HomeMy WebLinkAboutCanoe River CG #2 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: 2
PERMIT EXPIRES: December 31, 2017
Person Certified: MARK A. BURMEISTER
Pool/SPA Certification Date: October 25, 2013
Pool/SPA Certification Expires: October 25, 2018
Person Certified: PHILIP J. CARROLL
Pool/SPA Certification Date: October 25, 2013
Pool/Spa Certification Expires: October 25, 2018
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:
CANOE RIVER CAMPGROUND
for the operation of a ❑ Public
Method of water treatment is
Bathing load not to exceed:
i-_ Semi -Public
located at:
137 MILL STREET
CHLORINE
94 bathers
I Special Purpose Pool
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
-Amy Donovan-PaCmer, Heaah .Agent
None
,�
Date Issued
,r C F
Y
NOV
vi�own o Marsfield
Town of Mansfield - Board of Health
6 Park Row
Mansfield, MA 02048
Swimming Pool Application PERMIT NUMBER 2
FEE: $125
NAME OF OWNER: CANOE RIVER CAMPGROUND
ADDRESS: 137 MILL STREET
CITY: MANSFIELD
STATE: MA ZIP: 02048
TELEPHONE: (508) 339-6462
FAX: (508)339-5237
EMAIL
FED ID/SS NO: 04-2375571
Certification Expires Every 5 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED: MARK A. BURMEISTER
Pool/SPA Certification Date: 10/25/2013
Pool/SPA Certification Expires: 10/25/2018
PERSON CERTIFIED: PHILIP J. CARROLL
Pool/SPA Certification Date: 10/25/2013
F] Public
POOL OPERATION: F1 Semi -Public
n Special Purpose Pool
POOL LOCATION: 137 MILL STREET
TYPE/POOL: CEMENT
LENGTH: 40'
VOLUME: 12,000
MINIMAX DEPTH: 3'
SWIM AREA: 40'x22'
WATER SOURCE: TOWN
W[W DISPOSAL: TOWN SEWER
TYPE OF FINISH: CEMENT
SCUM GUTTER: NONE
DECK TYPE: CEMENT
SKMMR WEIR LENGTH: 2
TREATMENT SYSTEM: SAND
DISINFECT METHOD: CHLORINE
WIDTH: 22'
Pool/SPA Certification Expires: 10/25/2018 CHEMICAL TREATMENT: AUTOMATIC
certification remarks(if necessary):
REMARKS:
"NO LIFEGUARD ON DUTY" sign is required.
NUMBER OF BATHERS: 94
DIVE AREA: NONE
u.
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.
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 Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
CU q - a'-3 %
** 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 Legibly
Business/Organization Name: of , A-, (Q4J&4P-- /2 I C-4MP 6 2c
Address: l 3% //11 L L
City/State/Zip:
cQ o y,' Phone #:
Are you an employer? Check the appropriate box:
I
I am a employer with L1 employees (full and/
or part-time).*
2.0 1 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. nRestaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11.0 Health Care
12. EX Other C_Akl/' G-/& c.t u7 / /2 ✓ ' K
*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.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
1- i t l l e 14 NI c7" t e* fL)
Insurer's Address: �� �- (e! iLl t%. G' 0 r V
City/State/Zip
A C A A- tom. c) /_� L . rSo j L
// Z -LG c' `/ c9 J " V "i .S - 0 t ( Expiration Date: 1 / t I / 17
.Policy # or Self -ins, Lia #.C� Z
� � - ! p
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 llpe py�uj and penalties 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 #
i/ /I_X_/i (-,
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:
tvww.mass.gov/dia
Phone #:
I
ZURICH
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6ZZUB-0495N75-0-16)
RENEWAL OF (6ZZUB-0495N75-0-15)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
NCCI CO CODE: 17965
1.
