic System Deed Restriction,"see Exhibit C attached herewith). Thank you for your attention to this matter.I look forward to the opportunity to discuss this issue with the Board. Should you have any questions or concerns regarding the same,please do not hesitate to contact me at(617)723-3777 or by email at jmi(&iacoi-law.com. Very truly yours, John lacoi,Esq. Enclosures cc tolfenden(a)northandovemia.gov(w/enclosures) Thomas Scott William Dufresne,Certified Land Surveyor PROVIDENCE I Administrative Office 1 171 Broadway Providence,RI 02903 1 P 401.331.2191 1 F 401.331.2991 BOSTON I Lewis Wharf,Bay 228 Boston,MA 02110 1 P 617.723.3777 1 F 617.723.7876 WESTERLY 15 Grove Avenue,Westerly,RI 02891 1 P 401.265.3183 1 F 401.679.0280 Exhibit A Bk 11551 Pg235 #10281 DEED RESTRICTION Pursuant to 310 CMR 15.000 Title 5,and as a condition of the approval of the proposed two(2)room home addition by the North Andover Board of Health,notice is hereby given that real estate located at 39 Hawkins Lane,North Andover, Massachusetts,Assessor's Map 210/Lot 106,C-0124,as described in a deed from Thomas Scott to TMS Realty Trust, Thomas Scott, Trustee,dated December 161h 1993 and recorded in the Essex County Registry of Deeds in Book 03933 and Page 0060,is the subject of review and approval under the Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage A1.05 and C9.01(4). Said review and approval limits the maximum number of bedrooms at this dwelling to the existing four(4)Bedrooms. At the regularly scheduled North Andover Board of Health meeting held on March 261h 2009,the Board voted unanimouslu to accept this deed restriction granted to them by the property owner allowing the existing septic system to be considered in compliance with the requirements of Title V which otherwise would not be in compliance based upon the total number of rooms. Reference made herein to a future upgrade of the existing system shall mean that a new system be engineered and installed which conforms fully to the requirements of Title V by using the actual number of rooms as the basis of the design of the new system. This review and approval is within the jurisdiction of the North Andover Board of Health and is subject to the following conditions: 1. A Title V inspection shall be conducted by a licensed Title V inspector hired by the Homeowner every three years to ensure the health of the septic system; 2. There shall be no change to the configuration or number of bathrooms nor change in the occupancy of the home without the upgrade of the septic system; 3. This approval will expire upon the entrance into any purchase and sale agreement for the home and at such time,the current Homeowner will be required to upgrade the existing septic system to conform with all the current Title V requirements. The upgrade of the septic system must be completed prior to the sale of the property. Failure to upgrade the subsurface disposal system will result in an immediate issuance of a Board of Health, Order to Correct; 4. This deed restriction would be lifted prior to, or at the time of the sale, when the septic system is appropriately upgraded or if and when the owners conduct a sewer tie-in. Signed and seal this day of April,2009. �s .on Scott, T st Commonwealth of Massachusetts Essex,s.s. Date:April��2009. Then personally appeared the above-named Thomas Scott and acknowledged the foregoing instrument to be his free act and deed,before me. SHAUNA COl1EARY r�'_ (Cflea�-'W- 4Z'4?oe� Notary C�►r►wr�w+eet f M�edvAeft Name Notary P c My C Tr*Won hires Oct.22,2015 Exhibit B Commonwealth of Massachusetts Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is NORTH ANDOVER MA 01845 MAY 2,2022 requiredd for every ,. o_ _--__ _.. _..�_. page. Cdylrwn State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, s Todd Jame Bateson use only the tab _- key to move your Name of Inspector cursor•do not Bateson Enterprises Inc. use the return — — - key Company Name 111 Aa Road � Company any Address Andover MA 01810 State Zip Code �. 978-475-4786 SI-16 Teisphone Number Ucense Number B. Certification --_ - ---- I certify that I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3_ ❑ Needs Further Evaluation by the Local Approving Authority 4- ❑ Fails Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15^sc.6r.,•r + 't w:'G?:i T:Ue 5 C Tlial it :or.r«„ S.,tsu!ece S.wa;O DSPMa'Sjsirn c'72•Pag*1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 HAWKINS LANE Property Address THOMAS SCOTT Owner owners Name information is required for every NORTH ANDOVER MA 01845 MAY 2, 2022 __- page. Crty4own State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments PERMIT-BOARD OF HEALTH PUMP TANK, INSTALL OUTLET TEE AND GAS BAFFLE IN TANK REPLACE D-BOX AND INSTALL RISER SYSTEM NOW PASSES TITLE 5 INSPECTION 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old`or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System wIi pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. `A metal septic tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5-49*X rev 729Q018 Tee 5 Of5�af hsspea*ci Fr,,m S ZC Lase Sewage Onpcsal system•?a,*2 d 18 Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owners Narne n!uired fo +s NORTH ANDOVER MA 01845 APRIL 4,2022 required for every —.�-___-__ _.._ __ _._...__--____-_ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D-BOX NEEDS TO BE REPLACED INSTALL OUTLET TEE AND GAS BAFFLE IN TANK ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: tpnsa.ecc ra, i Title 5 CWJal inspection r'cm:Subwfsc*Sa%"2e ooposai System•Pspe 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F� 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 APRIL 4,2022 _------_—._—.- _ ---- -- — - page OtylTown State Zip Code Date of Inspection C. Inspection Summary (coot.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or ck)gged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t'c+spAoc-rev �rarzola Tde 6 CNidW Irspectiw form Svbsw40e Sewepa DhPosat System•Page J of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name required(o ati fo is every r NORTH ANDOVER MA 01845 APRIL 4,2022 requir page. Cltyrrown State Zip Code Date of ImpecWn C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/:day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. -1 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® Tho system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El Area system is located in a nitrogen sensitive area(interim Wellhead Protection Area— IWPA)or a mapped Zone If of a public water supply well 15inxp tlx•rev 7:26,7013 T'R'e 5 OrAdal vnpecSan Form'SubsuAaa Sewage Disposal System•Peps 5 ca r.. Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �'�' 39 HAWKINS LANE_ Property Address THOMAS SCOTT Owner Owners Name information is required for every NORTH ANDOVER MA 01845 APRIL 4,2022 __ ---- -----_.. page City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered'yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® Q Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t^lf.S0.d0.•ta`+7R8Y;010 Trse 5 OMWI Mspeerion Farce Sut4w.e Se *Q*044>osat System•N,,n 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 4� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 HAWKINS LANE Property Address _.. __....__ THOMAS SCOTT Owner O_-----.. . . wner's Name — informatlon is requireequred for every NORTH ANDOVER MA 01845 APRIL 4,2022 -:�-------_------.�.___ _. page. Gty/Town State Zp Code — Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 --- Number of bedrooms(actual): .4— DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 GPD Description: Number of current residents: -- Does residence have a garbage grincer, ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes 9 No information in this report.) Laundry system inspected? ® Yes Q No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage SEE ATTACHED 9 ( Y 9 (9Pd)}: Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date ,�ns�Coe•rev 7�2 '<J73 Tile 6 o?rda)r•,apecLron Form Skks,yf ce Sa+ j*Oftv:al Sysxn-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F., 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name _ require tifo is NORTH ANDOVER MA 01845 APRIL 4,2022 requited for every page. cftyfrown state Zip Code Date of Inspecbon D. System Information (cont.) 2. Commerciatllndustrial Flow Conditions: Type of Establishment: - - --- - -- Design flow(based on 310 CM 15.203): Gallons per day(Wd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: BOARD OF HEALTH,2 YEARS Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: -------.