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HomeMy WebLinkAboutReservoir Hotel/Fairfield -12/31/202110C)()--�I - (SC), c Town of Mansfield - Board of Health Swimming Pool Application NAME OF OWNER: Reservoir Hotel Partners, LLC DBA Fairfield Inn Mansfield ADDRESS: 50 Reservoir St. CITY: Mansfield STATE: MA ZIP: 02048 TELEPHONE: 508-452-0700 FAX: 508-452-0705 EMAIL: amelanson@lafrancehospitality.com FED ID/SS NO: 84-3716007 Permit Expires December 31st Yearly. PERSON CERTIFIED: David Jusseaume Pool/SPA Certification Date: April 20, 2018 Pool/SPA Certification Expires: April 20, 2023 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: POOL OPERATION: POOLLOCATION: 1st floor TYPE/POOL: in ground M T b T T JUN 28 2021 Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE:$150 Re -inspection fee: $100 Public Semi -Public Special Purpose Pool LENGTH: 21 ' - 8" WIDTH: 17' - 9" VOLUME: 7,734 gallons MIN/MAX DEPTH: 3' - 6" to 4' - 6" SWIM AREA: 292 sq it DIVE AREA: n/a WATER SOURCE: pool water delivery W/W DISPOSAL: (2) SDX high flow safety drain TYPEOFFINISH: gunite SCUM GUTTER: (2) pentair bermuda skimmers W/ strainer basket DECKTYPE: the SKMMR WEIR LENGTH: TREATMENT (2) pentair bermuda skimmers SYSTEM: DISINFECT METHOD: pentair he 3315 chlorine/bromine feeder, 15 Ib capacity CHEMICAL TREATMENT: chlorine/bromine feeder NUMBER OF BATHERS: 18 SIGNATURE DATE: 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 c O V A� W V V. L Q.. O NSPF® authorized fax copy For verification, call 719.540.9119 or email service@nspf.org NJ c O 6o•;dsu@aawes Iewe Jojo 9''uoeal;uan Fao j664W 1119a xe;pazliIdooy;ne ®:ldSN U L N O N o �NG @ VO ' K1 W 1 W 1 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law, Reservoir Hotel Partners, LLC Signature of Individual or Corporate Name 84-3716007 "*Social Security No. (Voluntary) or Federal Identification Number YA�� m y rporate 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 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:\UscBWeite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 W rvwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name 50 Reservoir Street Reservoir Hotel Partners, LLC DBA Fairfield Inn Mansfield City/State/Zip: Mansfield, MA 02048 Phone #: 508-452-0700 Are you an employer? Check the appropriate box: Business Type (required): I . ❑✓ 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 (met. real estate, auto, etc.) employees working for me in any capacity. 8• ❑Noti-profit 3.❑ [No workers' comp. insurance required] 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 Ln Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑✓ Other Hotel with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy mtormanon. **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 #I. I air an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Zurich American Insurance Company Insurer's Address First Canadian Place 100 High Street, #14 City/State/Zip: Boston, MA 02110 Policy # or Self -ins. Lic. # 1780862 Expiration Date: 12/31 /2021 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. t52 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 ce'tify, r r the pains and nal(&s ofperjury that the information provided above is true an correct Si *nature — Date: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: www.mass.gov/dia Phone Fairfield Inn & Suites Mansfield Pool Water Contamination Response Closure - In the event of a fecal, vomit, or blood contamination in a disinfected water venue, the operator shall