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HomeMy WebLinkAboutMansfield Meadows 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 PERMIT EXPIRES: Person Certified: MORRIS D. BARKLEY Pool/SPA Certification Date: April 28, 2016 Pool/SPA Certification Expires: April 28, 2021 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 7 December 31, 2017 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: MANSFIELD MEADOWS (BEACON PROPERTIES) for the operation of a ❑ Public Method of water treatment is Bathing load not to exceed: V Semi -Public (LI Special Purpose Pool located at: 12 BONNEY LANE #9 CHLORINE TABLETS 51 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. .Amy Donovan-PaCmer, Heaah .Agent ►= Date Issued Swimming ®®l Application NAME OF OWNER:Mansfield Meadows Apt (Beacon Properties) ADDRESS: 12 Bonney Lane #9 CITY: Mansfield STATE: MA ZIP: TELEPHONE: 508.339.3357 US; ,b � q -2 4,IS Z FAX:508.339.9761 EMAIL:brodriguez@beaconcommunitiesllc.co m FED ID/SS NO: 4R Certification Expires Every 5 Years. Permit Expires December 31st Yearly PERSON CERTIFIED: Morris Barkley Pool/SPA Certification Date: 4.28.16 Pool/SPA Certification Expires: 4.28.2021 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): "NO LIFEGUARD ON DUTY" sign is required. REMARKS: 5 POOL X 11 El POOL LOCATION: 12 Bonney Lane #9 TYPE/POOL:Main LENGTHAO' VOLUME:36,300 MIN/MAX DEPTH:3'-8' 1" �T n of Mansfield )W Mansfield, MA 02048 PERMIT NUMBER TM FEE: $125 Public OPERATION: Sem i -Public Special Purpose Pool WIDTH:22' SWIM AREA:440 DIVE AREA:NA WATER SOURCE: Town W/W DISPOSAL: Town Sewer TYPE OF FINISH: Paint SCUM GUTTER:NA DECK TYPE: concrete SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: DE DISINFECT METHOD: Chlorine tablets CHEMICAL TREATMENT: CL220 feeder NUMBER OF BATHERS:51 SIGNATURE: DATE: Please make appropriate 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. USAMA-1 OP ID: PP AC®R® CERTIFICATE OF LIABILITY INSURANCE DATE (.MIDDIYYYY) 11/16/2016 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). PRODUCER McIntire & Associates P.O. Box 1336 355 First Street, N.W. Cleveland, TN 37364-1336 CONTACT Patti Penepent PA/C.1%EXI).423.472-5058 FAX 423-479-6110 E-MAIL atti mcintireins.com ADDRESS: p _- INSURER(S)AFFORDING COVERAGE NAIC q Todd Walker INSURER A: Accident Fund 10166 INSURED USA Management, LLC Morris Barkley 10800 Alpharetta Hwy INSURER B: -- - — INSURER c INSURER D: Roswell, GA 30076 INSURER E: INSURER F GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT 0 LOC OTHER: 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 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. INSR LTR TYPE OF INSURANCE DDL INSD BR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ --._ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT 0 LOC OTHER: _ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea accident _ BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYSTATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? F-1 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 2388246-00 11/10/2016 11110/2017 OTH- x ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYE S 1,000,00 E.L. DISEASE - POLICY LIMIT I $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a c a A 04 N LM�1 IA? N CL ON �10co fjO6 N i IN 1 i .. •ten A- xwm"� LU CL■ eq p 4) �- W z FA rML■.. 0i ��. d . �1 m CL x rd CL as now m `',,� as�•� ���e��i�r�s geese ao 66�6'Oti4'6�L lE �dSN euayda�a}'ucr���ayuan�o,� il 111 ifff T, aUlm - Owl' rvimrMsr3 REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE XI✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. IF�F SIGNED € -g SIGNED, t _ ', . Operator x' ,'' Board of Health/Health Department Town of Mansfield q 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent SWIMMING POOL INSPECTION REPORT TVPF C)F PCV)T .• PT TRT .TC 1-1 CF.MT-PT TRT .TC rn SPFC`.TAT. PTTRPORF. P001, FI NAME OF POOLC- Xp ADDRESS � OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD 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 a 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 _� gpm. # of turnovers u, 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 _ e 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. V_ .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 Q 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 ,rte 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 Alkalini 50-150 ppmj,,(, Free Chlorine 1.0-3.0 ppm�,,o Cyanuric Acid (30-100 ppm) Comb. (0.0=0.2 ppm) Chlorine Water Temp. 104°F. pH level (7.2-7.8 )�9 arts er 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). f. .33 a. Thermostatic control provided for each SPP. b. Thermostatic control only accessible to the pool operator .38 General sanitation