--_ __ gallons How was quantity pumped determined? - — - Reason for pumping: t5insD.doe•rev.rr261201113 TK*5 CV!cW inapectfon forth.Subsodm s S—go D4;o-i Sfzlsm•Pa.7c 8 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form 2 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F� -, 39 HAWKINS LANE Property Address THOMA.S_ - -SCOTT Owner's_— —_ wner's Name reformation is NORTH ANDOVER MA 01845 APRIL 4,202-2 required for every _ -_- -----_-----�. page. CityfTown State Tip Code Date of inspection D. System Information (font.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract i Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: 1990 BOARD OF HEALTH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 5 feat Material of construction: ❑cast iron ®40 PVC ❑other(explain): --- - — Distance from private water supply well or suction line: feet --� Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS AND VENTING ARE GOOD NO EVIDENCE OF LEAKAGE Mnv.doc-my V25=18 T,ue S c4rdal lr3pe o_rwrt *".V'?ace< e 1)(U el S,3tem PaT,e 9 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form !1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner _ ---- --- .--._--- -- -- Owner's Name information is required for every NORTH ANDOVER MA 01845 APRIL 4,2022 page. Cityrrown State Zip Code Dete of Inspection D. System information (cons.) 6_ Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: -- ------ years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'X 5'X 4' Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 3% --- - ---- - Distance from top of scum to top of outlet tee or baffle NA -- - Distance from bottom of scum to bottom of outlet tee or baffle - — -- How were dimensions determined? TAPE MEASURE ANDSLUDGE JUDGE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET BAFFLE IS OK, OUTLET BAFFLE NEEDS REPLACED IT HAS ROTTED OFF NO SIGNS OF LEAKAGE TANK IS OK t5w*Aftc-my 701110M "true 5 oeftlai lrmgectbn Fonrr Subwtaoa Se Agv Cmgos i System•Pap+10 a!18 C Commonwealth of Massachusetts r _ g, Title 5 official Inspection Form r I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Fr 39 HAWKINS LANE Property Address THOMAS SCOTT Owner ---- t?rrnet's Name _ information is required to every NORTH ANDOVER MA 01845 APRIL 4,2022 _ -u..- _._. ..._�_.._. . page City/Town State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑ fiberglass ❑polyethylene ❑other(explain): Dimensions Scum thickness Distance from top of scum to top of outlet tee or baffle - - ---- - Distance from bottom of scum to bottom of outlet tee or baffle —--- Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions Capacity: gallons Design Flour. gaBonS per day t5:ns;A—•—71'3, J l g TMe 5 O1Ma1 MaAecfta Fam,Subwetace Se v. -Cngaaa4 Syr—•Page t t at 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - i4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Fr 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owners Name information is squired for every NORTH ANDOVER MA 01845 APRIL 4,2022 page. CityJTown State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: - - Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 - Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX 1S LEVEL AND DISTRIBUTION IS EQUAL NO SIGNS OF SOLIDS CARRYOVER D-BOX IS ROTTED AND NEEDS TO BE REPLACED t5srtsp.doc•rev 7rs&2018 Tree 5 OtPcW:nspecdon Fo m Subsuriau Sewage C4spo l System Pala 12 of 18 Commonwealth of Massachusetts q _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is NORTH ANDOVER MA 01845 APRIL 4,2022 required for every �- --------------------..__..... -----___. page Cityrrown State Zip code Cate of Inspection D. System Information (cons.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ® leaching fields number,dimensions: .15'X 60' ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: t�.inap.dx re+7:b+c47$ TjW 5 Cfidal asspec5on Foam SuCsntaos S—"a Disposal System•Page 13 01 18 Commonwealth of Massachusetts Title 5 Official Inspection Form wl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 HAWKINS LANs Property Address _ THOMAS SCOTT Owner Owner's Name required on NORTH ANDOVER MA 01845 APRIL 4,2022 required for every ___--.__�.... _ p �. — Pe�m— page Cityrrown State Zip Code Date of Ins D. System Information (cunt.) 11. Soil Absorption System(SAS)(coot.) Comments(note condition of sail,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): SOIL IS GOOD NO SIGNS OF HYDRAULIC FAILURE VEGETATION IS OK 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): �Cx rE, 7125'20+ Tke 5 Oft--l hspecbw Fo m sut3urta Sewage 0,sposs:Sys lrm•Pays 14 ct 18 Commonwealth of Massachusetts Title 5 Official Inspection Form UT!" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 APRIL 4,2022 -------------------__. _— �. ----- --- page. Cityrrown State Zap Code Date of Inspection D. System Information (cunt.) 13. Privy(locate on site plan): Materials of construction: " Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.ccc•rsv 7lZfij:G18 rmse 5 OMdal inspeaim Fe"..,Subsurface Sewne LN3006W 5 1%t •Paye 15 of 19 cmreft Title 5 Official Inspection Foam 39 HAMMtAW t ► THOMAS,SCO-17 00raft Narm k1f0mrsobw is for emY NORM ANDOVER MA 01845 APR1L 4,2022 Mae. Ciy/TO— 5ta4a zip Code Doe&of 4upec6an D. System Infiarmafion (cont) 14_ Sketch Of Sewage Disposal Spa: PrDVKW a view of the sewage d--WMW sysbx%irx kM ft ties to at leant hM parrrMert reietea M lsn&mfics or bmxhr"kS-Locate all web witfm 100 feet.Locate where pry waW apply sheers the bt idilg.Check am of the braces below: ® harxt•�in the area below ❑ drawer9 atteded se lY # 31 H.W k%O L�n� tea,\ c � O 'E t- O I-t r col, 56, ° 1 13 - / + �0 It hover 6(, 10 Val_ -,m neom+-%1dm-P"m*urn Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is NORTH ANDOVER MA 01845 APRIL 4,2022 required for every ---- - ------ - — page City/Town state Zip Code Date R Inspection D. System Information (cost.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feel Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Date---- CH 2O00 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: AS BUILT ON FILE _ ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: DESIGN PLAN Before filing this Inspection Report,please see Report Completeness Checklist on next page. t`%nsp.Cx•nv 7rSM- 18 T.te 5 CX"+c'al Insppcion Forth Subsurface sews;*Disposal Sys'em-page 17 0118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 HAWKINS LANE Property Address THOMAS SCOTT Owner Owner's Name information is re NORTH ANDOVER MA 01845 APRIL 4,2022 quired for every _ --- - ---. page CrtyfTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information:Complete all fields in this section. ® S. Certification: Signed 8 Dated and 1, 2, 3,or checked ® C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank-Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included U'ntD Coe•nr 7,'.'fif20t8 Title 5 0mcial Inspection Forth:subaLftce Sewage Datposai Syr—•Pape U of 18 a « ftmnwy Record Care as oMW an 3n7rA=s30;34 AM by strwn C000 Pop 1 Town of North Andover Tax Map # 210-106.C-0124-0000.0 Parcel Id 17759 39 HAWKINS LANE THOMAS SCOTT 15 RIVER STREET,APT.201 BOSTON MA 02'I08 FY 2W - UB Mailing Index NamelAddress Type Loan Number Active/lnact. From Until THOMAS SCOTT Owner Active 15 RIVER STREET,APT 201 BOSTON MA 02108 SCOTT.THOMAS Payor Inactive 1114/202' 39 HAWKINS LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name AcNvelinactive Bldg id.17368.0-39 HAWKINS LANE Last Billing Date 11102022 31700M 03 Cycle 03 Active UB Services Maint Account No.3170036 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 11 WTR WATER 01 ALL METER SIZE 22-80 /i UB Meter Maintenance Account No.3170038 Serial No Status Location Brand Type Size YTD Costs 35077345 a Active ERT HH b Badger w Water 1 1 382 Date Reading Code