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CHILDRENS ISLAND CAMP 2014 { Pon1'e ' 42336 1 Oolo c 4 Inspection ofL��`�y li i 3 '�'�At u`t K..�-i..✓J�r � , A*.yam Date }.. ` _Time 1 Name 1� Address lut OwnerMaw pnn�"�1./..�, �,, /� Tel. No- Type _1 Type of Inspection Q� t S 1 g.,c Al S 1IJ Inspectrre 91�„' CSS AP�Jt'�/��,�-�-I�tJ[�VC { ' Remarks and Violations are listed below: nk i, Report Received by: �. '.Inspection of Date Time �' �. ; �. 1 �...hJ ni'� r T Name Address Own{qer /.`1cA(A'y) ��-{)�i" � �''�+�� '1 J( //�� "41� 1� 1� Tel. No. '{ /� pp � Type of Inspection_�`- � �'.X 11 iv� i" CCAMO Inspector,)o. �s(� 1 O,.�O(z ILM 1 Remarks and Violations are listed below: J _ Swint Joy OOH — 1A. �e cau-Ar e t-5 —c 3v—i I 1iL �, Jahn 1?; nl( rnc,;;- �� r ' !t co.0�4 vl need a e+ kr-Li ha,)e- (ea Lei, o � �. W oC��n�Z..� /)11Tai�t �.c�C�,�2. -- .$YIG� CYIC'� 6:�tDcr fl��`P� .s _ r i Report Received by:e ' Microsoft Word-430-Rec Camp-Inspection Notes--Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dph/environmental/sanitation/camp-i... STATE SANITARY CODE: CHAPTER IV, MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT NAME OF CAMP: 111C;1`f{X15 Sind ADDRESS: i �� OWNER/OPERATOR: 'Il,l U 1 OFFSEASON ADDRESS: wl CAMP DIRECTOR: INSPECTED BY:� * p, \U -i' fL I�IGa TYPE OF CAMP: (Circle) WA ER SOURCE: DATE AND TIME OF INSPECTION: Day Residential 5vne 25,Db13 1 —'WyyI (Sport/Non-Sport) Trip Primitive Travel CAMPER CAPACITY: Swimming Pool:Yes No ACCOMPANIED BY: VGB Compliance Letter: Eliloe}h Yes No "No"column= '4"marked below indicates a violation of 430.000. "Yes"column= `4"marked below indicates compliance with provision of 430.000. "N/A"column= '4"marked below indicates that the provision of 430.000 is not applicable to this camp. R ulation , Yes I No. N/A Comments Permits .451 Current Certificate(s)of Occupancy from local building inspector for sleeping/assembly areas .215 Written compliance from local fire dept .633 Camp license postedin prominentlocation .300(Ax2)(a) Private water supply-DEP approval(>25 people,>60 days/yr) .300(A)(2)(b) Private water supply-BOH approval and chemical and bacterial analyses c25 people,<60da s/ Plans and Policies-Written .090(A) Procedures for background review of staff and volunteers Available/Followed .090(C) CORI and SORI,previous work history, / Q Ct f i S vn)AN'b— 3 references,out of state/international criminal V 111 U background checks for staff iit�1� 5 Um 1 r .090(D) CORI and SORI,previous work history, 3 references,out of state/intemational criminal C T background checks for volunteers _7CM(paying campers or unpaid volunteers .090E Background information maintained for 3 years .090(F) Received,reviewed,and made determination in regards to all background information V .091 Staff and volunteer orientation plan and review 093 Abuse and neglect prevention/reporting procedures .191(B)(C) Discipline Policy with: appropriate discipline / methods and prohibitions .210(A) Fire evacuation plan and drills -Drills conducted within the fast 24 hours of each session .210(B) Disaster Plan -Including information on trmEportafion 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page I of 12 1 of 12 6/17/2013 2:10 PM Microsoft Word-430-Ree Camp-Inspection Notes--Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dph/environmental/saritation/camp-i... [R_ lation.__ Yes No N/A Comments .21 Lost Camper Plan .21 Lost Swimmer Plan .21 D Traffic Control Plan Contingency lans-Da Camp: .211 (A) Camper doesn't show up for camp 1! B Camper doesn't show up at point of pick u C Child not registered arrives '1/ Contingency plans-Primitive,Travel and Trip: V .212 A Itinerary daily-copy provided to parents B Source of emergency care Camper release: .190(B) Camper released only to parents or parent- designated individual in writing -Otherplan- appmved in writing by BOH Promotional Literature and Informational Packets .159(B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision .190(0) Statement re:regulatory compliance and licensing .190(D) Inform parents of right to review background / check,health care,discipline policies and grievance procedures upon request Transportation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers and driver is camp coach, rl�� director,etc.private vehicles may be used >14 passengers,vehicle must be school bus All vehicles must be RMV compliant .253 Proper automobile insurance .251(C)(F) Seatbelts must be worn and special needs of campers communicated to driver .251(H) Camper<7yrs not transported longer than 1 hr to or from cam Staff Qualifications Camp Director: .102(A) Residential Camp: 25 yrs,completed course in camp administration or at least 2 seasons of ex erience .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons of experience .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex enence .102(D) Designated substitute when director off-site>12 q�1•_ � O Sub must meet criteria above K/�� JWO a-� 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 2 of 12 2 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-InspectionNotes--Revised 8-20-10.... hup://www.mass.gov/eohhs/does/dph/environmental/sanitation/camp-i... [Regulation _ _ _Yes _ N_oN/A .CommentsLL Counselors/Junior Counselors: .100 Day camps,non-sport: Counselor--163p. Junior Counselor=l5 s. .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counselors=16 s �/ .100 All counselors 3 yrs older than campers Required Counselor Ratios: .101(A) Residential and Day Camps: I staff per 10 kids over 6 yrs 1 staff per 5 campers 6 yrs and under .101 Primitive Travel Trip: 1 counselor per 10 campers. 2 counselor min l� .101(C) Special Needs: 1 counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled campers .103 Aquatics Directon Name :�lr None American Red Cross Lifeguard Tmg cert,CPR for Professional Rescuer and First Aid Cert. or their equivalents -If su ervise 2 staff,21yrs and eLperience w/management .103 Lifeguard: American Red Cross Lifeguard Trng cert.,CPR for Professional Rescuer cert G/� � old r and First Aid Cert. or their equivalents ff 4�-Listnames I/ T0+0I .103 Certifications for other high-risk activities,eg: Aalt4-y- Cert on NRA instructor certification for firearms. T -List Names and Certifications: .252 Camp vehicle drivers: I Syrs,2yrs driving experience,current license for type of vehicle 1� -First Aid certified if no other trained staff aboard Medical Personnel Records, and Facilities .159(A) Health Care Consultant Name: a,lWl(�(W jQr d�'2 MD NP PA(w/pediatric training) License 4: 9AS-77 %(n1 / Check for Health Care Consultant Agreement • Review and approve fust aid training of staff • HCC available for consolations at all times • Signed written orders for HS ^� .159(C) Health Supervisor(on site at all times) _ /KAP Name: 18yrs,First Aid and CPR certified OR, MD PA NP RN LPN EMT Jan � . - -special needs or residential with>150 staff and campers CPiZ� rifsk' S i (� must have health professional .159(B) Health Care Policy • Approved by LBOH and HCC • Policy provided to all full time staff during orientation 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 3 of 12 3 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-Inspection Notes--Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dph/environmental/sanitation/camp-i... �Nol�„N�A�.�Commenls. , .160(A) Medication stored in original containers .160(B) Meds stored in secured cabinet and if necessary refrigerated in box affixed to refrigerator(if no secondarylock) • Cabinet used for no other purpose • Refrigerator temperature 38 to 42°F .160(C) Medication administered by Health Supervisor • HCC written acknowledgement of all medications administered at eh camp(if H8 is not MD PA NP RN LPN) V • Written premising from t/ anlian .154 Injury Reports completed for fatality or serious injury. Copy sent to MDPH within 7 days .155 Medical log book-bound,pre-numbered pages, ink entries,no skipped lines .161(A) Infirmary provided-day and resident camps • Clearly Labeled as InStmary/Medical Area • Exterior! t residential Cam .453 Lighting providedininfirmary W .161(B) Area for isolation ofill cbild-Residential Camps • Not used for my other purpose .161(C) First Aid Kit non-perfumed soap,sterile gauze squares,compresses,adhesive tape,bandage scissors, triangular and rolled bandages,CPR mask,tweezers,cold pack gloves. .150 Health record for each camper and staff: Number of records checked: ._-------emergency contact info li camper<18 yrs must have.written parentalNumber-of med/care-___----. -Permission for meds and emergency care permissions missing: Residential,Sport,Travel/Trip: -Health History,Physical Exam(<2yrs) -Record of Immunizations(noted below) Day Camp Non-Sport: v Number health history/exam -Heath History signed by parent/guardian or physician missing: -Record of Immunizations(noted below) Immunizations• .152(A) Campers and staff under18yrs, qe(„-Iqq 6 Number of records checked: -MMR: 1"dose=12 mos or older,atm Q013 -Measles:2'ddose=grades K-12 or age equiv Vaccination records missing: -Polio:3 