immediately close the pool to swimmers until remediation procedures are complete. This includes the affected water feature and other features that share the same recirculation system. Physical removal - Contaminating material shall be removed (i.e., using a net, scoop, or bucket) and disposed of in a sanitary manner. Clean / disinfect net or scoop - Fecal or vomit contamination of the item used to remove the contamination (i.e., the net or bucket) shall be removed by thorough cleaning followed by disinfection (i.e., after cleaning, leave the net, scoop, or bucket immersed in the pool during the disinfection procedure prescribed for formed -stool, diarrheal-stool, or vomit contamination, as appropriate). No vacuum cleaners - Aquatic vacuum cleaners shall not be used for removal of contamination from the water or adjacent surfaces unless vacuum waste is discharged to a sanitary sewer and the vacuum equipment can be adequately disinfected. Disinfection: pH, temperature, filtration/ recirculation system, sampling locations Pool water that has been contaminated by feces, vomit, or blood shall be treated as follows: ♦ (a) Check to ensure that the water's pH is 7.5 or lower and adjust if necessary. ♦ (b) Verify and maintain water temperature at 770F (25°C) or higher. ♦ (c) Operate the filtration/recirculation system while the pool reaches and maintains the proper free chlorine concentration during the remediation process; and ♦ (d) Test the chlorine residual at multiple sampling points to ensure the proper free chlorine concentration is achieved throughout the pool for the entire disinfection time. Pool Water Contamination disinfection ♦ Formed -stool o Formed -stool contaminated water shall have the free chlorine residual checked and the free chlorine residual raised to 2.0 mg/L (if less than 2.0 mg/L) and maintained for at least 25 minutes before reopening the pool. ♦ Diarrheal-stool o Diarrheal-stool contaminated water shall have the free chlorine residual checked and the free chlorine residual raised to 20.0 mg/L and maintained for at least 12.75 hours before opening the pool. ♦ Vomit o Vomit -contaminated water shall have the free chlorine residual checked and the free chlorine residual raised to 2.0 mg/L (if less than 2.0 mg/L) and maintained for at least 25 minutes before reopening the pool. ♦ Blood o Blood -contaminated water shall have the free chlorine or bromine residual checked at the time of the incident. If below the required minimum residual level, the operator shall immediately close the affected water feature until the free chlorine or bromine residual is verified at or above the required minimum. Surface Contamination Cleaning and Disinfection Limit Access - If a bodily fluid such as feces, vomit, or blood, has contaminated a surface of the pool area, hotel staff shall limit access to the affected area until remediation procedures have been completed. Clean Surface - Before disinfection, all visible contaminants shall be cleaned and removed with disposable cleaning products effective with regard to type of contaminant present, type of surface to be cleaned, and the location within the hotel. Disposal - Contaminant removed by cleaning shall be disposed of in a sanitary manner or as required by law. Disinfect Surface - Contaminated surfaces shall be disinfected with: ♦ (a) A 5,000 mg/L bleach disinfection solution, such as a 1:10 dilution of fresh household bleach with water; or ♦ (b) An equivalent disinfectant that has been approved by the U.S. EPA for