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YMCA - ESTABLISHMENTSKi -153LPE UPC 13034 amead.com • Made In USA NFAIA®N9F44tR°kUCTita wrrFsnv�ocvaa� ._� ¢anuco soucGW° � m 14 0 Permit # PO -17-12 Date of Print 5/18/2017 Permit Issued 5/18/2017 Permit Expires 10/11/20117 Permit Fee $40.00 Late Fee $0.00 �e o 4 Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 health@salem.com PUBLIC POOL HEALTH PERMIT License For: Pool (seasonal) Granted To: Address: 40 Leggs Hill Road Location of Establishment: 40 Restrictions: Outdoor Pool Notes: LVO YMCA Marblehead LEGGS HILL ROAD 0 PublicmHeolcalth oteel Larry Ramdin, MPH, REHS, CHO Health Agent MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 10/1/2017, unless sooner revoked or suspended. Larry Ramdin, MPH, REHS, CHO Health Agent �l a, !! CITY OF SALEM, MASSACHUSETTS fib.. IoAKD INGTONSTREET,4 RECEIVED 120 WASHINGTON STREET, 4*" P1.00R Kl'n16ERI EY DRISCOLL TEf.. (978) 741-1800 FAX (978) 745-0343 MAY 1 MAYOR lramc mCa_)salem.com 82017 LARRY RAMDIN, RS/Iu HS, CHO, CP -FS CITY BOARD OFALEMHEALTH Hriru.TH AGENT 201[1 APPLICATION FOR id. AAA) OPERATE A SWIMMING POOL LOCATION OF POOL40 VW �/l. lid t�l(al �% A9 ,o) NAME OF APPLICANT LV/✓,41% OZ 7Q �� 631- 96 zz MAILING CER�•�c IED POOL PE TOR I d2/_2_?1 ff64 QQ Name:�/IA,SQA,� �. DLQ.,� L�6fl Cert TEL# L L Gp --70C? DATES OF OPERATION (if not DAYS & HOURS OF OPERATION: O M TYPE OF POOL Public Semi -Public ✓-Lv�� (i f7OK� Special Purpose 1 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. r7 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 I, to my best knowledge and belief, have filedall tte t x ret ns and paid all state taxes required under the law. (y',amJJ_ r7117 :& 042-(04 -ll3 Signature Date SS# or Federal Identification Number Revised 5123111 poolappl l.doc Check#Date r '7 $lfb,pb Purchase Order #7022 Approved C( Vendorli Ilwfta _.- t*��W �'* ev�� , ,- �4'f City Of Salem -Board of Health Lynch/van Otterloo YMCA 120 Washington St 40 Leggs Hill Road 4th Floor Marblehead, MA 01945 Salem, MA 01970 978-922-0990 WMIM0"'ii' Branch: LVO Maintenance YMCA of the North Shore, Inc. Mo/Yr: 5/2017 245 Cabot Street Date: 5/17/2017 Beverly, MA 01915 Paper Check 978-922-0990 1 EIN# 04-2104913 i-ID,;I4e664rit'# -It'eirh*t'P'A_9 ca Q N", �w 'irl�e'� 1 01-04-08-57204 Outdoor pool permit 1 40.00 Outdoor Pool Maintenance Total Service, Log Submitted by kuksing at 5/17/2017 11:17 AM t4s pw r ho iv 'F}9,{u i 4v! 40f Z'�s aha pari eio, a� ho i t Vhmi Q f Ivp w m ,baa; vj"4r.6 jIr 5 6 "d wre w'! t vv"ho�w tziolt'fifIZ apor, V*'wwtloa of ti0.1,41(ii 61 !ftp 3ffjr *f Tl'V "x'!145tweor wm4f'; mjv Ap"Ar qq [Whrl mvr)v'caft"; rm w0w, of m(' pwplaqInt'st V[4fA of TrP, No,'Vt 9,wP Aor. A�rowmB 94YAt5'f, ,v 1��' Cow strr-'vt' sqnny mA 0,191 Titt, '04C 1, 0 Tivi krrv, Slliote. ii;~6 expvlin vwiIow it of S;31,1 tAc' ',ia� und�t WS EN(tmoliian "i'm2- 104-9]l3, ewe w,tiro f 9 h sir a v e Y" A.C' V 0 Permit # PO -17-3 Date of Print 3/21/2017 Permit Issued 3/21/2017 Permit Expires 12/31/2017 Permit Fee $40.00 Late Fee $0.00 City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 health@salem.com Granted To: PUBLIC POOL HEALTH PERMIT License For : Pool (special purpose) LVO YMCA Address: 40 Leggs Hill Road Marblehead Location of Establishment: 40 LEGGS HILL ROAD Restrictions: Notes: �l �- Pft�� Larry Ramdin, MPH, REHS, CHO Health Agent MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2017 , unless sooner revoked or suspended. Larry Ramdin, MPH, REHS, CHO Health Agent Permit # PO -17-4 Date of Print 3/21/2017 Permit Issued 3/21/2017 Permit Expires 12/31/2017 Permit Fee $40.00 Late Fee $0.00 0 Kimberley Driscoll Mayor City of Salem, (Massachusetts Board of Health 120 Washington Street, 4th Floor; Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 . health@salem.com PUBLIC POOL HEALTH PERMIT License For: Pool (year round) Granted To: LVO YMCA PublicmHealth' Larry Ramdin, MPH, REHS, CHO Health Agent Address: 40 Leggs Hill Road Marblehead MA 01945 Location of Establishment: LEGGS HILL ROAD Restrictions: Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2017 , unless sooner revoked or suspended. City of Salem, Massachusetts Board of Health lu i R q 120 Washington Street, 4th Floor, Salem, MA 01970 PublicHeaith Pmrenr. Promote Pmmc[. fid Tel. (978)741-1800 Fax. (978) 745-0343 - Kimberley Driscoll Iramdlrt@Salem.Com - - Larry Ramdin,-MPH, REHS, CHO Mayor - - - - - - - - Health Agent PUBLIC POOL HEALTH PERMIT Permit # PO -16-3 Date of Print 5/19/2016 Permit Issued 1/1/2016 - Permit Expires 12/31/2016 Permit Fee $210.00 Late Fee $0.00 Granted To: LVO YMCA Address: 40 Leggs Hill Road MARBLEHAD MA 01945 Location of Establishment: LEGGS HILL ROAD Restrictions: Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2016, unless sooner revoked or suspended. License For: Pool (year round) Granted To: LVO YMCA Address: 40 Leggs Hill Road MARBLEHAD MA 01945 Location of Establishment: LEGGS HILL ROAD Restrictions: Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2016, unless sooner revoked or suspended. KIMBERLEY DRISCOLL MAYOR LOCATION OF CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4- FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 1Muia=n salem com 1P CHeakh LARRY RAmDIN, RS/RL'HS, C HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A S1a WMING POOL NAME OF APPLICANT —631 —1� 2 -2 - ?A (V / i4. CERTUF& POOL OPEN TO�j o 1!— 2Ni` ? ® 4 Name:. .b j / lti- i �� Cert #: TEL #--IV ?i V0 —7" DATES, OF OPERATION (ifnot annual):_ DAYS & HOURS OF OPERATION: 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 plan 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 I, to my best knowledge and belief h filed all tax Wturns prid paid all state taxes required der the law. ,20[6 Signature to SS# or Federal Identification Number Revised 523/11'poolappll.doe Check #Date City of Salem, Massachusetts s Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 PublpcOHeatth Tel. (978) 741-1800 Fax. (978) 745-0343 ote. Proteet. Kimberley DriscollLarry Ramdin, MPH, REHS, CHO Mayor _ _ _ _ _ Driscolllramdin@salem.com Health Agent PUBLIC POOL HEALTH PERMIT Permit # PO -16-4 Date of Print 5/19/2016 Permit Issued 1/1/2016 Permit Expires 12/31/2016 Permit Fee $40.00 Late Fee $0.00 License For: Pool (special purpose) Granted To: LVO YMCA Address: 40 Leggs Hill Road MARBLEHAD Location of Establishment: 40 Restrictions: Notes: LEGGS HILL ROAD MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2016, unless sooner revoked or suspended. < � 0� P Lr.Ja KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSE' TS BOARD OF HEALTH 120 WASHINGTON STREET 4TM FLOOR 'ILL. (978) 741-18�00 FAx (978) 745-0343 1_m� in11/ll a1em com PrerevG PrvmeU: Protect. LARRY RAMDIN, RS/REHS, Cl HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A S11idiMMING POOL A e mle. DATES OFOPERATION (ifnotannual):_._. DAYS & HOURS OF OPERATION: TYPE OF POOL Public Semi -Public Special Purpose 4,17" 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, orEquipment changes are made, allpI such must be submitted to and approved by the Salem Board of Health an Pursuant to MGL Chapter 63C, Section 49a, I certify under the pains and penalties of perjury that I, to my beat knowledge and belief; h filed alltax s d paid all state taxes W.�i; r the law. _C6an Signature SS# or Federal Identification Number Revised 523111 poolappl Ldoc Check # Date Permit # PO -16-14 Date of Print 6/7/2016 Permit Issued 6/7/2016 Permit Expires 10/1/2017 Permit Fee $40.00 Late Fee $0.00 0 Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com PUBLIC POOL HEALTH PERMIT License For: Pool (seasonal) Granted To: Address: 40 Leggs Hill Road Location of Establishment: Restrictions: Outdoor Pool Notes: LVO YMCA MARBLEHAD LEGGS HILL ROAD lu PublicHea Ith Prwrno Promote. Pmmct. Larry Ramdin, MPH, REHS, CHO Health Agent MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 1011/2017 unless sooner revoked or suspended. - �1, KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HF _IL rH 120 WASHINGTON STREET, 4r" FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 Iramdin u salem.com SWIMMING POOL INSPECTION REPORT UV PublicHealth Prevent. Promote Pratecr, LARRY RAMDIN, RS/REtIS, CI -10, CP -FS HEM. rli. AG IiiNr NAME: L. VU 1 M CA DATE:.OkV%L1G TIME IN: � 0Oan, r n f Mo -b A1,4 ADDRESS: Vo '3aa175 / II I7Coad 01.gY5' PHONE: ?Y1—. 31-V2z TIME OUT: 1LLL_a,., CERTIFIED POOL OPERATOR: Su sfun Regulations 105 CMR 435.000 :Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V Regulation Compliance Yes N Number Title and Description 435.03 Bathhouse: Separate sanitary dressing facilities and water closet for each sex which are well lighted, drained and ventilated - Showers with hot and cold water - Sanitary drinking water - toilet paper, soap at sink and in showers (shatter proof containers), paper towels and waste receptacle 435.06 Water Circulation and Filtration: Over-all recirculation and purification system designed recirculates and filters the entire volume as follows: • Swimming Pools - Once every eight hours • Wading Pools - Once every four hours • Special Purpose Pools (Spas) - Once every half hour Maximum design filtration for filters: • High rate sand filter - 15 gpm / ft' - 20 gpm / ft' (NSF filters) • DE filters - 2 gpm / ft? • Cartridge filters - 0.375 gpm / ft' Automatic hypochlorinators required feed -rate capacity: • Outdoor Pools -Three pounds of chlorine per 24 hours per 10,000 gallons • Indoor Pools - One pound of chlorine per 24 hour per 15,000 gallons 435.08 Inlets and Outlets - All special purpose and wading pools shall install an emergency shut off switch which is accessible, working and prominently marked 435.12 Water Depth Markings - Marked on pool deck and on vertical pool wall. Four -inch contrasting color stripe dividing shallow and deep ends including ledges and steps 435.21 Permit Requirements and Pool Records - Permit posted in conspicuous location. Maintain initialed records including daily attendance, amounts and types of chemicals used daily, chemical and bacteriological tests; dates and times of emptying, cleaning, and back -washing and hours of operation of purification equipment 435.22 Health Regulations, Signs - No employee working at swimming, wading or special purpose pool shall have a communicable disease. Operator shall enforce the following for bathers: All bathers shower before entering pool - Clean bathing suits - No communicable diseases (fever, cough, cold, inflamed eyes, nasal / ear discharge) - No open sores, skin diseases or bandages - No glass • Signage at entrance of pool enclosure or in dressing room - "All persons are required to take a cleansing shower bath before entering the pool. No person with a communicable disease is allowed to use the pool". • Additional signage for special purpose pools - "Do not use under these conditions: Alone - Under the influence of alcohol, anticoagulants, antihistamines, vasoconstrictors, vasodilators, stimulants, hypnotics or tranquilizers - Consult physician if person is elderly, pregnant, suffers from heart disease, diabetes, high / low blood pressure - Water temperature above 104°F - Observe reasonable time limits - No oils and body lotions" . Easily readable large dial clock -i SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V 1 NAME: `—' Q YM I Regulation Compliance Combined Chlorine Number I Title and Description Yes o 435.23 Alkalinity Lifeguards – Lifeguard certifications – Warning sign stating (if no lifeguard is required by Board of Health) "Warning – No lifeguard on Duty" and "Children under age 16 should not use swimming pool without an adult in attendance and "Adults should not swim alone" in four inch letters. Clothing – Lifeguards shall wear red or bright orange bathing suits, shirts or jackets with guard printed in 4 -inch lettering. Lifeguards shall direct their attention to area assigned 435.24 Safety Equipment – One ring Buoy for each 2000 ftz, One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 435.25 First Aid Equipment and Emergency Communication – Provide a standard Red Cross fust aid kit– Working, convenient, immediate, toll-free communication system with emergency medical services, local / state police, fire department available to staff and public at all times with instructions for use 435.29 Chemical Standards – Test for residual disinfectant and pH conducted four times a day (once during peak load), Alkalinity and calcium test conducted weekly. Ranges are: • Residual Chlorine 1.0 – 3.0 PPM Combined Chlorine 0.0 – 0.2 PPM • Bromine 2.0 – 6.0 PPM • pH 7.2 – 7.8 PPM • Alkalinity 50 – 150 PPM 435.30 Water Testing Equipment – Provide a DPD test kit for measuring chlorine / bromine and appropriate kit for measuring pH, alkalinity and cyanuric acid – Reagents shall not be more than one year old – Provide accurate, unbreakable thermometer for special purpose pools 435.31 Water Clarity – Water shall be clear (black disc on bottom of pool, clearly visible from sidewalks of pool at all distance up to ten yards) 435.32l / Water Quality Maintenance – Special purpose pools shall be drained, cleaned and refilled a IBJ minimum of once every 14 days 435.33 p j V Maximum Operating Temperature for Special Purpose Pools – Water temperature not more than 104°F – Water temperature shall be tested when residual disinfectant and pH are tested 435.34 Closure of Pool – Operator shall immediately close pool until pool water conforms to 105 CMR 435.28 through 435.31 standards 435.38 General Sanitation – All pools, bathhouses and grounds shall be maintained in good repair, safe and sanitary manner. Remarks, Results and Action Taken: Swimming Pool ' Wading / Kiddie Pool Free Chlorine Combined Chlorine Bromine PH Alkalinity Calcium Hardness Free Chlorine Combined Chlorine Bromine pH Alkalinity Calcium Hardness Spa Type: Free Chlorine Combined Chlorine Bromine pH Alkalini Calcium Hardness Type: Free Chlorine Combined Chlorine Bromine pH Alkalinity Calcium Hardness Free Chlorine Combined Chlorine Bromine pH Alkalinity Calcium Hardness SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V NAME: � V D YMCA `C Remarks, Results and Actions: TYpe:Lo.r a1n o Type: Small2ndoor Type: Oti+Aobr- Type: Type Free Chlorine y yQPM Combined 3'qfm Chlorine n Bromine D pg r/\ Filter Size ft' 1'SFiZ Minimum dz2-!' Flow Rate gpm ` Pool I �_©p Doo Volume g 3'qfm Combined n Filter Type D Filter Size ft= Cartridge Filter Size ft' 1'SFiZ Minimum \ Flow Rate gpm ` Maximum 330x3 Flow Rate gpm R D M Actual S23 r Flow Rate gpm q r� iWAWAN �/�M Person In Free 5S 000 Chlorine 3'qfm Combined \ Chlorine D Filter Size ft= \\ Bromine 1 Filter Size ftz Z PH ` Alkalin 1�0ff Calcium �6 Hardness 7oiom Free 5S 000 Chlorine 2.O rm Combined nd Chlorine D Filter Size ft= \ Bromine l Filter Size ftz r� PH ` Flow Rate gpm "0 FM Alkalinity 13W Calcium 7oiom Hardness q r� Pool 5S 000 Volume g / nd Filter Type D Filter Size ft= Cartridge Minimum Filter Size ftz \ Minimum ` Flow Rate gpm "0 FM Maximum 13W Flow Rate m g ..3�yPw� Actual q r� Flow Rate gpm Date: ' O is, f7A 010 R. Type: Pool %S' 0001 Volume g / an DE Filter Type Cartridge Filter Size ft= 1742 - Minimum Flow Rate gpm \ Maximum 270�c Z_ Flow Rate gpm "0 FM Actual 13W Flow Rate gpm KIMBERLEY DRISCOLL MAYOR LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF Hear_TH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 I ramdin(t_.sal em.com 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOLI V I l UGU SIL (/ l ,�X.r IW % I 1 I L, f� NAME OF APPLICANTS j/I tk P� �1 I)nw T�E/�L�# /(1\ I vl �V,, , �t(�/ MAILING ADDRESS —lV Loaa<� H l I I PmA f r r h'10 Y e a OC1. WV1 00- CERTIFi-�R1r� POOL OPERATOR 1 I . [ — p� Q Name: J(ASCc.41 C71.(�.f -bn Cert #: � tl' � SJLO TEL # / O I I qO �VV( DATES OF OPERATION (if not annual): DAYS & HOURS OF OPERATION: Nam — 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Date SS# or Federal Identification Number Revised 5/23/11 poolappl Ldoc Check # CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"1 FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 KIMBERLEY DRISCOLL lramdtnnae salem.com MAYOR SwimminE Pool Inspection Report Pool: LYVC Cny --*,PrQ Oddi CDate: s f a!l/(Lf Address per. S orf \?_ Phone: Operator: Max Bathing Load: u PublicHealth Prevent Promote. Protect. LARRY 12AMDIN, RS/REI-IS, CHO, CP -FS HEAI..TH AGENT Chanter V. 4IA nnual Permit Posted Health and Showers signs Posted ifeggaids:alth: Heno sick s, no sick bathers, bathers take showers, spitting prohibited, no glass. �LPresent employee ertification _ Red/orange suit I/ card" printed on jersey Sun block avail. _ Voice Amplifier _ Elevated seat f/ Emer. Communication: phone at pool Phone instructions _ Emergency numbers Phone in unlocked area _ZSafet_y quip: for each 2000, sq. feet scue tube or ring buoy (with rope) Backboard with collar and straps First d: Equipment area /5) 1" band-aids 10) 3x3 gauze 5x9 surgipads2) antiseptic wipes V (1) 8x10 Surgi � 2" soft roller bandages Issors 2)3" Soft roller bandages .Teezers 1�z roll hypoallergenic tape V R cue blanket L/��c.e packs ket mask t, sterile isotonic eyewash L, Disinfection _ Chlorine _ pH 7.2 — 7.8 Residual free 1-3, Combined 0-0.2 C( _ Bromine _ pH 7.2 7.8 Residual 2-6 (ppm) (mg/1) Recor Kept: attendance tests V Chemicals Used _ Backwashing / attendance _ Hours of operation V Depth Markings Sidewalk and inside pool P ,Diving Boards rigidly constructed, properly anchored, braced for heaviest load, no splinters or c t// 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 facilities Notes: KIM 3ERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4- FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 kam-d1n@salern.con . V12 6 �+Nil�:Hi8lth Prn.W. Promote. Protect. LARRY RAMDIN, RS/RE14S, CHO, HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL L- eW t (. NAME OF APPLICANT �yI if � I ©� J� 1 Cj R 1-6 31 -I �2 DATES OF OPERATION (if not A ® lgltS' - annual): Se -Q eA A2 DAYS & HOURS OF OPERATION: / A 6 a/;" 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 to, 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 I, to my best knowledge and belief, have filed all s tax 8 d paid all state taxes required under the law. o D 3 20�t a-�SSignature !