doses IPV or OPV, /fir or 4 doses mix IPV/OPV V// -Diphtheria,Tetanus Toxoids,and Pertussis*: Number of missing 4 doses DTaP/DTP/DT or, 3 doses of Td Campers and Staff>7 years "Booster dose of Td: 2009 Ord C(A&W Number of missing -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT �'� Gt{�{ l�1�2 Q -grades 11-12 need booster more than 10 yrs Number of missing since last dose of DTaP/DTP/DT/Td -H B: 3 doses if bom on or after 1/1/92 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 4 of 12 4 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-InspectionNotes--Revised 8-20-10.... http://www.mass.gov/eobhs/docs/dph/enviromnental/sanitation/camp-i... COIII1nCntS .152(B) Campers and staff 18 yrs or older:lqqs and £records checked: (Wlu -Measles: 2 doses(exempt if born before 195 7) -Mumps:l dose (exempt if bom before 1957) Vaccination records missing: -Rubella: 1 dose (exempt if born before 1957) -Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td Number ofmissingy *Booster dose of Td: -If more than 10 yrs since last dose Number ofmissing Activities .190(A) Activities and physical environment meet the needs of campers;do not pose hazard to health and safety .163 Operator encourages sunotection for all Aquatics: .430 Swimming Pool: in compliance with 105 CMR 435.00 ermit sted .204(B) Bathing Beach:in compliance with 105 CMR 445.00 -weekly water sampling conducted/available .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers -Plan to check swimmers=9md stem' .204(A) Swimming areas clean and safe,no swimming at undesignated sites or at night without lighting .204 Swim test to claskify swimmers by ability .20 Piers and floats in good repair .204(G) Watercraft: equipped with US Coast Guard approved flotation devices and worn by all campers and shaffparticipating in watercraft activities .204(H) Campers must be certified by American Red Cross or equivalent for white water,hazardous salt or fresh water activities .103(C) Minimum 2 counselors in separate watercraft supervising white water,hazardous salt or fresh water activities Arts and Crafts: .205 Equipment in good repair,safety precautions taken Plav2round and Athletic Equipment: .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure,no concrete under/around it pliable swing seals 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 5 of 12 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-Inspection Notes--Revised 8-20-10.... http://www.niass.gov/eohhs/docs/dph/environmental/sanitation/canip-i... w_ - l 4L. / t V f A Qu h — b 14 40 80 v John OgAMew —Td 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 9 of 12 9 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-Inspection Notes--Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dpi/environmental/sat itation/canip-i... 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 10 of 12 10 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-Inspection Notes--Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dph/environmental/sanitadon/camp-i... s 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 11 of 12 11 of 12 6/17/2013 2:10 PM Microsoft Word-430-Rec Camp-hispection Notes Revised 8-20-10.... http://www.mass.gov/eohhs/docs/dph/environmental/sanitation/camp-i... 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 12 of 12 12 of 12 6/17/2013 2:10 PM { •STATE SANITARY CODE: CHAPTER IV,MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN, 105 CMR 430.000 =INS)?� ><Q NAME OF CAMP l b 1 ( ADDRESS: l bcj 1 Lt, " OWNER/OPERATOR: OFF SEASON ADDRESS: CAMP DIRECTOR: INSPECTED BY: TYPE OF CAMP: (Circle) WATER SOURCE: DATE AND TIME OF INSPECTION: ' Day Residential (Sport/Non-Sport) Trip Primitive Travel CAMPER CAPACITY: . ACCOMPANIED BY: Swimming Pool:Yes No VGB Compliance Letter: Yes No "No"column= marked below indicates a violation of 430.000. "Yes"column marked below indicates compliance with provision of 430.000. "N/A"column= marked below indicates that the provision of 430.000 is not licable to this camp. Will,,t, 41-6-111.#1Q' �46}ntl t1t Permits .451 Current Certificate(s)of Occupancy from local building inspector for sleeping/assembly areas .215 . Written compliance from local fire dept .633 Camp license posted in prominent location .300(A)(2)(a) Private water supply-DEP approval(>25 people,>60 da s/ °300(A)(2)(b) Private water supply-BOH approval and r chemical and bacterial analyses t. <25 eo le, <60da s/ r Plans and Policies-Written .090(A) Procedures for background review of staff and' volunteers Available/Followed .090(C) CORI and SORI ,previous work history,,e 3 references,out of state/international criminal, background checks for staff " .090(D) CORI and SORI ,previous work history, 3 references,out of state/international criminal background checks for volunteers • -CITs(paying campers or unpaid volunteers - .090 Background information maintained for 3 years .090(F) Received,reviewed,and made determination < 0 in regards to all back o'und information .091 Staff and volunteer orientation plan and review . .093 Abuse and neglect prevention/reporting rocedures .191(B)(C) Discipline Policy with: appropriate discipline 4 methods and proltibitions .210(A) Fire evacuation plan and drills -Drills conducted within the fust 24 hours of each session .210(B) Disaster Plan t Y -Including information on transportation 430-Rec Camp-Inspection Notes-Revised 8-20-10 PageA 1 of 12 • y .210 C ' Lost Camper Plan .21O(C). Lost Swimmer Plan .210 Traffic Control Plan s Contin encplans-Day Cam .211 A Camper doesn't show up for camp - B Camper doesn't show up at point of pick u C Child not registered arrives 1 Contingency plans-Primitive,Travel and Tri - ♦ , .212 A Itinerary daily-copy provided to parents r. B Source of emer enc care , Camper release: " .190(B) Camper released only to parents or parent- ' designated individual in writing -Other plan- aLproved in writing by BOH Promotional Literature and Informational Packets .159(13)(2) Copy of policy re: care of mildly ill campers, ..administration of meds and emergency health • " care provision t a' .190(C) Statement re: regulatory compliance and licensing .190(D) Inform parents of right to review background check,health care,discipline policies and grievance procedures upon request Trans ortation .250 Vehicle must comply with MGLc.90 s7B&7D: o <14 passengers and driver is camp coach, ' director,etc.private vehicles may be used >14 passengers,vehicle must be school bus All vehicles must be RMV compliant .253 Proper automobile insurance + .251(C)(F) Seatbelts must be wom and special needs of- campers communicated to driver .251(Il)• Camper<7yrs not transported longer than 1 hr to or from cam Staff Qualifications Camp Director: .102(A) Residential Camp: 25 yrs, completed course in camp administration or at least 2 seasons of ' * experience i102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons of experience 102(C) Primitive,Travel,Trip: 21 yrs and proof of experience ° .102(D) Designated substitute when director off-site>12 hrs , -Sub must meet criteria above 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 2 of 12 e elation .. .v,_ ,-I .,, rCo e.' . _ C33_ Gi' 5r•r4Ye' :_... —iT wki' i �..... 5 R Counselors/Junior Counselors: .100 Day camps,non-sport: r Counselor=16 rs. Junior Counselor=15 rs. .100 Other camps: Counselors-- 18 yrs or graduated from high school.Junior Counselors= 16 yrs s .100 All counselors 3 yrs older.than campers Required Counselor Ratios: .101(A) Residential and Day Camps: e' 1 staff per 10 kids over 6 yrs 1 staff per 5 campers 6 yis and under .101(B) Primitive,Travel,Trip: 1 counselor per 10 campers. 2 counselor ming .101(C) Special Needs: - i 1 counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled campers ' .103 Aquatics Director: Name Idly &Ita None American Red Cross Lifeguard Trng cert., CPR � t for Professional Rescuer and First Aid Cert. or their equivalents -if supervise 2 staff,21 yrs and experience w/man ement .103 Lifeguard: American Red Cross Lifeguard hb BIallo r +Sy Tmg cert.,CPR for Professional Rescuer cert. �o AcLr n k lin and First Aid Cert. or their equivalents �lu�- raN�NtDt Io -List names .103 Certifications for other high-risk activities,eg: a. _+ __ NRA instructor certification for firearms. . a ,Y,ox + I Ncit t Xx 1 -List Names and Certifications: r .252 Camp vehicle drivers: 18yrs,2yrs driving experience,current license for type of vehicle. -First Aid certified if no other trained staff aboard i Medical Personnel,Records,and Facilities .159(A) Health Care Consultant - Name: r , MD NP PA(w/pediatric training) License#: Check for Health Care Consultant Agreement • Review and approve first aid training of staff t • HCC available for consolations at all times • Signed written orders for HS. .159(C) Health Supervisor(on site at all times) Name: 18yrs,First Aid and CPR certified OR, MD PA NP RN LPN EMT -special needs or residential with>150 staff and campers must have health professional Y .159(B) Health Care Policy • Approved by LBOH and HCC a s Policy provided to all full time staff during orientation 430-Rec Camp-Inspection Notes-Revised 8-20-10 'Page 3 of 12 w, e ,}, -# YrSt .1 {I t; t\S � f11ne' 'zee MIX .160 A Medication stored in original containers e .160(13) Meds stored in secured cabinet and if necessary refrigerated in box affixed to refrigerator(if no secondary lock) • Cabinet used for no other purpose + Refi erator tem ure 38 to 42°F .160(C) Medication administered by Health Supervisor • HCC written acknowledgement of all medications administered at eh camp(if HS is not MD PA NP RN LPN) • ^Written premisinifrom-arenU dian f .154 " Injury Reports completed for fatality or serious` injury.Copy sent to MDPH within 7 days .155 Medical log book-bound,pre-numbered pages, ink entries,no skipped lines t 161(A) Infirmary provided.