Consumption Posted Date Variance 3/4/2022 3948 a Actual 4 -30% 12f7/2021 3944 a Actual 6 1/1712022 -95% 9172021 3938 a Actual 116 10/1 V2021 39% 6/4/2021 3822 aActual 81 7/27/2021 751% 3/42021 3741 a Actual 9 4f212021 -95% 121712020 3732 aActual 170 1/1312021 6% 9/242020 3562 m Manual estimate 245 10/142020 290% MSG 613/2020 3317 a Actual 50 7/15/2020 222% 3f5/2020 3267 aActual 15 4/812020 -85% 112/92019 3252 aActual 100 1/15/2020 -55% 9/1312019 3152 a Actual 249 10/1012019 239% 6/72019 2903 a Actual 69 7252019 322% 3/7/2019 2834 a Actual 16 4/1612019 -85% 12(72018 2818 a Actual 100 12212019 14% 9/1112018 2718 a Actual 97 1011512018 109% 6172018 2621 a Actual 45 72312018 107% 3WO18 2576 a Actuai 21 4232018 -83% 12/612017 2555 a Actual 117 12512018 -18% 9/112017 2438 a Actual 160 10/182017 216% 6WO17 2278 aActua1 48 7252017 53% 3/62017 2230 a Actual 30 4/122017 -74% 12/82016 2200 a Actual 122 1/232017 48% 9172016 2078 a Actual 236 10242016 413% 6/712016 1842 a Actual 46 8=016 50% 3f72016 1796 a Actual 30 4222016 -78% 12/8/2015 1766 a Actual 135 120=16 87% 91&2015 1631 a Actual 73 10/162015 -15% 6AV2015 1558 a Actual 115 724/2015 190% Exhibit c PROPOSED SEPTIC SYSTEM DEED RESTRICTION Pursuant to 310 CMR 15.000 Title 5, and in order to protect the public health and the environment and ,notice is hereby given that real estate located at 39 Hawkins Lane, North Andover,Massachusetts,Assessor's Map 210/Lot 106.C-0124, as described in a deed from Thomas Scott to TMS Realty Trust,Thomas Scott,Trustee, dated December 16th 1993 and recorded in the Essex County Registry of Deeds in Book 03933 and Page 0060, is the subject of review and approval under the Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary SewageA1.05 and C9.01(4). Said review and approval limits the maximum number of bedrooms at this dwelling to the existing four(4) Bedrooms. At the regularly scheduled North Andover Board of Health meeting held on [ ], the Board voted unanimously to accept this modification to the deed restriction and reconfirm and grant the property owner allowance that the existing septic system to be considered in compliance with the requirements of Title V which otherwise would not be in compliance based upon the total number of rooms. Until the existing septic system fails,it shall not be upgraded,modified, altered, or expanded(the "Upgrade")without the prior written consent of the local health department. Moreover,the property owner shall be responsible for maintaining the existing septic system in good working order and for ensuring that it is regularly pumped as needed. No hazardous material, chemicals,or other substances that may damage or contaminate the groundwater shall be disposed of on the Property. Any violation of this restriction may result in legal action, including but not limited to fines,penalties,and injunctive relief. Reference made herein to a future Upgrade of the existing septic system shall mean that a new septic system be engineered and installed which conforms fully to the requirements of current Title V by using the actual number of rooms as the basis of the design of the new septic system. This review and approval is within the jurisdiction of the North Andover Board of Health and is subject to the following conditions: 1. A Title V inspection shall be conducted by a licensed Title V inspector hired by the Homeowner every two years to ensure the health of the septic system; 2. There shall be no change to the configuration or number of bathrooms in the home without the upgrade of the septic system; 3. Failure to comply with this deed restriction shall result in an immediate issuance of a Board of Health fine and/or an Order to Correct; 4. This deed restriction shall automatically terminate when the septic system is appropriately upgraded or if and when the Property is connected to municipal sewer;and, 5. The property owner shall comply with all other requirements of Title V. [SIGNATURE PAGE TO FOLLOW] 4/26/23,3:54 PM Town of North Andover Mail-FW:39 Hawkins Lane,North Andover, MA NORTH ANDOVER Massachusetts Toni Wolfenden <twolfenden@northandoverma.gov> FW: 39 Hawkins Lane, North Andover, MA 1 message Anne Konetzny <Anne@iacoi-law.com> Wed,Apr 26, 2023 at 3:36 PM To: "twolfenden@northandoverma.gov" <twolfenden@northandoverma.gov> Cc: John lacoi <jmi@iacoi-law.com>, "blagrasse@northandoverma.gov" <blagrasse@northandoverma.gov> Good Afternoon Ms. Wolfenden, Please see attached letter in request for a hearing with the Town of North Andover Board of Health; the same has been mailed to your office via USPS First Class Mail. Please confirm receipt. Sincerely, Anne Thank you, Anne I ACOI LANV Anne Konetzny Lewis Wharf,Bay 228 1 Boston,MA 02110 P 617.723.3777 F 617.723.7876 WEBSITE I ANNE@IACOI-LAW.COM T�ktl4.4¢YSf±f�1 "*Lenders: Please include titleorder@iacoi-law.com; closings@iacoi-law.com for all title requests" Wire Policy: Effective immediately, our office will no longer initiate or send out any wire transfers relative to any real estate closing. https://mail.google.com/ma i I/u/0/?ik=aOc6f4e4cf&view=pt&search=all&permth id=th read-f:1764268745519736244&simpl=msg-f:1764268745519736244 1/3 4/26/23,3:54 PM Town of North Andover Mail-FW:39 Hawkins Lane, North Andover,MA Statement of Confidentiality, The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s)and may contain confidential or privileged information.Ifthe reader of this message is not the intended recipient,you are hereby notified that any disclosure,distribution,forwarding,copying or other use of this information and attachments(if arty)is strictly prohibited.If you are not the intended recipient,please notify iacoi Law immediately at 401-331-2191 and destroy all copies of this message and any attachments you received Thank you. FRAU D ALERT Do not send any sensitive personal information to this office via unsecured e-mail.Call our office to verbally confirm any and all wiring instructions received. From:Anne Konetzny Sent:Wednesday,April 26, 2023 3:30 PM To: 'b lag rasse@northandoverma.gov' <blagrasse@northandoverma.gov> Cc: John lacoi <jmi@iacoi-law.com>; Thomas and Maureen Scott(tomnama@hotmail.com) <tomnama@hotmail.com>; William Dufresne <wrd ufresne@com cast.net> Subject: 39 Hawkins Lane, North Andover, MA Good Afternoon Mr. LaGrasse, Please see attached letter in request for a hearing with the Town of North Andover Board of Health; the same has been mailed to your office via USPS First Class Mail. Please confirm receipt. Sincerely, Anne OIACOI LAW PloyVIC&MCL-Ui»TfJ •R°itS71B1Y Anne Konetzny Lewis Wharf,Bay 228 1 Boston,MA 02110 P 617.723.3777 F 617.723.7876 V BSITE I ANNE@IACOI-LAW.COM It�ittl_i�ied "Lenders: Please include titleorder@iacoi-law.com; closings@iacoi-law.com for all title requests" https://mail.google.com/mail/u/0/?ik=a0c6f4e4cf&view=pt&search=all&permthid=thread-f:l764268745519736244&simpl=msg-f:1764268745519736244 2/3 4/26/23,3:54 PM Town of North Andover Mail-FW:39 Hawkins Lane,North Andover,MA Wire Policv-: Effective immediately, our office will no longer initiate or send out any wire transfers relative to any real estate closing. Statement of Confidentiality-• The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s)and may contain confidential or privileged information.If the reader ofthis message is not the intended recipient,you are hereby notified that any disclosure,distribution,forwarding,copying or other use of this information and attachments(f any)is strictly prohibited.Ifyou are not the intended recipient,please note lacoi Law immediately at 401-331-2191 and destroy all copies ofthis message and any attachments you received.Thank you. FRAUD ALERT Do not send any sensitive personal information to this office via unsecured e-mail.Call our office to verbally confirm any and all wiring instructions received. Letter Request for BOH Hearing.executed.pdf 7503K https://maiI.google.com/mail/u/0/?ik=aOc6f4e4cf&view=pt&search=all&permthid=thread-f:1764268745519736244&simpl=msg-f:1764268745519736244 3/3 Y, C In Massachusetts for recreational summer camps to be licenses they must provide a health care supervisor who must remain on site at all times during the