HomeMy WebLinkAboutMansfield Children's Center - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Permit to Operate a Swimming Pool
PERMIT NUMBER: 4
PERMIT EXPIRES: December 31, 2019
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Person Certified., KEVIN JOSEPH FALLON
Pool/SPA Certification Date: April 17, 2019
Pool/SPA Certification Expires: April 17, 2024
Person Certified: SANDRA L. KING
Pool/SPA Certification Date: April 17, 2019
Pool/Spa Certification Expires: April 17, 2024
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:
MANSFIELD CHILDREN'S CENTER
for the operation of a ❑ Public Semi -Public ❑ Special Purpose Pool
located at. -
1100
t:
1100 SCHOOL STREET
Method of water treatment is CHLORINE
Bathing load not to exceed: 42 bathers
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
Amy Donovan -Palmer, .Hfeaah Agent
None
4T Date Issued
ap3c)xcr ,�� r
Town of Mansfield - Board of Health
o �•
p'ff�.i3
Swimming Pool Application
I r..
t�fiY
08 2019
[ Town of Mansfield
6 Park Row
--Mansfield, MA 021148
PERMIT NUMBER
FEE: $150
Re -inspection fee: $100
0 Public
NAME OF OWNER: IM&hnt &Gt �il 1, r,.(ip 1 � `��� POOL OPERATION: Semi -Public
0 Special Purpose Pool
ADDRESS: 1 (OU
CITY:
STATE: Md— 21P: O 10 V i
TELEPHONE: _^0 S ' 33 q -4 11 !
POOL LOCATION:
TYPEIPOOL: T � ,,) may �h,�( /
LENGTH: %p / WIDTH: J�
FAX: 50,k-33 — 7 F1 T VOLUME: 31, t o-
EMAIL:SCLt)d r�tK (2,1'YlrlllS�eld Ch) ldrer)5 Ce nk4. MINIMAX DEPTH: 3 —G
FED IDISS NO: (� ��2 ,%-SSS.$"4 SWIM AREA: D U c DIVE AREA: ffP,11e
WATER SOURCE: 11110,
Certification Expires Every 5 Years. WIW DISPOSAL: Sotr4c
Permit Expires December 31st Yearly. TYPE OF FINISH: t l nor
rag Z6101IK43:1 E74 Ila r=[.i
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS:
SIGNATURE: v
Sign, date and enclose chec a,
Park Row, Mansfield, MA 02048.
SCUM GUTTER: A4
DECKTYPE:
SKMMR WEIR LENGTH:
TREATMENT SYSTEM:
DISINFECT METHOD: (d lur)n,e.
119 MAY3Am9:35
CHEMICAL TREATMENT:
NUMBER OF BATHERS: yR
DATE:
to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six
For verification, telephone NSPFIO at 719-540-9119 or email service*nspf.org
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152878-755563
TAX CERTIFICATION FORM
I certify tinder the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
tinder law.
, ZZ4"-J,-- u1)11JrLt",3
Sign 'hue of d vidual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
()c11 7,2S� 03 `1'
'Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished 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 tinder the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Domments\Pood Establishments-'remp\TAX CERTIFICATION FORNI.doe
-
Form ST -5
Rev. 6/09
Massachusetts
?
Sales Tax Exempt
Department of
Purchaser Certificate
Revenue
Part 1. Exempt taxpayer information. To be completed by exempt government or 501(c)(3) organization.
Name
11. Read Inc. /dba/ Mansfield Children's Center
Address
1100 School St.
City
Mansfield
State
MA
Zi
01048
Exemption number
042-725-454
Issue date
Date of expiration
of certificate
7/29/16
7/28/26
Certification Is hereby made that the organization named above is an exempt purchaser under Massachusetts General Laws, Chapter 64H, sections 6(d)
or 6(e). All purchases of tangible personal property or services by this organization are exempt from taxation under said chapter to the extent that such
property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or
any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation.
Signature � Title Date
Willful misuse of -this certificate may result In criminal tax evasion sanctions of up to one year in prison and $10,000 ($50,000 for
arts) in fines.