-day and resident camps • Clearly Labeled as Infirmary/Medical Area • Exterior light residential Cams ' .4453 Liplitina Provided in infirmary .161(B) Area for isolation of ill child-Residential Camps w • Not used for any other purpose .161(C) First Aid Kit: non-perfumed soap,sterile gauze squares,compresses,adhesive tape,bandage scissors, 4 triangular and rolled bandages,CPR mask,tweezers,cold pack, loves. .150 Health record for each camper and staff: Number of records checked: -emergency contact info -camper<19 yrs must have written parental Number of med/care -Permission for meds and emergency care permissions missing: Residential,Sport,Travel/Trip: -Health History,Physical Exam(<2yrs) -Record of Immunizations(noted below) Day Camp Non-Sport: Number health history/exam -Health History signed by parent/guardian or physician missing:, -Record of Immunizations(noted below) Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: -MMR: I' dose= 12 mos or older, -Measles: 2"`t dose=grades K-12 or age equiv Vaccination records missing: -Polio:3 doses IPV or OPV, or 4 doses mix lPV/OPV -Diphtheria,Tetanus Toxoids,and Pertussis*: Number of missing "4 doses DTaP/DTP/DT or, 3 doses of Td Campers and Staff>7 years Number of missirig II{ *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades I 1-12 need booster if more than 10 yrs Number of missing since last dose of DTaP/DTP/DTfrd -He B: 3 doses if horn on or after 1/1/92 430-Rec Camp-Inspection Note;-Revised 8-20-10 Page 4 of 12 rte-," w CITY OF SALEM; NLASSACHI7SETTS l\�V(f BOARD OF HEALTi-I 120 Wl1SHINCiTON STREET,4-FLOOR I'IIBliC1t;C811prcvcnt.Promote.P'or't,. TEL.(978)741-1500 FAX(978)745-4343 lr=dia@salem corn KIMBERLEY DRISCOLL LARRY RAMDN,RS/REI-IS,CIIO,CP- MAYOR HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL CVuk&rcNts tSta4 JC S 1 NAME OF APPLICANT_ �y�_ � TEL# -M -990--7012> MAILING ADDRESS 40 l"q S 1 bo o I�rMO�rRo EMAIL ADDRESS CERTIFIED POOL OPERATOR Name: W.'Iky L6e — Cert#: qaR38 T'EL# DATES OF OPERATION(if not annual): (012 0�/ I O ✓ 1�{ DAYS & HOURS OF OPERATION: V a T-te,5 Y".ov QA A �7, 1 TYPE OF POOL Public Semi-Public ✓ - Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City of Salem) This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 63C,Section 49a,I certify under the pains and penalties of perjury that L to my best knowledge and belief;have filed all state tax returns and pard all state taxes required under the law. q191 Cn! 2., l k it 61'� (oS i t7roq Signature Date SS#or Federal Identification Number Revised 11/20/13 poolappl Lem Check 4 Date . 6 Ink$ _Latton _ = ... rr € , a es 4 5 f :) ntnittem_ t _r .152(B) Campers and staff 18 yrs or older:. Number of records checked: Pr . -Measles: 2 doses(exempt if bom before 1957) -Mumps: 1 dose (exempt if bom before 1957) Vaccination records missing: -Rubella: 1 dose (exempt if born before 1957) . + Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td Number of missing *Booster dose of Td: -If more than 10 yrs since last dose Number of missing Activities " .190(A) Activities and physical environment meet the needs of campers; do not pose hazard to health ' and safe ' .163 Operator encourages sun protection for all Aquatics: .430 Swimming Pool: in compliance with 105 CMR 435.00 ' -permit posted .204(B) Bathing Beach: in compliance with 105 CMR 445.00 s -weekly water sampling conducted/available .103 Proper supervision at swimming venue: I'lifeguard per 25 campers 1 counselor per 10 campers' -Plan to check swimmers-"buddy system" .204(A) Swimming areas clean and safe,no swimming at undesignated sites or at night without lighting , .204(C) Swim test to classify swimmers by ability .204 Piers and floats in good repair ' .204(G) Watercraft : equipped with US Coast Guard approved flotation devices and wom by all campers and staff participating in watercraft activities .204(11) Campers must be certified by American Red " Cross or equivalent for white water,hazardous salt or fresh water activities .103(C) Minimum 2 counselors in separate watercraft supervising white water,hazardous salt or fresh water activities Arts and Crafts: .205 Equipment in good repair,safety precautions taken Plaveround and Athletic Equipment: .206 Equipment properly maintained,fields/surfaces free ofholes/accident hazards v .206 Playground equipment secure,no concrete under/around it,pliable swing seats 430-Rec Camp-Inspection Notes-Revised 8-20-10 ' Page 5 of 12 � k . 0 Horseback Riding: - .208(A) I certified instructor per 10 campers(Min.2 counselors 208(A) Riders must wear hard hat E.208(B) Licensed stable Firearms: Sin le shot rifles onl Shootin rane awa from other activi areas Firearms in good condition,stored in locked cabinet.`Ammunition locked in separate cabinet Archery: .202 Equipment in good condition,stored in locked L/ &zCXVqPad !J area I 202 Range away from other activity areas,clearly marked as danger area.Must have common firing line and 25 yards clearance behind targets .203 No personal weapons,bows,rifles allowed Cabins,Structures and Facilities All Structures: ,216 Smoke detectors provided in all structures .453 Lighting provided in: -kitchen and dining room -toilet rooms -stairways A54 Floors maintained in all structures .455/.456 Egresses comply with Bldg. Code and are free from obstruction Day Camp Shelters:. 457 Day Camp provides shelter for on-going camp « activities Residential Camps-Sleeping Areas: .452 Screens and self-closing screen door provided .458 Provide adequate space: 40sgft/person in single bed -35sgft/person in bunk bed, -50sqfUperson in sleeping area requiring special equipment .454 Campers and staff with limited mobility housed « on ground level with egresses leading to grade or ramp provided A70 Bed or cot provided to each person with: -6 feet between sleeper's heads , -3 feet between single beds or 4 t2 feet between bunks -Triple bunk beds are prohibited Tents: 217' Fire-retardant and non-toxic -No oven flame nearby .458 35 ft/ erson in tent Toilets and Showers: .301 1 Plumbing in good working order .302 Cross-connections 430-Ree Camp-Inspection Notes-Revised 8-20-10 Page 6 of 12 r ' r .360 Proper sewage disposal - ~' .370 Adequate#of toilets: -All camps:2 toilets/privy seats for each gender -Day Camp:>60 of one sex,provide I additional toilet per • every 30 people of that gender -Non-Day Camp:>20 of one sex,provide 1 additional toilet per every10 people of that gender .373 Adequate#of sinks: -Day Camp: I per every 30 people + r -Residential Camp: 1 per every 30 .374 Adequate#of showers: -Residential Can : 1 shower or tub per 20 people .375 Toilets and shower rooms ventilated to exterior :376 ; Hot water at sinks, showers,or tubs not more than 112°F . $. .377 Sanitary facilities maintained in clean-condition- ' Shower room floors washed daily « .378/.380 Special needs campers provided facilities that meet their needs Latindry .162 Residential Camp: Laundry_ Afacilities provided .472 Bedding and towels laundered;no common ' towels,sheets washed every 7 days, sleeping bags aired out every 5 days Grounds .165 Tobacco use restricted to designated areas not accessible to campers .207 Proper storage and operation of power equipment .209 ,, Telephone readily available: -with emergency contact number posted:HCC,EMS, « . police,fire - -Da and Residential Camps only .213 Emergency communications stem .214(A) Flammable and hazardous materials labeled and stored in locked unoccupied building 214 Storage of cleaning and other chemicals .300 Potable water provided .300/.304 Adequate and centralized drinking water facilities -No common drinking cups .350/.355 Pro er stora a and disposal of solid waste .400(A) Rodent and insect infestation .400(B) Rodent and insect control plan: -Proper extermination method .401(A)(B) Weed and noxious plant control I J .450(A)(D) Site location does not cause undue traffic ` hazards and is accessible at all times .450(B) Site location not located where surface drainage conditions create no Health or safety hazard. 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 7 of 12 � k •r4 f ' r • MR " Iabalt riPx x�,. .