camps operation to carry out the health policy written by the Health Care Consultant. The health care consultant is a person on the staff of a recreational camp for children who is 18 years of age or older and who is responsible for the day to day operation of the health program or component. The Health Care Supervisor shall be a Massachusetts licensed physician, physician assistant, nurse, or other person specially trained in accordance with 105 CMR 430.160 with a current CPR and First Aid certificate. In North Andover on December 12, 2019 a.revised regulation was made in which the designated Health Care Supervisor for residential or sports camps, regardless of the total number of staff and campers, be one of the following: 1. A nurse registered to practice in the Commonwealth; 2. A physician (MD/DO) licensed to practice in the Commonwealth; 3. A certified nurse practitioner or physician assistant licensed to practice in the Commonwealth; or 4. A Massachusetts licensed practical nurse. North Andover Fire Department is 6 minutes away from Brooks. Nearest Emergency Departments (according to google maps) Lawrence General = 12 minutes Holy Family Methuen = 18 minutes Holy Family Haverhill = 17 minutes One Soccer School is seeking a variance to have JORDAN SLIWOSKI MS, ATC, NASM-CES serve as their health care supervisor. She is a Massachusetts board certified Athletic Trainer who is currently the head athletic trainer at Millbury Memorial Jr./Sr. High school with 7 years of experience and previously an EMT. She will be trained by the Health Care Consultant Melissa Donais (current director of Health and Wellness at Brooks) and will be signed off on all competencies prior to the start of the camp season. She has her American Red Cross BLS Healthcare Provider CPR/AED Certification as well as a American Red Cross Certified Instructor. She is over the required age of 18. Attached is the letter written by One Soccer School seeking a variance along with Jordan Salkowski credentials. One Soccer School held recreational summer camp last summer with having an Athletic Trainer serve as an HCS and ran successfully and was able to demonstrate that they are able to follow the health care plans and meet all other criteria. I believe that One Soccer School will be able to safely operate a recreational summer camp with Jordan as the health care supervisor. May 8th, 2023 RE: ATHLETIC TRAINER REQUEST Dear North Andover Board of Health, We would like to place in writing a request to allow a qualified & practicing Athletic Trainer to take on the position of Healthcare Supervisor during our summer soccer camp, which will be held from July 23rd through to August 1st at Brooks School, 1160 Great Pond Road, N. Andover. MA 01845 Athletic Trainer Role & Responsibilities Preparation for the role of Health Care Supervisor during camp Melissa Donais, RN, FNP-BC, our Healthcare Consultant, will train the Athletic Trainer in all aspects related to the role of health care supervisor. She will train and competency test the Athletic Trainer in Epipen administration, medication administration, effects and possible side effects of all medications to be administered, confidentiality, the role and limits of the Healthcare Supervisor, camp safeguards and policies. The Athletic Trainer (AT) will be required on site at all times during the camp. The following is a job description of his/her roles and responsibilities while working for one. Soccer schools. Camp Dates: July 23rd, 10:30am, through to August 1st, 5:O0pm Venue: Brooks School, 1160 Great Pond Road, N. Andover. MA 01845 Arrival Time: All staff arrive at 10:30am at Brooks School for a team meeting prior to camp starting. Camp ends the final day at 5:00pm. Camp Registration for athletes is 1:00-2:30pm - During registration the Athletic Trainer will meet each athlete and discuss their medical history (All athletes complete a google form outlining their medical history, which the athletic trainers will review). Medication Protocols We do not allow any medication to be kept in the dorm rooms. Players will agree to meet the Athletic Trainer daily for medication administration if needed. All coaching staff will have the cell number of the Athletic Trainer who will be expected to be accessible via phone 24/7 to manage all issues related to the health management of all players at camp. one.Soccer Schools,315 Meigs Road,Suite A-431 Santa Barbara,CA 930194one. Website:www.onesoccerschools.com email: info(cDonesoccerschools.com office:805-845-6801 SOCCELS Basic outline of the Athletic Trainer's role • The Athletic Trainer is required to be on campus for the duration of the camp • Injury management (administratively and practically) for minor injuries. • Create and administer action plans for the health and safety of the athlete as it pertains to minor injuries throughout the camp. • Recognize any head injury as a potential concussion and take the necessary concussion protocols. • Able to administer CPR in the event that it would be required • Recognize a serious injury, call 911, take appropriate action to keep athlete comfortable until which time trained paramedics arrive • For ALL injuries the parent of the child must receive a phone call, and the injury written up on a one.Soccer.schools injury report form • Direct & administer the medical needs of all players attending the camp • Manage the water coolers on the field making sure that they do not run empty • The AT is responsible to provide equipment needed to carry out their job. one.Soccer.schools will reimburse expenses for all supplies used • The AT is expected to consult with Melissa Donais, RN, FNP-BC, Healthcare Consultant, as needed and required by guidelines for assistance with developing a plan to manage any injuries, illnesses, or other medical conditions beyond the scope of practice of the AT. Athletic Trainer credentials Name:Jordan Silwoski MS, ATC, NASM-CES MA Licensed Athletic Trainer License#2931 Serial Number 158523 Thank you for taking the time to review our request for a variance to allow an Athletic trainer to take up the position of Healthcare supervisor throughout our residential camp. Sincerely r r . Lloyd Biggs Camp Director/Coordinator one.Soccer Schools,315 Meigs Road,Suite A-431 Santa Barbara,CA 93019 ione.Website:www.onesoccerschools.com email: info(@onesoccerschools.com office:805-845-6801SOCCE DPH Standards for Training Health Care Supervisor in Medication Administration Each recreational camp must ensure that the health care supervisor(s) can meet the health and medical needs of each individual camper.The camp's health care consultant must provide training and document the competency of every health care supervisor.,This training does not need to be submitted for prior approval, but must be made available by request or during inspection. Training Topics: An approved training will address, at a minimum,the following issues: 1. Confidentiality 2. The Role of the Health Care Supervisor 3. Limits of the Health Care Supervisor 4. Effects and Possible Side Effects of all Medication Administered 5. Steps in Medication Administration 6. Camp Safeguards and Policies Test of Competency: Each health care supervisor must have a documented test of competency to administer medications. At a minimum, the health care supervisor must: 1. Demonstrate safe handling and proper storage of medication. 2. Demonstrate the ability to administer medication properly: • accurately read and interpret the medication label • follow the directions on the medication label correctly • accurately identify the camper for whom the medication is ordered 3. Demonstrate the appropriate and correct record keeping regarding medications given and/or self-administered. 4. Demonstrate correct and accurate notations on the record if medications are not taken/given either by refusal or omission and when adverse reactions occur. 5. Describe the proper action to be taken if any error is made in medication administration or if there is an adverse reaction possibly related to medication 7. Use resources appropriately, including the consultant, parent/guardian or emergency services when problems arise. 