Part 2. Agent information. To be completed by agent of exempt government or 501(c)(3) organization.
Name of agent's organization
Address
City State Zip
Agent's name
Address
City Slate Zip
I certify that in making this purchase, I am acting as an agent for the exempt organization named above (select one):
❑ Government organization (local public school, city/town government, state agency, etc.).
Attach Form ST -2, If available. if Form ST -2 is not available, enter exemption number, if known:
❑ 501(c)(3) organization (parochial school, Scout troop, etc.). Form ST -2 must be attached.
Signature Tills Date
Part 3. Vendor information
Vendor's name
Check applicable box:
❑ Single purchase certificate (attach detailed receipts or complete Part 4, on reverse)
❑ Blanket certificate
This form is approved by the Commissioner of Revenue and may be reproduced.
MASSACHUSETTS DEPARTMENT OF REVENUE
H READ INC
1100 SCHOOL ST
MANSFIELD MA 02048-2036
Certificate of Exemption
MA TaxpayerID: 11720038
Certificate Number: 2039861248
Form ST -2
This certifies that the organization named above is an exempt purchaser under Chapter 64H, section 6(d) or (e) of the
Massachusetts General Laws. All purchases of tangible personal property by this organization are exempt from taxation to the
extent that such property is used in the conduct of the business of the purchaser. Misuse of this certificate by any tax-exempt
organization or unauthorized use of this certificate by any individual will lead to revocation. Willful misuse of this certificate is
subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. This certificate is non-
transferable and may be suspended or revoked for failure to comply with state laws and regulations.
Effective Date: July 29, 2016 Expiration Date: July 28, 2026
A UTICA NATIONAL INSURANCE GROUP
V180 Genesee Street
New Hartford, NY 13413
Issuing Company: Utica Mutual Insurance Company
MEMBER OF UTICA NATIONAL INSURANCE GROUP
WORKERS COMPENSATION AND
EMPLOYERS LIABILITY INSURANCE POLICY
Information Page
1. The Insured and Mailing Address:
MANSFIELD CHILDREN'S CENTER, INC.
1100 SCHOOL STREET
MANSFIELD MA 02048
Entity of Insured: Corporation
Other workplaces not shown above:
Insured's I.D. Number: 042725454
Risk I.D. Number: MA:000165573
Policy Number: 2066058
Prior Policy Number:
Producer: Wm. F. Bomek Ins Agy Inc
311 Plymouth St
Halifax, MA 02338
Producer Number: 77377
SIC#: 83517
NCCI Company Number: 15717
WC 000001A
2. The policy period is from 10/07/2018 to 10/07/2019_.... 12:01 AM Standard Time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $100,000 Each Accident
Bodily Injury by Disease $500,000 Policy Limit
Bodily Injury by Disease $100,000 Each Employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All States except those listed in Item 3.A., ND, OH, WA, WY
D. This policy includes these endorsements and schedules:
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
See Extension of Information Page
El See
Classifications
Code
No.
Basis
Total est. Annual
Remuneration
Rate Per $100
of
Remuneration
Estimated Annual
Premium
Minimum Premium: $ 203 MA
Expense Constant
$
Employer's Liab Minimum Premium: $
Total Estimated Annual Premium
$ 11,747
If indicated below, interim adjustments of premium shall be made:
Deposit Premium
$ 11,747
Issuing Office: New Hartford, NY 13413 Date of Issue: 09-27-2018 Countersigned by
8 -D -WC Ed. 08-2008 Copyright 1988 National Council of Compensation Insurance
BILLING NO. 100362146
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
mvtv.mass.govIdia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: IY In r. 0/.)// LUe-,
Address: //(]a SJR 0, ( S'
City/State/Zip: /:%g o)v r(,KPhone #:
Are you an employer? Check the appropriate box.