� h rc, � , " '�'es' -s ;Noy r,1�1�` � omttlela` :� ' _� E,KK�°;_, Food Service .320 . Food service in compliance with 105 CMR 540.000,Minimum Standard's for Food Establishments.Permit posted in food service � • R facility 330 Nutritious meals that include a variety of foods served. Menus posted .331 Residential camps—Provide at least three nutritious meals. Foods must meet a . Recommended Dietary Allowances A .332 ' Day camps—Each meal provided must meet 1/3 of the RDA requirements « rt .3341 Adequately trained staff and equipment F provided to ensure handicapped campers are eating nutritious meals .335 Proper methods for storing meals brought from boy ar mt � w home. Meals provided to campers who arrive , . r (�. without a bag lunch .� .452 Screening provided for food preparation and food service areas. Screen doors must be self- closin Lighting rovided in kitchen and dining area 471 ^ Sleeping rohibited in food areas REGULATION 's NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE * w a O T k R y J i r { 436-Rec Camp-Inspection Notes-Revised 8-20=10 Page 8 of 12 C s a.. { i I d t � 4 + y Y d y + r y e ' e _ s 430-Rec Camp-Inspection Notes-Revised 8-20-10t Page 9 of 12 y { 1 K a r } F f F I Y r 4 , 6 • P t 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 10 of 12 s v p r} 1 „ .f s aq. 1 n 5 t " - d r Y }� « r « i r s i f g S e Y J � F J § a i Y i b w' 430-Ree Camp-Inspection Notes-Revised 8-20-10 Page I I of 12 _ t � p I • 1 Y y I L r t dr 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 12 of 12 I • CITY OF SALEM, MASSACHUSETTS O BOARD OF HEALTH 120 WASHINGTON STREET 4"'FLOOR - Promote.Prote1 TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL lramdin a,salem.com LARRY R4MDIN,RS/RF HS,(1110,CP-PS MAYOR HFAI,rri ACENt .. : ' - I Swimminh Pool Inspecti/on Report Pool: �feV�S IS� a �. Date- 6(111��' Address Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards for Swimminn Pools:State Sanitary Code Cha to V. Annual Permit Posted Health and Showers signs Posted ealth:no sick employees,no sick bathers,bathers take showers,spitting prohibited,no glass. Lifeguards: Present / Certification Red/orange suit _ward"printed on jersey _Sun block avail. Voice Amplifier Elevated seat Emer.Communication: phone at pool Phone instructions _Emergency numbers / _Phone in unlocked area t/ Safety Equip: for each 2000,sq. feet Rescue tube or ring buoy(with rope) _Backboard with collar ands ps First id: Equipment area (35) 1"band-aids )3x3 gauze V f2)5x9 surgipads �12)antiseptic wipes P )8x10 Surgi (2)2"soft roller bandages weezssors (2y3"Soft roller bandagesweezers �/0{)%roll hypoallergenic tape ` escue blanket jee packs Pocket mask sterile isotonic eyewash Disinfection C( -a-s _Chlorine _ H 7.2–7.8 Residual free 1-3 Combined 0-0.2 p _ , _Bromine _pH 7.2–7.8 Residual 2-6 (ppm)(mg/1) _ Records Kept: P Water tests _Chemicals Used Backwashing _Attendance _Hours of operation' s VDepth Markings Sidewalk and inside pool iving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c V/ cracks,non-slip surface, not over 10' above water level and at least 13' unobstructed headroom _Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted,` drained,ventilated, impervious construction,one shower and one toilet per 40 bathers,hot and- cold water, soap provided,no common cups,towels,combs,pool adequately enclosed,approved ' drinking water faciliti s Notes: UC t ' 'mp6l � f Received by: Inspected by: Suzanne Doty From: Chris Bevilacqua <bevilacquac@northshoreymca.org> Sent: Monday, July 28, 2014 7:25 AM To: Suzanne Doty Cc: John Brinkman; Scott Hitchcock; Gen Kuksin Subject: YMCA Children's Island Day Camp license change Good Morning Suzanne, We have had a leadership change at Children's Island. Beginning this morning, Holly Libert is no longer the camp director. To satisfy the BOH summer camp regulations, we have moved the following people into the roles that Holly Libert had previously held when the camp was initially licensed at the beginning of the summer. John Brinkman is now the camp director and health supervisor. He has been the assistant camp director up to this point and meets all the requirements to fill these roles. Gen Kuksin is now our certified pool operator. Up to this point he has been the certified pool operator for all other pools associated with the Lynch/van Otterloo YMCA and will now have the pool on Children's Island moved under his supervision. Please let me know if you need his CPO license number as I am happy to provide it. Mark Tintendo is now our aquatics director. Up to this point he has been a senior lifeguard on Children's Island and meets all the requirements to fill the position. Please let me know if you need copies of any of his certifications. All other staff and titles will remain the same for the remainder of the summer. Please let me know if you have any questions or if there is anything else you need from me. I appreciate your help with this matter. Best, Chris Chris Bevilacqua Associate Exec Director Lynch / van Otterloo YMCA 40 Leggs Hill Road, Marblehead MA 01945 (P) 781-990-7002 (F) 781-639-0190 E bevilac uac northshore mca.or W www.northshoreymca.org ( ) 4 �° Y 9 ( ) Y a (0) Facebook I Twitter I YouTube t The Y: We're for youth development, healthy living and social responsibility. 0 = z MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH COMMUNITY SANITATION PROGRkM. RECREATIONAL CAMPER INJURY REPORT FORM In accordance with M.G.L.c. 111, §§3 and 127A and 105 CMR 430.000:Minimum Sanitation and Safety Standards for Recreational Camps for Children(State Sanitary Code Chapter IV), 105 CMR 430.154 specifically requires that a report be completed,on a form prescribed by the Massachusetts Department of Public Health,for each fatality or serious injury as a result of which a camper or staff person is sent home,or is brought to the hospital or a physician's office and where a positive diagnosis is made. Such injuries shall include,but shall not necessarily be limited to,those where suturing or resuscitation is required,bones are broken,or the child is admitted to the hospital.A copy of each Injury report must be sent to the Massachusetts Department of Public Health within SEVEN f71 days of the occurrence of the injury. PLEASE PROVIDE A COMPREHENSIVE AND THOROUGH RESPONSE. TO EVERY QUESTION. 1. Name of Camp: yinc j): c rM tck rc V, 1;�tA+IV� .s..a+�A'1 CU� (� 2. Address: L i.1 �A b� City/Town_MaAnkpGlpa.hC M6 ' 41.1f t i ` 3. Name of Camp Director:i-i'c_I�T C..,6e t4 '"" 4.Telephone:L-17S<-.5oG'1 R 4 S 5. Today's Date: I 1 LA 6. Date of Injury: 1 7 1 7. Time of Injury: Z'2O (AM�Iv S. Did the injury involve a camper,staff person or both: .x- 9a. Age of Camper and/or Staff Person: L7 9b. Gender: Male Female 10. Briefly describe the incident and subsequent injury: (Please do not include aersonal iidentiifvinEninformatioin) �df� 2.+rWU�-�1tA.i.t`—��-. � _. O� ��twr Ll 1t-Db'}✓{tkxi�� nv� -4Llo \ t f Y� Ntv� to e-C' ee: TJ 4n 4wi tP.f 11. If the injury occurred outdoors,what were the weather conditions at the time of the incident? 0k=Lk+ "751!A'-ra,5 Report m Numbs (continued over) (Imuwl Ux Only) 12. Did the injury occur on the campground? If not,specify the off-site location where the injury occurred. III (please describe the exact location) �CS Orn 13. What body part(s)were injured: 01.Head/Skull_ .02.Face_ 03.Neck _04.Arm 05.Hand, 06. Back_ 07.Abdomen 08.Leg X 09.Ankle 10.Foot 11. Other,please specify 14. How did injury occur? 01.Falling 'C 02.Collision with person or object X 03.Struck by another person or object, 04.Drowning or near drowning_ 05.Bite or Sting _ 06.Cut - 07.Bum 08. Other,please specify 15. Where was the injured person treated? 01. Treated in camp infirmary_ 02.Treated in hospital Emergency Room,Physician's Office �(} 03. Admitted to Hospital_04.Other,please specify 16. Was the camper seat home as a result of the injury? Yes_Z_No 17. Was more than one camper injured? Yes_No 4 If Yes,how many? 18. Did the injury involve alleged abuse/neglect? Yes_No-K-- 19. om19. What changes were made in the camp,its environment,or operation as a-result of this injury to prevent a reoccurrence? Please describe specific changes made: /��/ L n 1,)G '4 Q DD 0 rp-�l�p &t.D cxt�W'i �l 16ti � CJS-YL - P,4q -:C 1 ' COLA-16Q ctt Le. 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"Yes"column= "�'marked below indicates compliance with provision of 430.000. "N/A"column= `�'marked below indicates that the pE2vision of 430.000 is not applicable to this camp. Permits .451 Current Certificate(s)of Occupancy from local building inspector for sleeping/assembly arm .215 Written compliance from local fire dept .633 Camp license posted in prominent location .300(A)(2)(a) Private water supply-DEP approval (>25 people,>60 da s/ -300(A)(2)(b) Private water supply,-BOH approval and chemical and bacterial analyses 1 (<25 people,<60days/yr)- Plans and Policies-Written Gkove C&CT .090(A) Procedures for background review of staff and volunteers(Available/Followed) V .090(c) CORI and SORI,previous work history, 3 references,out of state/international criminal background checks for staff .090(D) CORI and SORI,previous work history, 3 references,out of state/international criminal background checks for volunteers -Crrs(paying campers or unpaid volunteers) .090(E) Background information maintained for 3 years .090(F) Received,reviewed, and made determination in regards to all background information .