8. Understand and be able to implement: • emergency plans including when to call 911 • appropriate procedures that assure confidentiality If HCS is a licensed physician, nurse practitioner, registered nurse or physician's assistant with experience in pediatric care,that�oFM<,s certification is evidence of proper training and competency. March 2018 0 Vy g9Vv, LV� r Camp Medication Administration Training/Test Checklist: 1.Confidentiality: Importance of not sharing information about campers or medications with anyone unless directed to do so by the HCC 2. Role of Health Care Supervisor: Administer Medication only by Specific HCC Order to Specific Child Follow Instructions on Medication Sheet Record Time and Effects Observed Reports Any Problem or Uncertainty 3. Limits of the Health Care Supervisor: HCS may not administer ANY medication without HCC approval HCS may not administer ANY medication without parent/guardian permission HCS may not administer insulin (unless within scope of practice) 4. Effects and Possible Side Effects of all Medication Administered: Describe Effects of Medications Discuss Common Side-Effects of Medications(drowsiness,vomiting, allergic reaction) Report All Changes that may be side-effects to HCC and Parent/Guardian Record All Changes that may be side-effects in log 5.Steps in Medication Administration: 5 Rights of Medication Administration. 1. Right Camper 2. Right Medication 3. Right Dosage 4. Right Time 5. Right Route Steps in Medication Administration 1. Identify Camper 2. Read Medication Administration Sheet 3. Wash Hands 4. Select and Read Label of Medication 5. Prepare Medication and Read Label Again 6.Administer Medication and Make Sure Medication is Taken. 7. Replace Medication in Secure Location 8. Lock or Secure Location 9. Document in Medication Log Steps in Supervising Self-Administration 1. Identify Camper 2. Read Medication Administration Sheet 4. Select and Read Label of Medication 5. Observe Student Prepare and Take Medication 6. Replace Medication in Secure Location 7. Lock or Secure Location 8. Document in Medication Log 6.Camp Safeguards and Policies Report Any Error to HCC and Parent/Guardian including: 1. Camper Given Wrong/Unapproved Medication 2. Camper Refuses Medication 3. Camper Has Unusual or Adverse Reaction Possibly Related to Medication Review Camp's Emergency Plan and when to call Emergency Services aF Moss o��pl 9c L March 2018 105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN (STATE SANITARY CODE, CHAPTER IV) 430.020: Definitions Health Care Supervisor means a person on the staff of a recreational camp for children who is 18 years of age or older and who is responsible for the day to day operation of the health program or component.The Health Care Supervisor shall be a Massachusetts licensed physician, physician assistant, nurse, or other person specially trained in accordance with 105 CMR 430.160 with a current CPR and First Aid certificate. 430.159: Health Care Staff to be Provided The operator of each recreational camp for children shall provide: (A) A designated camp-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 staff; (5) Be available for consultation at all times; (6) Develop and sign written orders, including for prescription medication administration, to be followed by the on-site camp health care supervisor in the administration of their health related duties; and (7) Provide trainings as required by 105 CMR 430.160 to the health care supervisor(s)and other camp staff. (B) A written camp health care policy, approved by the Board of Health and by the camp health care consultant. Such policy shall include, but not be limited to: (1) Daily health supervision; (2) Infection control; (3) Medication storage and administration, including self-administration when appropriate, pursuant to the requirements of 105 CMR 430.160; (4) Procedures for using insect repellant and conducting tick checks; (5) Promoting allergy awareness; (6) Handling health emergencies and accidents, including parental/guardian notifications; (7)Available ambulance services; (8) Provision for medical, nursing and first aid services; (9)The name of the designated on-site camp health care supervisor; (10) The name, address, and phone number of the camp health care consultant required by 105 CMR 430.159(A); and (11)The name of the health care supervisor(s) required by 105 CMR 430.159(E), if applicable. (C) At least one health care supervisor, or more as determined by the camp operator based on camp size and ability to provide for the needs of the camp must be present at the camp at all times. Primitive, travel, and trip camps shall have at least one individual who possesses a current CPR and first aid certificate in addition to the health care supervisor accompanying the campers (D) In residential camps in which the total number of on-site campers and staff is less than 150 and in all day camps, the health care supervisor may have additional non-health related duties but shall at all times be available at the camp to render emergency first aid. NORTH ANDOVER BOARD OF HEALTH RECREATIONAL CAMPS FOR CHILDREN REGULATIONS Revised regulations. Authority F�j \ March 2018 M � Massachusetts General Laws (M.G.L.), Chapter 111, Section 31 and 105 CMR 430.000 Minimum Standards for Recreational Camps for Children (State Sanitary Code: Chapter IV). Section III Health Care Staff to be Provided A. In addition to the requirements set forth in 105 CMR 430.159 of the current Minimum Standards for Recreational Camps for Children (State Sanitary Code: Chapter IV) it is further required that the designated Health Care Supervisor for residential or sports camps, regardless of the total number of staff and campers, be one of the following: 1. A nurse registered to practice in the Commonwealth; 2. A physician (MD/DO) licensed to practice in the Commonwealth; 3. A certified nurse practitioner or physician assistant licensed to practice in the Commonwealth; or 4. A Massachusetts licensed practical nurse. aF M45 \'N March 2018 °fV s 1'FNr...00 A♦ ATHLETIC TRAINER JDRDAN SLIWDSKI Proof of professional liability insurance Client#1720879 .\IEMORANDUM OF INSURANCE ate Issued 06/06/2022 PI(KIUCCI This memorandum is issued as a matter of informatio only and confers no rights upon the holder. Thi Mercer Consumer,a service of memorandum does not amend. extend or alter Mercer Health & Benefits Administration LLC coverages afforded by the Certificate listed below. P.O. Box 14576 Des Moines. IA 50306-3576 1.800-375.2764 Company Affording Coverage nsured Liberty Insurance Underwriters Inc. Jordan L Orrell 29 Browning Pond Road Spencer, MA 01562 Phis is to certify that the Certificate listed tx:low has been issued to ItIC insured named above for the policy period indicated. not %% any requirement. term or condition of any contract or other document with respect to which this memorandum may be ,sued or may pertain.the insurance afforded by the Certificate described herein is subject to all the terms.exclusions and conditions of - such Certificate.The limits shown may have been reduced by paid claims. ['he Memorandum of Insurance and verification of payment are your evidence of coverage.No coverage is afforded unless the pretnium s successfully paid in full. Type of Insurance Certificate Number Effective Date Expiration Date Limits Professional Lability AHY-824874007 06/12/2022 06/12/2023 Per Incident/ $1,000.000 Athletic(rn a currcnce Athletic Trainer -annual Aggregate S 3.000,000 ROOF OF INSURANCI: Memorandum Holder: 3hould the atxivc describe: Certificate be canceller PROOF OF COVERAGE ONLY Tors the expiration date thereof,the issuing company gill endeavor to mail 30 days written notice to the Memorandum Holder named to the left, but failure tv nail such notice shall impose no obligation or liability of any kind upon the compam, its agents o epresentatives. Authorized Representative Mark Brostowitz Mercer Consumer.a service of Mercer Health&Benefits Administration LLC.In CA d h:a Mercer Health&Benefits Insurance Services LLC.CA License#OG39709 G04 I HEALTHCARE PROFESSIONALSON DEMAND Jordan Sliwoski, 1:)OcCERTIFIED ATH LETI C TRAI N E R BOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER Certification Number: 2000025428 Certification Date: 06/23/2016 Expiration Date: 12/31/2023 Proudly Display Your BOC Certification Order a professionally printed certificate with optional plaque by logging into your BOC profile. The BOC offers a Board Certified Specialist in Orthopedics certificate with a blue embossed BOC specialty logo and seal.The BOC also offers an Athletic Trainer certification certificate with a gold embossed BOC logo and seal. Each certificate is personalized with the Athletic Trainer's name,certification number and certification date.The certificate may be purchased alone or on a 12x16 inch hardwood plaque protected by plexiglass.Allow 10-12 weeks for delivery. ---------------------------------------------------------------------- ------------------------------------------------------------ 12/31/2022 Jordan ; Issue Date Signature 1:)OCCERTIFIED I At the time this card was issued,the cardholder was ATH LETIC TRAI N ER Irecognized as a BOC Certified Athletic Trainer in good standing by the Board of Certification(BOC)for the Athletic FO.tH.