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Home My WebLink AboutCanoe River C.G. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health __— - --- Permit to Operate a Swimming Pool i PERMIT NUMBER: 1 PERMIT EXPIRES: December 31, 2019 Person Certified. PHILIP J CARROLL Pool/SPA Certification Date: November 14, 2018 Pool/SPA Certification Expires: November 14, 2023 Person Certified: ERIC J CARROLL Pool/SPA Certification Date: November 14, 2018 Pool/Spa Certification Expires: November 14, 2023 In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: CANOE RIVER CAMPGROUND for the operation of a ❑ Public W Semi -Public ❑ Special Purpose Pool located at: 137 MILL STREET Method of water treatment is CHLORINE Bathing load not to exceed: 95 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan-PaCmer, Heaah Agent�' d 1 el 0' Date Issued �p Town af'Han#7eld - Board ofWealth Swimming Fool Application NAME OF OWNER: ADDRESS: CITY: /"! STATE: ZIP: TELEPHONE: FAX: - 3 7 EMAIL: 2. v - ," C FED IDISS NO: ertification Expires Every 5 Years ermit Expires December 31st Yea PERSON CERTIFIED: r 14 1 L 1,- C%- o L L 18 Pool/.SPA Certification Date: // 1/ Y/� //// ylao3 3 Pool/SPA Certification Expires: PERSON CERTIFIED: 2 1 C CA (U 0 <- Pool/SPA Certification Date: / / �/V(/a" r G Certification Exp / 1 A v41 Pool/SPA certification remarks(if necessary): REMARKS: �7,07 ' " r" R, i ' sA APR 051 L- Town o"Wansfieid--�� .. 6 Park Row Mansfield, MA 02048 PERMIT NUMBER PEE: $150 Re -inspection fee: $100 ❑ Public POOL OPERATION: W Semi -Public Ll Special Purpose Pool POOL LOCATION: 1 3 / L. -- TYPEIPOOL• LENGTH: " WIDTH:. �? ' VOLUME: MINIMAX DEPTH: SWIM AREA: v..,a,F"+ a. DIVE AREA: /4-'114 WATER SOURCE: ,/ 1 C. i , +s L LN W1W DISPOSAL: ! i C.1 ti C i /14 L TYPE OF FINISH: v<' 2. c ...7...4 SCUM GUTTER: jt J,r DECK TYPE: 4`- SKMMR WEIR LENGTH: j✓ f /4 TREATMENT SYSTEM: C /j - DISINFECT METHOD: ��_ t{-�__ct- CHEMICAL TREATMENT: NUMBER OF BATHERS: r SIGNATURE:' 2C, �" DATE: —_ 3_l 3 t / I - -- Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. s r, Town of Mansfield - Board of Health ♦M1 Swimming Pool Application NAME OF OWNER: C fit — (! � t o.._ w _ � 2c ct,ai,� _.,.» � ADDRESS: i 3 -/ ,V1 L_ f_ CITY: rL I — /--- / G t, r`1 STATE: /-I/4 LP: TELEPHONE, FAX: EMAIL: C- Q ' C. ii-,. , { v x fED ID1SS N6: , :f - ? j `, _5 -71 Certification Expires Every E Years Permit Exuirss December 31st Yeadv PERSON CERTIFIED: i�l't" rL l P C,�yKoL I Pool/SPA Certification Date: Pool/SPA Certification Expires: PERSON CERTIFIED: L=I� t C CA Pool/SPA Certification Date: f/ �i Y/a o r d' Poof1SPA Certification Expires: certification remarks(If necessary): REMARKS: ❑ Public POOLOPERATION: Semi -P Special POOL LOCATION: / "! TYPEIPOOL: Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 •.. LENGTH: ci /' WIDTH: VOLUME: L MINIMAX DEPTH: cf m — � 3 ' 3 SWIM AREA: �' ' ` '�' r' DIVE AREA: ff WATER SOURCE: WAN DISPOSAL: "'i✓4%i G1 -"-r (-- TYPE OF FINISH: C.c:^�C;:;v'.�'f SCUM GUTTER: ✓`-'O'f DECK TYPE: SKMMRWEIRLENGTH TREATMENT SYSTEM r DISINFECT METHOD: i CHEMICAL TREATMENT: NUMBER OF BATHERS: r' SIGNATURE: / "� �� -e DATE: Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, ' Park Row, Mansfield, MA 02048. of Mansfield, Six TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name *"Social Security No. (Voluntary) or Federal Identification Number 1 A By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be _R+rnished. to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\(Jsers�elei(a\Desk(op\Scott's DowmentsWood Establishimts-'remp\TAX CERTIFICATION EORM.doc The Commonwealth of Massachusetts Department oflndustriol Accidents Office of Investigations 600 Washington Street Boston, MA 02111 rvw%nmssgov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name;- sTif•> a ,� �� - �fs, ': A, 1 <- 1 , � � <-r4,ari6- tiro Phone #; Are you an employer? Clieck the appropriate box: 1.0 I am a employer with —employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for the in any capacity. [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): S. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc,) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.❑ Health Care 12.