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting procedures 191(B)(C) Discipline Policy with: appropriate discipline methods and prohibitions .210(A) Fire evacuation plan and drills I -Drills conducted within the first 24 hours of each session .210(B) Disaster Plan -Including information on transportation 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 1 of 12 uAgog aw `YDS6— n1V/A Co�iwertCs_.. � � .210(C) Lost Camper Plan .210(C) Lost Swimmer Plan .210(D) Traffic Control Plan -- " Contingency plans-Day Camp: .211 (A) Camper doesn't show up for cam (B Camper doesn't show u at point of ick u C) Child not registered arrives Contingency plans-Primitive,Travel and Trip: .212 A Itinerary daily-copy provided to parents Source of emergency care Camper release: .190(B) Camper released only to parents or parent- / designated individual in writing -Other plan- approved in writing by BOH Promotional Literature and Informational Packets .159(B)(2) Copy of policy re:care of mildly ill campers, / administration of meds and emergency health care provision I90(C) Statement re: regulatory compliance and licensing .190(D) Inform parents of right to review background / check,health care,discipline policies and v grievance procedures upon request Transportation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers and driver is camp coach, f director,etc.private vehicles may be used >14ers as vehicle must be school bus P > All vehicles must be RMV compliant .253 Proper automobile insurance .251(C)(F) Seatbelts must be worn and special needs of campers communicated to driver .251(H) Camper<7yrs not transported longer than 1 hr to or from cam Staff Qualifications Camp Director: 102(A) Residential Camp: 25 yrs,completed course in camp administration or at least 2 seasons of experience .102(B) Day Camp: 21 yrs,completed camp administration course or 2 seasons of experience .102(C) Primitive,Travel,Trip: 21 yrs and proof of experience .102(D) Designated substitute when director off-site>12 / Q�\N 1�r1�tav� hrs -Sub must meet criteria abovecc� 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 2 of 12 i WSW Counselors/Junior Counselors: .100 Day camps,non-sport: Counselor--l6 . Junior Counselor-15 yrs. .100 Other camps: Counselors= 18 yrs or graduated V from high school.Junior Counselors-- 16 .100 All counselors 3 yrs older than cam ers I Required Counselor Ratios: .101(A) Residential and Day Camps: I staff per 10 kids over 6 yrs I staff per 5 campers 6 yrs and under .101(B) Primitive,Travel,Trip: I counselor per 10 campers. 2 counselor min .101(C) Special Needs: IV/ I counselor per 4 mildly disabled campers I counselor per 2 severely disabled campers .103 Aqua D' ;a ,Tly ect D' r:` A- None Americaln Red[Cross Lifeguard Ting cert.,CPR for Professional Rescuer and First Aid Cert.or their equivalents -If supervise 2 staff,21 yrs and experience w/management .103 Lifeguard:American Red Cross Lifeguard Ting cert.,CPR for Professional Rescuer cert. and First Aid Cem or their equivalents -List names .103 Certifications for other high-risk activities,eg: NRA instructor certification for firearms. -List Names and Certifications. .252 Camp vehicle drivers: 18yrs,2yrs driving experience,current license for type of vehicle -First Aid certified if no other trained staff aboard Medical Personae Records,and Facilities .159(A) Health Care Consultant Narne:�iWW�D_Yl,a G le MD NP PA(w/pediatric training) License#: zm!(t5 Check for Health Care Consultant Agreement * Review and approve first aid training of staff * HCC available for consolations at all times * Signed written orders for HS .159(C) Health SVpervisor(on site at all times) Name: U U�(-� 18yrs,First Ai ld and CPR certified OR, MD PA NP RN LPN EMT -special needs or residential with>150 staff and campers must have health professional .159(B) Health Care Policy • Approved by LBOH and HCC • Policy provided to all full time staff during orientation 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 3 of 12 Mow .160(A) Medication stored in original containers V .160(B) Meds stored in secured cabinet and if necessary refrigerated in box affixed to refrigerator(if no secondary lock) * Cabinet used for no other purpose * Refri&Eatortem penature Mto 2F .160(C) Medication administered by Health Supervisor ® HCC written acknowledgement of all medications administered at eh camp(if HS is not MD PA NP RN LPN) ® Written premising from ardian .154 Injury Reports completed for fatality or serious injury.Copy sent to MDPH within 7 days .155 Medical log book-bound,pre-numbered pages, ink entries,no skipped lines .161(A) Infirmary provided-day and resident camps • Clearly Labeled as Infirmary/Medical Area • Exterior light(residential Camps) .453 Li tin prmided in infirmary .161(3) Area for isolation of ill child-Residential Camps A/ 0 Not used for any other purpose .161(C) First Aid Kit: non-peffunied soap,sterile gauze squares,compresses,adhesive tape,bandage scissors, triangular and rolled bandages,CPR mask,tweezers,cold pack,gloves. .150 Health record for each camper and staff. Number of records checked: -emergency contact into -camper<18 yrs must have written parental Number of mod/care -Permission for meds and emergency care permissions missing: Residential,Sport;Travelfrrip: -Health History,Physical Exarn(<2yrs) -Record of Immunizations(noted below) Number health history/exam Camp Non-Sport: -Health History signed by parent/guardian or physician missing: -Record of Immunizations(noted below) Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: -MMR- I'dose= 12 mos or older, -Measles:2nddose=grades K-12 or age equiv Vaccination records missing: -Polio:3 doses IPV or OPV, or 4 doses mix IPV/OPV -Diphtheria,Tetanus Toxoids,and Pertussis*: Number of missing 4 doses DTaP/DTP/DT or, 3 doses of Td Campers and Staff>7 years Number of missing *Booster dose of Td: -grades 7-10 need booster if>5yrs since last dose of DTaP/DTP/DT -grades 11-12 need booster if more than 10 yrs Number of missing since last dose of DTaP/DTP/DT/Td -Rep B: 3 doses if born on or after 1/1/92 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 4 of 12 _Yes, .152(B) Campers and staff 18 yrs or older: Number of records checked: -Measles:2 doses(exempt if born before 1957) -Mumps: I dose (exempt if born before 1957) Vaccination records missing: -Rubella: I dose (exempt if born before 1957) -Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td Number of missing *Booster dose of Td: -If more than 10 yrs since last dose Number of missing Activities .190(A) Activities and physical environment meet the needs of campers;do not pose hazard to health and safety .163 Operator encourages sun protection for all Aquatics: .430 Swimming Pool: in compliance with 105 CMR 435.00 -permit posted .204(B) Bathing Beach:in compliance with 105 CMR 445.00 -weekly water sampling conducted/available .103 Proper supervision at swimming venue: I lifeguard per 25 campers 1 counselor per 10 campers -Plan to check swimmers-"buddy system" .204(A) Swimming areas clean and safe,no swimming at undesignated sites or at night without ligbti ling .204(C) Swim test to classify swimmers by ability .204(E) Piers and floats in good repair .204(G) Watercraft: equipped with US Coast Guard approved flotation devices and worn by all campers and staff participating in watercraft activities .204(H) -Campers must be certified by American Red Cross or equivalent for white water,hazardous salt or fresh water activities .103(C) Minimum 2 counselors in separate watercraft supervising white water,hazardous salt or fresh water activities Arts and Crafts: 205 Equipment in good repair,safety precautions taken Playground and Athletic Equipment: .206 Equipment properly maintained, fields/surfaces free of holes/accident hazards 206 Playground equipment secure,no concrete under/around it,pliable swing seats 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 5 of 12 Horseback Riding: .208(A) I certified instructor per 10 campers(Mn.2 L counselors) .208(A) Riders must wear hard hat .208(B) Licensed stable Firearms• .201 Single shot rifles only .201 Shooting range away from other activity areas .201 Firearms in good condition,stored in locked cabinet.Ammunition locked in separate cabinet Archery: .202 Equipment in good condition,stored in locked area .202 Range away from other activity areas,clearly marked as danger area. Must have common firing line and 25 yards Clearance behind targets .203 Nopersonal weapons,bows,rifles allowed Cabins,Structures,and Facilities All Structures: .216 Smoke detectors provided in all structures .453 Lighting provided in: -kitchen and dining room -toilet rooms -stairways .454 Floors maintained in all structures .455/.456 Egresses comply with Bldg.Code and are free from obstruction Day Cam p Shelters: .457 Day Camp