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CHILDRENS ISLAND DAY CAMP 2017 2017 LVO YMCA CHILDREN' S ISLAND - D. Y CAMPi r0 � t 1: j t N V ` CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL.(978)741-1800 - IQMBERLEY DRISCOLL FAX(978)745-0343 RECEIVED MAYOR zc IramdinQsalem.com � LARRY RAMDIN,RS/REHS,CHCS,CP-FS ® JUN O 2 2017 ACTING HEALTH AGENT CITY OF SALEM BOARD OF HEALTH I APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: LUV YI'6-1� 6 Hmn,4e-e 7 Caw,o s Tel# $t� G 3 I S0 1 a- AddressofCamp: t10 (e )s /Peed Camp Website: w n. I° - Fax# 0 Name of Camp Director: &Clbv , Gr' Tel# Camp Director mailing address: Sa'� Email: JC-&U" ,b n�r d / 3 h°23°—a1 • e„ For The Emergency Telephone Notification System: J Emergency contact name: f-Ln A Tel#: Dates of operation: From: tC l.2 6/ 1 To: TIP l I Type of Camp: Day: Recreational: Sports: Travel: Trip: Approximate #'of campers: 1�0 Campers Ages:a/_/7#of counselors: i # of volunteers per season O Please attach the following information Medical consultant agreement and camp medical policy. Certificates of compliance from Salem Fire Prevention and Salem Building Department. Check payable to the City of Salem ($10). Written copies of your Emergency, Special Contingency and Staff Orientation plans. I agree to comply with all mandates of the State Sanitary Code, Chapter IV, 105 CMR 340., "Minimum Standards for Recreational Camps for Children", including required staff background checks. I understand that noncompliance may result in suspension of this license. Pursuant to MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filled all state tax returns and paid all state taxes required under the law. amm Signature m^ Date SS# or Federal Identification Number 9zo3 ZY- Updated 5/23/11 reccamp app. Check#&Date �' 3 CITY OF SALEM, MASSACHUSETTS J BOARD or HEALTH 120 WASI'IINGTON STRI31S r,41'1,FLOOR ' TeL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 RECEIVED MAYOR LRAMD1N1@1ALEN1.00N1 C Ff1 LAiu1v RA ro1131N;iz /Rr I�rs,c13(1,CP-FS �r®�,� JUN 0 2 2017 AC'PING HLAL11'I AGf?NP CITY OF SALEM BOARD OF HEALTH APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: L ,rO r/`1 A 5122dS (,r w1a Tel# 757 9q0 7oyzl Address of Camp: Yo L.4., All 7Sor, &WAJ MA 046 Camp Website:_ rlorAs6revmC&.ara Fax# Name of Camp Director: UavJ 5>. I1'fr/P Tel# 781 990 709Y Camp Director mailing address: 40tms 9111/ PM 1 UQ MA 01915 Email: S�)e, iX6J h bore yrnca,nrq For The Emergency Telephone Notification System: JJ Emergency contact name: JAY1 P9r"I"a rl Tel#: 761 M 70/3 Dates of operation: From: 06 1a6/17 TO:O$/a-5/17 Type of Camp: Day: Recreational: Sports: Travel: Trip: Approximate#of campers: 65 Campers Ages:y'1), #of counselors: I a #of volunteers per season 0 Please attach the following information Medical consultant agreement and camp medical policy. Certificates of compliance from Salem Fire Prevention and Salem Building Department. Check payable to the City of Salem ($10). Written copies of your Emergency, Special Contingency and Staff Orientation plans. I agree to comply with all mandates of the State Sanitary Code, Chapter IV, 105 CMR 340., "Minimum Standards for Recreational Camps for Children", including required staff background checks. I understand that noncompliance may result in suspension of this license. Pursuant to MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that 1, to my best knowledge and beliA have filled all state tax returns and paid all state taxes required under the law. / 3//0//7/ 01 fS 76 8'175 Signature Date. SS#or Federal Id ntification Number /L Updated 5/23/11 reccamp app. heck#& Datfi ' CITY OF SALEM, MASSACHUSETTS Bona D or Hi;'m,ni 120 WAsr1INGroN Srxri:,r,4" Ft.00iz 'nil..