INSURED:
STARLIN, INC. DBA CANOE RIVER
CAMPGROUNDS
137 MILL ST
MANSFIELD MA 02048
PRODUCER:
COLONIAL INS SERVICES IN
310NMAIN ST,#6
MANSFIELD MA 02048
Insured is A CORPORATION
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period is from 05-13-16 to 05.,.;;1,3 1 2:01 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:
027795
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: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
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: 04-17-16 WC
OFFICE: ZURICH-ORLAN 809
PRODUCER: COLONIAL INS SERVICES IN
75W2J
ST ASSIGN: MA
00- —qohy 't J i i'v'`i F l r .�' 1 i t • 4 0 �+�i+ ! 6' i i 5 5 : 4 3 l •7 F t •+
t41 !,c {IYf t tt kS t r ^/ t &tff v F S `i'y`39i 9,ir + S i4i ) i,'7 \ ti1V J i
,{4f 1. trfMi d St161 ✓.5 4ihS1.v SRSSJ fal%. §Sflt t41 f v ViPiR PViil >'F
i IRI f' 1fRf4$Sr� I f iii YY}G'9, i f •ii'! P Ij i'+ 1 jlykf i" I11 " Ali i t Iti v l t{ fd ilV %u I.i�a �'o`P f Pi iIr .+ rl�p�l
{I li I S P+ r i d i B}
r_ tom. s-!I�I�L�q•! i, 1#-.,.11.l`,tlr� .faLi �i �P��_� k1 ;,1 �Llilal 4¢I
.�I�i„ .rinRi'
v
TAN
i I
Olmom
CL
®
C�
i�w
�®
•®
i�
• nr
u �
a mom
wv LU
r�
rf
u
U
co
rnl
NG N
Of 12 11 k p
CIL
ujCLW anti
t
CL
®
C�
i�w
�®
•®
i�
• nr
r�
u
U
rnl
N
�I
N�
®
`
r
N
i
ao•jsu wej oa o77 0 1 EWO W 66 T NE LL
le AdSN
euNdgo 'UWegWeA CoA
ll
t 9{i F'i iIiIV 1
: 1{Ii I Ij , W l MOM ¢l1 Pi11yoi
r
111'I
tl 1 1TV
i it II
li
1`I pl llk{
itlpi 9 {t �yV. � iiiV4 Z'?flfl ti4 z
s IN 7 t F. 81Ro 4 3 14 -R
t f i
r
REGULATION
NO. I 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.
G \
SIGNED L 4—
SIGNS �1�
Operator Board of Health Health Department
II felvAlk [e7Zr11_l&'i Vt
STATE SANITARY CODE: CHAPTER V MINIMUM STANDARDS FOR SWIMMING POOLS,
165 CMR 435.000
SWIMMING L INSPECTION
TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC t K SPECIAL PITRPOSE FOOT, ❑
NAME OF POOL
cc"e �k"o-C
ADDRESS t3--) `
OWNER
ADDRESS
DATE OF
INSPECTION
.04 Sewage Disposal
POOL CAPACITY
# OF GALS
INSPECTED BY
METHOD OF WATER
TREATMENT
ScL� ci
BATHER
LOAD
# OF LIFEGUARDS WATER SOURCE:
A, v�
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.
kC
,
.04 Sewage Disposal
.05 Location, structural stability, finish.
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: gpm. # of turnovers c,
Q �7esl b
.06 Suitable automatic equipment for disi fection o p of
water.
.06 Carbon dioxide (CO2) equipment for pH control
adequate. CO2 cylinders anchored. Inaccessible to
IP,
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
until repairs can be made.
.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
Lyres.
I POOLSIDE READINGS I I I
Bromine 2.0-6.0 ppm'
Alkalinity 50-150 m
Cyanuric Acid (30-100 ppm)
Water Temp. 1104°F.
* 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
a
.Total Chlorine
Free Chlorine
1.0-3.0 m
Comb.
Chlorine
(0.0-0.2 ppm)
pH level
(7.2-7.8)
Other I
y X �-A' k-", w\,