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Home My WebLink AboutMansfield Children's Center - 12/31/2021W as aracr:p�i. Town of Mansfield - Board of Health 9�rFe^ A `gay Swimming Pool Application NAME OF OWNER: Mansfield Children's Center ADDRESS: 1100 School St. CITY: Mansfield STATE: MA ZIP: 02048 TELEPHONE:508-339-4111 FAX: 508-339-2714 EMAIL: info@mansfieldhcildrenscenter.org FED IDISS NO:042-725-454 Permit Expires December 31st Yearly. PERSON CERTIFIED: Kevin J. 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 certification remarks(If necessary): REMARKS: SIGNATURE: ZI r Sign, date and a close check pa Park Row, Mansfield, MA 02048. t C f1 W p Ip APR 11 U8. I f�1 v l! Town of MansflMd 6 Park Row Mansfield, MA 02048 PERMIT NUMBER I FEE: $150 Re -inspection fee: $100 Public POOL OPERATION: [M Semi -Public O Special Purpose Pool POOL LOCATION: TYPE/POOL: Semi -Public LENGTH:41' VOLUME: 30,000 MINIMAX DEPTH:3' SWIM AREA: 1000 sq. ft. WATER SOURCE: Well WIW DISPOSAL: Private TYPE OF FINISH: Liner SCUM GUTTER: DECK TYPE: 5' cement WIDTH: 25' SKMMR WEIR LENGTH: 2 Skimmers DIVE AREA: None TREATMENT SYSTEM: Diatomaceous earth DISINFECT METHOD: Chlorine CHEMICAL TREATMENT: NUMBER OF BATHERS: 43 DATE: ys. to Town of Mansfield. Mail to: Board of He Ith, Towl of Mansfield, Six 6 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 under law. y14j t:.'✓^ C.i',� .... Signature of Individual or Corporate Name By: Corpor to Officer (Mandatony if)Ipplicable) **Social Security No. ( olantary) or Federal Identii cation 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\Scott's Documonts\Food Establishments- Temp\TAX CERTIFICATION FORM.doo NeAAICr`NIA7 HWOODS •••,' --- - -- CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDMYY) 311612021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. the certain policies may require an endorsement. A statement on If SUBROGATION IS WAIVED, subject to the terms and conditions of policy, to the certificate holder in lieu of such endorsement(s). this certificate does not confer rights CONTACT PRODUCER PHONE FAX 293-2171 WM. F. Borhek Insurance Agency (AIC, No, Ent): (781) 293-6331 (AIC, No):(781 ) 311 Plymouth St E0MpRES Halifax, MA 02338 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Utica Mutual Insurance Company-25976 INSURER B : Utica National Of TX 25976 INSURED Mansfield Children's Center INSURERC: 1100 School St. INSURER D: INSURER E: Mansfield, MA 02058 INSURER F : _.. oCancrnrl \II IMRFR COVERAGES CERTIFICATE NUMBER: ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY BY THE POLICIES DESCRIBED HEREI N IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF POLICY EFF POLICY EXP LIMITS ADDL SUBR INSR POLICY NUMBER MID M IDD Y TYPE OF INSURANCE INSD MD 1,000,000 L A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED 1Q0,000 CLAIMS -MADE ❑X 1017l2020 1017I2021 OCCUR CPP1825346 rr PRE SES .occuence $ 5,000 X Abuse 5001500 MED EXP An one ersan $ 1,000,000 PERSONA L&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 X ❑ PRO- ❑ LOC PRODUCTS - COMPlOP AGG $ POLICY JECT OTHER: COMBINED SINGLE LIMIT $ 500,000 B AUTOMOBILE LIABILITY Ea accede 2954403 1017l2020 10/7/2021 rs BODILY INJURY Per ean $ ANYAUTO OWNED X SCHEDULED BODILYINJURY Per.ccident $ AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED NON-ON6NED Psra«ident AUTOS ONLY AUTOS NLY $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN 2066058 10/7/2020 10/712021 X 3TR UTE ORH A EL EACH ACCIDENT $ 100,000 ANY PROPRIETOWPARTNERIEXECUTIVE ❑ N /A 100'QQQ EXCLUDED? E.L. DISEASE -EA EMPLOYEE $ (4FICERIMEMBER (Mandatory in NH) 5QQ,000 e under HEesCRdIPTIbNSO E. L. DISEASE - POLICY LIMIT $ DOF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) i r= nvwcr� - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE „�Ta. 05W ACORD 25 (2016103) 9)1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf wiviv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Let=ibly r Business/Organization Name. z ,`•`E'. �_ 1 F_ ,Jr,d� �s., r,>f,t At��, f7�/(6 € f) City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 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. g, ELNon-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 no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0Other *Any applicant that checks box#I 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 41. I ant an employer that is providing workers' conepensation insurance for my employees. Below is the policy information. Insurance Company Name: f' { { f " �' 1>(t •`I<r {r-fi('r t,�c�' Insurer's Address: r' t "/i City/State/Zip: Policy # or Self -ins. Luc. # < r 'r` / > ` , `it �•, Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required tinder 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 cover�ge verification. I no hereby tl that the information provided above is trite 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 (cit•etc one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: JANE SWIFT GOVERNOR WILLIAM D. O'LEARY SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Division of Community Sanitation 305 South Street, Jamaica Plain, MA 02130-3597 (617) 983-6761 (617) 983-6770 - Fax Fecal, Vomit and Blood Incidents in Swimming Pools I. FECAL INCIDENT PREVENTION IN SWINIMING 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 PROCEDURE 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 0157:117, 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, Centers for Disease Control and Prevention http://www.edc.gov/mmwr/DdFwk/mm5020 tdf) 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. 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 the event, formed stool or diarrhea, 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) 9 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. 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 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 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. Tune 30, 2003 For verification, telephone NSPP at 719-540.9119 or email seivtcsOnspt org z � � o M Mh �. _ x m' A =� ® rok ® as ®. �aX 0� SE. 0 a :; �q n 0 I co tj a wo 44 M+t i• l 41 ' 152878-755563