[gOttter f �-n (�G✓'},- : r;�, t t !' l% 1 }�f- ". e`er. *Any appllcant that checks box lit mustalso fill out are section below showing theirworkers' contpensatioa policy information. **Ifthe corporate officers have exempted themselves, but die corporation has other employees, a workers' compensation policy is required and such an organbuition should check box 11. I nm nn employer flint is providing ;porkers' contpetisation insnritnce for »rya earployees. Below is the policy hrforrtration. Insurance Company Name: -'-. c,�t'' [ c- ! t - 14 t C-4 'C _ Insurer's Address: x L� 1_ 4 k <A,t C t- .r f7 City/State/Zip: r %r - L_ Policy 4 or Self -ins. Lie, # ( 2:7 u •FR <i s'A) "75 " .` ; k Expiration Date: l t ! % `1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo, ander titan the hilbrination provided alcove is true an it correct. Official use only. Do not write in this area, to be completed by city or love official City or Town: Permit/License # _ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone 9: �arwv,mnss,gov/ma VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GZZUB-0495N75-0-18) RENEWAL OF (GZZUB=0495N75-0-17) INSURER: AMERICAN ZURICH INSURANCE COMPANY CO CODE: 17965 1. INSURED: PRODUCER: STARLIN, INC. DBA CANOE RIVER C & S INSURANCE AGENCY CAMPGROUNDS 310 N MAIN ST #6 137 MILL ST MANSFIELD MA 02048 i MANSFIELD MA 02048 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05-13-18 to 05-13-19 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies towork in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee i C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068 — I o v —_ D. This policy includes these endorsements and schedules: o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information is subject to verification and change by audit t9 be made ANNUALLY. DATE OF ISSUE: 04-20-18 WC ST ASSIGN: MA OFFICE: ZURICH—ORLAN 809 PRODUCER: C & S INSURANCE AGENCY 75W2J oi9�44 For verification, WephoneNSPrat71954T911 I�rlerfnail5crvl say {cr IIII ri ,I I14 I IFI I r l I it lii 111 I I I _ Al Ifl.. _ I'V IF tlq.. I iY � Ili li �li� i illi �I law 1 6� II 1 `F h690 Fit, mud . Ili -,_ Ooj I SG c ® ... �F g 0 1 - R^� � ruZl�� I •� OC •� � � 1 II �, I it ,� 9 O I i r 5 __� Ric i l mA ow I+17lil�i `- '.T�� a®�� 1 ►'j I14 I IFI I r l it lii 111 Ifl.. tlq.. I iY � ®, �� 1 a .ry r ,� s �,�� , � � ; 4 , , , ,; t'��i ,,�,�� . �, i" ®, �� 1 a .ry r Fecal Response Formed Stool VCM ' T 1. Evacuate (and lock) the affected pool filtration system until all procedures have been completed. 2. Utilize appropriate Personal Protective Equipment / Body Substance Isolation precautions including disposable gloves. 3. Manually remove as much material as possible using a scoop or net. 4. Clean and disinfect all tools used to remove the material. 5. Raise the Free Available Chlorine level to 2 ppm (mg/L) and ensure the pH is 7.5 or less and the temperature is 77 degrees Farenheit (25 Celsius) or higher. 6. Maintain the Chlorine concentration for at least 25 minutes before re opening the pool. (Check AM state laws). 7. Ensure that the filtration system is operating functionally during the disinfection process. Diarrheal Discharge 1. Evacuate (and lock) the affected pool filtration system until all procedures have been completed. 2. Utilize appropriate Personal Protective Equipment / Body Substance Isolation precautions including disposable gloves. 3. Manually remove as much material as possible using a scoop or net. 4. Clean and disinfect all tools used to remove the material. 5. Raise the Free Available Chlorine level to 20 ppm (mg/L) and ensure the pH is 7.5 or less and the temperature is 77 degrees Farenheit (25 Celsius) or higher. 6. Maintain the Chlorine concentration and pH level for 12.75 hours before re- opening the pool. (Check MA state laws). 7. Ensure that the filtration system is operating functionally during the disinfection process. 8. Backwash the filter after the full disinfection time. The filter effluent should be directed to waste, and not back to the pool. q. Return Chlorine concentration to normal regulated levels. Mansfield Board of Health 6 Park Row Mansfield MA 02048 Tel.