provides shelter for on-going camp activities Residential Camps-Sleeping Areas: —452-- Screens and self-closing screen door provided .458 Provide adequate space: -40sqft/person in single bed -35sqft/person in bunk bed -50sqft/person in sleeping area requiring special equipment .459 Campers and staff with limited mobility housed on ground level with egresses leading to grade or ramp provided .470 Bed or cot provided to each person with: -6 feet between sleeper's heads -3 feet between single beds or 412 feet between bunks -Triple bunk beds are prohibited Tents• .217 Fire-retardant and non-toxic -No open flame nearby .458 35 sqft/pason in tent Toilets and Showers: .301 Plumbing in good working order r—.302 Cross-connections T_ 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 6 of 12 @ aA • .360 Proper sewage disposal .370 Adequate#of toilets: . -All camps:2 toilets/privy seats for each gender -Day Camp:>60 of one sex,provide 1 additional toilet per every 30 people of that gender -Non-Day Camp:>20 of one sex,provide I additional toilet per every 10 people of that gender .373 Adequate#of sinks: -Day Camp: 1 per every 30 people -Residential Camp: 1 per every 30 .374 Adequate#of showers: -Residential Camp: 1 shower or tub per 20 people .375 Toilets and shower rooms ventilated to exterior .376 Hot water at sinks,showers,or tubs not more than 112°F .377 Sanitary facilities maintained in clean condition- Shower room floors washed daily .378/.380 Special needs campers provided facilities that meet their needs Laundry .162 Residential Camp:Laundry facilities provided .472 Bedding and towels laundered;no common towels,sheets washed every 7 days,sleeping bags aired out every 5 days Grounds .165 Tobacco use restricted to designated areas not accessible to campers .207 Proper storage and operation of power equipment .209 Telephone readily available: -with emergency contact number posted:HCC,IMS, police,fire -Day and Residential Camps only .213 Emergency communication system .214(A) Flammable and hazardous materials labeled and stored in locked unoccupied building 214 Storage of cleaning and other chemicals .300 Potable water provided .300/.304 Adequate and centralized drinking water facilities •-No common drmlan cups .350/.355 Proper storage and disposal of solid waste .400(A) Rodent and insect infestation .400(B) Rodent and insect control plan: -Proper extermination method .401(A)(B) Weed and noxious plant control .450(A)(D) Site location does not cause undue traffic hazards and is accessible at all times 450(3) Site location not located where surface drainage conditions create no health or safety hazard 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 7 of 12 Y AY Food Service .320 Food service in compliance with 105 CMR 590.000, Minimum Standards for Food Establishments. Permit posted in food service facility .330 Nutritious meals that include a variety of foods served. Menus posted .331 Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances(RDA) .332 Day camps—Each meal provided must meet 1/3 of the RDA requirements .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch .452 Screening provided for food preparation and food service areas. Screen doors must be self- closing .453 Lighting provided in kitchen and dining area .471 Sleeping prohibited in food areas REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 8 of 12 430-Rec Carnp-hispection Notes-Revised 8-20-10 Page 9 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 10 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 11 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 12 of 12 Children's Island Day Camp 2014 Summer Staff • C O 0 N v > c U � v o E v c vE O ¢ v E O -2 U j W n x E _ z d= m 3 s �, a v 00 L '° w a r p� u Name Job Title a a 3 z u m aZ u u On 4yV�hL Holly Liben Camp Director 30 n/a x n/a x x x I x I x QUa�,J^ John Brinkman Assistant Camp Director 24 OSx' Rebecca Webb Assistant Camp Director 23 C(.�✓� Maxwell Anderson Specialist 22 x x x Sue• Jon Baker Jr.Counselor 17 x _ x x John Blanchard Lifeguard 18 x Drake Blodgett Counselor 16 x Aliza Bogosian Counselor 18 x Melissa Cary Jr,Counselor 17 x Samantha Claveau Jr.Counselor 12 x Daisy Duncan Lifeguard 19 x Ethan Dunleavy Counselor 19 x Brenna Gloudemans Counselor 22 x Sarah Hastings Specialist 21 x x Jim Henerberry Maintenance 53 x Kevin Jordan Counselor 20 x x lillian King Jr.Counselor 16 x - Emma Knittle Jr.Counselor 16 x Amanda Lindqvist Jr.Counselor 16 x Matthew MCAniff Specialist 2S x Paige Mentuck Counselor 18 x x Sean Murray Maintenance 50 x • Eli Neuman-Hammond Counselor 18 x Renee Pavlovich Jr.Counselor 16 x Olivia Perez Jr.Counselor 16 x Samantha Pineau Counselor 19 x Kathleen Rainer Counselor 18 x Kelly Roland Counselor 18+ x x x Richard Roland Specialist/Maintenance 21 x John Semexant Specialist 26 x Jacqueline Strauss Counselor 18 x x - Mark Tentindo Specialist/Lifeguard 25 x Emma Titus Counselor 20 x x x Pon Wetmore Counselor 45 x • r Children's Island Day Camp 2014 Health Care Policies and Emergency Plans the F� 1. Health Care Consultant: Philomena Asante, MD Telephone: 781-631-7800 Address: 70 Atlantic Avenue, Marblehead, MA 01945 Health Care Supervisor: Camp Director, Assistant Camp Directors 2. Emergency Telephone Numbers Salem Harbormaster 978-741-0098 Salem Fire: 978-744-1234 Salem Police: 978-744-1212 Poison Prevention Center: 1-800-222-1222 Emergencies VHF Channel 16 3. Hospital Utilized for Emergencies Name: North Shore Medical Center Salem Hospital Telephone: 978-741-1200 Address: 81 Highland Avenue, Salem, MA 01970 4. Emergency Procedures In the event of an emergency, a staff member will call the Salem Harbormaster via cell phone or VHF radio and their directions followed until the crew arrives. A second staff person will contact a parent at their emergency phone number (on file in Camp Office) immediately. • 5. Emergency Procedure If Parents Cannot Be Contacted. If a parent cannot be contacted, a staff person will accompany the camper to the hospital with their emergency information (on file in Camp Office) in hand. A second staff person will continue to try to contact a parent by calling them at home and at work (numbers on file in Camp Office and in YMCA registration computer program). 6. Off-Premise Emergency Procedures In the event of a medical emergency, the child is taken to the closest hospital and the parent/guardian and/or the emergency contact person is notified. Emergency procedures will be followed. The child's emergency information will accompany them. 7. Procedures for Utilizing First Aid Equipment 1. Location of First Aid Kit(s) Infirmary, Main Lodge, Pool House 2. Location of AED Camp Office 2. Location of First Aid Manual Infirmary 3. First Aid is administered by First Aid-certified counselors or Camp Directors 4. First Aid Kit is maintained by Camp Directors, Aquatics Supervisor 5. Contents of First Aid Kit • Non-perfumed soap • Sterile gauze squares • Compresses • Adhesive tape • Bandage scissors • Triangular Bandages • Rolled bandages • One-way valve mask • Tweezers 9 Cold Pack • Barrier Gloves 8. Plan for Injury Prevention and Management • Daily checks are made of the camp area, bathroom facilities, outdoor play areas and swimming areas by staff prior to camper use. Any problems found are reported to the maintenance staff and a work order is issued for immediate attention. Camp property and facilities are monitored daily for removal and/or repair of hazards. 9. Procedures for Reporting Serious Injury, In-patient Hospitalization, Death of a Camper or Staff Person to the Department of Public Health Immediately following any type of serious accident, the MDPH Injury Form will be filled out and filed with the Town of Salem and the YMCA of the North Shore. A copy of the form will be mailed to the Department of Public Health within one day of the incident. 10. Procedures for Informing Parents of First Aid Administration For minor injuries requiring first aid, a First Aid Administration Form is filled out in duplicate. Upon picking up the child from camp, the parent or guardian receives a copy of the form. 11. Head Injury Procedures For any injury involving the head, immediate evaluation of injury will take place by First Aid certified staff. If signs of serious injury exist, EMS will be called. If it is deemed there is no immediate danger, a phone call will be made to the Emergency Contact person informing them of injury and allowing them to evaluate injury and/or request additional medical attention. Upon signing Accident report, Emergency Contact must note their assessment of the injury. 12. Plan for Infection Control and Monitoring Hand sanitizing and personal hygiene are strictly enforced. Food and drink are brought from home and are not shared. Bathroom and changing rooms are attended daily by maintenance staff. Spray bleach/water solution is used daily on all surfaces as needed. 