Business Type (required):
I. ❑
I am a employer withJ— employees (full and/
5. []Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑
I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
B. Ion -profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per e. 152, § 1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I1
L❑Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
Ian an employer that is providing workers' compensation insurance foray employees. Belot, is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration
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 certifylut r dig p fl peryttyes ofperjury that the information provided above is true and correct
Official use only. Do not trite in anis area, to be completer) by city or town 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 #:
aww.mass.gov/dia
The Commonwealth of Massachusetts
Executive Office, of Health and Human Services .
Department of Public Health
Division.of Community Sanitation
MITT ROMNEY 305 South Street, Jamaica Plain, MA 02130-3597
GOVERNOR (617) 983-6761-- —(617) 983-6770 - Fax
KERRY HEAL EY -
UEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY -
CHRISTINE C. FERGUSON
COMMISSIONER
Fecal, Vomit and Blood Incidents in Swimming Pools
L FECAL, INCIDENT PREVENTION IN SW MM NG POOLS
Although the actual health and safety risks associated with fecal accidents are considered to be
minimal, provided that proper pool chemical levels are maintained, fecal incidents do pose a
significant interruption in pool operations. As such, prevention of fecal incidents should be
stressed. The following preventative measures shall be implemented at all pools:
A. Patrons must be directed to take a cleansing shower before entering the pool.
B. Do not permit diaper changing at poolside. Do not allow young children to be
"dipped" or rinsed off in the pool as part of the diaper -changing process.
C. Patrons who are ill or have suffered from diarrhea within the previous two (2)
weeks should be denied admittance into the water. It has been shown that persons
with cryptosporidiosis continue to shed crypto oocysts (the infectious form of the
organism) in their stool for 2 weeks after their diarrhea has ended and can
therefore infect others.
D. All persons wearing diapers, or who would be of diaper -wearing age (e.g. infants
and toddlers), should wear swimsuit diapers or tight -fitting rubber or plastic pants
which will contain fecal matter and prevent it from entering the pool.
E. Do not allow pets in the pool area. See 304 CMR 12.08.
F. Maintain the chemical feed equipment and chemicals at optimal levels. This
includes maintaining the disinfectant levels (residual chlorine levels between 2.0
and 3.0 ppm); optimal pH (7.4-7.6); alkalinity (80-120 ppm); and calcium
hardness (200-400 ppm). Note: Lack of proper pH can greatly affect disinfection
effectiveness in chlorinated pools.
It. FECAL INCIDENT PROCEDURE IN SwmnmYG POOLS
There is a concern regarding the potential transmission of cryptosporidium parvum (a parasite
excreted in the feces of infected humans and other mammals) and escherichia coli 0157:H7 (a
harmful strain of coliform bacteria living in the digestive tracts of humans and other animals).
Most organisms found in properly chlorinated pool water, including E.coli 0157:H7, are killed
very quickly. In fact, usually only a few seconds of disinfection are needed to kill 99.9% of
these organisms. Those organisms that are more resistant to disinfection, such as cryptosporidia,
are typically introduced into pool water via very watery diarrhea This is seldom noticed or
reported. Thus, solid stool is unlikely to contain cryptosporidia. This knowledge thus requires a
two-pronged approach to managing a fecal incident.
(The following information was adapted from "Responding to Fecal Accidents in Disinfected
Swimming Venues. "Morbidity and Mortality Weekly Report, May 25, 2001, Centersfor Disease
Control and Prevention bq://www.edc.ggy/mmwr/p df7wk/mm15O20Tdp
A. Formed stool (solid, nonliquid)
1. Direct everyone to leave all pools into which water containing the feces is circulated.
Do not allow anyone to enter the contaminated pool(s) until all decontamination procedures are
completed. Z
2. Remove as much of the fecal material as possible using a net or scoop and dispose of it
in a sanitary manner. Clean and disinfect the net or scoop (e.g., after cleaning, leave the net or
scoop immersed in the pool during disinfection). Vacuuming stool from the pool is not
recommended*.
3. Raise the free available chlorine concentration to 2 ppm (mg/L), pH 7.2-7.5, if it is '
<2.0 ppm (mg/L).. Ensure this concentration is found throughout all co -circulating pools by
sampling at least three widely spaced locations away from return water outlets. This free
available chlorine concentration was selected to keep the pool closure time to approximately 30
minutes.