►�i � f 0 C� or Federal Identification Number Revised 523/11 poolappl Ldoc Check# YMCA of the North Shore, Inc. 245 Cabot Street Beverly, MA 01915 (978)922-0990 Accounts Payable Vendor:SALBOH City Of Salem -Board of Health 120 Washington St 4th Floor Salem, MA ' 01970 Phone - 978-741-1800 / Fax - Document 'Information Document Date 05/23/2014 Required Date 06/02/2014 Prepared By Gen Kuksin Workflow ID 04-08 Status Accounting Documents Description Outdoor pool permit 1111111111111111111111111111111111111111111 REQUISITION Ship -to -Address 40 Leggs Hill Road Marblehead, MA 01945 (781)631-0870 Ext Gen Kuksin Comments : Unit Qty Received Account - Item Ite Unit Tax Qty Type Rec'd Date Information Number a ription Price % Total 1 EA 0' 57200 01 04 08 0 00 000 N/A O or pool permit 40.00 0.000 40.00 Total: $40.00 en Kuksin Requester 05/23/2014 3:29 PM This Purchase Order Authorizes the purchase of the Items or services in the quantities and the amounts specified above by the purchaser identified above on the presentation of proper Identification at time of purchase. The Purchase Order # number must appear on billing Invoices and packages and billing of the purchase must be submitted to the address shown above. Organization Name is exempt from payment of Sate sales tax under Exemption # 042-104-913 Control No. 46738 Friday, May 23, 2014 Page 1 of 1 �Cotnnionwealth of Massachuaetta 4,� City of Salem ` Kimberley Dnscoll Board of Health- ' 120 W ashmgton Street; , th Floor l fle Or k = t_. r •_� >-SALEM MA $ 01970 ' " Swlmming Pool Anhual Permit 3 c ED 12/177/2012 y DATE PRINT� � � s, F r 4. AESTABLISNAME."4 YMCA vLynch Van Otterloo ?� File Number BHF 2009 000002f a 4 ' X4? 40 Legga Hill Road" " TMa �. t3 §. MARBLEHAD l MA "01945 V LOCATED AT T2 x SALEM, MA 01979 .r 11 4 ,Permit Type zPermit No..' s Permit Issued Permit Expires Fee RRestrictions/Notes SWIMMING POOL BHP 2013.0205 Jan l - 2013 Dec 31, 2013 $40.00 ; ; s kz ANNUAL 'a' y •&Ty:. i� gSWIMMING POOL`S BHP-2013-02)(4 * Jan 1, 2013 :Dec 31,2013` x$40 00 Lap Pool ANNUAL _ 2 Total Fees $80 00 r a M � � 3 r Y s L3 F� 3 - A Ila, - ..... f q cd -4 SSR" Sk`_,d#` { PERMIT EXPIRES December 3i 2013 M N Board of Health HMENT n r.. sa m� AII $ E z -.,Pagec1 3 - KIMBERLEY DRISCOLL MAYOR DAVID GREHNEAum,RS ACTING H1iAt.Il1 AGENT' CITY OF SALEM, MASSACHUSETTS BOARD OF HEAL7'I-I 120 WASHINGTON SIREE'r, 4n FLOOR 'Mi_ (978) 741-1800 FAX (978)745-0343 DGRriENEAUNI&ALEM. COM 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION01, POOL /� p��////f� `//LJ NAME OF APPLICANTLt/�Q��j/Af/ !Jj%t°/1 (9Q Y TEL #721- l0 3 %- 96 2 Z MAILING ADDRESS0r`� 9� CERT IED POOLf,Q�PERA OR Name: uSt OunJ (rW/? t7 dz Cert #:©/-22f9&FL # 7,? — Fe — 700f DATES OF OPERATION (if not annual): aw;V &a DAYS & HOURS, OF OPERATION: Qiltit M,49 7W.? TYPE OF POOL' Public Semi -Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal $40.00 Non -Profit (Please pay total with one check payable to the City of Salem) This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code, before any renovations, improvements, or Equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 63C, Section 49a, I certify under the pains and penalties of perjury that I, to my best knowledge and belief; have filed all state taxfeturim�s and paid all state taxes required under the law. Signature Date SS# or F64deral Identification Number Revised 10/6/10 poolappl I.doc Check # dyb u� " Commonwealth of Massachusetts AV— f s m City of Salem e ri 4Board of xealtli Kimberley Dnscoll `" t 0c k r + zMayOr 120 Washington Street,v4th Floor. #' e� SALEM_ , MA,' 01970: a � w SW1ID1t11IIg YOOI AI1II1181 pCTllllt '-o ' "DATE PRINTED t .� �=, v-,` n ,€ Y ,� e fit` +. 'rt�' x n .� N �' b k se r. ��` a• .v 1: YMCA - Lynch Van Otterloo ESTABLISHMENT NAME s q y x -x 's >• 4 - kV a F3Ie NumberBHF 2009-000002 -` '' '' :40 Leggs'Htll Road vA�_` v SALEM, MA OIy7t) ; s`_ a. aa-} `° �$ ,-.rn ,3n..` -.r' i #, xx B K_ a -r ++ti :i P,erIIut Type > Perrmt No.- Permit Issued t Permit Expires k i. Fee Restrictions / Notes f SWIMMING POOL i BHP 2013 0207 Jan 1, 2013 x Dec 31, 2013 $40 00 Outdoor Seasonal Pool Open Gam to '� `� „ �' ,=,g ,� ""� � Tota► Fees ;� ,. 'x$40 00 � - � �„� -' ,� <.. ., .. g}o-�`ei E b s >� a a n'`" 'T F `,. h ' aF' it -INT, 4 s �r� s „s° ,, „u ms jr a .. '# Y ��ae �. � - a, Zt EPERMTT;EXPIRES r - December 31 2013 h `' Board: of Health 5 a .wi' ' r . � .5 W xs Ems.aee n 44 x #; ""`� 1 7F lal a r. '" "}•� r {`„£.`k 5 A wu a F ss xr eb9% g 2 KIIvIBERLEY DRISCOLL MAYOR DAVID GREENBAUM, RS AC 7NG,HI AL'M AGENT LCCATIO] NAME OF MAILING CITY OF SALEM, MASSACHUSETTS BOARD OT HEAL'T1i 120 WASHING'T'ON STMET, 4"' FLOOR 'ML. (978) 741-1800 FAX (978) 745-0343 DGREENBAUM@SAI,I3M. COM 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL �4 �S— CERT IED POOL,QQPERA OR Nor nJ (r W/? n /]/ Cert #:P(-27Jff?&EL # 7X l- `/QiO -%ho f DATES OF OPERATION (if not annual): DAYS & HOURS OF OPERATION: S a,;" (P 0 TYPE OF POOL Public q 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 I, to my best Imowledge and belief, have C��filed allstatetax et and paid all state taxes required under the law. �CO/1�/3 Signature Date SS# or F eral Identification Number Revised 10/6/10 000laml l.doc Check # 7` :+ Commonwealth of Massachusetts s City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Swimming Pool Seasonal Permit, DATE PRINTED: 05/25/2012 ESTABLISHMENT NAME: YMCA - Lynch Van Otterloo File Number: BHF -2009-000002 40 Leggs Hill Road MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SWIMMING POOL - BHP -2012-0448 May 25, 2012 Sep 29, 2012 Outdoor Seasonal Pool Open 6am to SEASONAL 8pm - Memorial Day weekend to Labor Day weekend Total Fees: PERMIT EXPIRES iSeptember29,2012 Board of Health 9, Page 1 KIMBERLEY DRISCOLL MAYOR L.ARm' R;An'mIN, RS/RFJ N, Cl to, CP -FS Htt.-u ,t i 1 AG ISN'1' CITY OF SALEM, MASSACHUSETTS Bov D OF Hi nI:r11 120 W!\51 -I ING 1 o ,A SHUT11, 41" 17 LOOR TI!1.. (978) 749-1800 FAN (978) 743-0343 JAU Nil)] NCI cA IInt(-OA[ 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL Lynch/vanOtterloo YMCA, 40 Leggs Hill Road, Marblehead, Ma. 01945 NAME OF APPLICANT Susan S. Guertin TEL # 781-990- 7009 MAILING ADDRESS 40 Leggs Hill Road, Marblehead, Ma. 01945 CERTIFIED POOL OPERATOR Name: Susan S. Guertin, Emily Korriku, Gen Kuksin 279998 TEL # 781-990-7009 DATES OF OPERATION (if not annual): May 26" -September 9, 20 DAYS & HOURS OF OPERATION: 5:30 a.m.-8:00 TYPE OF POOL Public Semi -Public x 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. Cert #:_01 -280003,01 - 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 YGL Chapter 63C Section 49a, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all st tax returns and ;)id a)lytate taxes required under the law. Revised I poolappl I.doc Check # Date /_04/23/12_/ 030-30-4988 Date SS# or Federal Identification Number o e C1 -1Y OF SALEM, MASSACHUSF:I"TS HOARD OF HF-uTH 10 120 WASHINGTON STREET, 4`" FLOOR. ..... 1Ptlblgfl411 1'rrvenl. VrooYrolpct. TEE_ (978) 741-1800 FAx (978) 745-0343 KIMBERI,LY DRISC;OLI. IraradinCa�salem.com LARRY RAMD1N, Rti�RU.I-I S, cl io, CP -II ;S MAYORH m,iiiA(uxr Swimming Pool Inspection Report Pool: �V t1U�dOOr llOt�� Date: 57 ati I A Address Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards for,VwimminjZ Pools • State Sanitary Code Chanter V. ✓ Annual Permit Posted Health and Showers signs Posted Health: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. Lifeguards: Present I'e Certification v&� Red/orange suit _ "Guard" printed on jersey _ Sun block avail. _ Voice Amplifier _ Elevated seat Enter. Communication: pqone at poo Phone instructions p true. j 1. W (I (,.P -Emergency numbers _ Phone in unlocked area P of OtA — Safety Equip: for each 2000, sq. feet kp/ceeNd�h Rescue tube or ring buoy (with rope) _ Backboard with collar and straps ✓ First id: Equipment area 35) I" band-aids ✓ (10) 30 gauze (2) 5x9 surgipads Z (12) antiseptic wipes (1) 8x10 Surgi %/ (2) 2" soft roller bandages Scissors (2) 3" Soft roller bandages Tweezers (1) %: roll hypoallergenic tape Rescue blanket _✓ ice packs Pocket mask sterile isotonic eyewash ✓ Disinfection —Chlorine ,a _ pH 7.2 - 7.8 Residual free 1-3, Combined 0-0.2 _Records Kept: Bromine yy 5 _ pH 7.2 - 7.8 Residual 2-6 (ppm) (mg/1) 'Y� � Water tests —Chemicals Used _ Backwashing _ Attendance _ Hours of operation Depth Markings Sidewalk and inside pool (J Diving Boards rigidly constructed, properly anchored, braced for heaviest load, no splinters or c 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 facilities Notes: Received by: Inspected by: theLV TRAINING CERTIFICATION { - y�j This recognizes that �• `T YMCA OF THE USA tj O - Brianna Feman ' i L has completed the requirements for e< Administering Emergency Oxygen 10MAAQ111BY070EV conducted by YMCA - Marblehead/Swampscott Q Date completed: 12/28/2010 BrIBMB F2rTlafl The American Red Cross recognizes - - - - - �- - this certificate is valid From - - - -YMCA-Lifeguard completion date for: l Year Expires 12/30/2012 This recognizes that HThis recognizes that 'i M IA Brianna Feman j Q Brianna Feman V 0 - has completed the requirements for V has completed the requirements for 'V V h' V - CPR/AED for Lifeguards � V Standard. First Aid d conducted by �'0 conducted. by - £� YMCA - Marblehead/Swampscott - a YMCA Marblehead/Swampscott Q a�. Date completed: 12/28/2010 Date completed: 12/28/2010 ` e American Red Cross recognizes The American Red Cross recognizes .I The certificate is valid from this certificate is valid from .completion date for: 1 Year completion date for: 3 Years - - - a c,, Lynch/van Otterloo YMCA 40 Leggs Hill Road Marblehead, MA 01945 781.631.9622 fax 781.639.0190 Cape Ann YMCA 71 Middle Street Gloucester, MA 01930 978.283.0470 fax 978.283.31 14 Greater Beverly YMCA 254 Essex Street Beverly, MA 01915 978.927.6855 fax 978.927.6530 Haverhill YMCA 81 Winter Street Haverhill, MA 01830 97$.374.0506 fax 978.373.07 10 Ipswich Family YMCA 110 County Road Ipswich,MA 01938 978.356.9622 fax 978.356.0625 Salem YMCA One Sewall Street Salem, MA 01970 978.744.0351 fax 978.740.9168 YNCA of the North Shore 245 Cabot Street Beverly, MA 0 19 15 978.922.0990 fax 978.922.7602 United Way Massachusetts Bay Merrimack Valley North Shore June 8, 2011 To Whom It May Concern: Please accept this letter as proof of certification for Shannon Tucker. She has successfully completed all of the requirements for YMCA Lifeguard. Her official certification is currently being processed out of the YMCA national offices and should arrive in 6 — 8 weeks. If you have any questions please feel free to contact me at the Lynch van Otterloo YMCA. Sincerely, Guertin, Aquatic Director Emily Korriku Asst. Aquatics Director www.northshoreymca.org Ins'pectia^.of Ir`7ii�r� 'J •tJ • Y 3t`t C,/ 1 SIi1C 16 `r1diJ')C Date � � � l� Time Name e �� Address Owner `` Tel. No. Type of Inspection Inspector 1 (�) Remarks and Violations are listed below: �! 'f.k7StkT Uhon CL C -CII k,DI W O i PCC C.� Y F \ ! l 1. 'i":(.V ri �I 1 'HylI f 1✓ �.�...../7 Cr I C roti rx t'i�r, cw,s h"d uur l me Cxuei{ C ucf(C.S� C�t°tfC t Cit tfl' IM 1,4, t-Ie.(�O IV\-Iif +Loo 4C.C(l (Y)cI vafs octill if r�-,xA `Ga -4 `uUi� e �iC�. YfttCi (YICtS 3�Y�c7((�c�clrtjj� �{LkyY_'4-��(lat� Irl -4-C� Pu -j `�-V\ t4 1ki -%X -) III ` :.t i —� 6�d1\Si i1 �V Q%4PAln I 05 Q'51`1-111 t�tDnix iq+ USM !rl C'Ilall-vD Is t�+_�(Pi�'er ` u"A IJ Pu r 5-n . tLL'Q g4iz--t5 t.W}`� � " lam! . 7-1.-P- tvtxe Giirn )d 1001 V 1,1:� Cititl�a'�Lfi ��',vg;""C =)D -w L JA I�I,44c2 V1'�p„C` i(5 r� i"1 C7 Q � Chrct's q isr) (1-14'� d Cit.--rilli i '-4) t ��rr1 ��(5 l�Yt � "?1tG -� �r1 ��-•�� (��: �`�� v'1`�"f cf r�r� a �r`�-f�_r X11 �3 'Oc- (--�c-Id "-Y+ C� 11 E f1ccv1 c. v t-4 PV?i CNVQC/o C i:ttc "t 1 ` tl (� i^r ; d l� 4, 6.0 (- 1 i l I -t , pv Fa Report Received by: KIMBERLEY DRISCOLL • MAYOR LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT • 0 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 LRAMDINQ,SALEM.COM COMPLAINT INTAKE FORM Dater Time: L9 Received By: Complaint Number: 0035 Complainant Address: Phone: h Investigated By: Date: Property Owner/Occupant Name Telephone #: KIMBERLEY LRISCOLL MAYOR LARRY RAMDINH , RS�Itri is, CO, CP -FS H F.AI: n i AG t'.N*r CITY OFS --,EM, MASSACHUSETTS Bo.ARu or Hi-,Ai,'rii 120 WASHINGTON STREET. 4"' FLOOR Tr'L. (978) 741-1800 FAX (978) 745-0343 Iramdin&salem.com Swimmine Pool Inspection Report Pool: LV-0WC6 in tioor - 101' I) Date: S'l3lli Address Phone: Operator: Max Bathing Load: 1n accordance with 105 CMR 435.00 Minimum Standards for Swimming Pools; State Sanitary Code Chanter V _Annual Permit Posted /Health and Showers signs Posted t_/I/ iealth: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. I/ L?feguards: Present Certification _ Red/orange suit _ "Guard" printed on jersey —Sun block avail. _ Voice Amplifier _ Elevated seat V Emer. Communication: phone at pool _ Phone instructions _ Emergency numbers _ Phone in unlocked area Safety Equip: for each 2000, sq. feet _ Rescue tube or ring buoy (with rope) _ Backboard with collar and straps First Yd: Equipment area 35) 1" band-aids 10) 30 gauze �2) 5x9 surgipads j12) antiseptic wipes4k-4ee�-r+Te�^e —S l) WO Surgij/ 2) 2" soft roller bandages Scissors t/— (() 3" Soft roller bandages /Tweezers ✓(I)'/2 roll hypoallergenic tape t�Rescue blanket me packs :Pocket mask. sterile isotonic eyewash Disinfection _ Chlorine _ pH 7.2 - 7.8 Residual free 1-3, Combined 0-0.2 t _ Bromine _ pH ,7.2 - 7.8 Residual 2-6 (ppm) (mg/I ) l/ecords Kept: _ Water tests _ Chemicals Used _ Backwashing _ Attendance _ Hours of operation Depth Markings Sidewalk and inside pool X401—Diving Boards rigidly constructed, properly anchored, braced for heaviest load, no splinters or c 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 Notes: Received by: Inspected by: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 41.. FLOOR TF.i . (978) 741-1800 ICIMBERIEY DRISCOLL FAX (978) 745-0343 MAYOR Ir,,iinchn@saletn.com LUIRY RAMDIN, RS/RISIIS, CI 10, CP -FS - HFAunIAGFr,NI' Swimming Pool Inspection Report ,Pool:d(D-o - Date: Address Phone: Operator: Max Bathing Load: o..,.,d...e.. . c ...:......:.... P-[ - C...m c. /Annual Permit Posted izAcalth and Showers signs Posted L/ ealth: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. Lifeguards: Present _ Certification _ Red/orange suit _ "Guard" printed on jersey Sun block avail. _ Voice Amplifier _ Elevated seat Emer. Communication: phone at pool _ Phone instructions _ Emergency numbers Phone in unlocked area --i/ Safety Equip: for each 2000, sq. feet _ Rescue tube or ring buoy (with rope) _ Backboard with collar and straps First Aid: Equipment area K05) I" band-aids ✓10) 3x3 gauze l I1 V (2) 5x9 surgipads 5i2) antiseptic wipesk"d n orc �Z 1) 8x 10 Surgi b/(2) 2" soft roller bandages a w bre- cissors V2) 3" Soft roller bandage 1*4W V Tweezers ✓ 1)'/, roll hypoallergenic tape V escue blanket it packs / -Pocket mask _✓sterile isotonic eyewash L/ Disinfection _ Chlorine —PH 7,2-7.8 Residual free 1-3, Combined 0-0.2 C I Z<G . Q Bromine _ pH 7.2 - 7.8 Residual 2-6 (ppm) (mg, I) 71 � ___(,/Records Kept: PHX _ Water tests _ Chemicals Used _ Backwashing Attendance _ Hours of operation V Depth Markings Sidewalk and inside pool j) Diving Boards rigidly constructed, properly anchored, braced for heaviest load, no splinters or c 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 Notes: Received by: Inspected by: 7k 12'qCh �np--Q"? I the FOR YOUTH DEVELOPMENT F� FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY { Dear Parents, Monday, July 25, 2011 As parents of campers in the Preschool Camps offered by the Salem YMCA, you have the right to review Background Checks (such as references) on counselors in the camp, the camp's Health Care Policy and Discipline Policy as listed in the Parent Handbook. If a'grievance or concern occurs, persons to contact are: Nicole Brennan 978.744.0351 ext.1516 Mary Sholds 978.744.0351 ext 1501 Sincerely, Nicole Brennan i I{ sy)q-ptl— �� /h� Staff Orientation Staff Name 1. Complete staff file 2. Review Emergency Procedures 3. Review Health Care Manual 4. Review Parent Handbook 5. Review Campers files 6. Review activities Y FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY Gv, r be �QLbn'1 �✓ Clir.LO i n C}�endar�e.E �so,l-�. a L TM the RFs .i f FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY Emergency Evacuation Plan Incase of an emergency please see below for exit plan. Exit Plan 1 Line campers up. Count campers and'take atten- dance book. Exit .room turn left. Walk towards front entrance on Essex Street'. Exit through Front door, walk down side walk and cross street. Exit Plan 2 _4 Line campers up. Count campers and take atten- dance book. Exit room turn right follow to exit door inside' YMCA. Take a left then right towards YMCA Main Doors onto Sewall Street. Cross street. t American Red Cross ' !KF�I. 4 PHONE E-MAILADDRESS course Record ;II'.STRUCTOR 7/eOIP Page of su'Mm•I IPnn hnW, jj^�'' SPONSORING RED CROSS UNIT HOURS ADDRESS—•g N•mm m wm i,reu•re•nrow n.°aawn°,.,,,np . /�� "_. y//J�� ( I ADDRESS . DATE COURSE STARTED DATE COURSE ENDED UL) YC A,Y ^3(J ` t / . I j./J COURSE NAME K. Check here if adtlress for ehher tha Instructor or co -instructor is new. ❑ I61°rel - AUTHORIZED PROVIDER ID NUMBER - PHONE �� ' lOICI"° i�Cl / wr)�f' COURSE CODE STREET - - E, -('SAIL ADDRESSbr &j( - CRY, STATE, ZIP UNR OF AUTHORIZARON h Q 0 /l � aro Lll- G}l N�9v a "-y TOTAL INDIVIDUALS ENROLLED IN THE COURSE '"ININGAUDIENCE ( v Q sem• �u nA / Check the boK that best describes the training audience: AOCCUPATIONALtWORKPLACE COMPONENT INFORMATION .ADDRESS c� ' (�/Y) �� CFYt�l__ y,^� 7lss�� (,_/^ `-✓ COMPONENT NAME CODE HOURS NUMBER NUMBER NUMBER SEX I,510`rel Inpl / ENROLLED PASSED AUDITANC CO -INSTRUCTOR MEDICAL/RESCUE Dan nonal mrsU babl MALE - ADDRESS�,- HISPANIC OR LATINO AMERICAN INDIAN/ALASKA NATIVE❑ FEMALE ACADEMIC . ASIAN 1°I�1 (K-12, Gollegowuniverslues) .NATIVE HAWAIIAN OR'PACIFIC ISLANDER❑ NN /G DID NOT REPORT M - lme�•1 kbl ' !KF�I. 4 PHONE E-MAILADDRESS TOTAL UNIT OF AUTHORIZATION HOURS N•mm m wm i,reu•re•nrow n.