HomeMy WebLinkAboutMilhaus 12/31/2017Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Swimming Pool
PERMIT NUMBER: 9
PERMIT EXPIRES: December 31, 2017
Person Certified: JOHN M. BURKETT
Pool/SPA Certification Date: March 19, 2014
Pool/SPA Certification Expires: March 19, 2019
Person Certified:
Pool/SPA Certification Date:
Pool/Spa Certification Expires;
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:
MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE
for the operation of a _! Public [yl Semi -Public F-1 Special Purpose Pool
located at:
150 RUMFORD AVENUE
Method of water treatment is AUTOMATIC CHLORINATOR MARC MAC, 22 PSI
Bathing load not to exceed: 70 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
.Amy Donovan-PaCmer, Heaah .Agent
Date Issued
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Tawe of Mansfield - Board
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L�own of Mansfield
&___ _--.��,.�. �.-6-Park Row
Mansfield, MA 02048
Swimming PoolApplication PERMIT NUMBER 9
FEE: $125
NAME OF OWNER: MILLHAUS @ MANSCONDO TRUST - DAVID
DOUCETTE
ADDRESS: 2 HAMPSHIRE STREET 100B
CITY: FOXBORO
STATE: MA ZIP: 02035
TELEPHONE: (508) 339-3078
FAX:
EMAIL:
FED ID/SS NO: 04-6551192
Certification Expires Every 5 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED: JOHN M. BURKETT
Pool/SPA Certification Date: 3/19/2014
Pool/SPA Certification Expires: 3/19/2019
PERSON CERTIFIED:
Poo11SPA Certification Date:
Pool1SPA Certification Expires:
certification remarks(if necessary):
❑ Public
POOL OPERATION: W Semi -Public
❑ Special Purpose Pool
POOL LOCATION: 150 RUMFORD AVENUE
TYPE/POOL: GUNITE
LENGTH: 60' WIDTH: 30'
VOLUME: 66,000
MINIMAX DEPTH: 4', 7', 10', 14'
SWIM AREA: 18,000sf DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH: CONCRETE
SCUM GUTTER: YES
DECK TYPE: CONCRETE16'
SKMMR WEIR LENGTH: 4, 8' APART
TREATMENT SYSTEM: HAYWOOD 3000
DISINFECT METHOD: AUTOMATIC CHLORINATOR MARC MAC, 22
PSI
CHEMICAL TREATMENT: SODIUM HYPOCHLORITE
NUMBER OF BATHERS: 70
REMARKS:"NO LIFEGUARD ON DUTY" sign is required.
(508) 339-7531 TRUSTEE NUMBER SAMANTHA CONTACT PERSON
SIGNATURE:
DATE: 1 /®
Plea p oprat6 changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of
Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
7
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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.
Sig eture�lndividual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
c I Congress Street, Suite 100
Boston, MA 02114-2017
www nass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
AAPplicant Information Please Print Legibly
Business/Organization Name: e dZ,6 a-4et � a: -I- MUL
Address:
City/State/Zip:In 1'W Phone #: �7
Are you an employer? Check the appropriate box:
1. a I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. ❑ Retail
6. ❑RestaurantBar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11. ❑ Health Care
12. ❑ Other
*Any 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: /l'}') . ! 44
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. # ✓lU L' 1691®n ,9 13/ Expiration Date:_IAIA.6)LZ
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 of perjury that the information provided above is true and correct.
Signature: 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: Phone #:
www.mass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
,4C"RE)W
12/2012016
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 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).
1CONTACT Branch 1917-1
PRODUCER 01917 - 001 NAME:
._-----------_......_...--------------.._.._.,._...._..-------_.__..._._-...-.__.__.__.._..----.__.
C & S Insurance Agency Inc 1_jA(CNNo.-Ext):(_508) 339-2951__..._._._._._...............___L(AIC_No_:(508) 339_2307
PO BOX 406 'EMAIL
jADDRESS:
_...... _......
Mansfield, MA 02048
k..-.__.......-_......._........_._.__INSURER(Sl_AFFORD"ING_CO"V""ERAGE_-..._._-...._____._..__----'--...._ NAIC._#..._...---
jINSURER A • A.I.M. Mutual Insurance Company3758 _
----
INSURED .INSURER B_
C _________
Millhaus At Mansfield Condominium Trust
INSURER___...-------......._......-------.._.._.._..._...._..._.---.._..__...----......._.__.__..._._._..-.--.._-...._...__...._.__...