4. Maintain the free available chlorine concentration at 2.0 ppm (mg/L), pH 7.2-7.5, for
at least 25 minutes before reopening the pool. In the presence of chlorine stabilizers such as
chlorinated isocyanurates, a level of 3.0 ppm (mg/L) of free available chlorine must be achieved.
Ensure that the filtration system is operating while the pool reaches and maintains the proper free
available chlorine concentration during the disinfection process.
5. Establish a fecal accident log. Document each fecal accident by. recording date and
time of event, formed stoohordiarrhea;^free-available chlorine concentration at the time or
observation of the event and before opening the pool, the pH, the procedures followed to respond
to the fecal accident (including the process used to increase free chlorine residual if necessary),
and the contact time.
B, Diarrhea (liquid stool)
1. See Al.
2. See A2.
3. Raise the free available chlorine concentration to 20 ppm (mg/L) I and maintain the pH
between 7.2 and 7.5. Ensure this concentration is found throughout all co -circulating pools by
sampling at least three widely spaced locations away from return water outlets. This chlorine and
pH level should be sufficient to inactivate Cryptosporidium and should be maintained for at least
8 hours (one turnover for a standard pool). If necessary, consult an aquatics professional to
determine and identify the feasibility, practical methods, and safety considerations before
attempting the hyperchlorination of any pool.
4. Ensure that the filtration system is operating while the pool reaches and maintains the
proper free available chlorine concentration during disinfection,
5. Backwash the filter thoroughly. Be sure the effluent is discharged directly to waste and
in accordance with state or local regulations. Do not return the backwash through the filter.
Where appropriate, replace the filter media.
6. Swimmers may be allowed into the pool after 8 hours and when the free
available chlorine level has been returned to the normal operating range, (1.0-3.0 ppm). Maintain
the free available chlorine concentration and pH (7.2-7.8) at standard operating levels. If
necessary, consult state or local regulatory authorities for recommendations on bringing the free
available chlorine levels back to an acceptable operating range.
7. See A5.
M. Vomit and Blood Incident Procedures in Swimming Pools
A. Vomit
Vomiting while swimming is frequently due to swallowing too much water and is
probably not infectious. It is possible for Noroviruses, also known as Norwalk -like viruses, to be
spread by vomit; therefore if the entire stomach contents are vomited, respond to the vomit
incident as you would the Tormed Stool' procedure above. The procedure is.,
1. Direct everyone to leave all pools into which water containing the vomit is circulated.
Do not allow anyone to enter the contaminated pool(s) until all decontamination procedures are
completed.
2. Remove as much of the vomit material as possible using a net or scoop and dispose of
it in a sanitary manner. Clean and disinfect the net or scoop (e.g., after cleaning, leave the net or
scoop immersed in the pool during disinfection). Vacuuming stool from the pool is not
recommended*.
3. Raise the free available chlorine concentration to 2 ppm (mg/L), pH 7.2-7.5, if it is
<2.0 ppm (mg/L). Ensure this concentration is found throughout all co -circulating pools by
sampling at least three widely spaced locations away from return water outlets. This free
available chlorine concentration was selected to keep the pool closure time to approximately 30
minutes. -.
4 Maintain the free available chlorine concentration at 2.0 ppm (mg/L), pH 7.2-7.5, for
at least 25,jminutes before reopening the pool. In the presence of chlorine stabilizers such as
chlorinated isocyanurates, a level of 3.0 ppm (mg/L) of free available chlorine must be achieved.
Ensure that the filtration system is operating while the pool reaches and maintains the proper free
available chlorine concentration during the disinfection process.
5. Establish a vomit accident log. Document each vomit accident by recording date and
time of the event, free available chlorine concentration at the time or observation of the event
and before opening the pool, the pH, the procedures followed to respond to the vomit accident
(including the process used to increase free chlorine residual if necessary), and the contact time.
