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Home My WebLink AboutTwin Oaks 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: 3 PERMIT EXPIRES: December 31, 2017 Person Certified: ROB MERCIER Pool/SPA Certification Date: June 09, 2017 Pool/SPA Certification Expires: June 09, 2022 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: POORVU CONSTRUCTION, CO., INC. - AGENT FOR TWIM OAKS ASSOCIATES, LLC for the operation of a [-I Public Method of water treatment is Bathing load not to exceed: F j Semi -Public [] Special Purpose Pool located at: 149 OAKLAND STREET CHLORINE 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 None -, Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $125 v iA C CnS+r`4 i R Public NAME OF 0 NER: POOL OPERATION: u Semi -Public Special Purpose Pool ADDRESS:I t POOL LOCATION: 1A 0`3 j CITY: N 2. vi tc, a t► o , STATE: A ZIP: 2-41 TELEPHONE: (�p z-1 (.fCj LENGTH: LA V WIDTH: FAX: L.a Il q EMAIL: FED ID/SS NO: 0,Lj_ I 9� FEE PER POOL: Certification Expires Every 6 Years. Permit Expires December 31st Yearlv. PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: VOLUME: C.) MINIMAX DEPTH: e c x3 C SWIM AREA: ° DIVE AREA: WATER SOURCE: ",.•� WIW DISPOSAL: TYPE OF FINISH: % § c � rxs i- e ( SCUM GUTTER: DECK TYPE: Ce ft c r e & e- SKMMR WEIR LENGTH: TREATMENT SYSTEM: c t� DISINFECT METHOD: (_h)or i, -se CHEMICAL TREATMENT: C V, % r �'ex NUMBER OF BATHERS: DATE: 6 k. I k 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. The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations 600 Washington Street t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Namd: �,(-Y\)", (:c: Y,�,roc ` e m 7Ci `I -) 0 1- 1 15 6 tees, L.L,(2 Address: f�L4 vJet rve City/State/Zip: e Are you an employer? Check the appropriate box: 1.9 I am a employer with employees (full and/ 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 #: iO _`i Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. Eg Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.04 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name; Insurer's Address: i O City/State/Zip: iEt Its Policy # or Self -ins. Lic. #( ( [ ` Expiration Dater 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 the pains and penalties of perjury that the information provided above is true and correct. pt. 44 L 0 --�')_-7®-G WC Date: H. )k 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: Phone #: www.inass.gov/dia 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) �2 By: Corporate Officer (Mandatory, if applicable) Ll -7 ** 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 fumished 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. --.4, AC"R o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 06/06/2017 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 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 Aronson Insurance 950 Highland Ave Needham MA 02494 CONTACT NAME: Arlene Marsh, CIC, CISR Xt: (781)444-3050 FAX , No: (781)444-3051 PHCONENo E.,): E-MAIL s: AMarsh@aronsoninsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Star Insurance Co INSURED Poorvu Construction Co., Inc. 154 Wells Ave., Suite 7 Newton MA 02459 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2017-2018 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 CONTRACTOR 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. INSRADDL LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS 6 Park Row COMMERCIAL GENERAL LIABILITY Mansfield MA MA 02046 EACH OCCURRENCE $ DAMAGE O RENTED PREMISES Ea occurrence $ CLAIMS -MADE D OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ PRO- LOC POLICY JECT $ OTHER: AUTOMOBILE LIABILITY (Ea accident)tNED SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR HCLAIMS-MADE DED I I RETENTION $ $ WORKERS COMPENSATION PER I OTH- STATUTE ER 1,000,000 E.L. EACH ACCIDENT $ A AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under1,000,000 DESCRIPTION OF OPERATIONS below N/A WC0428615 05/30/2017 05/30/2018 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CANCFI I ATInN CER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA MA 02046 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE �le c c_ ;c,VN, - �J\C 6�2 «. X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. --7 SIGNED Operator �4 SIGNED Board of Health/Health Department Town of Mansfield �. 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY .! CHAPTER ,._it MINIMUM STANDARDS D 4 T D 1 M 1 #' 105 CMR 435.000 SWIMMING POOL O INSPECTION NAME OF POOL �-W ADDRESS OWNER ADDRESS DATE OF INSPECTION POOL CAPACITY # OF GALS 3-300o INSPECTED BY METHOD OF WATERS TREATMENTS BATHER LOADwv� # 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. RI GULATION 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: 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 until repairs can be made. v. I C. a\v\ 5` Z_-�. �eA-vv h5 .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 1N No ❑ If lifeguards required. Prope(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 POOLSIDE READINGS Bromine 2.0-6.0 ppnV Alkalinity50-150 m` Cyanuric Acid (30-100 ppm; Water Temp. 104°F. * arts er 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 tq k \v, c o cs� • >\� �t,�.\� �c��ea Yhcx c-. vac-�S %A - Total Chlorine Free Chlorine Comb. level Other (0.0-0.2 ppm) (7.2-7.8)