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HomeMy WebLinkAboutGS West Village - 12/31/2021L(�-,i &4 �o Town of Mansfield - Board of Health Swimming Pool Application NAME OF OWNER: CIS West Village Project Owner, LLC ADDRESS: 792 West Street CITY: Mansfield STATE: MA ZIP: 02048 TELEPHONE: 508-261-0500 FAX: 508-261-0501 EMAIL: westvillagemamgr@greystar.com FED IDISS NO: 82-2524636 Permit Expires December 31st Yearly. PERSON CERTIFIED: Russell Smith Pool/SPA Certification Date: 3/12/2019 Pool/SPA Certification Expires: 81212024 PERSON CERTIFIED: Pool/SPA Certification Date: POOUSPA Certification Expires: certification remarkstif necessary): REMARKS: fino t_ f I ,.f m Town` "of"°INatis€let 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 ® Public POOL OPERATION: WSeml-Public ® Special Purpose Pool POOL LOCATION: 792 West Street Mansfield, MA 02048 TYPEIPOOL: Gunite Semi -Public LENGTH: 56' WIDTH: 25' VOLUME: 42,000 Gallons MINIMA% DEPTH: 4 ft. SWIM AREA: 1,400 sq. It. DIVE AREA: N/A WATER SOURCE: Town Water WIW DISPOSAL: Town Sewer TYPE OF FINISH: Plaster SCUM GUTTER: N/A DECKTYPE: Concrete SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: Astral Sand Filter DISINFECT METHOD: Chlorine/Chlorinator Rainbow 300 CHEMICAL TREATMENT: Chlorine NUMBER OF BATHERS: 93 SIGNATURE: RIkP a swith DATE: 3/4/2021 Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. h Town of Mansfield - Board of Health ,Swimming Pool Application NAME OF OWNER: GS West Village Project Owner, LLC ADDRESS: 792 West Street CITY: Mansfield STATE: MA ZIP: 02048 TELEPHONE: 508-261-0500 FAx: 508-261-0501 EMAIL: westvillagemamgr@greystar.com FED IDISS NO: 82-2524636 Permit Expires December 31st Yearly. PERSON CERTIFIED: Russell Smith Pool/SPA Certification Date: 311212019 Poo]/SPA Certification Expires: 3/12/2024 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign Is required. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 d Public POOLOPERATION: N Semi -Public Special Purpose Pool POOL LOCATION: 792 West Street Mansfield, MA 02048 TYPEIPOOL: Spa/Hot Tub LENGTH: NIA VOLUME: 1,500 Gallons MINIMA%DEPTH: 3.5It. SWIM AREA: N/A WATER SOURCE: Town Water WIW DISPOSAL: Town Sewer TYPE OF FINISH: Plaster SCUM GUTTER: N/A DECKTYPE: Concrete WIDTH: NIA DIVEAREA: N/A SKMMR WEIR LENGTH: 8° TREATMENT SYSTEM: Chlorine DISINFECT METHOD: Chlorinator/Sand Filter CHEMICAL TREATMENT: Chlorine NUMBER OF BATHERS: 8-10 SIGNATURE: RktiseusGI'iM DATE: 3/4/2021 Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. 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. RUSSCU sf ith Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 82-2524636 "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 under the authority of Massachusetts General Law Chapter 62C, section 49A. CdUsemWeite\Desktop\SootPs Documents\Pood Establisluneuts- Temp\TAX CERTIFICATION PORM.doo 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. Rysse66 SlNN Signature of Individual or Corporate Name By; Corporate Officer (Mandatory, if Applicable) 82-2524636 "*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 under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scotfs Downient0ood Establislnnents. Temp\TAX CERTIFICATION FORM,doc Farm *g Request for Taxpayer (rev. Catcher 2018) identification Number and Certification NPstlaieitorlheTreasury IlitehfalRetopp9 sayloa ►Go to rvww.fro gov/Formw9 for Inetructlone and the latest Information. 1 Name(wahown on wear Inn marav rst,...r ,.c..._,_.... Qlve Form to the requester. Do not send to the IRS, i unack owing seven to box for federal lax olesalflcallan of the person whose name is entered on line l: Chech onlyona o}the 4 Exemption9(code following seven boxes, certain entities, not I ❑ Indlvlduat/soleproprlatoror Q CCorporatlon 118 Corpomtion n Partmothl Instructions on page eingle-member LLC P El (]✓ Limited llahillty company. Enter the tax clesavloation (C=C corporation, 8.8 oofporatlon, P=Partnership)► p Ekempt payee code Qfany) Note: Cheokthe appropriate box In the llneaboveforfhe tax olassilloatlon of the aingle-memberowneK Da not check LLC If the LLC is classxled as a eingle-member LLC that is disregarded from the owner unless the owner of the LLC b Exemption from FATCA reporting another LLO that is not disregarded from the owner for U.S,federal tax purposes. Othame, a sloola-member LLC 140' code Of any).A_ Is disregarded Gem the owner should check the appropriate box for the tax classification of Its owner. 1`1 nth., rase rnefni9.U.i11 this is generally your soclei security number (SSN). However, for a •egarded entity, see the Instructions for part I, Istay, For other (ion number (EIN), if you do not have a number, see How to get a Note: If the account Is In more than one name, see the instructlons for line 1. Also 899 What Name and Number To Ova the Requester for guidelines on whose number to enter. unaer penalties of perjury, I certify that: .. 