13. Procedures For the Clean-Up of Blood Spills Area immediately evacuated, clean up using the Bloodborne Pathogen kit. Staff will use gloves, eye shield, mask and if necessary, a protective gown & cap. ILSC powder will be put on the blood and it gets scraped into a Bio-Hazard bag for disposal. 14. Emergency Plan for the Evacuation of the Program or Facility • Evacuation plans are posted next to building exits. Camp Counselors lead children out of buildings/structures/woods to designated areas. Camp Directors and Unit Leaders check for stragglers. Camp Directors ensure children in attendance equal the number of children safely evacuated. Camp Directors conduct evacuation drills at Camp Director's discretion, a surprise to the counselors, and documents effectiveness. For emergencies during transportation to and from the Island, Camp Counselors will cooperate with boat captains and crew and assist campers in following the appropriate emergency protocols. 15. Plan for Administering Medication (Prescription and Non-prescription) In order for a camper to be administered medication, an authorization form must be completed by the parent. This is kept on file and a log of the administration of medication is kept. Medication must be in original containers with the pharmacy label, date of filling, pharmacy name and address, filling pharmacist's initials, serial number of the prescription, name of the patient, name of the prescribing physician, name.of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law. If capsules or tablets, the number in the container. All over the counter medications shall be kept in the original containers with the original labels. All medicine brought to camp must be given to a camp counselor immediately for safe storage in a locked medicine cabinet or box. Locked medicine storage is located in the infirmary. Medicine will be stored according to its labeled directions. The Health Supervisors may administer medications. Only oral and topical medicines will be administered, with the exception of Epi-Pens for campers with known allergy or pre-existing • medical conditions. All medications dispensed at the camp will be recorded in the Daily Medication Log noting the date, time and dosage of medication given. • 16. Plan for Recording of the Disposal of Medication Unused medicine will be returned daily or at the end of the week to the adult supervisor to whom the camper is released. If the medication cannot be returned, it will be destroyed by the Health Care Supervisor, witnessed by a second person and recorded in the Medication Destruction Log. 17. Plan for the Care of Mildly III Campers First Aid will be provided by a staff certified in First Aid. Steps may include: Separation from larger group Rest in a shaded, quiet area Water to drink (unless contraindicated) Additional steps according to specific complaints Parents will be notified if the condition continues, worsens, or upsets the camper. Camper will be taken to the infirmary located in the Camp Office and made comfortable until being transported back to their pick-up location. 18. Medical Log If any camper has a health complaint, it will be entered in the camp Medical Log using the next available line with the entry in ink. Any communicable disease or unusual prevalence of any disease occurring in camp will be reported by the Camp Director immediately to the Board of Health. 19. Procedures for Identifying and Protecting Children with Allergies and/or Other Emergency Medical Information All parents/guardians must complete a Camper Information form (part of the Parent Packet) before their child may attend camp. Allergies, medications, and special conditions are specifically asked to be listed. This information is kept in a log and at the beginning of every day, the Camp Director reviews the information with camp counselors. For children with • extreme allergies, the parent must provide the camp with an Epi-Pen prescribed to the child before the child may attend camp. 20. Exclusion Policy for Serious Illnesses, Contagious Disease, Reportable Diseases to Board of Health Children with known serious illnesses or contagious diseases will not be permitted in the camp from the first day they are known to have the illness/disease until they can provide a doctor's notice saying they are no longer a threat to other persons.A report of the disease or illness will be completed and filed by the Camp Director with the Board of Health the same day the illness or disease is identified. 21. Location of Staff Smoking Area Smoking is not allowed anywhere on the camp property. - 22. Policy for Use of Bug Spray, Sunscreen, Lip Balm and Reducing Exposure to Sun Parents are asked to apply appropriate sunscreen and bug-spray before child enters camp. Additional bug spray, sunscreen, and lip balm are applied as designated by the parent on the Camper Information Form. 23. Grievance Policy Should a camper or their guardian have a grievance, it should be reported first to the Camp Director. The Camp Director will document the grievance, alert the Executive Director of the YMCA and all steps will be taken to correct the grievance immediately. • 24. Prevention of Abuse and Neglect • In the event that it is suspected a child is being abused or neglected, staff are required by MA State Law to immediately report the suspected abuse/neglect to the Camp Director. The Camp Director will then report it to the MA Department of Children and Families. In the event that a 51A Report alleging abuse or neglect of a child while in the care of the camp is filed, the Camp Director must notify the Board of Health immediately. The staff person accused in the report will be kept from working directly with campers until the investigation is completed. The staff will cooperate in any official investigation concerning the report. The YMCA will cooperate in all official investigations of abuse and neglect alleged to have occurred at the camp, including identifying parents of campers currently or previously enrolled in the camp who may have been in contact with the subject of the investigation. The YMCA will ensure that an allegedly abusive or neglectful staff person does not work directly with campers until MA Department of Children and Families investigation is completed. 25. Discipline Children are individuals - discipline should maximize the development of the child and ensure the safety of the child and the group. Behavior that is considered inappropriate: Behavior that could cause physical harm to themselves or anyone else. Refusing to comply to the staff or facility rules. Verbal abuse, degrading comments, inappropriate language. Inappropriate physical touching of staff member or another child. Acceptable Forms of Discipline: Removal from stressful situation. Limiting participation in certain activities. • Time Out in designated location for up to 5 minutes. Send to Camp Office (If deemed necessary by the Camp Director, the offender's parents may be called and the child removed from the camp.) Unacceptable Forms of Discipline: Corporal punishment including spanking. Cruel or severe punishment, humiliation, verbal abuse. Denial of food or shelter. Punishment for soiling, wetting or not using the toilet. Discipline Documentation Camper actions and discipline taken by staff will be documented. Persistent problems will be identified to the Camp Director and discussed with camper's parents. 26. Fire Drills Fire Drills will be held the first day of camp and once a month thereafter. Campers follow the posted emergency procedures for exiting the camp grounds in a calm and orderly fashion. Groups will meet at their designated evacuation areas. 27. Emergency Communication Walkie-talkies are provided for each director, unit leader, and/or program area. In addition, whistles are provided for each lifeguard (which includes a number of counselors) and should be used sparingly to get campers attention. Three sharp whistle blasts signal an emergency. Lifeguards may also have air-horns and/or VHF radios at the pool, water front areas, and on boats. Cell phones may also be used in an emergency to contact the Salem Harbormaster. 28. Disaster Plan If advised by authorities to evacuate an area, all campers will follow the posted emergency evacuation procedures. In the event transportation is required, emergency boat pick-up will • return campers to the Landing in Marblehead, and if necessary, transported by bus to the Lynch/van Otterloo YMCA. • 29. Tornado or High Winds In the event of a tornado or high winds, without time for Island evacuation, campers will immediately go to the Seal Pup Den or cellar or the Main Lodge. Crouch down against the floor by the center walls and cover the back of their head and neck with their hands. 30. Flash Flood In the event of a flash flood, all campers will immediately go to their designated shelters (Sailors Lodge or Main Lodge). Do not try to walk through flowing water more than ankle deep. 31. Lightning If lightning or thunder is in the area, swimming areas will be closed immediately and remain closed until at least 30 minutes after the last sighting of lightning or last clap of thunder. All campers will immediately report to their indoor,meeting spaces. Avoid using electrical appliances. Do not use the running water. 