°aawn°,.,,,np . TRAINING SRE INFORMATION (name Of a Omced provider, school, WOflWlace, organization or Red Cross ADDRESS . unit)commonly InM mmo (LPI NAME Check here if adtlress for ehher tha Instructor or co -instructor is new. ❑ - AUTHORIZED PROVIDER ID NUMBER - COMMENTS - STREET - - - CRY, STATE, ZIP - HOW COURSE WAS DELnfERED O FullseMce contact ❑ Community ❑ AuthodzOc provitler - '"ININGAUDIENCE ETHNIC Check the boK that best describes the training audience: AOCCUPATIONALtWORKPLACE ORIGIN INFORMATION WHITE SEX (Manufacturing, Adminishative/Offfces, Retail So'he"alls, Transportatlon Centers) BLACK OR AFRICAN AMERICANO MEDICAL/RESCUE MALE (Hospitals, EMS/Fim. Police) HISPANIC OR LATINO AMERICAN INDIAN/ALASKA NATIVE❑ FEMALE ACADEMIC . ASIAN (K-12, Gollegowuniverslues) .NATIVE HAWAIIAN OR'PACIFIC ISLANDER❑ DID NOT REPORT CONSUMER CERTIFICATES (Check one): ❑Instructor will Pick up certificates nd certificates to instructor (Youth Groups, Military, Organizations, Religious Group, Park & RecmatioNGovemment) I certify tNs training session M1ae been conducted in accOrdaa�nce h the re r - mOd ❑Send certificates to aNhonzeil rovitler ❑Cert?rotes Issued on site ❑Not applicable ❑ Other ��/w/' uirem/enis antl procetlures of Me American Retl Cross. Note: All co-Pnamed above INSTRUCTOR SIGNATURE or ID NUMBER IL.Ci(�(' X OiIAA� must sign or Include ID numbers •^'"1 CO -INSTRUCTOR SIGNATURE or ID NUMBER OFFICE USE ONLY DATE RECEIVED -.."DATE CERTIFICATES ' ...DATE nuRsrAuccl® - a®cMss IIWVICH IRSUED RECORDED'. _ - INDiALB OFiPEASON =" "ENZFRlNn4sne.. r ". IMSOR CFER9_Ct'A.Sg ,.. FORM TOTAL PASSED For information on component cotlee and certlfiwte(s) participants receive,. please contact your local chapter SPONSORING RED CROSS UNIT'S RECORD (Atltl each wlumn) Almerican Rec III, N American Red Cross _ Course Record Addendum T COURSE SE NA ME AND CODE '--' ...... Page —Of— of EOR, DIS/ISTER.SERYICE3 ANWAFM .� NAME OF INSTRUCTOR All//} /� n / `/ / ccxe �/S C nnar� ^A y Rift-ES' �V�kl� e�lr SP D RED GROSB UNIT'*.a;5'kd4°�}`r,'''"*},�5°i. NAME OF COy. -INSTRUCTOR CfTV AND STATE y IERIE CIX]�E ¢y + y `' _DATE �% AS HFSD"�•xi .. R• r - INSTRUCTOR'$ �gpNPTUREa'OR NUMBEq COURSE BEGAN �` J / V ---__ DATE COURSE ENDED / PO�•�K. ID r ��R,: x''t S'"ty r a a �.CO•INSTRUCfOR53NiNgil'ORID fTl CDMPoNORS .. NAME MAILING ADDRESS PHONE E-MAILADDRESS 0 ENROLLED usr AND STUDENT ID INSTRUCTOR COMMENTS, DSHR S''^^ EEr GRADE ENROLLED ,- , ..,.... h Ca. • O `..... BADE r FF L, eaer � s � ENROLLED- �J {JKI • I - QK ` 5J`r� i a}`b Y +S'� �b.`�JT fvb €�� 5� •( � srpeFr Ln GRADE ruler .ST0.1E. aP ) - p � ENROLLED MVC s faHT. •e i =4 ��Y1`; '•4' i S )f �uT.4•P y f GIY STVE.LP '�'N'�.4 HU+b 1K.. . j ENROLLED vsr zcy _: F"d s. �x�u kr a :. - }'s, 4.'ht h."l�.i ,,�,++ o_ smrfr . S GRADE nearad M p ENROLLED. sm�T 3 GRADE'.:., s.. •, �ta) 3'"H g ENROLLED GRADE ^^sr ( ) cnv, sr2le VP rn ENROUlt ama n GRADE IVaT � )� Siad rI*2 � i s� 0 ENROLLED 'er I r i• a+5 r t •a"t�' i#-` ' _ q{Y (/j b'IPEtT GRADEad rssr ( ) cm srnre, aP c ENROLL usr' � f r amPsr GRADE ENROLLED usr ...: J; �+` �� :.._•., rt N..:q t"., At .+' GRADE nssr ( ) - CR: s -lre, TOTAL ENROLLED (Add each column) .. TOTAL PASSED For information on component cotlee and certlfiwte(s) participants receive,. please contact your local chapter SPONSORING RED CROSS UNIT'S RECORD (Atltl each wlumn) Almerican Rec N O American Red Cross T Course Record //__ _INSTRUCTORA .Q h n ��) }.J/ GO (4., rcye_or_ SPONSORING RED CROSS UNIT - n." O / ADDRESS lD Imlaam' {'� y _ DATE COURSE STARTED- DATE COURSE ENDED COURSE NAME COURSE CODE 7 I M 1a10. -Ina) PHONEW /' 00 ' )NI -f/,I^E-MAILADDRESSban n TOTAL INDNIDUALS ENROLLED IN THE COURSE nArtwi, I kWF /MCA UNIT OF AUTHORIZATION f"j (' (}(-- /nA&S r COMPONENT INFORMATION Ne aor cnepler/alaXONnNJ M1wapanmsunlp ADDRESS�'7 ( "��/.YVI�� QQ�s�A ZK% Igla� COMPONENT NAME CODE HOURS NUMBER ENROLLED NUMBER NUMBER m sr Ilcl PASSED AUDITANC � 2J CO -INSTRUCTOR n el Illao Imiealel ADDRESS Imml Ismlel ,^�,,, PHONE E-MAILADDRESSTOTAL x s3'.:1'k tw•zY, "8x _t >nt'C HOURS UNIT OF AUTHORIZATION 1 0 oI Myr(e.nmlmNnelbNl neaeeuenea Mme TRAINING SITE INFORMATION (name of authorized provider, school, workplace, community organization or Red Chase unh) ADDRESS (co) (natal Idol NAME Check here if address for either the instructor or co -instructor is new. ❑ - AUTHORIZED PROVIDER ID NUMBER COMMENTS STREET CITY, STATE, ZIP - HOW COURSE WAS DELIVERED ❑ FUIIseMce conimet ❑ Community ❑ Authorized provider TRAINING AUDIENCE Check the box that best describes the training audience: OCCUPATIONAL/ WORKPLACE ETHNIC ORIGIN INFORMATION SEI (Manufacturing, Administrative/01115, Retail Stoms/Malls, Transportation Centers) WHITE BLACK OR AFRICAN. AMERICAN MALE MEDICAI/RESOUE (Hospitals, EMS/Fire, Police) HISPANIC OR LATINO / AMERICAN INDIAN/ALASKA NATIVE I a� FEMALE ❑ACADEMIC ,(� (K-12, Colleges/Univer flies) ASIAN NATIVE HAWAIIAN OR PACIFIC ISLANDER DID NOT REPORT O CONSUMER CERTIFICATES (Check one): ❑ Instructor will pick up certificates Ne.nd certificates to instructor (Volnh Groups, Military, Organizations, Religious Group, Park & Recreation/Governmant)'. ❑ Send certificates to authorized provider ❑ Certlflcates issued on site ❑ Not applicable ❑ Other I certify this training session has been conducted in/accordance withWerequirements and and procedures of the American Red Cross. Note: All co -instructors named above must sign ar inclutle ID numbers. INSTRUCTOR SIGNATURE or ID NUMBER``_-'�(MX CO -INSTRUCTOR SIGNATURE or ID NUMBER r ,,. OFFlCE USE ONLY 4Y. <DATERECENED DATE CERTIFICATES-. * ^"`k 7"a"^M""N* INITIALS OFPE901J . DATE RECORDED ` iN,# #?,S LMS OR CHEAS CLASS,i :. IAS TaTOCfffi Ca1[cRU kLD rnees aMI11H J ..;. i <, . x ^.d 5 n p,.-2NTERING DATA :'h' x^,x S' ID NUMBER ; SPONSORING RED CROSS UNIT'S RECORD y,y, d �... �� American Rod Cross Farm F841aRp4 (4/p4) N O N T N_ D American Red Cross CourgP RAdInrA AAA...A.._ 07/08/2009 3:48:20 PM -0400 POWERED BY ORCAFAX PAGE 3 OF 4 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTIX- COMMUNITY SANITATION PROGRAM RECREATIONAL CAMPER INJURY REPORT FORM JUL 120ng In accordance with M.G.L. c. I l 1, §§ 3 and 127A and l05 CMR 430.000: Minimum Sanitation and Safety S1 Recreational Camps for Children (State Sanitary Code Chapter IV), 105 CMR 430.154 specifically requires that a iepoorrPF r1EALTH be completed, on a form prescribed by the Massachusetts Department of Public Health, for each fatality orserious 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 07) days of the occurrence of the injury,. PLEASE PROVIDE A COMPREHENSIVE AND THOROUGH RESPONSE TO EVERY QUESTION. 1. NameofCamp: YMC-q S r-`p,l-�-�.( Cam z. Address: 40 W 1 i 11 �oaC� City/Town 1�A ar6U-Ked 3. Name of Camp Director. L. dy"k Qnn e. r�e(- 4, Telephone: -1 FS`' g C 0 --7 00-7 S. Today's Date: 1 (0 0 C1 - 6. Daze of Injury: ZL(o Uq 7. Time of Injury: I d , 15 ( M) 9, Did the injury involve a camper, staff person or both: GQ Yrs [,fie(" - 9a - Age of Camper and/or Staff Person: 9b. Gender: Male Female X to. Briefly describe the incident and subsequent injury: Mlease do not include ES1120W Wentifyinginformation G'l i t t� `•'" �-�'f- a-`-41 r� n -krl r a -f- C' h ,) -s (P mer Golt.�m btss -°fes° r!Q,n'nc� 1,) hi L2 on a- roaId 4-m r) -in 6o.Onn. IL If the injury occurred outdoors, what were the weather conditions at the time of the incident? 'm Dl um6a d- (continued over) IM�W UsndYJ - n 07/08/2009 3:48:20 PM —0400 POWERED BY ORCAFAX 12. Did the injury occur on the campground? If not, specify the off-si1c-I don where the injury ocqured. (please describe the exact location) 13. What body part(s) were injured: O1.Head/Skull X 02, Face_ 06. Back 07. Abdomen 11. Other, please specify 14. How did injury occur? 03. Neck —04. Arm _ 05. Hand _ 08. Leg _ 09. Ankle 10. Foot 1 01. Falling _ 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 _ 00. Other, please specify 15. Where was the injured person treated? 01. Treated in camp infirmary _ 02. Treated in hospital Emergency Room, Physician's Office X 03. Admitted to Hospital_ 04. Other, please specify 16. Was the camper sent home as a result of the injury? Yes_ No X 17. Was more than one camper injured? Yes_ No x If Yes, how many ? 18. Did the injury involve alleged abuse / neglect ? YM—No x PAGE 4 OF 4 19. 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: PLEASE MAIL OR FAX CAMPER INJURY REPORTS TO MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH BUREAU OF ENVIRONMENTAL, HEALTH COMMUNITY SANITATION PROGRAM 250 WASHINGTON STREET -7th FLOOR BOSTON, MA 02108-1619 TELEPHONE (617)-624-5757 FAX (617) 624-5777 (Revised May 2008) t i Commonwealth of Massachusetts City of Salem iGmberley Driscoll Board of Health Mayor 120 Washington Street, 4th Floor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED: 06/23/2010 ESTABLISHMENT NAME:. YMCA - Rising Star Gymnastics File Number: BHF -2010-000032 40 Leggs Hill Roa MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0456 Jun 28, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 6 PERMIT EXPIRES ISeptember3,2010 r ' Board of Health U Page 1 K IMMERLEY DRISCOLL MAYOR DAVID GRgENBAUM, ACTING HFAIXI-I. AGENT CITY OF SALEM, MASSACHUSETTS BOARD OIC H[Aun-1 120 WASHING I'ONSRI.' T,4T"FLOOR Ti.J- (978) 741-1800 FAX (978) 745-0343 DGREENBAUM&ALE4LCOM APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: Address of Tel# W /— / 70 _70// fi,vd , 4z, om6 Camp Website:M /Y 1011S / Fax# 71/1 i� 3 cl(j yv Name of Camp Director. �/JG�i>�C k Wa�i ells /Tel# �g/"/ 7101 70// p� Camp Director mailing address: yU 71Py 5 All rJ . � / 9kr< Email: A)a/ V�/%iOr�hS e yl a t/ Emergency contact name: 10a12161le /�GZ / r� Tel#: 70 J� / — ZI Dates of operation: From:, 4W / /0 To: y 13 / ID Type of Camp:, Day: If�$ational: Sports: v Travel: Trip: S ki fO Approximate # of campers:06 Campers Ages"/—/V #.of counselors: P � yoP�� /xr u7e�k 7 # of volunteers per season 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. ,I SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date s Commonwealth of Massachusetts City of Salem Board of Health IGmberley Driscoll Mayor 120 Washington Street, 4th Floor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED: 06/23/2010 ESTABLISHMENT NAME: YMCA - Shotting Star Gymnastics File Number: BHF-2010-000031 40 Leggs Hill Roa ' "l MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type r Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP-2010-0455 Jun 28, 2010 Sep 3; 2010 $10.00 DAY CAMP I Total Fees: $10.00 a ,;t« KIMBERLEY DRISCOLL MAYOR DAVID GIZETNBAUNI, ACTING HEM.,n i AGENT' CITY OF SALEM, MASSACHUSETTS BOARD GE HE AIA 1-1 120 WASHING'rON S'rareT, 4'°' FLOOR T1'.L. (978) 741-1800 FAX (978) 745-0343 DGREENBA uMnSALEM.00A1 APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP r7 Name of Camp deo,//%% (/ ��fel,#{ %�� / /Gp 0 - /U// Address of Camp: 1 r // --hm la, Q1G7�y� 11 Camp Website: 6/ 7,D 0� Q/�e/ Fax# 75/—�3/ Name of Camp` Direct/?//X N/Q ` �� Tel# Camp Director mailing address: Email: For The Emergancv Telephone Notification System: Emergency contact name: TeI#: Dates of operation: From: � WY1 /0 To: g' /a%/ /v Type of Camp: Day: reational: V- Sports: Travel: Trip: 2 /��/ Approximate # of camper s�� Campers Ages # of counselors: # of volunteers per season )f- X10 4tr ural_ 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, 1 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. Alkll-tt /�jo Dad -L5, '- dU� Signature Date SS# or Federal Identification Number P Revised 5/15/07 reccamp app. Check# 6 Date Commonwealth of Massachusetts City of Salem ' s ° Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000026 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0444 Jul 5, 2010 Jul 16, 2010 $10.00 DAY CAMP PERMIT EXPIRES Total Fees: $10.00 July 16, 2010 Board of Health _„i/ 7 A Page 1 BERLEY DRISCOLL I\4AYOR DAVID GREENBAUM, ACCING H-CeUXI I AGENT CITY OF SALEM, MASSACHUSETTS BOARD O'FFIFAL'1 H 120 WASHINGTON STRuli.;T, 41" FI..00it TrL. (978) 741-1800 FAX (978) 745-0343 DGR)~ENRAUMnQ SALEA1.COM APPLICATION, FOR LICENSE TO CONDUCT A RECREATIONAL CAMP NameofCamp: ThC07f Cf- At/ Tel# 791-63i-9�aa Address of Camp: Fio r-c(,as At/ QC as "aHokhead Camp Website'WtotO. W4 -t shore onca. Name of Camp Director: piiin berL 4 4�Urc Z L Tel# q7$- Ga7 -0955 Camp Director mailing address:_146 I�C>%td Email:-KUrCZy KcDnor+ Emergency contact name:l�i(n 9'hU r'CZV Tel#: Dates of operation: From: 7 / S /to To: 711(0// 0 Type of Camp:' Day: X Recreational: Sports: Travel• Trip: Approximate # of campers: 05 Campers Ages:Lct/4 # of counselors: 4 # 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. 1 yrrico,org 11 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,Agave filled all state tax returns and paid all state taxes required under the law. -a/o 4 -913 Signature Date ISS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date i Commonwealth of Massachusetts � E City of Salem Board of Health IGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000020 LOCATED AT: YMCA - Adventure Camp 40 Leggs Hill Road MARBLEHAD SALEM, MA 01970 MA 01945 Permit Type I Permit No. Permit Issued Permit Expires Fee Restrictions / Notes i RECREATIONAL BHP -2010-0438 Jul 5, 2010 Aug 27, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES lAugust27,2010 Board of Health d. Page 1 • e KIMBERLEY DRISCOU MAYOR DAVID GRE']ENBAUM, ACTING I-IEALfFi AGENT CITY OF SALEM, MASSACHUSETTS BOARD of 1IEAJ,T1-1 120 WASHINGTON S,nzi?e'r, 4'01 Fcooiz TEL. (978) 741-1800 FAX (978) 745-0343 DGR73hNBAU NInSALrD7.COiNI APPLICATION, FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: Adye.n- Ure Camp Tel#-781—qqC) '700% 4�3 Address of Camp: ill ^OQ� �Aarb"eGt6 Camp Website:Wt.()W. florid reyrncg. orr/q Fax# `781-&39-0190 Name ofCamp'Director: i4cirlonrl2 /�Xarier Tel# —0-99D 700% Camp Director mailing address: /J0 teWS *// 150QU Email: bfVVrm@/)p ) Emergency contact name: /' Karl Tel#: i8/-2190 -7lO% Dates of operation: From: ,715110 To: 5la7/ 10 Type of Camp: Day: L Recreational: Sports: Travel: Trip: X Approximate # of campers: 10 Campers Ages:9=l / # of counselors: # 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. yffca 10T 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 M L Chapter 63C, Section 49A, I certify under the penalties of perjury that I, to my best knowledge and belie , ave -filled all state tax returns and paid all state taxes required under the law. (l/l i0 Oct -a/01k Signature I Date SS# or Federal Identification Number r Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts C�. Pr: City of Salem Board of Health IGmberiey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED.: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000023 LOCATED AT: YMCA - Book Club 40 Leggs Hill Road MARBLEHAD MA 01945 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0441 Jul 12, 2010 Aug 6, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES �jgust 6, 2010 Board of Healthdt 2.14 l d � Page 1 is KIMI3ERLEY DRISCOLL AtAYOR DAV11) GREENBAUM, ACTING HF.1(,�L'I'H t1GLN'f CITY OF SALEM, MASSACHUSETTS BOARD of Ht-M.'n i 120 WASHINGTON Sfxrr r, 4"n, Fwolt TidL. (978) 741-1800 FAX (978) 745-0343 DGRECNBAUi�1nQ Sill:Elv1.00A1 APPLICATION' FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp; Boog C`ob Tel# 7 - _9I`- 9 c1 0 -7007 Address of Camp: 40 LSLQ;., P6I I . R OQGi � -" car-blszh Camp Website WWVJ.nor�hsh0�eym��cC``l.Orq Fax#7S1'(o39.-0)q0 Name of Camp Director: Tel# `7F1 -CICO --7007 Camp Director mailing address: 40 I --e, S I I; I I QC08 Email: t czKC'f rYl�D [1O(4INQh0YP.yMW -OD M arbl.� For The Emeraancy Telephone Notification System: Emergency contact name: i" QLri an n e .� r Tel#: 791 -CI (40 -i007 Dates of operation: From: -7//2//0 To: 8/ & / 10 Type of Camp: Day: X Recreational: Sports: ` Travel: Trip: Approximate # of campers: 114 Campers Ages: # of counselors: .3 6dssion # of volunteers per season 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 oto MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, h ve filled all state tax returns and paid all state taxes required under the law. `-Mai 1,aak a& b / I /- /0 O q -a10 q - C/ /--3 Signature I Date SS# or Federal, identification Number Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts ss City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: . 'File Number: BHF -2010-000024 LOCATED AT: YMCA - Book Cooks 40 Leggs Hill Road MARBLEHAD MA 01945 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0442 Jul 26, 2010 Aug 27, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES LAugust 27, 2010 Board of Health s ,,/Jv, Page 1 KIMI3ERLEY DRISCOU MAYOR DAVID GREENBAUM, ACTING HI£Al; n i AGENT CITY OF SALEM, MASSACHUSETTS BoAm) OF HI`A1.PR 120 WASI-IINGrON S'T'REET, 411, F1,001z TEL (978) 741-1800 FAX (978) 745-0343 DGR FENBAUM0SAL3U COQ I APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp; QOOK ''COO-79--7C07KS - Tel# �� -9�O--7C07Address of Camp:40 f -r 1I Pcad MAar-WeheOd r Camp Website:WNW. rIOr4-hl &l-preyncCL.Ora Fax# `791-G-Yll-0190 Name of Camp Director: Mctr--icn n P10-%< er Tel#. 781-gq 0--7007 Camp Director mailing address:40 S 1-4;l I Road Email: bO K2r (YlQ`7(lof 1 lS} Ort/ I o� Marl-, � ecad • For The Emergancy Telephone Notification System: �/ Emergency contact name�Qri C(il n Bo -Ker Tel#: 721-990-7007 Dates of operation: From: 7 /Z / t 0 To: 8 /d7/ /0 Type of Camp: Day: X Recreational: Sports: Travel: Trip: Approximate # of campers: ILi Campers Ages: 4-7 # of counselors: 3 Se-slorN # 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 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. to-aly-�(� Signature Date SS# or Federal Identification Number reccamp app. Commonwealth of Massachusetts City of Salem Board of Health IGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED:. 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000019 LOCATED AT: YMCA - Chefs Camp 40 Leggs Hill Road MARBLEHAD MA 01945 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0437 Jul 19, 2010 Sep 3, 2010 $10.00 DAY CAMP PERMIT EXPIRES Total Fees: $10.00 2UIU Board of Health Page 1 CITY OF SALEM, MASSACHUSETTS BOARD ov I-IF_AI,: i f 120 WASI-IING'1'ON S'n211?1,, 4'ni Fr.00R TEL (978) 741-1800 KIMBERL EY DRISCOLL FAx (978) 745-0343 MAYOR DGREENBAU?Y1na_SAr i c OM DAN7ID GIZ U.NBAUM, ACTING HE,A]XI I AGENT APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP NameofCamp: ChC'.f tS Can-) ] Tell# 79J -490' -?0o7 Address of Camp: 40 *'5 L 11// R0, ad l� orb j �lte Q c4 Camp Website: U)UJ�. f)Orn)ShOt'2U(Y1CL(, 0 Fax# 7Q—.k3?