1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (I)) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (a) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA coders) entered on this form (If any) Indicating that I am exempt from FATCA reporting Is correct. Certification instructions. You must arose out Item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRFQ, and generally, aym other than interest and dividends, you are not Co, ujr to sign the certification, but you must provide your gdfhop! TIN. See the instruotlons for pail I1. hiter, $[ n F, Ante flee eignperoof nI U,&Posen►_ ...... _. .. _ .' : bete ► � .::f4�f . /':�i' General instructions Section references are to the Internal Revenue Cade unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and Its Instructions, such as 10910latlon enacted after they were published, go to www.rrs,gov/FcrmW9, Purpose of Form An Individual or entity (Farm W-9 requester) who Is required to Ilia an In(p611011 r} return with the IRS must c}�Idr *r$orraol tgxpayar idsblitoatltinnumber (FIN)which mayboyourgreotaleanpPlty number (8gN), )n:.0llrldual taxpayer Idontiflcail§n hljm0dgITIN�), i0bin, n taxpayer Idenll(Icatlon number {gTIN), or employer I GrItlfloeton number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an Information retum. Examples of Information returns Include, but are not limited to, the following, • Form 1099-INT (Interest earned or paid) cat. No. 10231X • Form 1099-Div (dividends, Including those from Blocks or mutual funds) • Form 1099-MISC (various types or Income, prizes, awards, or gross proceeds) • Form 1099.E (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1099-E 1098-T (tuition) (student loan Interest), • Form 1099-D (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (Including a resident allen), to provide your correct TIN. Uyou*rnot return Aoml W-9 to the requester with a TIN yb. might WWail_ f to backup Vj1fN(idltlfii©, $Ae What Is backup Willi iUfd Mi, reran Fenn The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 rvww.mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: CS West Village Project Owner, LLC Address: 792 West Street City/State/Zip: Mansfield, MA 02048 Phone #: 608-201.0500 Areyou an employer? Check the appropriate box: Business Type (required): 1.9 I am a employer with 5 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. [No workers' comp, insurance required] 8. ❑ Non-profit 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 no employees. [No workers' comp, insurance required]* I .❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.gOther Property Management *Any applicant that checks box #1 must also fill out are 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 A, lam an employer tliat is providhig workers' cmnpensation insurance for my employees. Below is the policy information. Insurance Company Name: Sompo America Insurance Co. c/o Sompo Insurer's Address: 1221 Avenue of the Americas City/State/Zip: New York, NY 10020 Policy # or Self -ins. Lie. # WCDS108610 Expiration Date: 1/1/2022 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 certify, under the pains and penalties ofperjury that the information provided above is true and correcR CiannbwPl�l'lt, seu St�(A Dnte: 3/4/2021 Phone #: 508-261-0500 Official use oily. Do not write he this area, to be completed 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 #: www.moss.gov/dia NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727-4900 — www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above -mentioned chapter by insuring with: po America Insurance Co. % SOMPO NAME OF INSURANCE COMPANY 1221 Avenue of the Americas New York NY 10020 ADDRESS OF INSURANCE COMPANY WCDS108610 11112021 to 111/2022 POLICY NUMBER EFFECTIVE DATES NAME OF INSURANCE AGENT ADDRESS PHONE # Greystar Real Estate Partners, LLC 600 E Las Colinas Blvd Ste 2100, Irving, TX 75039 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL AL TO BE POSTED BY EMPLOYER -Mac0b f j9j)W6jMhh(9[hM*nMftgiAft Department of Public Health Division of Community Sanitation 305 South Street, Jamaica Plain, MA 02130-3597 (617) 983.6761 (617) 983-6770 - Fax JANE SWIFT GOVERNOR WILLIAM D. O'LEARY SEORETARY HOWARD K. KOH, MD, MPH COMMISSIONER Fecal, Vomit and Blood Incidents in Swimming Pools I. FECAL INCIDENT PREVENTION IN SWIMMING 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. II. FECAL INCIDENT IN SWIMMING 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 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. III. 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 "Formed 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 fiom the pool is not recommended*. 3. Raise the fiee available chlorine concentration to 2 plan (mg/L), pH 7.2-7.5, if it is <2.0 plan (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 fiee 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 plan (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. 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