°A-418;::C. 1�:: Certification Number:2000025428 Trainer.Please visit BOCATC.org to verify the current Certification Datete:12/31/2023 certification status of the cardholder.This card is property Expiration Date:t2is>i2ozs of the BOC and valid as of the issued date if signed above. BOC 11415 Harney Street,Suite 200 1 Omaha,Nebraska 68102 Voice(402)559-0091 1 Fax(402)561-0598 Cut along the solid line. Fold along the dashed line. o COMMONWEALTH OF MDIVISION OF PROFESSIONAL LICENSURE . . . ... . . . . . . . ... AS�ACHUSETTS > . . . . . . . . . .. . .. . . . .. . . . . .. . .. . . . . . . . . . . . .. . . . . . . . . . .. . .. . . . . . .. . . . .. . . . . .. BQ.. . . . . . . . . .. . . . . . .. . . . . ARD OF ALLIED HEALTH' PROFESSIONALS ' ISSU:ES:-.TH*E FOLLOWING LICENSE I.ICE.. . . .. NSED AT . . . ... ...HLETI... .....CT. . . . . . . . . . . . . . . . .. .. . . . . RAINER � !. . . . . . ORDAN L ORRELL 'n 9-BROWNflN,G."PON o RoaO y . . . ... ....... . . . . .. . . .. . . . .. SPENCER"'M. . .A 0 756 2 ... ...< ;: � 2931 12/14/2Q43 158523 MRS. JORDAN SLIWOSKI MS, ATC, NASM-CES 29 Browning Pond Road, Spencer, MA 01562 • (774) 633-1257 Jordlindsey16@gmail.com EXPERIENCE 2022 - CURRENT HEAD ATHLETIC TRAINER, MILLBURY MEMORIAL JR./SR. HIGH SCHOOL Responsibilities consist of: - Care, prevention, rehabilitation and treatment of injuries/conditions, as well as, practice, and competition coverage - Strength and conditioning programming with student-athletes - Electronic medical documentation - Maintaining an inventory of athletic training room supplies - Updating protocols and policies as needed - Carrying out return to play protocols for Junior and Senior high school student-athletes - Collection and documentation of all pre-participation physicals in conjunction with the school nursing staff - Disbursement and collection of all medkits and AEDs to in-season teams - Assist with game-day management 2020 - 2022 HEAD ATHLETIC TRAINER, SELECT PHYSICAL THERAPY Provide athletic training services to Tolland High School in Tolland, CT. Responsibilities consist of: - Care, prevention, rehabilitation and treatment of injuries/conditions, as well as, practice, and competition coverage - Strength and conditioning programming with student-athletes - Electronic medical documentation - Implementing and carrying out concussion baseline testing through ImPACT - Maintaining an inventory of athletic training room supplies - Communicating and referring to the team doctors/orthopedic office and physical therapy - Updating protocols and policies as needed - Communicating with physical therapists and MDs for continuity of care - Carrying out return to play protocols for district-wide student-athletes Additionally, I oversaw the fitness room within the Vernon Senior Center, two days a week. While overseeing the fitness center, I helped create personalized exercise programs for a number of the senior members. I also taught senior fitness classes at the Vernon Senior Center and Glastonbury Recreation, while also providing educational presentations to their members. Part of my responsibilities within Select Physical Therapy was oversight of the company bracing program. This consisted of marketing of our products to clinic and athletic training staff, ensuring orders have been taken care of, answering questions regarding the program, and overall development of the program. 2016—2020 ATHLETIC TRAINER, FITCHBURG STATE UNIVERSITY From August 2016 to May 2018 worked as a part-time athletic trainer. Promoted to full-time athletic trainer beginning in July 2018. Provided athletic training services for 17 intercollegiate sports teams alongside two full-time athletic trainers. Responsibilities consisted of: - Care, prevention, rehabilitation and treatment of injuries/conditions, as well as, practice, competition coverage and travel. - Electronic medical documentation - Scheduling of medical appointments and diagnostic procedures - Assisting in pre-participation paperwork and examinations - Implementing and carrying out concussion baseline testing - Taking inventory and putting together supply lists - Creating injury reports for coaches and staff - Updating sports medicine policies and procedures in conjunction with the athletic department and necessary personnel 2016— CURRENT PER DIEM ATHLETIC TRAINER, PRECISION ATHLETIC TRAINING, LLC. & G04ELLIS Provide medical coverage for various organizations and schools at various ages and levels throughout the states of Massachusetts and Connecticut. 2017 — CURRENT SELF-EMPLOYED PER DIEM ATHLETIC TRAINER Provide regular medical coverage for a variety of organizations, including MIAA, USATF, FMC, WPI, Primetime Lacrosse, and Brandeis University. 2017 EMERGENCY MEDICAL TECHNICIAN, LIFELINE AMBULANCE SERVICE Worked briefly as a per diem EMT primarily focused on transporting patients to and from facilities. Responsibilities consisted of thorough medical documentation, monitoring of vitals, taking inventory of supplies, cleaning the ambulance, and providing care to patients as needed. SUMMER 2016 CAMP ATHLETIC TRAINER, CAMP WALT WHITMAN Worked within a six-person team of professionally licensed nurses and in-residence doctors to provide excellent services to all campers and staff members. SUMMERS 2013-2017 MEDICAL VOLUNTEER, BAY STATE SUMMER GAMES Volunteered as an athletic training student and as a certified athletic trainer to provide coverage for a variety of sports, including baseball, field hockey, track and field, soccer, and lacrosse. EDUCATION DECEMBER 2017 MASTER OF SCIENCE IN REHABILITATION SCIENCE, CALIFORNIA UNIVERSITY OF PENNSYLVANIA This degree was completed entirely online while I was working part-time at Fitchburg State University. Through this program, I also became a Corrective Exercise Specialist through the National Academy of Sports Medicine (NASM). MAY 2016 BACHELOR OF SCIENCE IN ATHLETIC TRAINING, UNIVERSITY OF MAINE - ORONO Graduated Magna Cum Laude with a cumulative GPA of 3.6. Clinical athletic training student experiences included: - UMaine field hockey - UMaine men's basketball - UMaine softball - UMaine women's soccer - UMaine track and field - UMaine football - Husson University men's and women's basketball - Husson University men's and women's lacrosse Additionally, my supervised undergraduate internship experience was with Bradley Libby, DPT at Performance Physical Therapy and Sports Rehabilitation Inc. in Bangor, Maine. As a senior athletic training student, I served as a first aid responder in September of 2015 for the Twin City Riots Bangor semi-professional football team. I provided pre-game taping and stretching preparations and game coverage alongside the team chiropractor and volunteer EMTs. SKILLS & CERTIFICATIONS • BOC Certified Athletic Trainer • Connecticut State Athletic Trainer • American Red Cross BLS Healthcare Licensure Provider CPR/AED Certification • NASM Corrective Exercise Specialist • American Red Cross Certified • Inter-departmental communication Instructor • Implementation of concussion testing • Massachusetts