(508) 261-7366 Fax (508) 261-7343 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORTS TYPE OF POOL: PUBLIC Ll SEMI-PUBLIC 9 SPECIAL PURPOSE POOL Lj NAME OF POOL: Canoe River wading ADDRESS: 137 Mill St. n/a ventilation; Sanitary condition. ADDRESS: 137 Mill St. DATE OF INSPECTION: 05/22/2019 POOL CAPACITY # OF CALS: 10000 INSPECTED BY: J. Lee RE -INSPECTION DATE: Call Office METHOD OF WATER TREATMENT: Chlorine BATHER LOAD: 0 NUMBER OF LIFEGUARDS: 0 WATER SOURCE: Town Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000. Items marked with 'V are satisfactory. REGULATION X N VIOLATIONS/COMMENTS .03 Bathhouse and sanitary facilities adequate lighting; n/a ventilation; Sanitary condition. .03 Adequate enclosure around pool. Gate self -latching wAalch 4 ft above ground. Flow meter reading 89 gpm; Water turn over rate: 1.87 hours. .04 Sewage Disposal. No .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filler Effluent flow meter reading_gpm. # of turnovers .06 Suitable automatic equipment for disinfection of pool water. .06 Carbon dioxode (CO2) equipment for PH control adequate. n/a Carbon dioxode (CO2) cylinders anchored, Inaccessible to public, adquate ventilation provided. .08 Inlets and outlets - Inlets located produce uniform circulation. Over rim fill spout 6" above maximum water level. Properly shield and located. .08 main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without the use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain provided. .08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump. Properly located and plumbed. .08 Suction outlet cover in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools until repairs can be made. .08 Special purpose pool and wading pools equipped with n/a emergency shut off pump switch. Accessible and prominently marked Prepared by: PIC: Page 1 of 2 Pages .09 Cross connections. Portable water supplied through air gap. n/o .10 Skimming facilities. 50% of circulation drawn from surface of pool. .12 Line with floats separates non -swimmer area from deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. .15 Diving equipment in safe condition. n/a .17 Pool supervision - Pool supervision provided. Effective Jan 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. .21 Permit requirements- Permit issued. Adequate maintenance n/o and testing records maintained. Records initialed by person making test. .22 Health regulations: Signs posted. Health warning signs posted for special purpose pools. .23 Lifeguards required Yes .____ Noif lifeguards n/a required, Proper credentials, proper suits and garments worn. Whistle and bullhorn provided. .24 Safety Equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. .25 Emergency Communication System at pool and in working order. Emergency communication device in unlocked area and available at all times to staff and the public. Operating instruction and emergency number provided. .26 Waste and back wash water disposal properly discharged. No n/o direct connection to sewer system. Separation tank provided for diaatomaceous earth filter backwash water. Free Chlorine 8.6ppm; Combined chlorine 0.0; PH: 7.2; .29 Chemical statdards. Bromine(2.0-6.Oppm), X Alkalinty(50-150ppm), Cyanuric Acid(30-100ppm), Water Alkalinty 100ppm; Regulation Free Chlorine 1.0 - 3.Oppm temp.(104F), Total Chlorine Free Chlorine(1.0 - 3.0 M�L,lu. ppm), Comb. Chlorine(0.0 - 0.2ppm), PH level(7.2 - 7.8) ,1C i .29 Pool water tested with appropriate frequency. n/o .30 Water test equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools Water clarity picture taken. Both drain cover grids were .31 Water clarity visually clear. .32 Water clarity maitenance. Filtration system operating continuously. .32 Special purpose pool drained, cleaned and every 14 days. n/a Maximum operating temperatures for special purpose Pools. .33 Thermostatic control provided, and only accessible to the n/a pool operator, for each SPP. Pool shall remain closed till Tree chlorine level drop .38 General sanitation. .34 Closure of the pool. Pool must be closed until it meets the X standards of 105 CMR 435.29 through 435.31. down to 1.0 - 3.Oppm. Call office for reinspection Page 2 Mansfield Board of Health 6 Park Row Mansfield MA 02048 Tel.