-61'70 Name of Campl Director: ' -E/ kl Q1)o�?I ` Tel# 7/91-490-700') Camp Director mailing address: '410 �g9S AW 1 06d Email: f ��e(�%%�1)Orii15h0Yey(Y1CC(,0� Emergency contact name: W2AO1/M �JG[V\-er Tel#: '91—WO -7007 Dates of operation: From: 7//7/11) To: Type of Camp: Day: X Recreational: Sports: Travel: Trip: Approximate # of campers: /ai. Campers Ages:7- /0 # of counselors: 3 # 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 I, to my best knowledge and belie ave filled all state tax returns and paid all state taxes required under the law. ajutt lin oaf -aloe-9/3 Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date - Commonwealth of Massachusetts City of Salem Board of Health IGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Recreational Summer Camp Permit DATE PRINTED:.. 06/08/2010 1 ESTABLISHMENT NAME: File Number: BHF -2010-000029 LOCATED AT: YMCA - Explorers Camp. 40 Leggs Hill Road MARBLEHAD MA 01945 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL 13HP-2010-0447 Jun 28, 2010 Sep 3, 2010 $10.00 DAYCAMP PERMIT EXPIRES Total Fees: $10.00 tier 3, 2010 Board of Health Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OFHL'AL'TFI 120 WASHINGTON STREET, 4�1' F1,00Ii Ti.:I- (978) 741-1800 KINMERLEY DRISCOIJ FAX (978) 745-0343 MAYOR DGRL:LNBAUM(CI]SAI E[v1.CO�I DAVID GREENBAUM, ACTING HEALTH AGI -,N I APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp Explorers Camp Tel# X81 -9q0-7007 Address of Camp: �-F�S 7� � � ROcI ci IA O r�OUL � l � Q Campwebsite:wwW. nO`-VhSk)or��/MCCCI" -0q Fax# 791-6- -01 0 Name of Camp Director: MO -rt Qnr'le 1�2( Tel# -791—gCi0-7007 Camp Director mailing address: 40 (- as a I; i I RCGLd Email: %Ke(' In 3D (lQc shpYeV(11CQ bre Mo.rble. ec�d / JJ For The Emergancy Telephone Notification System: Emergency contact name:_Lv `(3, i a nne P---GiVeY- Tel#: 7g1 `qq0 -7oo7 Dates of operation: From: % /Z//O To: q/.3 / 10 Type of Camp: Day: X Recreational: , Sports: Travel: Trip: k Approximate # of campers: a Campers Ages:=9 # of counselors: 5 Session # of volunteers per season 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, ve filled all state tax returns and paid all state taxes required under the law. 6/ / //0 oµ aloe -q/3 Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor IGmbedey'Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000022 YMCA - Jr. Adventure Camp 40 Leggs Hill Road MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0440 Jun 28, 2010 Aug 20, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES 10 Board of Health Page 1 i KIMBERLEY, DRISCOLL MJ�YOR DAVID G IU.17N13AU11, ACTING HIS:AI rI-IAGENT CITY OF SALEM, MASSACHUSETTS BOARD Or He.Am l-1 120 WASHINGTON S71tEET, 41t' FLOOR. TI -L. (978) 741-1800 FAx (978) 745-0343 DGRGHNI3A UMnSA Lr?D,t. rO\f APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: Tr. f 1p ie -n+ -u fe-- Camp Tel# -7gI -q9D- 7o67 Address of Camp: 4b Lf� S iii I ( Qoa(A Ctr-UO-h .Qd Camp Fax# 7&[- C3 l -0j qQ Name of Camp Director. MQrICInn &ck r Tel# 791-9 /D -2007 'Camp Director mailing address: 40 � � Email: (W)2i)lbr4b-CbCKCY1 ")C0,0O 9 hear b" h.e aCf ..// For The Emer anc Tele hone otiftca ion S -stem: Emergency contact name: Ma( OntiQTel#: 7g/" %QO '700 % Dates of operation: From: (0 /ag/ /O To: 9 /do/ !O Type of Camp: Day: Recreational: Sports: Travel Trip: Approximate # of campers: 14 Campers Ages:S g # of counselors: 3 # 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 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 beliefsbave filled all state tax returns and paid all state taxes required under the law. //o Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts City of Salem cr Board of Health 120 Washington Street, 4th Floor 19mberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000021 YMCA - Junior Leaders 40 Leggs Hill Road MARBLEHAD MA 01945 LUCA'1'ED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0439 Jun 28, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES September 3, 2010 Board of Health i Page 1 DAVID Gill d>NBAUNI, ACTING HEAL7l-I AGli'IM, CITY OF SALEM, MASSACHUSETTS BOAR D or HFALTFI 120 WASHINGTON SIU -17I', 41" FLOOR TF.L. (978) 741-1800 FAX (978) 745-0343 DGRCI3N BAUM(a]SALE M.CO\d APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: 3-GLn 1 O r Tel#_ Address of CamD: Camp Name of Camp, Director: Camp Director mailing For The Emergancv Telephone Notification System: t /� Emergency contact name: L Iann-p.. Ea Dates of operation: From: 6/d9/ /D To: 9/ 340 - 996 --)oo Fax# 7SI- 6bi-0190 Tel# 7,&I-9qD-70()% I: rma-mo shc-ey�,o� Tel#: 7rE'�— 99D Type of Camp:, Day: Recreational: Sports: Travel Trip:_ Approximate # of campers: 10 Campers Ages: /O -Aa # of counselors: 6L # of volunteers per season 6 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 ave filled all state tax returns and paid all state taxes required under the law. ad.aw t lol I 110 oLJ-a10q-g1? Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date ;ry Commonwealth of Massachusetts i City of Salem ` Board of Health 120 Washington Street, 4th Floor lQmberiey Driscoll, - SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000027 YMCA - Mini Sports Mania Camp 40 Leggs Hill Road MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued. Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0445 Jun 28, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES Board of Health Page 1 KBIBERLEY DRISCOU. N4AYOR D.AA'ID GRRI(NBA0N1, -A( I]vcHi?.vi:rilAG N'i. CITY OF SALEM, MASSACHUSETTS 1 1 i'.i..(9/8) 74,1-1800 F%N (918) 74r0343 tx;rrrNts.u:ntrnlsa(.eni.cuni APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: /11 O't Spo4s Marin CCtMp Tel# -4*3 1 - G2I-°i b "LZ Address of Camp:. q0 L e5ls 1r it ka/ G1 �1 Camp Website { : (UUlU1,Nrr}a�S�ore/ljrncc� , 0r4 Fax# ��f- 639 - UIC(O Name of Camp Director: Ifni -_11 u(9�G� Tel#�I�Ll Camp Director lmailing address: 4-10D te95J uO1f%t".lf Email: A14dA ))Ake@A1JVrY�^j 0rey✓ L4 -U!5 For The Emergancy Telephone Notification System: Inergencycontact name: FMi �� r1/ALIaK Tel#: 1$1- Dates of operation: From: 6 /Z%/ 10 To: 9 / 3 / 10 Type of Camp: Day: / Recreational:— Sports: / Travel: Trip: LJ1- Approximate # of campers: 2S/ Campers Ages: fS _6 # of counselors: 5 # 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 ($10). Written copies of your Emergency, Special Contingency and Staff Orientation plans. „I agree to comply with all mandates of the State Sanitary Code, Chapter IU, 105 CMR 340., "Minimum Standards for Recreational Camps for Children", including required staff background checks. I understand that noncompliance may result in suspension of this license. Pursuant to MGL Chapter 63C, Section 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filled all state tax returns and paid all state taxes required under the law. 6 / l 10 ®10 67 - 0$c1 gnature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: I File Number: BHF -2010-000018 YMCA - Senior Adventure Camp 40 Leggs Hill Road MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/ Notes RECREATIONAL BHP -2010-0436 Jul 26, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES September 3, 2010 Board of Health Alii)l NA Page 1 T MAYOR DAVID GRELNBAUM, ACTING HliAi mi AG FNr CITY OF SALEM, MASSACHUSETTS BOARD Or HE'AI PFI LO WASHINGTON S"rima*, 4T" FLOOR Tfl1,. (978) 741-1800 FAN (978) 745-0343 DG11FENBAUM(Da SALEM.COM - APPLICATION' FORLICENSETO CONDUCT -AIRECREATIONAL CAMP Name of Camp: Sen iib r- TTd Name of Camp'Director:� Camp Director mailing address Emergency contact Dates of operation: From: 7/Z/ /0 To: 713110 --7r F 7UU? Fax# 78/ -- 6939 -0/ 90 Tel# 78/-990 -700% Tela: 78J-996 700 Type of Camp: i Day:_11Q Recreational: Sports: Travel: Trip: xl Approximate # of campers: g Campers Ages:/6 -/a # of counselors: oZ # of volunteers per season C> 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 all state tax returns and paid all state taxes required under the law. 'Mai- a4"' 6/ / l i0 oq-aloe-T 3 Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app.' Check# & Date _ Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000025 LOCATED AT: YMCA - Small Fry Camp 40 Leggs Hill Road MARBLEHAD MA 01945 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0443 Jun 28, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES September 3, 2010 Board of Health llId Page 1 d f t • s KIMBERLEY, DRISCOLL TNIAYOR DAVID G2GENHAUM, ACTING HBAiNI-I AGENT CITY OF SALEM, MASSACHUSETTS BoeRD of HiEtu:rI-I 120 WASHINGTON STREET, 4:O1 FLOOR TG:L. (978) 741-1800 FAX (978) 745-0343 DG RLENBAUM(CISALE\4.COil I APPLICATION1 FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Address of Cam MOM Ir -r\) ( ,am I7 N; I I Q Oaa Tel# 7.8I-qq0-7007 r Camp Website: W1NVJ.MCCL-Ora Fax#'751-(0?)q-OILIO Name of Camp ,Director: M Qrl at -\r)2, e 11 II V<�� f jj Tel# 7gI qq0 `-%Od7 Camp Director mailing address: LAO �S 411 *SOQU Email: bat Cern Q�flor� Marb �Pnt ri Emergency contact name: Mar-'1GL lrl2 Tel#: -791-qq0-7007 Dates of operation: From: 6 /a 8/ 10 To: 9/3/10 Type of Camp: I Day: X Recreational: Sports: Travel: Trip: X Approximate # of campers: Go . Campers Ages:4 -7 # of counselors: 10- sZ99m # 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. ,,l MCa. 0rJ 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. `fY1 L /%� - �l 1 //0 N-0/04 -'9/3 Signature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app: Check# & Dale Commonwealth of Massachusetts City of galem ° Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2009-000014 YMCA - Sports Mania Camp 40 Leggs Hill Road MARBLEHEAD MA 01945 LVUA1Ell A'1': _ 1. SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0435 Jun 28, 2010 Sep 3, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES September 3, 2010 19 Board of Health Page 1 KIMBERLLY DRISCOLL T\4AYOR D.vvu) (;Ri;TNH.wNi, _A("I'im; HI::V:I'l l AGIT'I' CITY OF SALEI\,I, MASSACHUSETTS 120 AA'.ASII im; F( IN SIRE: -1, 41'" Fl.Oolt Tlu.. (978) 741-1800 Fps (978) 745-0343 llGRhl!V''H VLNl(q�9 11 1+1LC(lpl APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp:�Qo4s flan;" CC,Mp Tel# -7'9 I - 631- `1 6 2Z Address of Camp: qd Ze` s AW egad Camp Website: WWW, ftrt4S6reVltl/cg . 09-4 Fax# -771- 639 - 0150 r Name of Camp Director: G/27dV PUCAK J Tel# -781- q hU- -+04i q Camp Director mailing address:_1/0 4951 All lflo�d Email: A4dAkeCN1JrAS)1OK y/>1Ic-4. Uy For The Emeraancy Telephone Notification System: lnergency contact name: ��'� y H(Ad AK Z $ Dates of operation: From: 6 /Z%/ 10 To: Q / 3 / 10 Type of Camp: Day: / Recreational: Sports: ✓ Travel: Trip: JK tpra, Approximate # of campers: ZS'LCampers Ages:►t ' # of counselors: # 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 I, to my best knowledge and belief, have filled all state tax returns and paid all state taxes required under the law. IG M-62 - 051 (� mature Date SS# or Federal Identification Number. I Revised 5/15/07 reccamp app. Check# & Date Commonwealth of Massachusetts r City of Salem Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll SALEM, MA 01970 Mayor Recreational Summer Camp Permit DATE PRINTED: 06/08/2010 ESTABLISHMENT NAME: File Number: BHF -2010-000028 YMCA - Squash Camp 40 Leggs Hill Road MARBLEHAD MA 01945 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RECREATIONAL BHP -2010-0446 Sun 28, 2010 Aug 16, 2010 $10.00 DAY CAMP Total Fees: $10.00 PERMIT EXPIRES August 16, 2010 Board of Health Page 1 KBIBM-EY DR]SCOLL ,\L11'doR ll.\\ 11) GIJ(IiNH.U',\I, CITY OF SALEM, MASSACHUSETTS 120 1()N Sre ra -r, 411 1 F),i n as 11 a .. (9-18) 741-1£,00 F_vs (9%S) 735 (1343 DG)MIN .\].( ml APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: S.4uas/? a, -n1 J Tel#. Address of Camp: q0 zejj) etiad T81-G31-`t62"L Camp Website:'Lk)k1, f10ry�S6re�Mccl 0r4 Fax# L 639 - 0 I 0 r/' I, Name of Camp Director: 1/77 lY I&CJOK Tel# Camp Director mailing address: yU teMf 91) 1'?(1,J Email: �U1�A/cG'�f✓�rfr^jdiu�C y/✓f/!C✓}- 05 For The Emergancy Telephone Notification System: )nergency contact name: k'm/' fY fOLJ aK Tel#: X81- -4-43' - 2 -1 $ � Approximate # of campers: Campers Ages:# of counselors: 1 # of volunteers per season (� 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 belief, have filled all state tax returns and paid all state taxes required under the law. lo +nature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date Dates of operation: From: 6 /Z%/ 10 To:'g/a / 10 Q,cl -3/16/lo +o 8/20/io Type of Camp: Day: / Recreational: Sports: ✓ Travel: Trip: Approximate # of campers: Campers Ages:# of counselors: 1 # of volunteers per season (� 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 belief, have filled all state tax returns and paid all state taxes required under the law. lo +nature Date SS# or Federal Identification Number Revised 5/15/07 reccamp app. Check# & Date the FOR YOUTH DEVELOPMENT® FOR HEALTHY WING FOR SOCIAL RESPONSIBILITY YMCA OF THE USA RECORD OF COURSE COMPLETION Angelina Caggiano Has successfully completed the course requirements for YMCA Lifeguard v6 DATE ACHIEVED June 26, 2016 KEVIN WASHINGTON PRESIDENT AND CHIEF EXECUTIVE OFFICER Document serves as an official record of course completion as tracked by YMCA of the USA C511314T AMERICAN ■ SAFETY& HEALTH® INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Dear Angelina Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passporti Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 has successfully completed and the requlred knowledge and skill o BLS (CPR and AED) for Healthcare Providers has successfully completed and the required knowledge and skill o for this program. AMERICAN eSAFETYa HEALTH■ INSTITUTE r 1 re. ,,C t, d Certlffea#fon Cardl' Angelina Caggiano, has successfully completed and competently performed the required knowledge and skill objectives far thl§prggrem; CAN, .SAFET,. HEALTHIM INSTITUTE ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (PHM Name) 119125 0612612016 0612612017 Glass Ccmpletim Date Expiration Date 978.356.9622 Y2861 Trelning Center Pham No. Trelning Center I.D. The card cenXles the holder nae demonstrated the Assured knowledge and akill objectives to s cur rally eunlorlow ASHI Instructor. CMllicelon does not guarantee future pedomame, or mMY Iken- sum or aedemming. course cadent coven all age groups and conforms Was, 2010 AHA Gulde msec for cPReMECG, and offer Mdence-based ffeatmem recomrnendagons. Gerllncation Perietl may not exceed 24 monahe from class completion. More frecryant minforcement of skills h recommended. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Nem.) 119125 06126/20116 Class Completion Date 978356.9622 Training center Ram No. 612612018 Expiration Det. Y2861 Training center I.D. This card centime the Foster hes demonstrated the resulted knowledge and Will oblectNea to a cur- rently amd,uMd ASHI Im"or.. CertAlcatmn does not guarantee future performence, or imply Ilcen- sure or crecamafng. Courea content rovers all age groups and conforms to the 2010 AHA Guidelines for CPP and ECC, and other evidence -based ceduhmm Mcemma Bels-- Gerdficallon'mm may not exceed 24 manths from Gass completion data. More frequent ashfomement of skills m remmmeMed. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Nam) 119125 Registry No. 0612612016 - 6126/2018 Class Completion Date Expiration Date 978356-9622 Y2861 Training Center Phone No. Tra ring Center I.D. This card cadres the holder has demonstrated the required knowledge and akin objectives to e currently eutnorizad ASHI Instructor. Certification does not guarantee future performance Or imply I cemure or cadentleling. Courae content Is evidereat esed (Emergency Dxygen Use N Adult Patients nOd. 2cfe) and comlereat with widery accepted guidelines far emergency oxygen admin chation. Certification paHod may not exceed 24 months from class oompmlbn. Certificate of. Completion Olivia Mento has completed requirements for Lifeguarding/First Aid/CPR/AED conducted by American Red Cross Date completed: 04/23/2015 Validity Period: 2 Years Certificate to: GRM88S gaTcrlCnn H dCross pal FJ.trs Scan code or visit: redcross.org/confirm am Marcos Castellano has successfully completed requirements for Lifeguarding/First Aid/CPR/AED: valid 2 Years Date Completed: 0212012016 conducted by: American Red Cross Instructor: Hailey Buxton Ni ID: GSTJ3R Scan code or visit: AMERICAN ■ SAFETY& HEALTH! INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Dear Jeremy Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www hsi conn/passport! Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 has successfully completed and the required knowledge and skill 0 BLS(CPR and AED)for Healthcare Providers has successfully completed and competently performed the required knowledge and skill objectwes for this program. Jeremy Swil has successfully completed and the required knowledge and skill 0 AMERICAN (SAFETY& HEALTH■ INSTITUTE ASHI-Approved Certification Card O'Malley Barton Authoraed Instructor (Print Name) 119125 0511412016 Class Completion Data 978.3569622 Trelning Cama- Phom No. 0 511 412 01 7 Expiration Date Y2861 Veining center I.D. This rand cenXies the holler hes demonahated the moored Imoehetlge and skill objectives to a wr- rsmly eothdixed ASHI Instmcbr. Gamnookon does not guarantee idiom Pedormance, or Imply licen- sure or cmdemialing. Course schism cons¢ dI age groups end cordon's to the 2010 AHA Guldeilnes for CPR ant ECC, ell oMerevidence-based caatmem recommendetlons. ceniliralian period may not exceed 24 momhs tram class mAp cn. More frequent relnfcm=tIo N sk01s k reccmmantletl. ASHI-Approved Certification Card O'Malley Barton Authar¢ed Instructor (Print Name) 119125 05/14/2016 Class completion Date 978.356.9622 Trelning Cents Plans No. 5/1412018 E mimtlon Date Y2861 Trelning Center I.D. This card wmlias the holder has demonslmted the mcwhod krowletlge and skill oblectivaa to a ca - Army, autriunred ASHI Instructs. certification doss nrt goommee fun°¢ periamance, or imply Ilcen- sure or conforming. Course content cows ell age groups and conforms to the 2010 AHA Gadef. Mr CPR and ECG and other evidence -basad treatment recommendations. CenHkation pedod may rot exceed 24 months from class completion dare. More frequent Alnfomemem of skills Is recommended. ASHI-Approved Certification Card O'Malley Barton Authorized instructor (Print Neme) 119125 0511412016 Class Complefion Date 978.356-9622 Trelning center Poona No. 511412018 Expiration Date Y2861 Training Center I.D. IThis cand conflies the holder has demonstrated th required knowledge and skfll objectives toounettiy eothoriced ASHI Instruct°' Csgfcanpeon does not guarantee tuwm domanca, a Imply l'iana'sorandentiaing. Course cohromeaviden.e-basedi mergencyoxy,en Usein AdultPatients Thoma 2008) and consistent wdh widely accepted guidelines for ¢sang n oxygen aim nistrat on. yay.,,.;;; W {i yiyW�'}a ry' Cemficanon period may nor ..W 24 months tram class cumplanan. the F� YMCA OF THE USA FOR YOUTH DEVELOPMENT® FOR HEALTHY LYING FOR SOCIAL RESPONSIBILITY RECORD OF COURSE COMPLETION Jeremy Swiniuch Has successfully completed the course requirements for YMCA Lifeguard Crossover v6 DATE ACHIEVED May 15, 2016 KEVIN WASHINGTON PRESIDENT AND CHIEF EXECUTI-V_E OFFICER Document serves as an official record of course completion as tracked by YMCA of the USA C65M53A AMERICAN ■ SAFETY& HEALTH INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Dear Shannon Congratulations on successfully completing your American Safety & Health Institute CPRPro 0 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 ASHI-Approved Certification Card 1 it O'Malley Barton Instructor (Print Name) ' .fxm61'�tlflCatiOnktezarlAuthorized 119125 rye." ..kt'1GT�I4;yet S � ;. i Rag'sM No. 0412212017 04122/2016 Shannon roan;, Expiration Date hassuccessfully completed and competently pertarrried`�`' _. Gene conroletion Data Y2861 the required knowledge and skill objectives for this program 978-356.9622 I.D. TralNag Cella Phone No. Trammg Center Amf:M4AN , SAFETY'&. The Card canHba the holder has demormtrated the required kmwledge antl sell oblectivee to a cur- BLS(CPR and AED)for t1EALTHIl: randy auhorized ASHI Immuctcr. Cenifloetlon does nM guamrrtae imUm penornwasi,orImply liren- sure a credon leling, Course ¢ntent covers ell ego groups and Cardona, tothe 2010 PHA GuMellre Healthcare Providers INSTITUTE::. far CPRmnd Ec ,, and other eNdenae-eased iremimela recommendation,. cenheauon peeled may net :I av exceetl 2A monksironcbss complmtbn. More frequent mInforcaaent Cl sldtt Is mcamnended. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Neme) 119125 0412212016 412212018 �r -' Shannon Dinan '^ - has successfully completed and competently performed „j {. Glass Completion Date Expiration Date the required knowledge and skill objectives for this program. 978-356-9622 Y2861 Training Center Rune No. Training Gunter I.D. AMERICAN N SAFETY& Thi, card cengies the holder hes demonstrated the required knowledge and skill objeadvas b e cur - HEALTH ® eMly a,,amed ASHI Instructor, certification does,mt geararcee future performance, ce, a haply It-- sumorcredentaGng. Ceeme content ed,osallage groups and whams to the 2010 AHA Guidelines INSTITUTE Ion CPRand ECC, and other evide^caLeead "anent recommendations. certKicatk n period may act exceed 24 months from class Completion dam. More heavers mInforemmeM of skills is recommended. �,,—s�+*—•�-�* . ASHI-Approved Certification Card O'Malley Barton ' �� - "Certnffcatfo d" y� v. r M1 Authorized Instructor (Print Name) 119125 Shannon Dinan 04/22/2016 4/2212018 :, class completbn Data Expiration Date has successfully completed and competently performed - ,y., Y2861 the required knowledge and skill objectives for this piogtam t 978-356.9622 •- ra3 F� Trdiniig Center Phone No. Training center I.D. 'AMERICAN, A$AFETY& This can ca ries the holder Inc deCartio do the rot guarantee knowledge end skill obectiv to a HEALTHH cu a ty a ho zetl ASHII or Ced &tion does a Emengatutors perionn nce,Mu P Imply _ licensure a crodentlaling. C.no content isevidence-based lEmergency�ygen UseIn Mut Patients INSTITiiTE �� 2 M andel maysmt o,Ah 24�mmfhstram cls slcoapts o^ r c ox gen wmaistretion. t . the FOR YOUTH OEVELOPMENT® FOR HEALTHY LMNG FOR SWAL RESPONSIBILITY YMCA OF THE USA CERTIFICATION Shannon Dinan Has successfully completed the certification requirements for YMCA Lifeguard v6 Certification DATE ACHIEVED CERTIFICATION EXPIRATION April 22, 2016 April 22, 2018 KEVIN WASHINGTON PRESIDENT AND CHIEF EXECUTIVE OFFICER Document serves as an official record of certification as tracked by YMCA of the USA SCOOGOON79U24608 AMERICAN 0 SAFETY& HEALTH® INSTITUTE Dear Shannon American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. I Register for refreshers or download the Passport App at www.hsi.com/passport! Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 has successfully completed at the required knowledge and skill BLS (CPR and AED) for -1 Healthcare Providers Shannon Dinan has successfully completed and competently performed the required knowledge and skill objectives for this program. Shannon 0 has successfully completed and the required knowledge and skill o AMERICAN (SAFETY& HEALTH® INSTITUTE ASHI-Approved Certification Card O'Malley Barton Authorized Irelructor (Print Name) 119125 04122/2016 0412212017 Class Cor llon Date aplratim We 978.356.9622 Y2861 Training Cerner Phone No. Training Center I.D. This cad certifies is holder Tons demonstrated the requlreC kndvAedge and skill oblectives b a cur- remry al thonzed A5HI Instructor. Certll!cetlon does not guarantee future performance. or imply licen- sure or credemlaling. course content coves all age groups and comorms to the 2010 AHA Guidelines {or CPRand ECC, no diner evidence -based treatment recommendations. certification pertool may not exceed 24 months from class completion. More frequent minforcement of skills Is nessamended. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Name) 1 119125 04/22/2016 Clew Completion Date 978356-9622 Training Came, Phone No. 4/22/2018 Expiration Data Y2861 Training center I'M This cad certifies the holder has demonstrated the required 1Mowted1e and skill objectives to a cur - rend, aulbonaed ASHI Instructor. Gedlticatlon does not guarantee future Performance, a mphy Iloan- sure or cretlentaung. Course content covers all age groups and conforms to the 2010 AHA Ell brCPR and ECC, and other evdence-based treatment recommendations. cemncntion period may Mn exceed 24 months Mom class completion date. More frequent reinforcement of skills k recommended. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Name) 119125 Registry No. 04/22/2016 4122/2018 eptly performed e 'sx's ` Class Gompletlon Data Expiration Date for this praijram4 978-356.9622 Y2861 AMERICAN Tol Center Phone No. Trebling Center D ! SAFETY&. . HEALTH® ; This cad certifies the holder has demonstrated the required knowledge and skill objectives to a mm ear, euthoraed ASHI Instmetor. Certification does not gnarl future pedormanca « Imply INSTITUTE; Identrum or cmdenbaffng. course content is erderce-tsarmd (EmorgendyOxygen Use n Adult Patterns for Thorax 2008) and consistent vlth wdey, accepted 9,4deinas emergency oxygen acimnistration. Certification Period may not euedd 24 months from class completion. AMERICAN ■ SAFETY& HEALTH i INSTITUTE A member of the HSI family of brands Monday, September 28, 2015 Shannon Dinan Dear Shannon American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro for the Professional Rescuer class. In an effort to be more environmentally friendly your ASHI Approved Training Center has chosen to issue your certification card electronically. The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Go online to access your ASHI Passport and take advantage of the additional training resources available to you: Digital download of Student Handbook LearningLinksTM Refresher Scenarios Mobile Application Downloads E-mail Renewal Notification Rate Your Program Survey Register now at www.hsi.com/passport/. Use the registration code 7762 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St ' Beverly, MA 01915 has successfully completed end conrpetenfy,oe the required knowledge and skill objechves for'thilie BLS (CPR and AED) for Healthcare Providers ASHI-Approved Certification Card O'Malley Barton AWhorizad Instructor (Prim Nemo) 119125 Regotry No. 04/1212015 class complatbn DNB 978.356.9622 Tolle, center Ph.. N. 412017 expiration Date Y2861 Training Center I.D. TNs raN oaNhes the holtler has demmelra mi the reeuiretl knowletlge end skill-bjeclims to a wr- x®ry�3a mroly euthonretl ASHI lerA uctor cerMioadon does net guerantse fNure pedo,manee or r" Iloen- �UrG? sure ar m,sMaArg course oee nt covers sl age gmups an, conforms to the MO MA culdNtnes for CPR and ECC, and other evldenee-0 wd treatment recnmmendNbna Csnffc lon Periotl may not exceed 24 moNhe from -less wmplNun. More lm,,kint relnforcemerH of -kola Is recrnerundetl Thursday, May 19,.2016 Eliza Jane Holtz Dear Eliza Jane American Safety & Heafth Institute 1450 Westec Drive Eugene. OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro for the Professional Rescuer (1yr) class. In an effort to be more environmentally friendly your ASHI Approved Training Center has chosen to issue your certification card electronically. The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Go online to access your ASHI Passport and take advantage of the additional training resources available to you: • Digital download of Student Handbook • LeamingLinks'"' Refresher Scenarios • Mobile Application Downloads • E-mail Renewal Notification • Rate Your Program Survey Register now at www.hsl.com/passport/. Use the registration code 7762 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St ' Beverly, MA 01915 Eliza Jane Holtz has succeaaduly completed ar the required Imowledge and AM BLS (CPR and AED) for Healthcare Providers program..; ANIGnM IIISAFETYa HEALTHE INSTITUTE ASHI-Approved Certification Card Joteen Knox ALMwixed Methlww (PrAd NAM$) 278425 Hscish No. 03M812016 rT-062 Z Wring Center Ph. Nm 5!2017 E*W Date Y2861 TrairtV Gencor l.D. This caro oeMn ga holder hes damwattSW ale egAW IMOWWge eM $01 ahjalMs to a wr- "auecdeed ASHI Mwrucea. CwaOcadce door not 9umawee tAN Pte• wft* lwn- WMuweftdL4. cane emmw ea W.Smp. cod oWma to The 2010 AHA tAdW#W for WRe EM aid~wMwr= eed tmtrnwa nw Gdvlam. cwffllWwn Pedod my nd exceed 24 nwft tam dew MMOBIbn Mme Rmpud Mnf=Wnmt cd slab 15 recon^endod. AMERICAN ■ SAFETY& HEALTH! INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 500-447-3177 Dear Eliza Jane Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/O2 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport( Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 0 bAt`t 1 T& This card sertakis du holder has demonstrated the required knowledge and skill oblectives to a cur - HEALTH E rently authorized ASHI Instructor, certification does not guarchae future pe omame, or Imply Wan - sure or credenraling.come¢ content covers all age groups and commms to the 2010 AHA Guipsones INSTITUTE for CPR and ECC, and other eviderae4ased tmatment recommendatbns. Cenigcatlon period may not exceed 24 rwnthe from class completion date. More irequent reinlamartlBm of sxAs Is recommended. ASHI-Approved Certification Card q',' r I r ' ' " Deirdre Barrett p Authorized Instructor (Pont Name) �Y Certlficatlon Cardr t�, 118167 Pi At ASHI-Approved Certification Card .. Deirdre Barrett O N � Cert #lcationhCardl Authorized Instructor (Prim theme) 1 the required knowledge and skill objectives for this program"".-. 118167 a f - Registry No. AMERICAN , . 0610112015 0610112016 hes suc cessfully completed antl competemly�perfgrmedrs. . - Ckss Completion Date Explatim Date the required knowledge antl &kill obledtives for this progrem. _� 978-356-96 22 Y2861 I TrelNng Canto Phone NohemMg center D. ' AMERIGAN��` Thema 2") and consistent with widely accepted guidelines f« emergency oxygen administration. 24 from class completion. /SAFETY& This pard centres the holder has demonstrated the required kfwwledge and skill ob)eclives to a can BLSCPR and AED for 'HEALTHi®�' t mildly authorised ASHI inetrucl«. Certllicallon does not guaranties lunare performance, or miayliven sure««edentlaing. Course moment covers all age groups arta conforms W the 2010 AHA Guhadlima IN$TITUTI Healthcare Providers f . I for CPR and, EDC, aneOther witticism. based treatment hammmendagona ceriffooion pedal may nm exdeed 24 rtromhs from close comPlatbn. More frequent relmorcement of sklk k recormrended. ASHI-Approved Certification Card a 1 r • . I Deirdre Barrett Name) 1 fu e6tlfMatt; 0n Card:` t8 r *a, Authorized Instructor (Print A 118187 � xou. _;.;" h �;'Ah, As„x ,,,fi?2' Registry No. �')k�t � l Eliza Jane Holtz ` "a 0610112015 61112017 n a has successfully completed and competently performed a..compkfion Data Expiration Date the required knowledge and skill objectives for this progna 978.356-9622Y2861 ewxhr•awmur Training tamer Phone No. Training Center LD. 0 bAt`t 1 T& This card sertakis du holder has demonstrated the required knowledge and skill oblectives to a cur - HEALTH E rently authorized ASHI Instructor, certification does not guarchae future pe omame, or Imply Wan - sure or credenraling.come¢ content covers all age groups and commms to the 2010 AHA Guipsones INSTITUTE for CPR and ECC, and other eviderae4ased tmatment recommendatbns. Cenigcatlon period may not exceed 24 rwnthe from class completion date. More irequent reinlamartlBm of sxAs Is recommended. ASHI-Approved Certification Card q',' r I r ' ' " Deirdre Barrett p Authorized Instructor (Pont Name) �Y Certlficatlon Cardr t�, 118167 Pi At 0610112015 81112017 Eliza Jane Holtz "~ le,, has successfully completed and competently performs class completion Date Expiation Data Y2861 1 the required knowledge and skill objectives for this program"".-. 978356.9622 i Training center Phone No. Training center I.D. AMERICAN , . OSAFETY&. This pard c«hfes the hostler has d mo retell the required knowledge and skill obiectives to a HEALTHY currently euth«Ized ASHI Irstmctor certification does not g,arentes imm perminvrse, or Impy p licensure or credenticurg. Course content is evidence-oased(Emergency can I use m Adult Patients INSTITUTE�3 Thema 2") and consistent with widely accepted guidelines f« emergency oxygen administration. 24 from class completion. rf:gc�Ky<.% Wtti "' Cenificstion period may not ¢mead months �- TRAINING CERTIFICATION the YMCA OF THE USA Eliza Jane Holtz 2011 Edition Lifeguard Certification Expiration: 06/20/2017 ID#:S000AOOH7602OV08 Awarded: 06/20/2015 at: -® the FOR YOUTH DEVELOPMENTO - - - - - - FOR HEALTHY p1JM6 FOR SOCIAL RESPONSIBILITY YMCA OF THE USA CERTIFICATION Aidan Keenan Has successfully completed the certification requirements for YMCA Lifeguard v6 Certification DATE ACHIEVED CERTIFICATION EXPIRATION June 26, 2016 June 26, 2018 KEVIN WASHINGTON PRESIDENT AND CHIEF EXECUTIVE OFFICER Document serves as an official record of certification as tracked by YMCA of the USA SCOOXOOE8OL23SO5 AMERICAN ■SAFETY& HEALTH INSTITUTE Dear Aidan American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport! Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 has successfully completed and the required knowledge and skill o BLS (CPR and AED) for Healthcare Providers t Aidan Keenan has successfully completed and competently the required knowledge and skill objectives for Aldan Kee has successfully completed and the required knowledge and skill o program. AMERICAN (SAFETY& HEALTH® INSTITUTE ASHI-Approved Certification Card Catherine Marcoux Authorized Instructor (print Name) 1368877 Registry No. 06/2612016 06/26/2017 Close Complefie, Date 6piration Date 978.3563622 Y2861 Training Center Phm,e No. Training Center LD. This cad certlas the holler Etas demxmstrated the metered Imowledge and skill ob)eMinves to a cur - rarity slam zed ASHI Instructor. CenXicoWn does not guarantee future performance, or Imply licen- sure or cmdemlafng. Course consent coves all age groups and confortrs mile, MO PHA Guidtllres for CPRam1 ECC, and dinnerevidence-based treatment recommendatiorm. Certiticaron ironed may not exceed 24 manths from class completion. Mom frequent reinforcement of skills Is recommended. ASHI-Approved Certification Card Catherine Marcoux Authorized Instructor (Print Name) 1368877 0612612016 612612018 Class C.wlet'on Cate Expiration Date 978.356.9622 Y2861 Training Center Plane No. Training Center I.O. This caro certifies the Indoor has demonstrated the required knowledge and skill oblectNes to a cur- reMly authorized ASHI InsWcto. Certification does not guarantee future performance, or Imply Ilcen- wm or madentaling. Course content coven all age groups and conforms to the 2010 AHA Gunnalimes for CPR and ECC, and other evidence -based treatment recommendations. CertHkation perlod may not exceed 24 months from ddass completion den. More frequent ralnsomeone M of skills Is recommended. ASHI-Approved Certification Card Catherine Marcoux Authorized Instructor (Print Name) 1368877 06126/2016 Class Completion Date 978-356-9622 Tm"ng Center Phone No. 612612018 Expiration Date Y2861 Training Comer LD. III 3i This wk oertifies the holder hes demonstrated the required knowledge end .1,111 obleetiven m a emrently aWhoradd ASHI Irelrudar. Certification does rat guamntea future ped onare., or Iwl, x licarmasoremdentialing, Course content isevidence-based(Emergency Oxygen Use in MA Patients I', G Ther. 211011) and omm, nM yon wid.ly accepted gudelines for emergency mrygen ArrinistraV.d. e1 da Codification po sol may not exceed 24 months from class completion. AMERICAN (SAFETY& HEALTH® INSTITUTE Dear Elizabeth American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passportl Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 ASHI-Approved Certification Card O'Malley Barton Authorized instructor (Prim Name) 119125 6w s Elizabeth Cayouette-GluckmaEr ' 0412212016 04/2212017 has successfully completed and competently performedY Chas compktlm Date r piretim Date the required knowledge and skill objectives for this pragremi — 978.356-9622 Y2861 vY Training center Phone No. Training center D. "`ki igk.tf Tralning Center Phone No. Training Canter I.D. ANIERICANg rently eumorized ASHI instructor. Cadificatlo t does net guarantee future Padormence, or trnpty li cen- (SAFETY& The card aerthbs the nolder Ines demonstrated the required knowledge and skill alikeness to a cur BLS (CPR and AED)for -HEALTH®r ormence,orilicen- mertyaumonzedA,SNlinstructor. CertHkauondcesnet guarenureteerutpedmmy AHA Guka'f�s Healthcare Providers INSTITU i TE; sure a credenticng. course scream.. ell age groups and C -neves totterra, 2010 for CPRand ECC, and other evidance-0aad treatment recommendeuans congestion centrad may not - ,.t: _ mv. queinforcement ah skills a; recommended exceed 24 mon le from class complete'. More tiam re ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Name) 119125 Elisabeth Cayouette-Gluckman -'h, 5g+4c'`N+` 04122/2016 4/2212018 has successfully completed and competently performed '" class Completion Date expiration Date the required knowledge and skill objectives for this program. 