B. Blood
Disease -causing organisms found in blood (e.g., Hepatitis B virus or HIV) are spread
only through activities that involve the exchange of infected bodily fluids, such as, in sexual
contact and sharing needles with an infected individual. According to the CDC, that agency is
not aware of any of these organisms being transmitted to swimmers from a blood spill in a pool;
therefore, there is no recommended procedure to be followed after a blood spill in a swimming
pool. As a matter of comfort, the pool operator may choose to close the pool temporarily to
satisfy patrons.
No uniform recommendations for disinfection of vacuum systems are available. However, if a
vacuum system is accidentally used, the waste should be discharged directly to a sewer or other
approved waste disposal system and not through the filtration system. The dilution effect of the
pool water going through the hose may reduce the risk for high-level contamination of the
vacuum system.
¶ Many conventional.test kits cannot measure free available chlorine levels this high. Use
chlorine test strips that.can measure free available chlorine in a range that includes 20mg/L (such.
as those used in the food industry) or make dilutions for use in a standard DPD (N, N -diethyl- p-
phenylenediamine) test'kit using chlorine -free water.
Jane 30, 2003
° o Town of Mansfield
6 Park Row, Mansfield, Massachusetts 02048
a' R 508-261-7366
Health Department
Amy Donovan -Palmer, Health Agent
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
... re.whsrwu�reiwn�w�Y'JwM�i\wIJ\1:1rUAYG.Y\Ulww�wwww�
NAME OF POOL
OWNER
\ v o :\
ADDRESS
DATE OF
ivt\q� 1'N
POOL CAPACII
INSPECTED BY
INSPECTION
# OF GALS
r�0
METHOD OF WATERG�\a
C;
BATHER
k OF LIFEGUARDS
WATER SOURCE:
TREATMENT
LOAD
Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.VOV.
Items marked with a "✓" are satisfactory.
ventilation; sanitary condition.
.03 Adequate enclosure around pool. Gate self -latching wl
latch 4 ft above ground.
.04 Sewage Disposal
.05 Location, structural stability, finish.
.06 Water circulatio.� & filtration systems. Filter Efflue flow
meter reading: `,�V _gpm. # of turnovers -ants
.06 Suitable automatic equipment for disinfection of pool
water.
.06 Carbon dioxide (CO2) equipment for pH control
adequate. CO2 cylinders anchored. Inaccessible to
public, adequate ventilation provided.
.08 Inlets and outlets - Inlets located to produce uniform
circulation. Over rim fill spout 6" above maximum
water level. Properly shielded and located.
,06 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 covers 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
Special purpose pool and wading pools equipped
emergency shut off pump switch. Accessible and
prominently marked.
.09 Cross connections. Portable water supplied through air
gap.
.10 Skimming facilities. 50% of recirculation 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.
.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 and testing records maintained. Records
initialed by person making tests.
.22 Health regulations: Signs posted. Health warning
signs posted for special purpos'p pools,
.23 Lifeguards required: Yes No ❑
If lifeguards required. Proper credentials, proper sults
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 the pool and In
working order. Emergency communication device in
unlocked area and available at all times to staff and the
public. Operating Instructions and emergency
numbers posted.
.26 Waste and backwash water disposal properly
discharged. No direct connection to sewer system.
Separation tank provided for dlatomaceous earth filter
backwash water.
.29 Chemical standards
Wca ar "4 u %. " 01 -tqo Q
A
v�QGC7 a Sv��S ceckvvc ¢ci Q Soc.7!
clnuwsvv._c�} 3L.cwuac� c.ar+v�nvv�.c���e.
✓ uq!" o�.�c� 1 Ci
POOLSIDE READINGS
Bromine
'?rQ6Q 'J-
Total Chlorine
Alkalin
;'iii LSO tt2'-�'+ -s
00
Free Chlorine
1r0 { ray ±a.5
Cyanuric Acrd
;. E) �Q ppin) 4f .:
Comb.
Chlorine
VM' pin)
Water Tem
]OQ?F "_`
pH level
7„Z`,8 .:r..
* arts per million
QTD
.29 Pool water tested with appropriate frequency.
.30 Water testing equipment. DPD kit provided for
chlorine and bromine. Unbreakable thermometer for
special purpose pools.
