EASTERN FRANKLIN COUNTY HEALTH DISTRICT
P.O. BOX 592
SHUTESBURY, MA. 01072
APPLICATION FOR A RECREATION CAMP PERMIT
105 CMR 430.00
DATE_____________________ NEW______________
PRIOR YEAR’S PERMIT #______ RENEWAL___________
ANNUAL FEE $25.00 enclosed Payable to: TOWN OF NORTHFIELD
CAMP NAME:___________________________________________________
LOCATION:_____________________________________________________
PHONE NUMBER AT CAMP: ( ) ________________ FAX: ( ) ________
Applicants Name___________________________________________________
Address__________________________________________________________
City/Town________________________________________________________
Contact Person____________________________________Phone #__________
Number of Campers____________________ Number of Staff_______________
Number of dates open: __________________ Dates:_______________________
Comments:________________________________________________________
Applicants Signature________________________________________________
By affixing his signature above, the CAMP DIRECTOR agrees to operate the recreational camp in the Town of NORTHFIELD in Strict Accordance with all requirements of the State Sanitary Code, 105 CMR 430.00 and related codes and local Board of Health Regulations.
105 CMR 430.632: Board of Health Shall Grant, Suspend or Revoke License
The board of health shall grant, suspend or revoke licenses for recreational camps for children in accordance with the provision of M.G.L. c. 140 32B and 32C. All licenses for recreational camps granted under 105 CMR 430.000 shall state the maximum number of occupants authorized for such camp and the capacity shall not be excelled by the operator at any time. Upon the issurance of a license, the local board of health shall notify the Massachusetts Department of Environmental Protection and the Massachussetts Department of Public Health. Said notification shall include the name and address of the camp, the name of the owner, the number of campers and staff, and the number of days per year that the camp will be in operation.
SEND THIS FORM TO THE LOCAL BOARD OF HEALTH