978.356.9622 Y2861 � AMERICAN Training center Phone No. Training center D. SAFETY& This card certifies the holds, hes demorstmted the requited knowledge and skill oblectwes to a ser - HEALTHM rently eumorized ASHI instructor. Cadificatlo t does net guarantee future Padormence, or trnpty li cen- INSTITUTEbr sure or credemisling. Course content canes els age ..,and conformers to me 2010 AHA Gusher. CPRand ECC, and omer evidence,based treatment recommendation. certllkation period may not exceed 24 months from class complamin date. More frequent relNomemend of aklils Is recommended. ASHI-Approved Certification Card O'Malley Barton s>T(iel t+fteafton Caz KK .„ } x nth Authorized! instructor (Print Name) ��^ `t: • It 119125 t, + -., p*`a. t Registry No. 4aa �„k•s x Elizabeth Cayouette Gi uckman�,a�x�. ' �� 04/2212016 4/22/2018 has successfully completed and competently peAorntini tri for this e�, cies completion Date Expiretlm Date Y2861 the required knowledge and skill objectives prc`gram . .r �� 978.356-9622 TO. mi AMEIUCAN� Tramn, center Phone No. Tied, Center �ISAFETY& This card seniles the holder has demonstrated the modked knowledge and skill objectives to a HEALTH® currently authorized ASHI instructor. Certification does net guarantee future performance or imply fiI INS11 iUTE-yi licensure or credentialing. Course content is evidence bused(Emergency Oxygen Use a Adult Patients Thorax 2008) and consistent with widely accepted guelelines for emergency oxygen administration. Certi catlon period may not exceed 24 monms from class completion. . TRAINING CERTIFICATION the YMCA OF THE USA Elizabeth Cayouette-Gluckman YMCA Lifeguard v6 Certification Expiration: 04/22/2018 ID#:S000J00Q79X24E11 Awarded: 04/22/2016 Verify at: AMERICAN BSAFETY& HEALTH INSTITUTE Dear Owen American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport! Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 ASHI-Approved Certification Card Catherine Marcoux Authorized instructor (Prim Name) 1368877 Owen CIyrie'9 ': f,'� 0612612016 0612612017 hes successfully completed and competently performed^' class completlon Date EExplretion Date the required knowledge and skill objectives fcr thr gnogram 1368877 or 978.356-9622 Y2861 AMERICANi, Training center Phone No. Training center I.D. 0 SAFETY& BL5AED)for HEALTH®�"' The cad cengles the Witter Imo demonstrated the required knawl.oge and .dli oblecrives to a cur- remy eulhollzed ASHI Instructor. Comicatlon docs not future (CPR and HealthcareProviders INSTITUTE guarantee performance,orlrM*lmn- sure or aedemlaMg. Course content covers all age groups Intl conforms to the 2010 AHA Guidelbres for CPR and ECC, and other evidence -based eeffiment recommendations Certification Palod may not ss=h"a exceed 24 months frau class mmdallon. More frequent mInfacement of skills Is a commended. .1111SAFETUT ASHI-Approved Certification Card `r • T • a 8 Catherine Marcoux F N CerdtficattonfC��ia�rd��,� �� r: "#y guarantee Periam licensureorcredentaling.Cour =ntentlsewdwn Msed(Ememencycxygen Usem Adult Patients Tlmrex for Authorized Instructor (Print Name) 2008) and consistent with widely accepted gudelines emergency oxygen administration. Centhatlon period may not exceed 24 maahs from class completbn Registry No. Owen Clyne �.R 06126/2016 6/26/2018 has successfully completed and competently pertortnetl %' 4:§, Class completion Date &pirafsn Date the required knowledge and skill objectives for this progrem. 978-356.9622 Y2861 ---------- Training Canter Phone No. Training Center I.D. a r R This cant centime the holder hes demonstrated the requiretl knowledge antl Will abpctrv% to a cur- ! ® renty mAronzed ASHI Instructor. Camhosttan does not guarantee future performance, or i npy Ilcen- um or cmdentlaling. Course content covers all age groups and conforms to Me 2010 AHA GWdelines UTE /or CPR and ECC, and amer evidence -based treatment recomnrendatbrs. Certification period may not exceed 24 months from chars completion date. More frequent reinfamemend of skNs h recommended. O ASHI-Approved Certification Card r Catherine Marcoux EN ez„ �.Certlfication Card4 ^ ¢ 't't r Authorized Instructor(Phnt Name) ,t n,v?;✓; w s x 1368877 `tM. Registry No. Ow en Clyne 06/26/2016 6/2612018 has successfully completed and eompetently per/oriiiedlr ', Cies. Completion care Erprmtion Date the required knowledge and skill objectives for tills program! - w,' 978.356-9622 Y2861 AMERICAN'' Tmining Center Phone No, Training Center I.E. .1111SAFETUT HEALTH® This caN centres the holder has demmstmted the required knowledge and skill objectives to e currently aWhodmd MW Instructor. CerMicabon does not lutum anca or Imply INSTITUTE' r guarantee Periam licensureorcredentaling.Cour =ntentlsewdwn Msed(Ememencycxygen Usem Adult Patients Tlmrex for . "L 2008) and consistent with widely accepted gudelines emergency oxygen administration. Centhatlon period may not exceed 24 maahs from class completbn ®® the �� YMCA OF THE USA FOR YOUM DEVELOPMENTS FOR HEALTHY LMNG FOR 50OAL RESPONSIBILITY RECORD OF COURSE COMPLETION Owen Clyne Has successfully completed the course requirements for YMCA Lifeguard v6 DATE ACHIEVED June 26, 2016 KEVIN WASHINGTON PRESIDENT AND CHIEF_ EXECUTIVE OFFICER Document serves as an official record of course completion as tracked by YMCA of the USA C51D14T ----------------- ASHI-Approved Certification Car ■ • • O'Malley Barton puthsized Instructor (Pnrrt Nana) .wnr H7cAtion GBn 119125 has successfully c,mPletod and the required knowledge and skill c BLS (CPR and AED) for Healthcare Providers 04222016 Ciass Ganplegon Date 978,166-9622 78 gCe3 n6-962 ne No. 04ma017 ExPvetion De1e Y2861 Training Center LD. This cab cend,es the 1 i has derranstrated the required Imowtetlge arM &kilt ohkatives toe cur- reniry eMhonzed ASNI Instructs Certniration tices not 9uarsnlee talon pedomance, s imply li fro �re ar cndentiaGng. Course cstent ower& all egg grcuPa antl cwNorms to the 2010ANA Ghoduidelires ceetl 26�monihs fromc lass -pi 'awn. W. thequen leis n nacnemml of skiilsflr'atrecwnmentleEY &ot ............................................................ • ASH I -Approved Certification Card G • O'Malley Barton ■//r��f ■ I ''? Authorized Instructor (Print Name) 6°�i�t '` 4 Eertficatlon Card�y 119125 fhe required knowledge and skill objectives for Tn's pray. ars.. AMERICAN ®SAFETY& HEALTHIM INSTITUTE 94222916 claw comPleran Daze 978-3569822 Training Gaoler Phone No, 4222018 Eypirehm Data Y2861 Trainin0 Daher LD. This cam cedgles he holder hes demonstrated the require` k Wlsdge and skill ohlechves to i ceo- renty authonzed ASHI InslvMor. Cenifaatlon does nm 9 .rttconforhi b thenen AHA Gu Defines sure or oredeMlaling. Course content coven eli age grouphot s sh,sxcee` 24 Eorrl hodmtclass ca Ola�cn ", M.,, Irsquenl reirlto�celnsC o IskJlsps r�ewm enCM. -•--- ...._- _••--,- ...,, „. ---•-•- .• ASHI Approved Certification Car n 4 ..•Malley Barton ®�p��,T� Authorized Instructor iPnnl Name) I1i-u t : �fiCertification'Card ^, 119125 nas suwea�..•v--.....___ -. the required knowledge and skill 04222016 Class Completion Date 976-356-9622 Treinin9 Center Plane No. 4222018 Expiration Date Y2961 Training Center ID. This oar` erifles the holtler has tlerrwnstrated the rtquireG knowledge and s«I ribI rtl" imply curtently eMM1sizetl ASHI Instructor. CMglicVti cebauL 1guamronety Qtxyge�Use m Adult Patients licensure s cretleMialirg. Course conte dsiinss for emerger, oxygen administrabs, iMrsx 2WB) antl cons3tent with widely accepted gut ,srhhcaboh period may not exceed 24 hi Imm class completion. �• TRAINING CERTIFICATION the YMCA OF THE USA Diana Tarnowski YMCA Lifeguard v6 Certification Expiration: 04/22/2018 ID#:SCOOEOOL79S24Z06 Awarded: 04/22/2016 at: AMERICAN ■ SAFETY& HEALTH® INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Dear Laura Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 Laura Bar has successfully completed and the required knowledge and skill of BLS (CPR and AED) for Healthcare Providers Laura Barnes .}' has successfully completed and competently performed the required knowledge and skill objectives for this program. Laura Barnes has successfully completed and the required knowledge and skill c AMERICAN (SAFETY& HEALTH® INSTITUTE ASHI-Approved Certification Card Dorothy Calandra Aumorized Ircelmdo, (Print Nance) 118058 0411812016 0411812017 Claes Completim Date Expiration Date 978.356.9622 Y2861 TmlNng Center Phone No. Trani, Center I.D. This teal ceRgles the holder has demonstrated the required knowledge and skill oblee lves to a cu,- remry authorized ASHI InsWcta. ohnnsatlon does not guarantee (inure P normanot, or Imply licen- sure a credentleling. Course colon, oovsm all age groups ad tarts. to the 2010 AHA Guidelines for CPR aM ECC, aM other "ohnce-basao treatment rconamsn amens, certRicatlon notion may not exceed 24 months fon clans completkan. More hegoent minfamement of skills Is recommended. ASHI-Approved Certification Card Dorothy Calandra Authorized Inslmctor (Print Name) 118058 Registry No. 0411812016 411812018 Claes Completion Date apinelo Date 978-356.9622 Y2861 Trelnmg Gamer PMrm No. Training (Dents, I.D. This ear, ocn," the hsider has dathe nshaled the required knowledge she skill obleclNes to a cur- rently aumodzad ASHI Inseucla. Cenuselio does not guarantee fulure performance, or imply licen- sure or cadenteling. Course eantent covers all age groups and tontorms to Me 2010 AHA Guidelines horCPR end ECC, and other evidence -basad veamem acomm sedations. Counkation period may not exceed 24 rronme from class somptetim date. More frequent remfamement of skills is recammarded. ASHI-Approved Certification Card Dorothy Calandra Authorizetl Instructor (Print Name) 118058 sjt 04118/2016 411812018 - x c^7 -1`x ^ V PBAQrmed class Completion Date ExPiret'wn Date Y��., this program -; -v_ 978-356-9622 Y2861 " M1 Training- Tralnirg Center Pro. No Centan.D. pMERICAId ®SAFETYC, This cath califes the holder has demonstrated the required knowledge and skill objectives to a does not future Deferments a Imply HEALTNIFs�4T currently enunciated ASHI Instructor. Certification guarantee licensure or credendaling. Course content is evidence -based tEmehgency Oxygen Use in Adun Patents INSTITU Three 2008) and consistent with wooly accepted guidelines for emergency oxygen atlmm stration. Csninestion period may not exceed 24 moms from class completbn. TRAINING CERTIFICATION th2� YMCA OF THE USA laura barnes YMCA Lifeguard v6 Certification Expiration: 04/22/2018 ID#: SCOO13OOI79P24W55 Awarded: 04/22/2016 at: IF TRAINING CERTIFICATION the YMCA OF THE USA Christiaan vandeStadt YMCA Lifeguard v6 Certification Expiration: 05/15/2018 ID#: SCOOTOOA79H62095 Awarded: 05/15/2016 Verify at: AMERICAN Y SAFETY& HEALTH® INSTITUTE Dear Christian American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hsi.com/passport( Use the registration code CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office 245 Cabot St Beverly, MA 01915 has successfully completed ler the required knowledge and skill BLS (CPR and AED) for Healthcare Providers ASHI-Approved Certification Card O'Malley Barton Authored Instructor (Print Na") 119125 Registry No. 05/14/2016 Cess Completion Date 978.356.9622 rreinirg Comer Phone No. 05/1412017 Expiration Dele Y2861 Treating Center I.D. HEALTH® skill krowledge and oor ass demoragered the grantee cand! owiffles the stru rehmly authorized ASHI nis a Camfkatbn does not future Pedorammoce olr stmly Ilcen sure or credentiai'mg. Course content covers At age groups and conforms to the 2010 AHA GuldeNes dNSTITUTEA, to, CPR arrd[CC, ead other evtdoce-easedlreatment moanmwweeore CenXratan pedod may not : •4� - `'""'`' exceed 24 morons, from class completion. More frequent reinforcement of skills is recommended. R s ' �4� Christian Vandestadt ��' 7><t? has successfully completed and cornpetemly performed 'Ej me required knowledge and skill objectives for this program. AMERICAN (SAFETY& HEALTH® INSTITUTE Christian Vandestadl . has successfully completed and compete the required knowledge and skill objectives ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Name) 119125 0511412016 511412018 Class Completion Date Expiration Dete 978-356.9622 Y2861 TreWng Cerner Ptrora No. Trelning Center I.D. This card comics the ladder has demonstrated the required knowledge and soil oblectives to a.1 remy nothorized ASHI Instructor. Confiscation does not guarantee future performance, or imply licen- sure or credenteing. Course content covers all age groups and comorms to the 2010 AHA Guidelines for CPR and ECC, and other evidence -based treavrem recommendations. Cati cation period may ral exceed 24 irons from class completion data More frequent reinforcement of sl'.vlls is recommended. ASHI-Approved Certification Card O'Malley Barton Authorized Instructor (Print Name) 119125 05/14/20`16 Class Completion Date 978.356.9622 Trelning Center Phone No. 5/14/2018 Expiration Date Y2861 Treating Center In. This Gaal codifies the holder has demonstrated the required knowledge al skll obje tims to a currently authorized ASHI Instructor. Comacation does not gumarme future performance• or Imply licensure or credeotaling. Course content is evidence -based (Eme m,n Oxygen use h Adult Patients Thos, 2000) and consistent v4th widely accepted guidelines for emergency oxygen edimmidastca. Certification period may not exceed 24 months from class completion. AMERICAN ■ SAFETY& HEALTH® INSTITUTE American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Dear Hannah Congratulations on successfully completing your American Safety &Health Institute CPRPro (1 year) /BFA/02 (G10). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of ymur training.SSPOrti Use the registration code Register for refreshers or download the Passport App at CPRPro: 7762 /BFA: 2662 /02: 2362 to register. YMCA of the North Shore Inc - Association Office has successfully completed and competenny the required knowledge and skill objectives for 245 Cabot St Beverly, MA 01915 ASHI-Approved Certification Card O'Malley Barton A.1hm.ed Inatnu tel (Print Name) 119125 05114120116 Doss Cornpkdon Dees 978-356.9622 TraIMn9 Carom Picone No. 05/14/2017 Expiration Dale Y2861 Trelning Denur LD. /UYIGrtlVM ®SAFETY& This card cendbe the holder tms demonstrated the requi�antee tNure padode;ledge and armance or TaWy Ileal HEALTH® rerdbauthodzed ASH I lnskuclm. Certification does o g and eardorms to the 2010 ANArcD oNt es BLS (CPR and AEC) for surem etlentlaling. Co rse maentro ersel age group INSTITUTE, CPR o,d ECD, and Other wMenee-based res-rnant recommrearens Dkills Ierlo^pe . Healthcare Providers w; s„.jvy exceed 2e moMlu from cesss completion. More frequent relntacement al skills is recommended. ASHI-Approved Certification Card �O a A V I1 O'Malley Barton T puthodz� lnstmctor (Print Nem-) �N rCertrflcatio�rd 119125 �s �If Registry No. 05/1412016 511412818 Hannah Vandestadt w...„� Exmrano^Dare .. has successfully completed and cope tentlypeAormed .i, Clew Completion Date Y2861 g 978.356.9622 P Trel^mg tamer LD. the required knowledge and skill Objectives for this ro mm. AMERICAN Trelrun9 CenterPMrc No. AMERICAN ad knowledge” skill able -was to cur- ISAFETY& This card saddles the hold., has demonstrated the ¢,ease IUWre padonance, or Imply Ilren- HEALTH� mealy solea tl ASHI InsWmm. Certilicatio doe no g 2010 INSTITUTE sumo, and E(iali^and aNeevidanca--based umure^aa° ^reds ° 'CeM1c o "iodu roved neat br CPR and ECC, nt rel `.Damao of skies 5 recommended. - exceed 24 mAnthS from lass completion dere. Mme treque has successfully complet o ane oo nvv...nD the required knowledge and skill objectives for ASHI-Approved Certification 4;ara O'Malley Barton Authorized Instructed' (Print Name) 119125 05/11412016 Glass Completion Data 978.356.9622 Training Canter Phone No. 5114/2018 Expiration Date Y2861 Tramin9 Center LD. and eldil This cant cotiges the holler has demmeratad Ithe oess at 9 nknowledge eef uwre pedoneenoe,l or Imply eenently authorized ASHI lnaWctm.. Certg'x:etion c Ca en Use 1" -al Palienls licensure or ears lieling. Couree content is evidence-�iMe�es� .r.",ge¢y oxygen adirrinistmlear, Than 2008) and consistent vdth widely aecapted 9 Cedi iastion period may not exceed 24 mmths from class comPlelion. Q IF TRAINING CERTIFICATION the YMCA OF THE USA Hannah Van de Stadt YMCA Lifeguard v6 Certification Expiration: 05/15/2018 ID#:S000ROOY79F62M93 Awarded: 05/15/2016 at 6/30/2016 imagel.jpeg Jazmilet Tavarez has successfully completed requirements for LifeguardinglFirst Aid/CPRrAED: valid 2 Years Date Completed: 03/22/2015 conducted by: American Red Cross Instructors: Jorge Hiram Cardoso Scan cuje or visit: https://maiI-google.com/mail/WD/?tab=om#inbox/i55275cdc92b6fb7?projector=1 1/1 5/10/2016 Saba h"://classes.redcross.org/SabaANeb/Main 9/13 American ' Red Cross Certificate of Completion Julie Nguyen has successfully completed requirements for Lifeguarding/First _valid 2 Years Aid/CPR/AED conducted by American Red Cross 0 Date Completed: 05/10/2016 IN S19 Instructors: Melinda B Williams Certificate ID: CT411T To verify, scan code or visit: redcross.or /confirm h"://classes.redcross.org/SabaANeb/Main 9/13 American Red Cross Jonathan Prentice has successfully completed requirements for Lifeguard i ng/First Aid/CPR/AED: valid 2 Years Date Completed: 06/23/2016 conducted by: American Red Cross Instructor: Quinlan Locke ID:GTE5PM Scan code or visit: redcrnss. nro/cnnfir KIMBERLEY DRISCOLL MAYOR December 21, 2015 Theresa Finn Dever Riley & Dever, P.C. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, Ott' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 Iramdin@salem.com Lynnfield Woods Office Park 210 Broadway, Suite 101 Lynnfield, MA 01940 Dear Ms. Dever, IV PublicHealth Prevent. Promote, Protect. LARRY R ,\MDIN, RS/REHS, CIAO, CP-I;S HEALTH ACE'.NP Enclosed please find copies of the documents requested in the Freedom of Information Act letter dated November 23, 2015. Should you require any further information please do not hesitate to contact me directly. Sincerely, David j Greenbaum Senior Sanitarian Salem Board of Health RILEY & DEVER, P.C. ATTORNEYS AT LAW Lynnfield Woods Office Park 210 Broadway, Suite 101 Lynnfield, MA 01940-2351 (781)581-9880 Facsimile: (781) 581-7301 Frederick W. Riley Joseph P. Dever Theresa Finn Dever Paula A Walker November 23, 2015 Larry Ramdin Health Agent Salem Health Department 93 Washington Street Salem, MA 01970 Dear Mr. Ramdin: 'L O CoOeYJGOFF uxuAA- H Hon. Joseph L Dever (Ret.) George J. Nader Pursuant to the Freedom of Information Act, please forward to me the following documents: (1) Copies of Swimming Pool Inspection Reports for the YMCA, 40 Leggs Hill Road, Marblehead, Massachusetts from January 1, 2008 to the present. (2) Copies of any and all documents pertaining to a drowning incident that occurred at the YMCA, 40 Leggs Hill Road, Marblehead, MA on or about June 3, 2013. (3) Any and all documents pertaining to incidents, injuries, fatalities, permitting, inspections or certification of the swimming pools at 40 Leggs Hill Road, Marblehead, MA from January 1, 2008 to the present. Thank you for your assistance in this matter. Very truly yours, Q""M iqn/� Theresa Finn Dever Riley & Dever,-P.C. ATTORNEYS AT LAW Lynnfield woods Office Park 210 Broadway, Suite lot Lynnfield, MA. 01940-2351 Lang Rain&ri Health Agent Salem Health Department 93 Washington Street Saler. MA 01970 p<F8 POST Z r�- � PITNEY BOWES 02 1P $ 000.485 0000271391 NOV 23 2015 MAILED FROM ZIP CODE 01940 I Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Swimming Pool Annual Permit DATE PRINTED: 02/07/2011 ESTABLISHMENT NAME: File Number: BHF -2009-000002 LOCATED AT: YMCA - Lynch Van Otterloo 40 Leggs Hill Road SALEM MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/ Notes SWRIMING POOL - BHP -2011-0351 Jan 1, 2011 Dec 31, 2011 $40.00 Lap Pool ANNUAL Total Fees: $40.00 r PERMIT EXPIRES IDecember3l,2011 Board of Health md >A Page 1 a CITY Or SALEM, MASSACHUSETTS BOARD of Hi:AL 1-I 130 WASHINGTON S'IR8F11�, 4T" FLOOR T7 L. (978) 741-1800 KIMBERLEY DRISCOLL FAX (978) 745-0343 MAYOR Dc1a11Nlsnunl(�sal.i:=,at. COM DAVID GizFENBAILU, RS A TING HI fACrH AGIiN'I' LO.n.AT.O OF 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL NAME OF APPLICANT MAILING ADDRES d f'' S— TEL #791 —63/—f92–L, CERTIFIED POOL OPERATOR . Cert #: TEL DATES OF OPERATION (if not annual): DAYS & HOURS OF OPERATION: --ru Ai — l 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 I, to my best knowledge and belief; have filed all state tax returns and paid all state taxes required under the law. jignature ,12,2-1910 --279/-12-/Ol>-?/3 Date : SS# or Federal Identification Number devised 10/6/10 poolappl l.doc Check#Date ;�'!) �Yp Commonwealth of Massachusetts -City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Swimming Pool Annual Permit DATE PRINTED: 02/07/2011 ESTABLISHMENT NAME: " File Number: BHF -2009-000002 LOCATED AT: YMCA - Lynch Van Otterloo 40 Leggs Hill Road SALEM MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SWIMMING POOL - BHP -2011-0352 Jan 1, 2011 Dec 31, 2011 $40.00 ANNUAL Total Fees: $40.00 PERMIT EXPIRES IDecember3l,2011 Board of Health Page 1 KIN113ERLLY DRISCOLL NLYOR DAvn) GREGNnAum,RS Ac'1, IN(; Ht?A1a71 AGP.N'I' CITY OF SALEM, MASSACHUSETTS BOARD or HisAl:rrl 120 WASHINGTON S'mmr r 4m Fl ooit 'I7a,. (978) 741=1800 FAX (978) 745-0343 DGRrp.NnAubI@S,y.I:M. CODE 20111 APPLICATION FOR PERMIT / TO OPERA�TQE�ASWIMMING POOL (/ L^Ci�TION OF POOL 1 `j. NAME OF APPLICANT MAILING ADDRESS CERTIFIED POOL OPERATOR Mame: TEL #7,?/-63/-96z2_- Cert #: TEL # DATES OF OPERATION (if not annual): O_Al� DAYS & HOURS OF OPERATION: fq tir — l e olh- 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. AIA olq11's-, 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 I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. signature / 1Z IZ.o1a _` C/y z-/Ol,°- FC Date SS# or Federal Identification Number ievised 10/6/10 poolappl l.doc Check Date Y6 4 Fillion Associates, Inc. lhwµ,y evwte sdWae,a M.l�cbw,avnita aiee �9a] City of Salem Board of Health 120 Washington Street Salem MA 01970 Attn: Janet Mancini Dear Janet: April 9, 2009 Per our conversation today regarding the Leggs Hill YMCA swimming pool project and slide installation, we are requesting a variance for the indoor slide. The plans and specifications were submitted to your office for the lap pool and training pool which clearly included the slide. The pool was approved by the City as well as the City's Consultant with a four (4) hour turnover rate, and subsequently the pool was built. The only way to change the turnover rate would be to remove the deck and filtration equipment at this newly constructed facility. The State would have liked to see the turnover rate at one (1) hour which is the flowrate for a water slide flume versus a pool with a slide, or a splash down pool. We have submitted the additional treatment methods which would be employed for this pool under separate cover. Please feel free to call if you have any questions or need further information. Very truly yours, FILLION ASSOCIATES, INC. RutIV . Howse PO Box 14518 East Providence, RI 02914 800-776-7665 rbowser@fillionassociates.com Fillion Associates, Inc. NoviOUW wvwk.xuions:rtn cleer,eSWls anxv r99] City of Salem Board of Health 120 Washington Street Salem MA 01970 Attn: Janet Mancini Dear Janet: March 31. 2009 We have spoken with Steven Hughes from the State and the following clarifications are to be submitted by the City of Salem with a request for a variance to the State for the installation of a slide on the Leggs Hill YMCA indoor training pool. The variance request is for the four (4) hour turnover rate versus the one (1) hour turnover rate specified in the code for a water slide flume. 1. Standards of water quality for water slide flumes shall conform with the requirements set forth in 105 CMR 435.28 through 435.3. 2. Clarity and cleanliness of the water shall be maintained by a continuous recirculation of the water through and appropriate filtration system approved by the Board of Health. The turnover rate for the training pool will be four (4) hours. 3. The operator shall be familiar with the provisions of 105 CMR 435.000 and every other applicable law and regulation pertaining to water slide flumes. 4. If at any time the water does not conform with the requirements set forth in 105 CMR 435.35 (1), the operator shall immediately close the water slide flume until the water conforms with those standards. 5. The flume shall be perpendicular to the pool wall for a distance of at least ten feet from the exit end of the flume. The last ten feet of the flume shall have a slope which is not steeper than 1 in 10. 6. The distance between the side of the flume terminus and the pool side wall shall be at least five (5) feet. The distance between the flume terminus and the opposite side of the pool shall be at least 25 feet and steps shall not infringe upon this area. 7. The flume shall terminate 1-1/2" above the water surface. 8. The construction dimensions and the mechanical attachment of the flume components shall be such that the surface of the flume is smooth and continuous for its entire length. 9.r Each flume shall have a distinctive line or marking to indicate the starting zone in which only one rider at a time is permitted. This line shall be in accordance with the manufacturer's specifications or 30 feet, whichever is the longer distance. The facility shall post a sign at the top of the slide warning all sliders not to proceed down the slide until the slider in front has passed this line. 10. The depth of the pool at the terminus of the slide shall be 3-1/2 feet deep. 11. The pool water elevation will not be lowered by more than one inch when the flume pump is in operation. Training pool has a surge tank. 12. The splash down area shall be roped off from the area of the pool used for swimming and bathing. 13. A gate shall be installed at the entrance to the stairs leading up to the slide to deter usage without supervision. 14. The facility will have two (2) persons on duty to monitor slide usage when the slide is " actively in use. The water supply shall be turned off when the slide is not in use. PO Box 14518 East Providence, RI 02914 800-776-7665 rbowser@fillionassociates.com Fillion Associates, Inc. Pmri."eq 'i mM . e ckwrealle yrs 1987 Additional treatment methods: 1. The training pool contains 57,643 gallons of water, and has a turnover rate of four (4) hours for a Flow of 240 gallons per minute. 2. The filter system used on this pool is an EPD Hi -Rate sand filter which utilizes a #30 silica sand (27 mm) which will filter down to 2 — 3 microns, allowing the removal of Cryptosporidium oocysts in a single pass. This as compared to a traditional Hi -Rate sand filter which utilizes a #20 silica sand (.55 mm) which can filter down to 15 — 20 microns. 3. The system also features an advanced BECSys7 automatic chemistry controller which monitors the all important ORP, or chlorine strength value which ensures 24/7 chemistry monitoring and control for both chlorine and pH levels in the pool. The system boasts multiple fail safe mechanisms and alarms which alert pool staff by automatically calling them via its on board modem and connected phone line. 4. The BECS control system is operating a PPG calcium hypochlorite feeder with an output capacity of 60 pounds per 24 hours. This ensures more than adequate response to any type of bather load experienced throughout the day. 5. The system also employs a secondary treatment Ultraviolet disinfection system through which 100% of the system flow must pass. The UV system employs multiple operation fail -safes to ensure 24/7 treatment including low UV intensity alarms and fault alarms. The YMCA of the North Shore has installed these UV systems on the majority of their facilities, and the maintenance and upkeep has been flawless. We are very quickly contacted and dispatched for any alarms occurring with these systems. The YMCA staff is very serious about water quality, as evidenced by the large investment they have made in installing UV systems in their facilities swimming pools. 6. In light of the slide installation on the training pool, the Leggs Hill YMCA staff will increase their usual diligence by testing and documenting the chemistry tests on the training pool on an hourly basis. 7. The Leggs Hill YMCA staff will send a water sample out for biological tests at a minimum of once per year. PO Box 14518 East Providence, RI 02914 800-776-7665 rbowser@fillionassociates.com Fillion Associates, Inc. rre,Wi,v swat sain�ms w�m,rexres�,n„e;,„.re rne� City of Salem Board of Health 120 Washington Street Salem MA 01970 Attn: Janet Mancini Dear Janet: March 5, 2009 It was a pleasure speaking with you today regarding the final slide details for the Leggs Hill YMCA project. Please see clarifications we discussed regarding the indoor slide below. 1. Standards of water quality for water slide flumes shall conform with the requirements set forth in 105 CMR 435.28 through 435.3. 2. Clarity and cleanliness of the water shall be maintained by a continuous recirculation of the water through and appropriate filtration system approved by the Board of Health. The turnover rate for the training pool will be four (4) hours. 3. The operator shall be familiar with the provisions of 105 CMR 435.000 and every other applicable law and regulation pertaining to water slide flumes. 4. If at any time the water does not conform with the requirements set forth in 105 CMR 435.35 (1), the operator shall immediately close the water slide flume until the water conforms with those standards. 5. The flume shall be perpendicular to the pool wall for a distance of at least ten feet from the exit end of the flume. The last ten feet of the flume shall have a slope which is not steeper than 1 in 10. 6. The distance between the side of the flume terminus and the pool side wall shall be at least five (5) feet. The distance between the flume terminus and the opposite side of the pool shall be at least 25 feet and steps shall not infringe upon this area. 7. The flume shall terminate 1-1/2" above the water surface. 8. The construction dimensions and the mechanical attachment of the flume components shall be such that the surface of the flume is smooth and continuous for its entire length. 9. Each flume shall have a distinctive line or marking to indicate the starting zone in which only one rider at a time is permitted. This line shall be in accordance with the manufacturer's specifications or 30 feet, whichever is the longer distance. The facility shall post a sign at the top of the slide warning all sliders not to proceed down the slide until the slider in front has passed this line. 10. The depth of the pool at the terminus of the slide shall be 3-1/2 feet deep. 11. The pool water elevation will not be lowered by more than one inch when the flume pump is in operation. 12. The splash down area shall be roped off from the area of the pool used for swimming and bathing. 13. A gate shall be installed at the entrance to the stairs leading up to the slide to deter usage without supervision. 14. The facility will have two (2) persons on duty to monitor slide usage when the slide is actively in use. The water supply shall be turned off when the slide is not in use. Please review the above and do not hesitate to call if you have any questions, or need further information. Very, truly yours, FILLION ASSOCIATES, INC. ?211th E. Bowser PO Box 14518 East Providence, RI 02914 800-776-7665 rbowser@fillionassociates.com 1 Commonwealth of Massachusetts s b City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 04/23/2009 ESTABLISHMENT NAME: File Number: BHF -2009-000002 YMCA - Lynch Van Otterloo 40 Leggs Hill Road SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SWIMMING POOL - BHP -2009-0447 Jun 1, 2009 Sep 30, 2009 Outdoor Seasonal Pool Open 9am to SEASONAL gpm t Total Fees: PERMIT EXPIRES Board of Health Page 1 I 0 t. KIMBERLEY DRISCOLL MAYOR JANB'IDIONNp:, SENIOR SANI'I'ARIiAN CITY OF SALEM, MASSACHUSETTS BOARD OF HP'Al:111 120 WASI [INGPON Sf ZI.D.; ', 4'"' FLOOR MA.. (978) 741-1800 FAx (978) 745-0343 IDIONNCnSAI FNI. COM 2008 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL ©oly0art 100B/ LOCATION OF POOL AY AY G- A. ?!1- I,crc r � L� %1 NAME OF A MAILING A CERTIFIED POOL OPERATOR Cert #: TEL # DATES OF OPERATION (if not DAYS & HOURS OF OPERATION: 7. ed 4. fG t.,00 ty 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. Is 0(,&3 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 1, to my best knowledge and belief, have filed all state tax return and paid taxes required under the law. /X -al FL, 7 V9w05r7Yd 'a Date SS# or Federal Identification PC Revised 8/14/07 poolappmpd Check # ®Salem YMCA One Sewall Street Salem, MA 01970 978.744.0351 ext 101 978.740.9168 fax ® www.northihoreymca.org Deborah Amaral Executive Director amamld@northshoreymca.org YMCA OF THE NORTH SHORE 13® wherM on9 YMCA ComPlimentary Guest Pass Please be our guest. Use this pass for a visit at any of our YMCAs. Beverly Cabot Street YMCA • 245 Cabot Street • Beverly, MA 07915 • 978.922.0990 Beverly Sterling YMCA • 254 Essex Street • Beverly, MA 01915 978.927,6855 Cape Aon YMCA • 71 Middle Street • Gloucerter, MA 01930 97g.283.Oq]0 Ipswich Family YMCA .110 County Road • Ipswich, MA 01938 Marblehead Swam979,356.9622 Swampscott YMCA • 94 pleasant St • Marblehead, MA 01945 • 781.631.0870 Salem YMCA • One Sewall Street • Salem, MA 01970 • 978 7" 035, Haverhill YMCA • 81 Winter Street • Haverhill, MA 01830 • 978.374.0506 Phone Authorized by CITY OF SALEM, MASSACHUSETTS + r BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 KIMBERLEY'DRISCOLL Fax (978) 745-0343 MAYOR IMANCINI(@SAI.FAI COM JANET Mr\NCINI. ACTING HIsAM'i-I AGr;N'r Facsimile Transmittal To: 01()2� l Fax # 01 RE: Date: Page(s): including this cover # Z" Messaae: ) "=3 9 iir ti IS, 1 4G P-o(L- , ")av V ii Board of Health News ----------------------------------------------------------For Your Information OFFICE HOURS: Monday, Tuesday, Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 12:00 NOON KIMBERLEY DRISCOLL MAYOR JANI.i r MANCINI ACTING HEALTI-i AGENT Salem Board of Health 120 Washington Street 40' Floor Salem, MA 01970 CITY OF SALEM, MASSACHUSETTS BOARD. OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TELL. (978) 741-1800 FAX (978) 745-0343 INIANCIN19SALEM COM Pursuant to The Virginia Graeme Baker Pool & Spa Safety Act and the Commonwealth of Massachusetts Minimum Standards For Swimming Pools (State Sanitary Code: Chapter V -105 CMR 435.00), Lcertify that the pool and all pool drain/grate covers in the semi-public or public pool (choose the type of pool below) swimming wading _ special purpose located at Establishment Name Establishment Address rr ❑ conform to the The Virginia Graeme Baker Pool & Spa Safety Act and the American National Standard ASME At 12.19.8 — 2007 I OR: ❑ do not conform to The Virginia Graeme Baker Pool & Spa Safety Act and the American National Standard ASME A] 12.19.8 — 2007 and that the pool will be shut down effective December 19, 2008. Signature of pool owner /Corporation President Title Print name Date , IAPMO RESEARCH AND TESTING, INC. 5001 East Philadelphia Street, Ontario; California 91761-2816 • (909) 472-4100 Fax (909) 472-4244 • www.iapmo.org ox •, I J ' AxSl OcttaCIbORWram ��? emwaicb,ar w�.