(508) 261-7366 Fax (508) 261-7343 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORTS TYPE OF POOL: PUBLIC Lj SEMI-PUBLIC 9 SPECIAL PURPOSE POOL NAME OF POOL: Canoe River .03 Bathhouse and sanitary facilities adequate lighting; ADDRESS: 137 Mill St. ventilation; sanitary condition. ADDRESS: 137 Mill St, .03 Adequate enclosure around pool. Gate self -latching wllatch DATE OF INSPECTION: 05/22/2019 POOL CAPACITY # OF CALS: 50000 INSPECTED BY: J. Lee RE -INSPECTION DATE: Call Office METHOD OF WATER TREATMENT: Chlorine BATHER LOAD: 0 NUMBER OF LIFEGUARDS: 0 WATER SOURCE: Town Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000. Items marked with'.7' are satisfactory. REGULATION X / V VIOLATIONS/COMMENTS .03 Bathhouse and sanitary facilities adequate lighting; ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching wllatch 4 It above ground. Flow of meter stuck on the bottom, wont move/repair .04 Sewage Disposal. n/o .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter Effluent X flow meter reading_- a- a=gpm. # of turnovers _ .06 Suitable automatic equipment for disinfection of pool water. .06 Carbon dioxode (CO2) equipment for PH control adequate. n/a Carbon dioxode (CO2) cylinders anchored. Inaccessible to public, adquate ventilation provided. .08 Inlets and outlets - Inlets located produce uniform circulation. Over rim fill spout 6" above maximum water level. Properly shield and located. .08 main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without the use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain provided. Only one outlet with anti -entrapment, antivortex cover, .08 Each system outlet protected against user entrapment by X antivortex cover or other means. Minimum of 2 suction regulation require two for each pool. outlets provided for each pump. Property located and plumbed. .08 Suction outlet cover in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools until repairs can be made. .08 Special purpose pool and wading pools equipped with n/a emergency shut off pump switch. Accessible and prominently marked Prepared by: PIC: Page 1 of 2 Pages .09 Cross connections. Portable water supplied through air gap. n/o .10 Skimming facilities. 50% of circulation drawn from surface of pool. .12 Line with floats separates non-swimmer area from deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. Eric Carroll, CPO with certificate. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. .15 Diving equipment in safe condition. n/a .17 Pool supervision - Pool supervision provided. Effective Jan 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. .21 Permit requirements- Permit issued. Adequate maintenance n/o and testing records maintained. Records initialed by person making test. .22 Health regulations: Signs posted. Health warning signs posted for special purpose pools. .23 Lifeguards required Yes No if lifeguards n/a required, Proper credentials, proper suits and garments worn. Whistle and bullhorn provided. .24 Safety Equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. .25 Emergency Communication System at pool and in working order. Emergency communication device in unlocked area and available at all times to staff and the public. Operating instruction and emergency number provided. .26 Waste and back wash water disposal properly discharged. No n/o direct connection to sewer system. Separation tank provided for diaatomaceous earth filter backwash water. Free Chlorine 10.2ppm; Combined Chlorine 0.0, PH: 7.4; ,29 Chemical statdards. Bromine(2.0-6.Oppm), X Alkalinty(50-150ppm), Cyanuric Acid(30-100ppm), Water Alkalinity 90ppm , Regulation Free Chlorine 1.0 - 3.Oppm temp.(104F), Total Chlorine ,.__ Free Chlorine(1.0- 3.0 ppm), Comb. Chlorine(0.0 - 0.2ppm), PH level(7.2 - 7.8)...,,,_ .29 Pool water tested with appropriate frequency. n/o .30 Water test equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools Water clarity picture taken. .31 Water clarity .32 Water clarity maitenance. Filtration system operating continuously. .32 Special purpose pool drained, cleaned and every 14 days. n/a Maximum operating temperatures for special purpose Pools. .33 Thermostatic control provided, and only accessible to the n/a pool operator, for each SPP. recommend the pool remain closed till flow meter fixed and .38 General sanitation. .34 Closure of the pool. Pool must be closed until it meets the X standards of 105 CMR 435.29 through 435.31. free chlorine level drop down to Pool Regulation standard. Page 2