HomeMy WebLinkAboutWillow Crossing - 12/31/2020NOV Ohs 2015
own ofMa�isfiehl - Board of Health
Swimming Pool Application
NAME OF OWNER: KRE Husky Willows Crossings Licensee LLC
d/b/a The Village at Willow Crossings
ADDRESS: 25 Cobb Street
CITY: Mansfield
STATE: MA ZIP: 02048
TELEPHONE:
FAX: 508-261-1333
EMAIL: ademinico@benchmarkqualily.com
FED IDISS NO: 84-1955974
Permit Expires December 31st Yearly.
PERSON CERTIFIED: Patricia M. Suydan
Pool/SPA Certification Date: 3/28/2019
Pool/SPA Certification Expires: 3/28/2024
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS:
-�f 6
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER
FEE: $150
Re -inspection fee: $100
El Public
POOL OPERATION: ❑ Semi -Public
[:� Special Purpose Pool
POOL LOCATION: 25 Cobb Street
Clubhouse
TYPEIPOOL: Gunite concrete
LENGTH: 32' WIDTH: 14'
VOLUME: 12,544
MINIMAX DEPTH: 3'6" to 3'9"
SWIM AREA: 448 s.f. DIVE AREA: None
WATER SOURCE: Town
WIW DISPOSAL: Town Sewer
TYPE OF FINISH: Blue Marbleile
SCUM GUTTER: None
DECKTYPE: Concrete
SKMMR WEIR LENGTH: 8.5"
TREATMENT SYSTEM: Hayward C-600 LK Brominator
DISINFECT METHOD: Bromine
CHEMICAL TREATMENT: Bromine
NUMBER OF BATHERS: 22
SIGNATURE:/G/d//e (fl7 DATE:
Andrea M% in7an,ce reesideAF�ecreta� 8
Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six
Park Row, Mansfield, MA 02048.
The Village at Willow Crossings Pool Policy
For all Pool water contamination incidents
- Direct all users to leave the pool and any water that's interconnected.
-Manually remove as much of the material as possible.
-Log the incident. Record the date, time, AFR type, chlorine and PH levels. Note the response taken to
the event, and the time the pool is reopened for use.
Helpful information
Germ inactivation formula (CT VALUE)
CT value = (Free) chlorine x Time
Time = 15,300 / 15ppm(MG/L)= 1020 minutes or 17 hours
The formula is based off the Cryptosporidium inactivation time.
Remember to rebalance the pool after the event. Chlorine levels can be neutralized using the following.
Sodium Thiosulfate: 26 oz per 10ppm per 10,000 gallons
Sodium Sulfite: 1.5 lbs. per 10ppm per 10,000 gallons
Additional steps by specific incident below.
Formed stool
Raise the free available chlorine level to 2ppm(mg/1) and ensure the PH is 7.5 or less and a temperature
of 77F(25c) or higher
Maintain the chlorine concentration for at least 25 minutes before opening the pool
Ensure the filtration system is operating while the pool reaches proper free chlorine concentration
during the disinfection process.
Diarrheal discharge
-Raise the free available chlorine level to 20 ppm(mg/1). Maintain the PH of 7.5 or less and a
temperature of 77F(25c) or higher Maintain the PH and chlorine level for 12.75 hours.
-The filter system should be operating the entire disinfection time.
-Backwash the filter after the full disinfection time. The filter effluent should be directed to waste and
not back to the pool.
-Return the chlorine level to normal levels, as required by state/local regulations.
-Open the pool to normal user activities.
Vomit and blood contamination in pool water
Pool water in unlikely to spread illness via vomit or blood.
-If the full contents of the stomach are vomited, respond as you would to a formed fecal accident.
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.
RRe Husky Willows Crossings Licensee LLC
Signature of Individual or Corporate Name
54-1955974
"Social Security No. (Voluntary) or Federal
Identification Number
{`/�
By: Corporate Officer (Mandatory, if Applicable)
Andrea M. Teichman, Vice President and Secretary
*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 under the authority of Massachusetts General Law
Chapter 62C, section 49A.
Q\Users\s(eite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMAoc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Ulf
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leailily
Business/Organization Name:. KRE Husky Willow Crossings Licensee LLC d/b/a The Village at Willow
Address: 25 Cobb
City/State/Zip: Manseeld, MA 02048
Phone
508-261-1333
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. Q
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.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have
10.❑ Manufacturing
4. ❑
no employees. [No workers' comp. insurance required]*
We
11. ❑ Health Care
are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12. ❑ Other
*Anv awlicant that checks box #I must also fill out the section helnw sh.v,m,, n.fl. inf ,,, 1;r
**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 #l.
I ant an employer that is providing ivorkers' eowpensation insurance for my employees. Below is fire policy information.
Insurance Company
Insurer's
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 cerhfy,14in jer the pains andpenalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
i. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.inass.gov/dia