State Athletic Training and knowledge of concussion Licensure return-to-play protocols Use of electronic medical records • Injury prevention and corrective • Recognition and care of exercise injuries/illnesses . Rehabilitation of injuries '4Q1"0�e�-k J. In Massachusetts for recreational summer camps to be licenses they must provide a health care supervisor who must remain on site at all times during the camps operation to carry out the health policy written by the Health Care Consultant. The health care consultant is a person on the staff of a recreational camp for children who is 18 years of age or older and who is responsible for the day to day operation of the health program or component. The Health Care Supervisor shall be a Massachusetts licensed physician, physician assistant, nurse, or other person specially trained in accordance with 105 CMR 430.160 with a current CPR and First Aid certificate. In North Andover on December 12, 2019 a revised regulation was made in which the designated Health Care Supervisor for residential or sports camps, regardless of the total number of staff and campers, be one of the following: 1. A nurse registered to practice in the Commonwealth; 2. A physician (MD/DO) licensed to practice in the Commonwealth; 3. A certified nurse practitioner or physician assistant licensed to practice in the Commonwealth; or 4. A Massachusetts licensed practical nurse. North Andover Fire Department is 6 minutes away from Brooks. Nearest Emergency Departments (according to google maps) Lawrence General = 12 minutes Holy Family Methuen = 18 minutes Holy Family Haverhill = 17 minutes Homegrown Lacrosse Summer camp is seeking a variance to have Jordan Mardirossian, LAT, ATC, NREMT serve as their health care supervisor. He is a Massachusetts board certified Athletic Trainer who is currently an athletic trainer at Austin Prep. He will be trained by the Health Care Consultant Ashley Smyth who is a nurse practitioner and he will be signed off on all competencies prior to the start of the camp season. Jordan has an active EMT certification and is an EMT with Trinity ambulance. He is BLS provider trained (CPR/AED/first aid). He is over the required age of 18. Attached is the letter written by Homegrown Lacrosse seeking a variance along with Jordan Mardirossian credentials. Homegrown Lacrosse held recreational summer camp last summer with having an Athletic Trainer serve as an HCS and ran successfully and was able to demonstrate that they are able to follow the health care plans and meet all other criteria. I believe that Homegrown Lacrosse will be able to safely operate a recreational summer camp with Jordan as the health care supervisor. iiiJOLACROSSE From LAX Skills to Life Skills » (978)208-2300 May 17th, 2023 RE: ATHLETIC TRAINER REQUEST Dear North Andover Board of Health, We would like to place in writing a request to allow a qualified & practicing Athletic Trainer to take on the position of Healthcare Supervisor during our summer lacrosse camp, which will be held from July 9-13th and July 16-20, 2023 at Brooks School, 1160 Great Pond Road, N. Andover. MA 01845 Athletic Trainer Role & Responsibilities Preparation for the role of Health Care Supervisor during camp Ashley Smyth, RN, FNP-C, our Healthcare Consultant, will train the Athletic Trainer in all aspects related to the role of health care supervisor. She will train and competency test the Athletic Trainer in Epipen administration, medication administration, effects and possible side effects of all medications to be administered, confidentiality, the role and limits of the Healthcare Supervisor, camp safeguards and policies. The Athletic Trainer (AT) will be required on site at all times during the camp. The following is a job description of his/her roles and responsibilities while working for HGR Lacrosse Summer Camp Camp Dates: July 9-131h and July 16-20th Overnight and Day ( 9am-3pm) Venue: Brooks School, 1160 Great Pond Road, N. Andover, MA 01845 Arrival Time: All staff arrive at Sam at Brooks School for a team meeting prior to camp starting. Camp ends the final day at 3:00pm. Medication Protocols We do not allow any medication to be kept in the dorm rooms. Players will agree to meet the Athletic Trainer daily for medication administration if needed. All coaching staff will have the cell number of the Athletic Trainer who will be expected to be accessible via phone 24/7 to manage all issues related to the health management of all players at camp. Basic Outline of the Athletic Trainer's role The Athletic Trainer is required to be on campus for the duration of the camp • Injury management (administratively and practically) for minor injuries. Create and administer action plans for the health and safety of the athlete as it pertains to minor injuries throughout the camp. Recognize any head injury as a potential concussion and take the necessary concussion protocols. Able to administer CPR in the event that it would be required Recognize a serious injury, call 911, take appropriate action to keep athlete comfortable until which time trained paramedics arrive For ALL injuries the parent of the child must receive a phone call, and the injury written up on a HGR Lacrosse Summer Camp injury report form Direct & administer the medical needs of all players attending the camp Manage the water coolers on the field making sure that they do not run empty The AT is responsible to provide equipment needed to carry out their job. HGR Lacrosse will reimburse expenses for all supplies used The AT is expected to consult with Ashley Smyth, RN, FNP-C, Healthcare Consultant, as needed and required by guidelines for assistance with developing a plan to manage any injuries, illnesses, or other medical conditions beyond the scope of practice of the AT. Athletic Trainer Credentials Name: Jordan Mardirossian MA Licensed Athletic Trainer License #3552 Serial Number 315437 Thank you for taking the time to review our request for a variance to allow an Athletic trainer to take up the position of Healthcare supervisor throughout our residential camp. Sincerely Bryan Brazill Camp Director/Coordinator HGR Lacrosse 400 Osgood Street North Andover MA, 01845 978-208-2300 DPH Standards for Training Health Care Supervisor in Medication Administration Each recreational camp must ensure that the health care supervisor(s) can meet the health and medical needs of each individual camper.The camp's health care consultant must provide training and document the competency of every health care supervisor.,This training does not need to be submitted for prior approval, but must be made available by request or during inspection. Training Topics: An approved training will address, at a minimum,the following issues: 1. Confidentiality 2. The Role of the Health Care Supervisor 3. Limits of the Health Care Supervisor 4. Effects and Possible Side Effects of all Medication Administered 5. Steps in Medication Administration 6. Camp Safeguards and Policies Test of Competency: Each health care supervisor must have a documented test of competency to administer medications. At a minimum,the health care supervisor must: 1. Demonstrate safe handling and proper storage of medication. 2. Demonstrate the ability to administer medication properly: • accurately read and interpret the medication label • follow the directions on the medication label correctly • accurately identify the camper for whom the medication is ordered 3. Demonstrate the appropriate and correct record keeping regarding medications given and/or self-administered. 4. Demonstrate correct and accurate notations on the record if medications are not taken/given either by refusal or omission and when adverse reactions occur. 5. Describe the proper action to be taken if any error is made in medication administration or if there is an adverse reaction possibly related to medication 7. Use resources appropriately, including the consultant, parent/guardian or emergency services when problems arise. 