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Home My WebLink AboutHoliday Inn 12/31/2017Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 14 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 ❑ Semi -Public Special Purpose Pool located at: 31 HAMPSHIRE STREET Method of water treatment is SALINE Bathing load not to exceed: 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 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming POOL Application PERMIT NUMBER 14 FEE: $125 NAME OF OWNER: VISION HAMPSHIRE LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: (508) 339-1040 EMAIL: FED ID/SS NO: 47-3112140 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARCIO B. TAKIMOTO Poo//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): ❑ Public POOL OPERATION: ❑ Semi -Public ❑ Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SPECIAL PURPOSE LENGTH: 7 WIDTH: 7 VOLUME: 863 MIN/MAX DEPTH: 3' SWIM AREA: 154 sq ft DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: BRICK RAISED SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: SALINE DISINFECT METHOD: SALINE CHEMICAL TREAT9t1ENT: CHLORINE SAND FILTER NUMBER OF BATHERS: REMARKS: "NO LIFEGUARD ON DUTY" sign is required. "No Lifeguard on Duty" sign SIGNATURE: _ C U % - DATE: _._ — —3 Please make p ropriate chang s. Sign, date an close check payable to Town of Mansfield. Mail to: Board, of Health, Town o Mansfield, 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. of Individual or Corporate Name Social Security Number (Voluntary) or Federal Identification Number" By: Corporate 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. The Commonwealth of Massachusetts r Department of Industrial Accidents y I Congress Street, Suite 100 Boston, MA 02114-2017 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: \) �� ,NLS �i + �'— CAV)"— 6A i Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. [ I am a employer with % employees (full and/ l 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.] Phone #: S;, t- 3 3 i `2- 2-4fU Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10. ❑ Manufacturing 11.❑ Health Care 12. EZ 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 is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1 Insurer's Address: L-> I City/State/Zip: Z Policy # or Self -ins, Lic. # • _TtJ 0 _35 5m3 & 2Z Expiration Date: 6 l , /" 1:2 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 pawns enalties of perjury that the information provided above is true and correct. 0:,..,.,,,,.o. nate- /1 j /(4/;LA)/4 Phone #: ,� 3 —� T� 5 1 6 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.gowma Phone GLOBVIS-01 .11-I0GAN ACOROM CERTIFICATE OF LIABILITY INSURANCE `•..�� DATE(MM/DDNYYY) 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(les) 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 Roblin Insurance Agency 144 Gould Street Suite 100 Needham, MA 02494 CONTACT AME: A/cH°, No, Ext): (781) 455-0700 jac, No):(781) 449-8976 E -L -- MAIE s. certificates@roblininsurance.com INSURERS AFFORDING COVERAGE NAIC # 06/24/2016 INSURER A: Travelers Insurance Co 36161 EACH OCCURRENCE $ 1,000,000 INSURED INSURERB:TraVelers Indemnity &Affiliates 25658 INSURER C:ACE American Insurance Co. 22667 Vision Hampshire LLC dba Holiday Inn INSURER D:AmTrust Insurance Company of Kansas 115954 31 Hampshire Street Mansfield, MA 02048 INSURER E INSURER F: AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY NON-OWNED O —O ONLY Rr1VFRAr:F9 CFRTIFICATF NIIMRFR- REVISION NIIMRER-_ 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 LTRA TYPE OF INSURANCE ADSD SUBR WVDPOLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_X] OCCUR X Liquor Liability $1M P -630 -9C747111 -TIL -16 06/24/2016 06/24/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 S S Ea cp curmace $ MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000'000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ jECT El LOC OTHER: GENERAL AGGREGATE $. 20,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 EMPLOYEE BENEFI 1,000,000 B AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY NON-OWNED O —O ONLY BA -4H060824 -16 -CAG 06/24/2016 06/24/2017 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE er accident $ Par. C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE PUMB16-A-G26785789 06/24/2016 06/24/2017 EACH OCCURRENCE $ 125,000,000 AGGREGATE $ 125,000,000 DED RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE Mandatory In NH) EXCLUDED? If yes, describe under DESCRIPTION OF OPERATIONS below N / A TWC3562216 06/01/2016 06/0112017' X PER ERH E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Issued as evidence of Insurance. rFRTIFIrATF FIOI nFR CANCELLATION ACORD 25 (2016/03) @ 1988-2015 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 Issued as Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD glM' ZWK ANN 'r— s 1 Nh REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED i SIGNED a,44 -j ('-k A OA Operator Board of Health/Health Department Town of Mansfield 6 Park Row, Mansfield, Massachusetts 020463 508-261-7366 orf"44" Health Department ,> Amy Donovan -Palmer, Health Agent SWIMMING POOL :.. .ORT TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC ❑ SPECIAL PURPOSE POOL ❑ NAME OF POOL ADDRESS OWNER ADDRESS DATE OF INSPECTION POOL CAPACITY # OF GALSu INSPECTED BY METHOD OF WATER TREATMENT BATHER LOAD # 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 ventilation; sanitary condition. tf .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 �Itration systems. Filter Effluent flow meter reading:N l� 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 'C- .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 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 ppm* Alkalinity 50-150 m Cyanuric Acid (30-100 ppm) Water Temp. 104°F. partsper million .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 'c� (V G1 V"", YA Total Chlorine Free Chlorine 1.0-3.0 m s•P Comb. (0.0-0.2 ppm) Chlorine pH level (7.2-7.8) Other j,e <- C,-) �,e v� \ Lam' loci_\ t ` 1 c