HomeMy WebLinkAboutCedar Heights 12/31/2017Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Permit to Operate a Swimming Pool
PERMIT NUMBER: 13
PERMIT EXPIRES: December 31, 2017
Person Certified: MICHAELLA J. (JOHNSON) SAMPSON
Pool/SPA Certification Date: March 20, 2013
Pool/SPA Certification Expires: March 20, 2018
Person Certified:
Pool/SPA Certification Date:
Pool/Spa Certification Expires:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:
CEDAR HEIGHTS
for the operation of a F Public [ 1 Semi -Public [-] Special Purpose Pool
located at:
10 CONNORS AVENUE
Method of water treatment is CHLORINE
Bathing load not to exceed: 61 bathers
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
.Amy Donovan-PaCmer, Health .Agent
None
Date Issued
J
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Town of Mansfield - Board of Health
ASA
Swimming Pool Application
PERMIT NUMBER 13
FEE: $125
❑ Public
NAME OF OWNER: CEDAR HEIGHTS POOL OPERATION: W Semi -Public
❑ Special Purpose Pool
ADDRESS: 10 CONNORS AVENUE
POOL LOCATION: 10 CONNORS AVENUE
CITY: MANSFIELD
STATE: MA ZIP: 02048 TYPE/POOL: GUNITE/PLASTER
TELEPHONE: (508) 337-0040 LENGTH: 42'6" WIDTH: 27'
FAX: (508) 337-0042, VOLUME: 27,510 GALLONS
EMAIL t. /' �''9 } 4 r tit C t c t` ii is€ i� .' �� MW/MAX DEPTH: 3'/5'
FED ID/SS NO: 56-2332456 SWIM AREA: 917 sq. ft. DIVE AREA: N/A
WATER SOURCE: TOWN
Certification Expires Every 5 Years. W/W DISPOSAL: TOWN
Permit Expires December 31st Yearly. TYPE OF FINISH: PLASTER
PERSON CERTIFIED: MICHAELLA J. (JOHNSON) SAMPSON SCUM GUTTER: NONE
Poo//SPA Certification Date: 3/20/2013 DECK TYPE: CONCRETE
PoollSPA Certification Expires: 3/20/2018 SKMMR WEIR LENGTH: 8 1/2"
PERSON CERTIFIED: TREATMENT SYSTEM: CHLORINE
PoWASPA Certification Date' DISINFECT METHOD: CHLORINE
Pool/SPA Certification Expires:
certification remarks(if necessary):
CHEMICAL TREATMENT: CHLORINE
NUMBER OF BATHERS: 61
REMARKS: "NO LIFEGUARD ON DUTY" sign is required.
MICHALLA JOHNSON - AGENT OF CEDAR HEIGHTS
i
SIGNATURE.
DATE: f H/
Please make appropriate changes. ►gn, date°' nd enclose check payable to Town of Mansfield. Mail to: Board of
Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
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.
* Signature of lnailviau6f or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if,applicable)K,
*" 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 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 Lezibly
Business/Organization Name:
Address:'
City/State/Zip:
Phone
Are you an employer? Check the Ippropriate box:
Business Type (required):
1. [I am a employer with ` 3 employees (full and/
5. ❑ Retail
or part-time).*
6. ❑Restaurant/Bar/Eating Establishment
2. -EJ I am a sole proprietor or partnership and have no
7• � Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• F1 Non-profit
[No workers' comp. insurance required]
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. F1 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req j
12. ❑ Other
*Any applicant that checks box #] 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' conipensation insurance for my employees. Below is the policy information.
Insurance Company Name: `_ 16
Insurer's Ad
City/State/Zip:
I
Policy # or Self -ins. Lie. # E % /t;+, i lgf ' Expiration Date: t :} -- /
Attach -a copy of the workers' compensationpolicydeclaration 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 penallles` of perjury that the information provided above is true and correct.
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
J
u
001586
/
TRAVELERS J WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IEUB-2DG3148-7-16)
RENEWAL OF (IEUB-2D63148-7-15)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
1.
INSURED:
CEDAR HEIGHTS,LLC DBA
SEE ENDORSEMENT WC 99 06 01
34 BELLOWS RD
RAYNHAM MA 02767
NCCI CO CODE: 12637
PRODUCER:
GLOVER-PADULA INS INC
16 MAIN ST
EAST GREENWICH RI 02818
Insured Is A LIMITED LIABILITY COMPANY
Other work places and Identificatlon numbers are shown in the schedule(s) attached.
2. The policy period is from 08-25-16 to 08-25-17:-12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 07-15-16 MP
OFFICE: BOSTON SOUTH MA 853
PRODUCER: GLOVER-PADULA INS INC
32964
DIRECT BILL
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The Village at
Cedar
Heights
A Turner Properfles Apartment Community
January 19, 2017
Board of Health
Town of Mansfield
Attn: Jane Doucette
6 Park Row
Mansfield, MA 02048
Certified Mail, Return Receipt Requested
RE: 2017 Swimming Pool Permit
www.CedarHeightsMansfield.com
Enclosed please find a completed Swimming Pool Application, Worker's Compensation
Insurance Affidavit, Insurance Policy Declaration Page, a copy of my CPO Certificate, tax
Certification Form and a check in the amount of $125.00.
Should you have any questions or require anything further, please feel free to contact the
office. Also, here is my email which was requested: msampson@cedarheightsmansfield.com
Thank you, �(
Michaella J. Sampson
Property Manager'
REGULATION
NO.
THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
V\- C3
cc,vvN
X/✓
.34
Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED T[
L� (off �` ' =�i/
SIG_NE �
Operator ,` .
Board o ealthlHealth Department
Town of Mansfield
6 Park Row, Mansfield, Massachusetts 02048
508-261-7366
1 '�3
Health Department
Amy Donovan -Palmer, Health Agent
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING INSPECTION
TYPF. OF PrinT.- PTIRLIC M SEMI -PT IRT.IC I SPFCTAT. P1IRP()SF. P(1(N. rl
NAME OF POOL
ADDRESS
.05 Location, structural stability, finish.
�✓
OWNER
ADDRESS
water.
DATE OF POOL CAPACITY-�,
c�\o'
INSPECTED BY
public, adequate ventilation provided.
INSPECTION # OF GALS
S l
.08 Inlets and outlets - Inlets located to produce uniform
circulation. Over rim fill spout 6" above maximum
METHOD OF WATER BATHER
TREATMENT LOAD
G \
# OF LIFEGUARDS
WATER SOURCE:
protective covers or grates. Cannot be removed
without the use of tools. Open area does not provide
V
C"
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
N/'
.05 Location, structural stability, finish.
�✓
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: � O gpm. # of turnovers I X Ay
G.5; he
.06 Suitable automatic equipment for disinfection of pool
water.
I
.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
V
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 j
emergency shut off pump switch. Accessible and 1�
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.
nkk
.17 Pool supervision - Pool supervision provided.
S
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
i
.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
POOLSfDE READINGS
Bromine 2.0-6.0 m*
Alkalinity 50-150 m
Cyanuric Acid (30-100 ppm)
Water Temp. 104°F.
arts 2er 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.
i
b. Thermostatic control only accessible to the pool
operator
.38 General sanitation
Total Chlorine
Free Chlorine 1.0-3.0 ppm
Comb. (0.0-0.2 ppm)
Chlorine
PH level (7.2-7
Other
A-'ssA .rn?-a -L
In