body fluids disinfection; and ♦ (c) The disinfectant shall be left on the affected area for a minimum of 20 minutes or as otherwise indicated on the disinfectant label directions. ISWGIO48000 Rev D CERTIFICATION OF COMPLIANCE Contains: WG1048E, WG1048EBLK, WG1048EGR, or WG1048EDGR Description: 8" Round Suction Outlet Cover Ratings: Floor: 112ZSSGPPM� Wall: 72 GPM Oppen Area: 8 s Certified to Comply with Section?4o4 of the Virginia Graeme Baker Act (VGB) Pool & Spa afety Act codified at 16 CFR part 1450. Initial Certification May 2011. Manufactured: After September 10, 2oo9, by a Division of Hayward Industries, Inc. at %A, 214028 Block K4- A, Export Processing Zone Wuxi New District Jiangsu Province PRC 214028, China; or at One Hayward Industrial Drive, Clemmons, NC 27012. Certified by Hayward Pool Products, 62o Division Street, Elizabeth, NJ 07207, Phone 9o8-355-7995 Contact at www.haMardngt.com Record Custodian is Customer Service at www.havwardnet.com. Hayward Pool Products P.O. Box 5100 Clemmons, NC 27012-5100, 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 1 = 2ou) and the second character the month (A=Jan, B=Feb, H=Aug, I is skipped, J=Sep, etc) Tested to: ANSI/APSP 16 (ANSI/ASME 112.i9.8-2007 (addendum 9b-2009)) per Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act. Tested by NSF International, 789 Dixboro Road, Ann Arbor, MI 48113, Phone 734-769.8oio in April 2011. Certificate at: Date of Installation: C - / 7" 1 Suction outlet components have a finite life, the cover/grate should be inspected frequently and replaced at least every 7 years or if found to be damaged, broken, cracked, missing, or not securely attached. Hayward Pool Products acknowledges that it is a federal crime to knowingly and willinglymake materially false, fictitious, or fraudulent statements, representations, or omissions on this certification. 6„ SPACING BETWEEN MOUNTING HOLES 0 7 3/4" SUCTION OUTLET COVER WGI048E USED ON FOLLOWING SERIES: WG1030AVPAK2 SPI030AVPAK2 WG1048AVPAK2 SP1048AVPAK2 WG1049AVPAK2 SP7049AVPAK2 WGI051AVPAK2 SPI051AVPAK2 WG1052AVPAK2 SP1052AVPAK2 WG1053AVPAK2 SP1053AVPAK2 WG1054AVPAK2 SP1054AVPAK2 WG1153AVPAK2 SP1153AVPAK2 WGI 154AVPAK2 SP1154AVPAK2 ® 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 surface 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 11/2" above the finished pool surface over an area largerthan 40" on a diagonal. r RESEHOT-01 LMENDES 7 CERTIFICATE OF LIABILITY INSURANCE DATE 6123/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 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. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # 1780862 CONTACT Lucia Mantles PHONE FAX tA1c, No, E.t:(508)235-2210 JAM, No), HUB International New England 222 Milliken Boulevard Fall River, MA 02721 noorslESS: Lucia.Mendes@hubinternational.com INSURERS AFFORDING COVERAGE NAIC 11 INSURERA:Zurich American Insurance Company 16635 INSURED INSURER B:Bea2le Insurance Company 37540 INSURER C Reservoir Hotel Partners LLC c/o Lafrance Bros. P.O. Box 248 INSURER D : INSURER E : Westport, MA 02790 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE AINSO 4WD POLICY NUMBER MMIDDY EFF MMIODY E%PWAnone LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X CP00926814 6/23/2021 12/31/2021 URRENCE 5 2,000,000 RENTS enc Eaow nr $ 1,000,000 An one erson $ 10,000 &ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEOT LOC OTHER: AGGREGATE $ 4,000,000 S-COMP/OPAGG $ 4,000,000 iab. $ 1,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTO pS AUTOS