I, _____________________, certify that _______________________________ is authorized to receive a license to operate a recreational camp for children in the city/town of ________________________________ for the summer of ___(year)___ without prior inspection, in accordance with 105 CMR 430.650. The local board of health for _____________ hereby exercises its discretion to authorize ___________________________ to operate a recreational camp without a prior inspection based on the following (all must be checked to waive the pre-inspection): ___ The recreational camp submitted a timely application for renewal of its license. ___ The recreational camp is under the same ownership and directorship as the prior camping season. ___ The recreational camp is located at the same site as the prior camping season. ___ The recreational camp had a satisfactory inspection report during the prior camping season. ___ Based on a review of the recreational camp record, there is no evident risk to health and safety. ___ The local board of health will inspect the recreational camp during the 2018 camping season. ________________________________________________ __________________ Signature of Designated Authority at Local Board of Health Date Print Name of Designated Authority and Title
I, _____________________, certify that _______________________________ is authorized to receive a license to operate a recreational camp for children in the city/town of ________________________________ for the summer of ___(year)___ without prior inspection, in accordance with 105 CMR 430.650. The local board of health for _____________ hereby exercises its discretion to authorize ___________________________ to operate a recreational camp without a prior inspection based on the following (all must be checked to waive the pre-inspection): ___ The recreational camp submitted a timely application for renewal of its license. ___ The recreational camp is under the same ownership and directorship as the prior camping season. ___ The recreational camp is located at the same site as the prior camping season. ___ The recreational camp had a satisfactory inspection report during the prior camping season. ___ Based on a review of the recreational camp record, there is no evident risk to health and safety. ___ The local board of health will inspect the recreational camp during the 2018 camping season. ________________________________________________ __________________ Signature of Designated Authority at Local Board of Health Date Print Name of Designated Authority and Title
EEC-Template-for-Local-Board-of-Health-Summer-Camp-Renewals-2018-FINAL-4-3-18.docx