(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR LR AMDIN12SgLF,WCOM RECEIVED LARRY RAMDIN,RS/RF1IS,C.r10,CP-rS ��®�` _y JUN 022017 CTNGIv AIHAVii'i AGFN'1' H CITY OF SALEM BOARD OF HEALTH APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: LVO Oi G S Tel# 78 I -99b -7007 Address of Camp: 1-40 �.P. s 4 t l kor, ,��,II� Camp Website: yJ1NY�(, Hort 1�5�lore�mcoCeorn Fax# 781 - 4,39-0190 Name of Camp Director: MCirt o n ri e- Gaxcf- Tel# '781-c1g0 --700-1 Camp Director mailing address: 40 1-e QS "it 'KQOJ:3 Email: bo-Vex- MEL)11or� 41sho✓QYmcrt,orq 4-Aarb CkC J For The Emerqancy Telephone Notification System:/ - Emergency contact name: M(X6C,tnne. P� Tel#:784-qqC) 7Q77 cell -784-aqq-1531? Dates of operation: From: 6 1.26117 To: 9 Q51 /7 Type of Camp: Day: x Recreational: Sports: Travel: Trip: Approximate#of,campers: /&O Campers Ages:5- #of counselors: '-la- # of volunteers per season_ Please attach the followinu information Medical consultant agreement and camp medical policy. Certificates of compliance from Salem Fire Prevention and Salem Building Department. Check payable to the City of Salem ($10). Written copies of your Emergency, Special Contingency and Staff Orientation plans. I agree to comply with all mandates of the State Sanitary Code, Chapter IV, 105 CMR 340., "Minimum Standards for Recreational Camps for Children", including required staff background checks. I understand that noncompliance may result in suspension of this license. Pursuant to'MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filled all state tax returns and paid all state taxes required under the law. Ma 6-1 10 1 / 7 o4a -10q-g13 Signature Date SS#or FederalI entification Number I92DO� /4 .27/7 / 62 49 Updated 5/23/11 reccamp app. Check#&D r T— City Of Salem, Massachusetts n Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 �� Tel. (978) 741-1800 Fax. (978) 745-0343 ;Prevei nWJL{'orHealth. Kimberley Driscoll health@salem.com Larry Ramdin, MPH, REHS, CHO Mayor : Health Agent CAMP PERMIT Permit# License For : Recreational Camps CA-17-4 Granted To: Children's Island, LVO YMCA Date of Print 6/5/2017 Permit Address: . Salem Harbor Salem MA 01970 _ ' 6/5/2017 Location of Establishment: Permit Expires 8/25/2017 Permit Fee Restrictions: $10.00 Late Fee Notes: Children's Island Day Camp Salem Harbor $0.00 Approx. 225 campers ' Campers' ages: 5-15 yrs. #of counselors`. 40 r -Camp Director: Damien Reynolds(978)360-1948 Emergency Contact: John Brinkman (774) 6445281 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 8/25/2017 unless sooner revoked or suspended. V CITY OF SALEM, MASSACHUSETTS BOARD oil HrN,n-t 120 WASI'IINGTON SmET.rr,4T"FLOOR TEL.(978)741-1800 KIMBERLEY DRIKOLL FAX(978)745-0343 MAYOR LRAMDINQSALHM.COM LARRY RAM1>IN,RS/KERS,CRO,CP-PS, RECEIVED ACTING HEAETI-,AGENT JUN 022017 CITY OF SALEM APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP BOARD OF HEALTH NameofCamp: ( 1 �, ��t i 9�� 2 o Tel# C.�-7 360 ' Address of Camp' Le. f(q 7 a Camp Website: w�� na�J�sGI�� 2_a Fax# (*(e 34 -Ooy o Name of Camp Director. Tel# C4Z,J) 360-mks Camp Director mailing address:-/ )s )�! I - Email: ✓'t For The Emergency Telephone Notification System: � pp Emergency contact name: 77j;4,1 Tel#: (� -710 ��I�FSar f <1 Dates of operation; From: b U&/ I To: $/25'/ 1 -7 Type of Camp: Day: Recreational: Sports: Travel: Trip: Approximate# of campers:2� Campers Ages: #of counselors: 4(� #of volunteers per,season V Please attach the following information Medical consultant agreement and camp medical policy. Certificates of compliance from Salem Fire Prevention and Salem Building Department. Check payable to the City of Salem ($10). Written copies of your Emergency, Special Contingency and Staff Orientation plans. I agree to comply with all mandates of the State Sanitary Code, Chapter IV, 105 CMR 340., "Minimum Standards for Recreational Camps for Children",,including required staff background checks. I understand that noncompliance may result in suspension of this license. Pursuant to MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that 1, to my best kn ledge and belief, a filled all state tax returns and paid all state taxes required under the law. Signature Date SS#or Federal 1dentification Number 10 03 7 -27--�ri 4t r Updated 5/23/11 reccamp app. heck#&Dat �