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Home My WebLink AboutHoliday Inn #2 12/31/2017Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 15 PERMIT EXPIRES: December 31, 2017 Town of Mansfield 6 Park Row Mansfield, MA 02048 Person Certified: STEVEN M. PASCALE Pool/SPA Certification Date: November 09, 20 Pool/SPA Certification Expires: November 09, 20 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: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a ❑ Public n Semi -Public ❑ Special Purpose Pool located at: 31 HAMPSHIRE STREET Method of water treatment is SALINE Bathing load not to exceed: 83 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 ,g Date Issued Town of Mansfield - Board of Health Swimming Pool Application NAME OF OWNER: VISION HAMPSHIRE LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: EMAIL: FED ID/SS NO: 47-3112140 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARCID B. TAKIMOTO Pool/SPA Certification Date: 3/19/2013 Pool/SPA Certification Expires: 3/19/2018 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS:" NO LIFEGUARD ON DUTY" sign is required. No lifeguard on duty. Sign is required. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 15 FEE: $125 ❑ Public POOL OPERATION: ❑ Semi -Public ❑ Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 62 VOLUME: 42,666 GALS MIN/MAX DEPTH: 375' SWIM AREA: 1,426 SQ. FT. WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: SALINE DISINFECT METHOD: SALINE WIDTH: 23 DIVE AREA: N/A CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: 83 SIGNATURErMapnsfield, _ DATE: Please make te cha ges. Sign, dat and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town 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. al or Corporate Name By: Corporate Officer (Mandatory, IF Applicable) Social Security Number (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. <899Z a M, g. w ei r MO; Ism J2 �; IIIIIIIII Vi, III �� IIIIIIIIIIIIIIiill Ims NEEN �II�I�I��'II�IIIIIIIIUIiII = ____ I�. -�� N w 04 am _ - = ■LLI IIIIII��IIIiIiIIIII��I�II!� " ' - ; � '. I '� _= � IIII�I�IIIIIIIIIIII'' —_■_ ' ' 1 IIIIIIIIIIIII1111111111111P — � a' � dIIIIIIIIIIIIIIIIP � ' IIIIIIIIIilllllll I � � � I I�IIIIIIIIIiIII'„ � ' ' �, II��IIIIIIIIIIIII,II�III I � � Id6111111f � i III i ' IIIIIIIIIIIIiill p = '� "' � � ' illl(IIIIIIIIiII' I �p -- dlllllllllllllll��lllllll =MOO- IIIIIIIIIIIIIIIillll�llll pIIIIIIIIIIIIIIIIII _ _ IIIIIIIIIIIIIIIII _ ,, dIIIII�lllllll'dlll � � __ ��' � .� __= �I IIIIIIIIIiII I�VI� IIIIIIIIIIIIIIIIIIIIIIIIIII' — � � �� IIIIIIIIIIIIIIIIIIIIIIIIIII' III�IIIIIIIIIIIIII��II I � !' III��IIII�IIIIIIIIIII��III '� IIIIIIIIIIIIIIII'I, q — I ; ' ,IIIIIIIIIUIIIII�IIIp — I � '; ,. dlllllllllllllll�ll!IIII' = AOI M? a�n�as �ie�SII 646 L a� -AdS�! auoi _� uIu I a�x!ue ylp �I�il�l� I � � �III��Illlllll�yl�l i ilillli I'il I. "li i � � Illllllli l� �l ldllllllllil' 0 0 ,noo , o„ _ —121- Me-� _ ylli �l�il —_---_ �IIdI��illllrlll��I�lll' I I I ii � I' iiu'i �IIIIIIIIII' III � � �IIIIIIIII II, dl�'�� JIIIIIIII�I� \ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 s, "r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Business/Organization Name: \J w, ��' ' b.. I A,® -t -� Address: ► tie o n-�� t J . Phone #:�'� i) t '335 Are you an employer? Check the appropriate box: Business Type (required): I. [ I am a employer with % v employees (full and/ 5. ❑ Retail [ or part-time).* 6. rlRestaurant/Bar/Eating Establishment 2: 1 am a sole proprietor or partnership and have no 7, Fj 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]* 1111 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.2 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 #1. I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: w �+csz3 Insurer's Address: City/State/Zip: Z Policy # or Self -ins. Lic. # 3S J 3 b -z� Expiration Date: 6 l % 11 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 r t pains . enaltles of perjury that the information provided above is true a/nddcorrect Si % Signature: Date: ! ( �i `� Phone #: 3 •_,2 T ! — '75 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/ma Phone #: REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE -, n X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED SIGNE VWDepat Operator Board of Health/Hment m Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent SWIMMING POOL INSPECTI•'REPORT TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC ❑ SPECIAL PURPOSE POOL ❑ NAME OF POOL ADDRESS c OWNER latch 4 ft above ground. ADDRESS DATE OF INSPECTION POOL CAPACITY # OF GALS LAQ (0 INSPECTED BY METHOD OF WATER,L TREATMENT BATHER LOAD (B3 # OF LIFEGUARDS WATER SOURCE: 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 .03 Bathhouse and sanitary facilities adequate lighting; 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: r �t:, 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 / V 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, p oper 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 ppiril Alkalinity (50-150 m Cyanuric Acid (30-100 ppm) Water I * parts per million 1 .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 f� )�Cks i\ Total Chlorine Free Chlorine 1.0-3.0 ppm) Comb. (0.0-0.2 ppm) Chlorine pH level (7.2-7.8) Other