32. Wildfire Follow the instructions of local officials. Wildfire can change direction and speed suddenly. Local officials will advise of the safest escape route. If trapped, enter the swimming area. Campers cannot outrun a fire. Breathe the air close to the ground through a wet cloth to avoid scorching lungs or inhaling smoke. 33. Swimming All campers must be tested prior to being included in the camp swim time by the lifeguard staff. The swim test consists of submerging completely, swimming 25 yards on your front and treading water for 30 seconds. All campers will be designated as either swimmers or non- swimmers and noted as such in the Swim Log. At risk swimmers will be considered non- swimmers. Non-swimmers must wear ATTACHED, properly fitting flotation (PFD Type I,II or • III) and may only wade in the water up to waist deep. Swimmers may move freely in the designated swimming area. All camp swimmers must stay in the area designated for swimming at all times. There will be a minimum of 1 camp counselor per 10 swimmers present for swimming (5 for children age 6 and under). There will be a lifeguard present at all times when swimming. Campers not swimming during the scheduled swim time must sit on the beach away from the water. To come to Children's Island, campers are required to bring a properly-fitting USCG-approved PFD Type I, II or III. A Camper who forgets to bring their PFD may be provided one from Mahi Mahi Cruises and Baker's Transport for the boat ride to the Island. The Camp will provide a PFD to the Camper if they are a non-swimmer. Campers who repeatedly forget or lose their PFD may be billed by the YMCA for a replacement one. See Children's Island Day Camp Christian's Law policies for further information regarding PFDs and swim tests. 34. Buddy System Each camper must choose a fellow camper to be their Buddy while swimming. Buddies must be of the same swimming classification. Head Camp Counselor must note how many sets of Buddy's are going to the pool. Buddy checks are done at regular intervals (not more than 20 minutes apart) by the camp counselors and/or lifeguard. At the Buddy check, Buddies must hold hands up in the air and be counted. 35. Lost Swimmer Plan In the event that one buddy or a set of buddy's are missing at the Buddy Check, the camp counselor should immediately signal the lifeguard. The lifeguard will empty the swimming area with three sharp whistle blasts and check for swimmers in the water. If the buddies are not • located in the water, then it is the Camp Counselor's responsibility to check the surrounding areas including play areas and bathrooms for the missing children while the Camp Directors supervise the rest of the campers. If the campers are not found, enact Lost Camper Plan. 36. Lost Camper Plan • In the event that a camper becomes lost, the camp counselor must immediately report to the Camp Director the name, description and last known location of the missing child. The Camp Directors are then in charge of the search. Use three whistle or air horn blasts to alert everyone of an emergency. Gather all campers in their evacuation areas and take roll call and double-check rosters to confirm that child was at camp. Camp counselors search the bathrooms, camp buildings, play areas and swimming area (including if necessary removing everyone from the water). If the child is not found there, then search the outlying and coastal areas of the Island. Within five minutes of beginning the search, if the child still hasn't been found, the Camp Director will contact the Executive Director of the YMCA and Salem harbormaster. Once they have been alerted, the Camp Director will call the parent/guardian at their emergency phone number on file, then continue the search. For a lost camper ata pick-up/drop-off point, Camp Staff follow same procedures and search the surrounding areas accordingly. 37. Plan for When A Registered Camper Does Not Arrive Double check attendance and roster. Alert the Camp Director(s) immediately. Camp Directors will call the parent/guardian of the registered camper both at home and at their emergency contact number to try to identify where the camper is and make the necessary adjustments to the camp schedule. If there is no response, the Camp Director will leave a message and report the no-show to the YMCA Executive Director. 38. Plan for Arrival of Non-Registered Camper Should a camper arrive who is not registered, alert the Camp Directors immediately for verification. We cannot accept them into camp this session. Camp policy states that all paper work and balances for the upcoming session are due prior to the child's first day of camp. Alert the adult attempting to drop off the camper that we will not be able to take them today and inform them of the Camp's registration policy. • 39. Camper Not At Pick-Up Point Double check attendance and roster, confirm that the camper was not already picked up by parents or sent on the wrong boat. Alert the Camp Director. The Camp Director will contact other Camp Directors and Counselors to determine the location of the camper. If the camper is not immediately located, then enact the Lost Camper Plan. 40. Camper Dining Plan All campers must be seated while eating. Only camp counselors may distribute drinks, food, etc. after sanitizing hands by washing or with hand-wipes. The sharing of utensils, food or drinking cups is permitted. Campers will be encouraged to eat, but cannot be forced to eat. Campers are recommended to bring their own food, but in event of a lost or missing meal, one will be provided for them by the Camp Director. No camper will be denied a meal for any reason other than medical written direction. 41. Traffic Control Plan Pick-up and drop-off for camp will follow specific procedures for each location (see Pick- Up/Drop-Off Plans). All vehicles must proceed with caution in parking lots, park in an orderly fashion, and follow all staff directions when picking up or dropping off children. Parents or guardians who fail to follow procedures and staff directions, resulting in safety hazards, may receive written warnings from the YMCA and/or have their child unenrolled from the remaining camp session. 42. Camp Organization Camps are offered for children entering Kindergarten through grade 10, on a Monday through n Friday basis. The Camp Day on Children's Island runs from approximately 9 AM-3:30 PM (not including transportation). • 43. Chain of Command Lifeguards and camp counselors will report to the Camp Director. The.Camp Director reports to the YMCA Executive Director. 44. Camper to Counselor Ratios . (All ages are determined as of the actual calendar date) Ages six and under require one camp counselor for every 5 children. Ages seven and over require one camp counselor for every 10 children. 45. Required Counselor Information All counselors must have completed an extensive background check including prior work history, three reference checks, juvenile CORI checks and SORI checks. Kept on file are a Health History and Emergency Contact Form, a report of Physical Examination in the last 24 months and"a complete record of immunizations. Counselors must also attend a staff orientation before working. 46. Required Camper Information All campers must have completed and on file BEFORE attending camp a Camper Information Form, Liability Release, Health Record Form, a report of Physical Examination in last 24 months and a certificate of immunization. If medication is to be administered to the camper, they need to have in addition an Authorization to Administer Medication form and a record of dosages kept in the Daily Log for Medication Administration. 47. Telephone Usage Camp Counselors may have access to one of the camp cell phones at all times for emergency use. Emergency numbers are posted in each building. 48. Personal Hygiene/Behavior Expectations for Staff and Campers • Hands must be cleaned with soap and water or hand wipes before eating and after using the restrooms. • Campers will always visit the bathroom before swimming. • No sharing of towels, campers provide their own towels. • Campers will be encouraged to reapply sunscreen/bug spray throughout the day. • No sharing of cups, food, or eating utensils. • No use of drugs or alcohol. Tobacco use by staff is not permitted. • Nothing that could be construed as a weapon (pocket knives, personal bows, rifles; etc.) is allowed on camp property. • All poisonous/hazardous chemicals must be kept in designated, locked areas. • Surfaces should be disinfected daily. 49. Camp Philosophy - The YMCA of the North Shore is committed to the values of Caring, Honesty, Respect and Responsibility. Our YMCA provides all children, adults and families, regardless of income, with opportunities to develop a healthy spirit, mind and body. This camp must comply with the regulations of the MA Department of Public Health and be licensed by the local Board of Health. •