8. Understand and be able to implement: • emergency plans including when to call 911 • appropriate procedures that assure confidentiality 1 If HCS is a licensed physician, nurse practitioner, registered nurse or physician's assistant with experience in pediatric care,that...., certification is evidence of proper training and competency. �sN March 2018 1/V/ VV s Camp Medication Administration Training/Test Checklist: V/ 1. Confidentiality: Importance of not sharing information about campers or medications with anyone unless directed to do so by the HCC 2. Role of Health Care Supervisor: Administer Medication only by Specific HCC Order to Specific Child Follow Instructions on Medication Sheet Record Time and Effects Observed Reports Any Problem or Uncertainty 3. Limits of the Health Care Supervisor: HCS may not administer ANY medication without HCC approval HCS may not administer ANY medication without parent/guardian permission HCS may not administer insulin (unless within scope of practice) 4. Effects and Possible Side Effects of all Medication Administered: Describe Effects of Medications Discuss Common Side-Effects of Medications (drowsiness,vomiting, allergic reaction) Report All Changes that may be side-effects to HCC and Parent/Guardian Record All Changes that may be side-effects in log 5.Steps in Medication Administration: 5 Rights of Medication Administration. 1. Right Camper 2. Right Medication 3. Right Dosage 4. Right Time 5. Right Route Steps in Medication Administration 1. Identify Camper 2. Read Medication Administration Sheet 3.Wash Hands 4. Select and Read Label of Medication 5. Prepare Medication and Read Label Again 6.Administer Medication and Make Sure Medication is Taken. 7. Replace Medication in Secure Location 8. Lock or Secure Location 9. Document in Medication Log Steps in Supervising Self-Administration 1. Identify Camper 2. Read Medication Administration Sheet 4. Select and Read Label of Medication 5. Observe Student Prepare and Take Medication 6. Replace Medication in Secure Location 7. Lock or Secure Location 8. Document in Medication Log 6.Camp Safeguards and Policies Report Any Error to HCC and Parent/Guardian including: 1. Camper Given Wrong/Unapproved Medication ' t 2. Camper Refuses Medication 3. Camper Has Unusual or Adverse Reaction Possibly Related to Medication Review Camp s Emergency Plan and when to call Emergency Services 2�P�1H or MySS \'N March 2018 ) vV �P FNi...o,iOJG 105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN (STATE SANITARY CODE, CHAPTER IV) 430.020: Definitions Health Care Supervisor means a person on the staff of a recreational camp for children who is 18 years of age or older and who is responsible for the day to day operation of the health program or component. The Health Care Supervisor shall be a Massachusetts licensed physician, physician assistant, nurse, or other person specially trained in accordance with 105 CMR 430.160 with a current CPR and First Aid certificate. 430.159: Health Care Staff to be Provided The operator of each recreational camp for children shall provide: (A) A designated camp-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 staff; (5) Be available for consultation at all times; (6) Develop and sign written orders, including for prescription medication administration, to be followed by the on-site camp health care supervisor in the administration of their health related duties; and (7) Provide trainings as required by 105 CMR 430.160 to the health care supervisor(s)and other camp staff. (B) A written camp health care policy, approved by the Board of Health and by the camp health care consultant. Such policy shall include, but not be limited to: (1) Daily health supervision; (2) Infection control; (3) Medication storage and administration, including self-administration when appropriate, pursuant to the requirements of 105 CMR 430.160; (4) Procedures for using insect repellant and conducting tick checks; (5) Promoting allergy awareness; (6) Handling health emergencies and accidents, including parental/guardian notifications; (7)Available ambulance services; (8) Provision for medical, nursing and first aid services; (9)The name of the designated on-site camp health care supervisor; (10) The name, address, and phone number of the camp health care consultant required by 105 CMR 430.159(A); and (11)The name of the health care supervisor(s) required by 105 CMR 430.159(E), if applicable. (C) At least one health care supervisor, or more as determined by the camp operator based on camp size and ability to provide for the needs of the camp must be present at the camp at all times. Primitive, travel, and trip camps shall have at least one individual who possesses a current CPR and first aid certificate in addition to the health care supervisor accompanying the campers (D) In residential camps in which the total number of on-site campers and staff is less than 150 and in all day camps, the health care supervisor may have additional non-health related duties but shall at all times be available at the camp to render emergency first aid. NORTH ANDOVER BOARD OF HEALTH RECREATIONAL CAMPS FOR CHILDREN REGULATIONS Revised regulations. or M 5 Authority March 2018 V V� m9u� Lv. Massachusetts General Laws (M.G.L.), Chapter 111, Section 31 and 105 CMR 430.000 Minimum Standards for Recreational Camps for Children (State Sanitary Code: Chapter IV). Section III Health Care Staff to be Provided A. In addition to the requirements set forth in 105 CMR 430.159 of the current Minimum Standards for Recreational Camps for Children (State Sanitary Code: Chapter IV) it is further required that the designated Health Care Supervisor for residential or sports camps, regardless of the total number of staff and campers, be one of the following: 1. A nurse registered to practice in the Commonwealth; 2. A physician (MD/DO) licensed to practice in the Commonwealth; 3. A certified nurse practitioner or physician assistant licensed to practice in the Commonwealth; or 4. A Massachusetts licensed practical nurse. �PiH a Mgys March 2018 V M �P FNr...o.OJ 5/23/23,4:40 PM HRG lax bls.jpg BASIC LIFE SUPPORT BLSAmerican Provider Assaociation Jordan Mardirossian has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 8/27/2022 08/2024 Training Center Name Instructor Name Bayside CPR&AED Training Center Angel Mendez Instructor ID Training Center ID 06200871542 MD20981 eCard Code Training Center City, State 225418008792 Annapolis. MD OR Code Training Center Phone Number A (800)364-3679 o To view or venty authenticity.students and employers should scan this OR code with their mobile device or go to wv;w heart.org/cprtmycards. 0 2020 American Heart Association.All nghts reserved. 20.3001 10/20 https://mail.google.com/mail/u/0/#inbox/FMfcgzGsmhdSKFtFKXwsFgrzdccLgxWW?projector=1&messagePartld=0.2 1/1 one.Soccer Schools,315 Meigs Road,Suite A-431 Santa Barbara, CA Co 930194ong. Website:www.onesoccerschools.com email: info onesoccerschools.com office:805-845-6801 SOCCE 5/23/23,3:55 PM Details Licensee Information Close Window Note:to print this page properly select File, Page Setup,and Landscape. Name Full Name: Jordan Joseph Mardirossian License Information License Number: E0918489 Profession: EMERGENCY MEDICAL SERVICES License Type: EMT Basic Issue Date: 10/5/2020 Date of Last Renewal:4/3/2023 icense Status: Current Expiration Date: 3/31/2025 Reciprocity State: Toda 's Date: 5/23/2023 Address Information ity: Tewksbury tate: MA ipcode: 01876 ount : United States Education Information No Education Information Prerequisite Information No Prerequisite Information Disciplinary Information Important: Disciplinary actions taken against a license will NOT display on any other license or associated permit or authorization.You must look up every license, permit,or authorization held by a licensee to see all disciplinary actions. Caziv f Discipline End Disciplinary information is not available for EMTs on this web site. Disclaimer:The information contained in this website("website content")is made available as a public service by the Massachusetts Department of Public Health (the Department).The Department considers this information to constitute primary source verification. Click here for full disclaimer. https://madph.myiicense.com/verification/Details.aspx?result=d75a68ba-ad38-4dOf-88aa-4la9dl lfll5a 1/1