ONLY AUTOS ONLB 11 COMBINED SINGLE LIMIT $ BODILY INJURY Perperson) $ BODILY INJURY Per amitlenl $ PPeLacEdatleni DAMAGE $ UMBRELLA LIAB EXCESSLIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY ANY �FFICERIMEMBEREXCLUEUE ECUTIVE Y� (Mantla ory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA C0770372 6/2312021 12/31/2021 STATUTE OTH- E.L. EACH ACCIDENT 11000,000 E.L. DISEASE - EA EMPLOYE 1,000,000 $ E.L. DISEASE -POLICY LIMIT 1,000,000 $ B Cyber/Privacy/Networ V2F518210101 6/23/2021 12131/2021 Cyber 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES 1ACORD tot, Additional Remarks Schedule ma be attached if more space is required) RE: Reservoir Hotel Partners LLC (Fairfield Inn & Suites) Mansfield 50 Reservoir §t. Mansfield MA 02048 Marriott International, Inc. & its affiliates and subsidiaries are an additional insured/Grantor on a Primary Non-contributory basis, on the general liability policy as respects to operations of the named insured when required by executed contract prior to the loss/claim. A 30-day notice of cancellation applies. CFRTIFICATF HOI_DFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Marriott International Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10400 Ferwood Rd. Attn: Law Dept. 521923.27 Bethesda, MD 20817 AUTHORIZED REPRESENTATIVE ?V ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1'-5g' r RFi WT�A 1 DEPTH MARKER DETAIL SCALE: 2 = I —U GENERAL SPECIFICATIONS POOL DIMENSIONS. 21'-8" X IT-9' SURFACE AREA: 292 SQUARE FEET PERIMETER: 78'-10" LINEAR FEET POOL DEPTHS: 3'-6" TO 4'-6" TANK VOLUME: 7,734 GALLONS TURNOVER RATE: 2.6 HOURS HEALTH CODE NOTES POOL LENGTH: 21'-8" FT WIDTH: 17'-9' FT SURFACE AREA: 292 ED FT PERIMETER: 78'-10" LF VOLUME OF TANK = 1,034 CUBIC FEET OR 7,734 GALLONS WATER DEPTHS: S-6" TO 4'-6' PUMP = HAYWARD 1/2 HP TRISTAR MOVING 50 GPM AT 50 FEET TDII ACTUAL TURNOVER RATE IS 2.6 HOURS MAIN DRAINS: (2) SDX HIGH ROW SAFETY DRAIN W111 43.2 SO IN OPEN AREA EA. TOTAL OPEN AREA OF DRAIN IS 86.4 ED IN OR 0.6 50 FT 50 GALLONS PER MINUTE = O11 CUBIC FEET PER SECOND (CFS) VOLUME RATE OF FLOW (0) CFS / AREA (A) SF = VELOCITY (V) FEET PER SECOND (FPS) 0.11 CPS / 0.6 SF = 0.2 FPS OT4 FPS — ONE DRAINED BLOCKED) FILTRATION: HAYWARD S31D SAND FILTER W4TH 4.91 SF MEDIA AREA 50 GPM / 4.91 SF = LOS GPM PER SF SANITIZED: PENTAIR HE 3315 CHLORINE/BROMINE FEEDER, 15 LB CAPACITY SANITIZER: HAYWARD AOUARITE T CELL 15 WITH SENSE & DISPENSE FLOP! METER: FLO—VS, 0 TO 100 GPM RANGE SKIMMERS: (2) PENTAIR BERMUDA SKIMMERS W/ STRAINER BASKET AND 2 INCH PORTS RETURNS: (4) WITH INDIVIDUALLY ADJUSTABLE FITTINGS DEPTH MARKERS: ENGLISH & METRIC WITH 'NO DIVING' IN WATERLINE TILE AND ON DECK ADA COMPLIANT LIFT: 400 LB CAPACITY (BATTERY OPERATED) FATHER CAPACITY: IB NON—SWMMERS HAIR AND LINT STRAINER INTEGRAL TO PUMP SEE SHEET P-3 FOR RAIL, LADDER, DEPTH MARKER, ASSIST CHAIR AND TILE TRIM LOCATIONS POOL MECHANICAL DECK PLAN BCALE: 1 4 = I —0' GFHHS.AC & SONS. INC. Fit a ivieRexl'cur�cov xx GENERAL CONTRACTOR ALL DOORS ACCESSING THE POOL ROOM TO BE SELF CLOSING AND SELF LATCHING BRAD FROM DECK DRAIN TO SANITARY BY OFFERS LADDER AND RAIL ANCHOR CUPS MUST BE GROUNDED IN ACCORDANCE WTH NATIONAL ELECTRIC CODE. INSTALL FOAM EXPANSION JOINT WITH SEALANT BETWEEN INSIDE EDGE OF DECK AND COPING/GUNNE. DECK TO PITCH AWAY FROM POOL AT MINIMUM 1/4" PER FOOT TOWARD DECK DRAINS (BY DECK CONTRACTOR.) FELD FIT LADDER AND RAIL ANCHOR CUPS TO INSURE RUDE INSTALLATION. DECK CONTRACTOR TO PROVIDE SUITABLE RECESS FOR DECK MOUNTED DEPTH MARKERS. M