�e U 9C0P LISTED PRODUCTS IAPMO Research and Test ng, Inc, is a product certification body which tests and Inspects samples taken from the suppliers stock or the market or a whichu tion of both to verity compliance to the requirements of applicable codes and standards. This activity is coupled with periodic surveillance of the supplier's factory and warehouses as well as the assessment of the supplier's Quality Assurance System. This listing is subject to the conditions sat forth in the characteristics below and is not to be construed as any recommendation, assurance or guarantee by IAPMO Research and Testing, Inc. of the product acceptance by Authorities Having Jurisdiction. Effective Date: November 2008 Void After: November 2009 Product: Suction Fittings - File No. SP -5917 Yssued To: Eureka Manufacturing Co. P.o. Box 1473 Bismarck, NO 58502 - - IDENTIFICATION: Fittings shall be permanently marked as follows in a manner so as to be visible after installation in the following sequence (lithe statement' "For Single or Multiple Drain Use Only", "For Single Drain Use", or "For Multiple Drain,Use only" (2)maximum flow rate (3)type of fitting (4)life of the fitting in years (5)Installation position (6)Manufacturersname t - or requested trademark and (7)model designation and the USPC _ certification mark®. CHARACTERISTICS: Suction fittings for use in swimming pools, wading pools, spas, hot tubs,and other aquatic facilities. Products comply with the applicable. sections of the latest edition of the Uniform Swimming Pool, Spa and Hot Tub Code®. Manufactured in compliance with ASME A112.19.8 -2008a. Products listed on this certificate have been tested by an IAPMO R&T recognized laboratory. This recognition has been granted based upon the laboratory's compliance to the applicable requirements of ISO/IEC 17025. Chairman, Product Certification Committee Executive Director This listing is for the period indicated herein and is void after tire data shown above. Any change in material,, manufacturing process, marking or design without having first ahenned the approval of the Product Certification Committee, or any evidence of non-compliance with applicable codes and standards or of infienorworkmansidip, may be confined sufficient cause for revocation of this listing. Reproduction of or reference to this form for advertising purposes may be made only by specific written permission of IAPMO.Research and Testing, Inc. Any alterimmon of INS certificate could be grounds for revocation of the listing. DOC#O81A IAPMO RESEARCH AND TESTING, INC. LISTED PRODUCTS 4 (ext Page 2 Effective Date: November 2008 a Product: Suction Fittings Issued To: Eureka Manufacturing Co. MODELS: - - Model No. Description -AV20x20 Stainless Steel Entrapment Cover For Pool/Spas (223 GPM) AV26x26 Stainless Steel Entrapment Cover For Pool/Spas (495 GPM) AV32x32 Stainless Steel Entrapment Cover For .Pool/Spas (675 GPM) AV44x44 Stainless Steel Entrapment Cover For Pool/Spas (975 GPM) Void After: November 2009 File No. SP -5917 DOC4091A OLS 1.TOCONCRETTEI DRIINSTALLATION 2. 0%` CONCRETE DRILLBIT 3, 4jr'ALLEN WRENCH , 4. .PENCIL OR MARKER DO��O OOOOO a 5. HAMMER 6. DROP-IN SETTING TOOL (PROVIDED' INSTALLATION INSTRUCTIONS ANTI -ENTRAPMENT PLACE NEW ANTENTRAPMENT COVER IN PLACE COVER 2. MARK. LOCATIONS OF ANCHOR HOLES LEAVING O �� MINIMUM 1' OF CONCRETE BETWEEN MAIN DRAIN - - AND LOCATION TO BE DRILLED OO OO ANCHOR HOLES 3. 'DRILL 0%' HOLE i' DEEP AT ALL 4 LOCATIONS, CHECK MARKS AFTER EACH HOLE IS DRILLED (DRILL BIT MAY WALK) 4. INSERT Y.' S/S DROP-IN ANCHORS, MAKE SURE THEY ARE FLUSH OR SLIGHTLY BELOW CONCRETE, W S/S DROP-IN ANCHORS SET THE ANCHOR BY STRIKING THE INTERNAL PIN bl// WITH THE PROVIDED SETTING TOOL I I 5. ATTACH THE GROUNDING LUG TO A SUITABLE GROUND (IF REQUIRED) G. PUT COVER IN PLACE, TRACE AROUND PERIMETER, PLACE ROPE CAULKING. AROUND PERIMETER 75% 1' MINIMUM TYP OUTSIDE OF THE LINE 7. APPLY ANTI -SEIZE LUBRICANT TO THE PROVIDED SCREWS AND INSTALL COVER, LONGER SCREWS CAN BE PROVIDED IF NEEDED DUE TO AN UNEVEN FL30R >5, B. INSERT PLASTIC CAPS IN ALL SCREW HOLES 9, MOLD CAULKING AROUND COVER TO FILL ANY GAPS ` MAIN DRAIN CHECK COVER AND CAULKING BEFORE EACH USE OF - THE FACILITY. REPLACE CAULKING IF CAPS BECOME PRESENT OR CAULKING BEGINS TO DET.I_RIORATE 20'X20' ANTI -ENTRAPMENT CUVER INFORMATION 'READ AND UNDERSTAND COMPLETELY BEFORE INSTALLATION FAILURE TO DO SO CAN CAUSE SEVERE. INJURY AND/OR DEATH 1. THIS COVER MEETS ASME A112.19.8-2007 STANDARDS AND COMPLIES WITH VIRGINIA GRAEME BAKER ACT 2008 L. MANUFACTURED BY EUREKA MANUFACTURING, MODEL NUMBER AV2CX20, MAXIMUM FLOW.RATING IS 223 GPM 3. CLASSIFICATION IS 'SUBMERGED SUCTION OUTLET' AND IS APPROVED FOR FLOOR AND WALL INSTALLATIONS 4. THIS DESIGN IS MADE TO FIT OVER AN EXISTINGMAINDRAIN, REMOVE ALL PRESENT GRATING AND HARDWARE TO PREVENT AN ENTANGLEMENT HAZARD 5. ACCEPTABLE CONNECTING PIPE SIZES ARE 3',. 4'; 6', AND 8' 6. REPLACE HARDWARE -WITHIN 10 .YEARS. REPLACE COVER ITSELF WITHIN 20 YEAI:S. (NOT. AN IMPLIED WARRANTY) 7, DO. .NOT LOCATE SUCTION CUTLET. ON SEATING AREA OR ON THE BACK RESTS FOR SUCH SEATING AREAS 8, WHEN TWO OR MORE SUCTION FITTINGS ARE USED ON A COMMON SUCTION LINE THEY MUST BE SEPARATED BY A MINIMUM OF 3' (91.44 CM) OR PUSITIDNED ON TWO SEPARATE PLANES 9. IN THE EVENT OF ONE SUCfIDN OUTLET BEING COMPLETELY BLOCKED, THE REMAINING SUCTION OUTLETS SERVING THE SYSTEM SHALL HAVE A FLOW RATING CAPABLE OF THE FULL FLOW OF THE PUMP(S) FOR THE SPECIFIC SUCTION SYSTEM -10. DO NOT EXCEED THE MAXIMUM ALLOWABLE FLOW OF 223 GPM _ 11. THE SUCTION OUTLET SHOULD BE CHECKED FOR DAMAGE OR TAMPERING BEFORE EACH USE OF THE FACILITY 12. MISSING, BROKEN, UR CRACKED SUCTION OUTLETS SHALL BE a REPLACED BEFORE USING THIS FACILITY J 0.6 13. LOOSE SUCTION OUTLETS SHALL BE REATTACHED OR REPLACED o D5 BEFORE USING THE FACILITY 04 14. WHEN REPLACING THE PUMP, MAKE,SURE NOT TO EXCEED THE v O'3 MAXIMUM FLOW FOR THE SUCTION OUTLET_ R2 15. SERVICE AND WINTERIZING INSTRUCTIONS, CHECK CAULKING AND o 0I COVER DAILY WHILE POOL IS IN USE, IF COVER SHOULD BECOME ` 0 LOOSE TIGHTEN SOCKET -HEAD SCREWS OR REINSTALL COVER 50 100 150 200 250 FLOW (GPM) 16. READ, THEN KEEP THESE INSTRUCTIONS FOR FUTURE REFERENCE ANTI—ENTRAPMENT COVER INSTALL ISCale 'NONE 10-24-08 1 Drawn AKP I Chk. I Rev. Drawing No. 20X20 NONE AVINSTALL 01/15/2009 15:18 9782830577 January 15,2009 FREEDOM DIVING Freedom Diving Corp. 63 Rogers Street Gloucester, MA 01930 (978)283-2600 YMCA of North Shore 45 Cabot Street Beverly, Ma 01915 Dear Debbie: 1, Theodore Barnes, of Freedom Diving Corp. have installed approved drain covers on coater drains of the Small Pool. Two (2) covers were used to cover drains and no alterations were made to the covers during the installation. Drain covers are fastened seewely to the wall and bottom of pool and sit flush to both surfaces. Sincerely, Theordore Barnes President Freedom Diving Corp. i PAGE 01 Permit # PO -15-13 Date of Print 6/12/20.15 Permit Issued 1/1/2015 Permit Expires 12/31/2015 Permit Fee $40.00 Late Fee $0.00 00 n F Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com PUBLIC POOL HEALTH PERMIT License For: Granted To: Address: 40 Leggs Hill Road Location of Establishment: Restrictions: Notes: Pool (year round) LVO YMCA MARBLEHAD LEGGS HILL ROAD rubhcxesith Larry Ramdin, MPH, RENS, CHO Health Agent MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/3112015, unless_ sooner revoked or suspended. - - - CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4- FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 Izamdin@salem con IV r W/LL{:a1GiYth Prcrmt. Promote. Protect. LARRY RmDIN, RS/ItEHS, CHO, HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL V/'- ?,Nv. Cert #: M � ®(wed q � zZ A ® l9lr S� #_ i81- FYO -7" g DATES OF OPERATION (if not annual):_ DAYS & HOURS OF OPERATION: _ f' S ql;" !.0 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 fo: 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 I, to my best knowledge and belief, have filed all s to tax /rturna nsd paid all state taxes required under the law. �Li.Ji .f d.) ,_1 QLD' Signature Date SS# or Federal Identification Number Revised 523/11 poolappl Ldoc �6 Permit # PO -15-12 Date of Print 6/12/2015 Permit Issued 1/1/2015 Permit Expires 12/31/2015 Permit Fee $40.00 Late Fee $0.00 �pNOf I R� Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com PUBLIC POOL HEALTH PERMIT License For: Pool (year round) Granted To: LVO YMCA Address: 40 Leggs Hill Road MARBLEHAD Location of Establishment: 40 Restrictions: Notes: LEGGS HILL ROAD lu - PublicmIiealth P Pr . Pmt¢t. Larry Ramdin, MPH, RENS, CHO Health Agent MA 01945 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2015, unless sooner revoked or suspended. - 0 KIMBERLEY DRISCOLL MAYOR LOCATION OF POOL CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TM FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 kam a Salem corn PabliCHealth Prevent Promote. Protect. LARRY RAMDIN, RS/REHS, CHO, HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL M # e(gje� —I� ZZ A dq l94 So� #-7V — ffO -7&C 1 DATES OF OPERATION (ifnotannual):_._�� _ - DAYS & HOURS OF OPERATION: f 4a& S r IX4 10 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, allplans fo: 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 I, to my best knowledge and belief, have filed all a taxi; °s nd paid all state taxes required under the law. Signature Date SS# or Federal Identification Number Revised 523/11 poolappl Ldoc Check# VV Permit # PO -15-14 Date of Print 6/12/2015 Permit Issued 5/28/2015 Permit Expires 9/18/2015 Permit Fee $40.00 Late Fee $0.00 �pNO Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com PUBLIC POOL HEALTH PERMIT License For Granted To: Address: 40 Leggs Hill Road Location of Establishment: 40 Restrictions: Notes: 40 Leggs Hill Road Pool (special purpose) LVO YMCA MARBLEHAD LEGGS HILL ROAD ]PublicHealth Prevent. Promote. Protect, Larry Ramdin, MPH, REHS, CHO Health Agent MA 01945 This permit or license is granted inconformity with the statues and ordinances relating thereto, and expires on 9/18/2015 , unless sooner revoked or suspended: �1 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4- FLOOR Tial.. (978) 741-1800 FAx (978) 745-0343 jjawd1n (! saleMcom, LARRY RAMDIN, RS/REHS, CHO, HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL DATES OF OPERATION (ifnot annual DAYS & HOURS OF OPERATION: 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 fo: 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 I, to my best knowledge and belief, have filed all a tax turns d paid all state taxes required under the law. � 9 rte �' X2-0 t►�r�� rok- C3 Signature Date Date SS# or Federal Identification Number Revised 523/11 poolappl Ldoc /V " CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 KIMI3ERLEY DRISCOLL FAY (978) 745-0343 MAYOR lramdin@a salem com LARRY RAMDIN, RS/Rril-IS, C110, (P -I'S HEAL: i -I AGu,N r Swimming Pool Inspection Report Pool: MLA 6LO - nos\. Date: io l%1 J Address Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435-00 Minimum Standards for Swimming Pools; State Sanitary Code Chapier V. 5/ nnual Permit Posted 5 health and Showers signs Posted L --,Health: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. _✓Lifegu"s: Present v' Certification _✓Red/orange suit _V"Guard" printed on jersey _✓Sun block avail. _ Voice Amplifier _,elevated seat Emer. Communication: phone at pool f Phone instructions ✓Emergency numbers ,-Ffione in unlocked area 'Safety Equip: for each 2000, sq. feet `Rescue tube or ring buoy (with rope) / e—Sackboard with collar and straps t/ First Aid: Equipment area 5) 1" band-aids✓(l0) 3x3 gauze Y (z) 5x9 surgipads 5/(12) antiseptic wipes _ (1) 8x10 Surgi ✓(2) 2" soft roller bandages ✓Scissors ✓(2) 3" Soft roller bandages ✓Tweezers ✓(1)'/: roll hypoallergenic tape fescue blanket ✓�-packs >,�rocket mask _ stenle isotonic eyewash ,/Disinfection7.9 Chlorine -2.\o �H 7.2 - 7.8 Residual free 1-3, Combined 0-0.2 n _ Bromine _ pH 7.2 - 7.8 Residual 2-6 (ppm) (mg/1) _ 4 ✓Reeor s Kept: — _ Water tests ✓5hemicals Used ✓ Backwashing attendance ours of operation -�-✓� Depth Markings Sidewalk and inside pool N I W Diving Boards rigidly constructed, property anchored, braced for heaviest load, no splinters or c 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 facilities Notes: Receivedby: K6ff(^4A Inspected r CITY OF SALEM, MASSACHUSETTS „ . J BoAm-) OF HEALTH 120 WASHINGTON STREET, 4 .. FLOOR KIMBERLEY DRISCOLL TEL. (978) 741-1800 MAYOR FAY (978) 745-0343 Itamdin@saleAn.com salern.com LARRY RAMDIN, RS/RFIHS, CHO, CP -FS HEAlxij AGENT Swimming Pool Inspection Report uARRtae. (D¢<` PooiOr4 tl Vrto) gj QLLoo Ym(A Date: b -1? -13 Address Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards for Swimming Pools; State Sanitary Code Chapter V. _,✓ Annual Permit Posted �t1� ealth and Showers signs Posted 7 Health: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. Lifegunds: Present f Certification ` Red/orange suit l�>uard" printed on jersey / dun block avail. _✓Voice Amplifier — Elevated seat ✓ Emer. Communication: phone at pool _✓Phone instructions Emergency numbers _✓Phone in unlocked area Safety Equip: for each 2000, sq. feet ✓ Rescue tube or ring buoy (with rope) 'Backboard with collar and straps _✓First Aid: Equipment area f 5) 1" band-aids -_ (10) 3x3 gauze ✓(2) 5x9 surgipads (l 2) antiseptic wipes ✓(1) 8x10 Surgi2) 2" soft roller bandages _I,f-acissors (2) 3" Soft roller bandages Tweezers j L 1/2 roll hypoallergenic tape escue blanket /—fie packs Pocket mask _✓sterile isotonic eyewash Disinfection ✓ Z.'% ✓ Chlorine -'Z.2 _ pH 7.2 - 7.8 Residual free 1-3, Combined 0-0.2 LA 1' 0—,2 2 ` 7. w _ Bromine _ pH 7.2 - 7.8 Residual 2-6 (ppm) (mg/1) _✓Records Kept: �W ter tests ✓Chemicals Used ✓ Backwashing /Attendance _?—Hours of operation Depth Markings Sidewalk and inside pool ✓Diving Boards rigidly constructed, properly anchored, braced for heaviest load, no splinters or c 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 facilities Notes: Receivec _ Commonwealth of Massachusetts rr City of Salem Boars of Health Kimberley.Driscoll 120 Washington Street, 4th Floor Mayor" SALEM, MA 01970 Swimming Pool Annual Permit DATE PRINTED: 02/29/2012 KIMBERLEY DRISCOLL MAYOR LAIim' R;\n11)lN, RS/RLPIS, CMO, CP -FS HFAi:m AGI?N'r CITY OF SALEM, MASSACHUSETTS BOARD or• HFALT] 1 120 WAST IING ON S1RFE'r, 401 F1 4)0]t Tia.. (978) 741-1800 FAX (978) 745-0343 lramdin(r�salem.com 2011. APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL rl D P Q �li.� //'A A NAME OF APPLICANT MAILING ADDRES TEL # 7,' (-63 � — 9'0',7,9_ CERTIF D P OL O E TOR yp p 7 Name: ✓D ( �`�f/ Cert #: C Z / !�%/TEL #7e t� �—%�O-700? DATES OF OPERATION (if not DAYS & HOURS OF OPERATION: 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 I, to my best knowledge and belief, have filed all state returns and paid all state taxes required under the law. Signature Date SS# or Federal Identification Number Revised 523/I1 poolappl I.doc Check qV KIMBERLEY DRISCOLL MAYOR LARRY RANIUIN, QRS/RVA IS, (110, C11-1.5 H £:•11;19 i A01'.N'r CITY OF SALEM, MASSACHUSETTS BOARD oP Hi;AL l'1 T 120 WASI-IINCIDN STREET, 4p1 FIL)OR TEL. (978) 741-1800 FAX (978) 745-0343 lramdin@salem corn 2011 -APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL&) L eolat N /,4S /L,nl P NAME OF APPLICANT MAILING ADDRES RIP I9iQ4r1-� TEL # CERTIFIP POOL OPERATO Name: �'v(��,/ Ze1g_1i`A1 Cert #inf--:�L#7.L(-9Ye-7e r? DATES OF OPERATION(if not annual): ,t/— DAYS &t HOURS OF OPERATION: TYPE OF POOL Public Semi -Public Special Purpose - /62 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 ovmership. In accordance with the State Sanitary Code, before any renovatiens, 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 I, to my best knowledge and belief, have filed all s tax re;urns and paid all state taxes required under the law, c7 atuta r lel 0-0 61 $l gn Date SS# or Federal Identification Number Revised 523/11 poolappl I.doc Check # Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Swimming Pool Annual Permit DATE PRINTED:. 03/11/2010 ESTABLISHMENT NAME: File Number: BHF -2009-000002 LOCATED AT: Kimberley Driscoll Mayor YMCA - Lynch Van Otterloo 40 Leggs Hill Road SALEM MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SWIMMING POOL - BHP -2010-0380 Feb 10, 2010 Dec 31, 2010 $40.00 ANNUAL Total Fees: $40.00 PERMIT EXPIRES December 31, 2010 Board of Health Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OI� HFA1.11I 120 WASHING'R)N S'Ilil?li'1', 4"' FLOOR TEE. (978) 741-1800 KIMBERLEY DRISCOLL FAX (978) 745-0343 MAYOR DGR1,kNl3 wn1QS,v.EK COM DAVID GREENBAUM, AC1lNG HCiA1:11'I AGENT' , 2010 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL qV NAME OF APPLICANT MAILING ADDRESS CERTIF�IFD POO PE T_OR Q �j Name: 1 f�[d[/D �P y��ro Cert #: ®TEL DATES OF OPERATION (if not annual): Q /I/A/QtA DAYS & HOURS OF OPERATION: 5� — �0 TYPE OF POOL Public Semi -Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonaflQ4 . oma— (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 1, to my best knowledge and belief, have filed all state tax retums �rtd paid all state taxes required under the law. ^loo -g/3 31guature I Date SS# or Federal Identification Number Revised 8/14/07 poolapp.wpd Check #Date Commonwealth of Massachusetts City of Salem Board of Health lQmberley Driscoll \��"`✓/��/ 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Swimming Pool Annual Permit DATE PRINTED:. 03/11/2010 ESTABLISHMENT NAME: File Number: BHF -2009-000002 YMCA - Lynch Van Otterloo 40 Leggs Hill Road SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SWIMMING POOL - BHP -2010-0382 Mar 11, 2010 Dec 31, 2010 Lap Pool ANNUAL PERMIT EXPIRES Total Fees: December 31, 2010 Board of Health Page 1 r CITY OF SALEM, MASSACHUSETTS BOAIID D r Hi4AL II I 120 WASHING IDN S'IR1:9i'r, 471' FLOOR TI311. (978) 741-1800 KIMBERLEY DRISCOLL FAX (978) 745-0343 MAYOR DGREU.NBAUM(n7S v r• M. CObI DAN'm GRffiiNBAUM, ACTING HEAI:II-I AGENT 2010APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL 40 4WA /// C - lea �� , /�" 0/ ?4l NAME OF MAILING ADDRESS TEL CERTIFIED POPERf),TOR Name: .?e✓/l��PICA��JJ Cert #: 9f�TEL # DATES OF OPERATION (if not annual): g"411 �. DAYS & HOURS OF OPERATION: 5—, — (0 TYPE OF POOL Public Semi -Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonalO z3M;_Rrof (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 I, to my best knowledge and belief, have filed all state tax returns d paid all state taxes required under the law. ...'- Signa&e r 1 Date SS# or Federal Identification Number Revised 8/14/07 poolapp.wpd Check # Date l� -