.31 Water clarity
.32 Water clarity maintenance. Filtration system operating
continuously.
.32 Special purpose pool drained, cleaned and every 14
days.
Maximum Operating Temperatures for Special Purpose
Pools. (SPP).
.33 a. Thermostatic control provided for each SPP.
b. Thermostatic control only accessible to the pool
operator
.36 General sanitation
ICA
yX y w�8r GsQr
G\n. L+eaC-..C.ye. r7a'fe-� mY'•`t's.�
NO.
.34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED
11/07/2018 12:12 5083781315 SUPERIOR PM
PAGE 02/02
ISWG'048[Oc Rev E
CERTIFICATION OF COMPLIANCE
Contains: WG10 8E, WG'048EBLK, WG1048EGR, or WG1048EDGR
Description: 8" Round Suction Outlet Cover
Ratings: Floor: .S GPM_ Wall: T2 GPM Open Area: s s -'
Certified to Comply with Section -1404 of the Virginia Graeme Baker Act (VGB) Pool &Spa afery Act
codified at 16 CFR part 1450, Initial Certification May toss,
Manufactured: After September 1o, 20o9, byy a Division of Hayward Industries, Inc. at K4 -A, 224028
Block K4- A, Export Processing Zone Wuxi IVew District Jiangsu Province PRC 214028, China; or at
One Hayward Industrial Drive, C(emmons, NC 2701z.
Certified by Hayward Pool Products, 62o Division Street, Elizabeth, NJ 07207, Phone 908-355-7995
Contact at www hayward corm
n is Customer Service atwwW_hayward cram.
)ducts P;O, Box 5100, Clemmons, NC 2022^5100, Phone: 336-712.9900
Date of Mfr: The Lot Number shown on the product label contains the Year & Month of manufacture.
The first number represents the year (ex i = 2o11) and the second characterthe month (A=Jan,
B=Feb, H=Aug, I is skipped, J=Sep, etc)
Tested to. ANSI/APSP-16 per Section 1404 ofthe Virginia Graeme Baker Act (VGB) Pool & Spa Safety
Act. Tested by NSF International, 789 Dixboro Road, Ann Arbor, MI 48213, Phone 734-769-8o10 in
Anril en44 fo.rrfln-,r•n fit.
Date of Installation:
Suction outlet components have a finite life, the cover/grate should be inspected frequently and
Te'plaleed'at least ever zYeaTs or 1 ound-to be clNirlageZ,Vokeh, cracked; missing,'6r not"securely
-,lFn r h nN
Hayward Pool Products acknowledges that it is a federal crime to knowingly and willingly make
materially false, fictitious, orrraudulentstatements, representations, or omissions on this
certification.
6"
SPAC1140 BETWEEN
MOUNTING HOLES
07 3/4"
SUCTION OUTLET
COVER WG1048E
USED ON FOLLOWING SERIES:
WG1030AV PAK2
WG1040AVPAK2
WG10A9AV PAK2
WGi0S1AVPAK2
WC1052AV PAK2
WG1053AVPAK2
W01054AV PAK2
WG1153AVPAK2
WG1154AVPAK2
SPI030AVPAK2
SP 1040 AV eA K2
SPI049AVPAK2
SP 1051 AV PAK2
SP1052AVPAK2
SP1053AVPAK2
Sr1054AVPAK2
SP1153AVPAK2
SP1154AVPAK2
A Warning— Suction Entrapment Hazard.
Suction in suction outlets and/or suction Outlet covers which are installed in a small area and/or below the surrounding
Surf can cause severe injury or death due to body entrapment hazard,
To reduce the risk of body entrapment, installation of the field fabricated sumps must be such that the top of the
mounted cover is a minimum of> 1/2" above the finished pool surface over an area targerthan 4o" on a diagonal.
a�--ani-u9ii
Mansfield Children's Center
"where children thrive"
www.mansfietdchitdrenscenter.org
1100 School Street Tel: 508-339-4111
Mansfield, MA 02048 Fax: 508-339-2714
email: wherekidsthrive@verizon.net