I I
2 Hampshire Street Ste 100B .....
INS D_;....___..._......._...........----_.____._.--------_..—_.._...___-.....--------...__'........-----..__._.._.._...._..._
Foxboro, MA 02035-0000.-"URER3
INSURER E:—............ ... .._..—..----- -- ... -t- - - - ---
( INSURER F:
r-nvconr-cc CFRTIFICATE 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 CONTRACT OR 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.
(NSR TYPE OF INSURANCE �ADDL�SUBR� POLICY NUMBER POLICY EFF POLICY EXP
LIMITS
_LTR _. _ ----...... .___.._.E O - _....._.. ..NUMBER._____ ..._ {MMIDDIYYYY) i {MMlDD/YYYY)_ ....... _ ....... .—........... -- ._ .. ...._ _....
EACH OCC 1
GENERAL LIABILITY ! I L ' '
RRENCE
COMMERCIAL GENERA(_ UASILITY
CLAIMS -MADE i OCCUR MED FRCP (Any one Person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
;EN'L AGGREGATE LIMIT APPLIES PER: i PRODUC.CS- COMPlOP AGC; $
F
.- -I
�70LICY PRO- l LOC
..F
AUTOMOBILE LIABILITY
ANY AUTO
_-- ALLOVYNEU—....iSCHPDt.1LF..0
AI.IrOS AUTOS
HIRED AUTOS NON-OM17D
AOTOS
f
UMBRELLA LIAR i OCCUR
EXCESS LIAS 1 CLAIMS MADE
DED i RLTENnON $ !
AtJD EMPLOYERS€LIABILQTY Y i N
ANY PPOPRIk.TORIPARTNERtEXECUTIVE -7 's
A OFFIC RIME iB R GLUUUEEU? N I NIA
(Mandatory in NH) 1
VWC-100-6020536-2016A 112120/2016 1
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is require
DER CANCELLATION
CIJMt)nVCU JnVULC u�vi� i
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERT"Y DAMAGE
ACCORDANCE WITH THE POLICY PROVISIONS.
(Per accident)_-.
AUTHORIZED REPRESENTATIVE �,�...
s
EACH OCCURRENCE
AGGREGATE $
E.L.ACH ACC IDENr 100,000 00-
_
EI_ DISEASE EA EMPLOYEE 100,000 001
P.L.DISEASE POLICY LIMIT 500,000.00
CERTIFICATE HOL
TOWN OF MANSFIELD
6 PARK ROW
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MANSFIELD, MA 02048
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE �,�...
6:4-
n Ono MArinf.l All r tihfe ---1
ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD
H_
14/2010 00:32 50
01
PAGE 02/02
REGULATION REGULATION
NO. T 1:0 N] THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
N70 THE SPACE BE
v", v) C-11 �4:r
06-cv-,L
Cy'N—
S2
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.34
Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 436.29 THROUGH 435.31.
SIG ED_
SIGNED
,,k.,
Operat
Board of Health/Health Department
J , Town of Mansfield
as 6 Park Row, Mansfield, Massachusetts 02048
v
"" 508-261-7366
Health Department
Amy Donovan -Palmer, Health Agent
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105
. 435.000
SWIMMING POOL INSPECTION
,. REPORT �, , . R mow.
TYPE. OF POOL: PI TBLTC ❑
SEMI-PUBLIC
SPECIAL PURPOSE POOL ❑
NAME OF POOL
, r _ ADDRESS
v` mac,
OWNER
ADDRESS
DATE OF
INSPECTION
POOL CAPACITYINSPECTED
# OF GALS
BY
METHOD OF WATER
TREATMENT
hC�t�vice-
2Oa`J
BATHER
LOAD
# OF LIFEGUARDS WATER SOURCE:
0 i-,
Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000.
Items marked with a "✓" are satisfactory.
REGULATION X/✓ VIOLATIONS/COMMENTS
ventilation; sanitary condition.
.03 Adequate enclosure around pool. Gate self -latching w/
latch 4 ft above ground.
.04 Sewage Disposal
.05 Location, structural stability, finish.`
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: 12��gpm. # of turnovers
.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.
.08 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
.08 Special purpose pool and wading pools equipped with
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 purpose pools.
.23 Lifeguards required: Yes ❑ No
If lifeguards required. Proper credentials, proper suits
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 diatomaceous earth filter
backwash water.
.29 Chemical standards
POOLSIDE READINGS
Bromine
2.0-6.0 m*
Total Chlorine
Alkalinity
50-150 m
Free Chlorine
1.0-3.0 m`
Cyanuric Acid
(30-100 ppm)
Comb.
Chlorine
(0.0-0.2 ppm)
Water Temp.
104°F,
pH level
(7.2-7.8)
* earts eer million
Other
.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
.38 General sanitation
r`(
"I