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Home My WebLink AboutMansfield Children's Center 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: 8 PERMIT EXPIRES: December 31, 2017 Person Certified: KEVIN J. FALLON Pool/SPA Certification Date: April 16, 2014 Pool/SPA Certification Expires: April 16, 2019 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: MANSFIELD CHILDREN'S CENTER for the operation of a F i Public Method of water treatment is Bathing load not to exceed: Semi -Public ] Special Purpose Pool located at: 1100 SCHOOL STREET CHLORINE 43 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 He ith s Park -,,Row Mansfield, MA 02048 s i Swimming Pool ��i�L��at�on � y„� PERMIT NUMBER 8 FEE: $125 NAME OF OWNER: MANSFIELD CHILDREN'S CENTER ADDRESS: 1100 SCHOOL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-9211 FAX: EMAIL: FED ID/SS NO: 042 725 454 Certification Expires Every 5 Years. Permit Expires December 31st Yearlv. PERSON CERTIFIED: KEVIN J. FALLON Pool/SPA Certification Date: 4/16/2014 Poo//SPA Certification Expires: 4/16/2019 PERSON CERTIFIED: Poo1/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY” sign is required. ❑ Public POOL OPERATION:❑ Semi -Public ❑ Special Purpose Pool POOL LOCATION: 1100 SCHOOL STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 41'• WIDTH: 25' VOLUME: 30,000 MIN/MAX DEPTH: T SWIM AREA: 1000sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: PRIVATE TYPE OF FINISH: LINER SCUM GUTTER: DECK TYPE: 5' CEMENT SKMMR WEIR LENGTH: 2 SKIMMERS TREATMENT SYSTEM: DIATOMACIOUS EARTH DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: NUMBER OF BATHERS: 43 SIGNATURE: DATE: l2 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. A� I Z�_ ignatUV6./of Individual or Corpora e Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** 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 1 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 Leaibl,Y� Business/Organization Name: � ()(�/(,I17f / �Q�JJ (�C l �rLLf'�(jq i_5 �Cftkll Address: City/State/Zi Are you you an employer? Check theppropriate box: 1. LTJ i am a employer with employees (full and/ or part-time).* 2:0 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#: e7f- 3Jg _V11 Business Type (required): 5. ❑ Retail 6. F]Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8, Q'Non-profit 9. ❑ Entertainment 10, ❑ Manufacturing 11.❑ Health Care 12. ❑ 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 Inas other employees, a workers' compensation policy is required and such an organization should check box #1. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. # - Expiration Date: 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 certifylyKder thelpraiA-�d pina4itpeijury 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 A UTICA NATIONAL INSURANCE GROUP 180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page 1. The Insured and Mailing Address: MANSFIELD CHILDREN'S CENTER, INC. 1100 SCHOOL STREET MANSFIELD MA 02048 Entity of Insured: Corporation Other workplaces not shown above: Policy Number: 2066058 Prior Policy Number: Producer: Wm. F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 Producer Number: 77377 SIC#: 83517 WC 000001A Insured's I.D. Number: 042725454 NCCI Company Number: 15717 Risk I.D. Number: MA:000165573 2. The policy period is from 10/07/2016 to 10107/2017,, 12:01 AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states 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 $100,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $100,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, WY D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ❑ See Extension of Information Page Classifications Code No.Remuneration Premium Basis Total est. Annual Rate Per $100 of Remuneration Estimated Annual Premium Minimum Premium: $ 207 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 12,597 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 12,597 Issuing Office: New Hartford, NY 13413 8 -D -WC Ed. 08-2008 BILLING NO. 100362146 Date of Issue: 09-06-2016 Countersigned by Copyright 1988 National Council of Compensation Insurance NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Utica Mutual Insurance Company NAME OF INSURANCE COMPANY 201 Edgewater Place, Suite 295 Wakefield, MA 01880 ADDRESS OF INSURANCE COMPANY 2066058 10-07-2016 10-07-2017 POLICY NUMBER EFFECTIVE DATES Wm. F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 781-293-6331 NAME OF INSURANCE AGENT ADDRESS PHONE # MANSFIELD CHILDREN'S CEN 1100 SCHOOL STREET MANSFIELD MA 02048 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to ftimish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER WC 7506h (8-10) Wolters Kluwer Financial Services I Uniform Forms TM Rev. 6/09 Form ST -5 Massachusetts Sales Tax Exempt Department of Purchaser Certificate Revenue Part 1. Exempt taxpayer information. To be completed by exempt government or 501(c)(3) organization. Name H. Read Inc. /dba/ NIansf"ield Children's Center Address 1100 School St. City State Zi Mansfield MA 01048 Exemption number 042-725-454 Issue date Date of expiration of certificate 7/29/16 7/28/26 Certification is hereby made that the organization named above is an exempt purchaser under Massachusetts General Laws, Chapter 64H, sections 6(d) or 6(e). All purchases of tangible personal property or services by this organization are exempt from taxation under said chapter to the extent that such property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation. Signature �jTitle Date WarDtng: Willful misuse of -this certificate may result in criminal tax evasion sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. Part 2. Agent information. To be completed by agent of exempt government or 501(c)(3) organization. Name of agent's organization Address City State Zip Agent's name Address City State Zip I certify that in making this purchase, I am acting as an agent for the exempt organization named above (select one): ❑ Government organization (local public school, city/town government, state agency, etc.), Attach Form ST -2, if available. if Form ST -2 is not available, enter exemption number, if known: ❑ 501(c)(3) organization (parochial school, Scout troop, etc.). Form ST -2 must be attached. Signature Title Date Part 3. Vendor information Vendor's name Check applicable box: ❑ Single purchase certificate (attach detailed receipts or complete Part 4, on reverse) ❑ Blanket certificate This form is approved by the Commissioner of Revenue and may be reproduced. ------------------------------------------------------------------------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE r Certificate of Exemption H READ INC 1100 SCHOOL ST MANSFIELD MA 02048-2036 NIA Taxpayer ID: 11720038 Certificate Number: 2039861248 -------------------------- Form ST -2 This certifies that the organization named above is an exempt purchaser under Chapter 64H, section 6(d) or (e) of the Massachusetts General Laws. All purchases of tangible personal property by this organization are exempt from taxation to the extent that such property is used in the conduct of the business of the purchaser. Misuse of this certificate by any tax-exempt organization or unauthorized use of this certificate by any individual will lead to revocation. Willful misuse of this certificate is subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. This certificate is non- transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: July 29, 2016 Expiration Date: July 28, 2026 Kevin J. Fallon - Certification Number: CPO -188453 1132 School Street Mansfield, MA 02048 Hello, Kevin Congratulations on achieving your Certified Pool / Spa Operator® (CPO®) certification. We are proud you have earned a CPO® certification, the most widely accepted training program in the world! Please continue to use the NSPF® Pool & Spa OperatorTM Handbook to expand your knowledge, and to maintain high standards to keep the pools you care for open and safer. NSPF is here to help! While your instructor should be a constant source to answer questions and provide resources in your community, NSPF also provides several resources to help you become more effective. a You will receive the periodic Prevention AdvisorTM eNewsletter that provides information on prevention topics, emerging issues in the industry, and the health benefits of aquatic activity. If you did not include your email address on the CPO Certification exam, please sign up at www.nsof.or- under the Resources tab. Q The Resources section of the NSPF website has lots of information to -help you stay ahead: • State and County Codes • RWI Prevention Toolkit • Compliance with the VGB--Pool & Spa Safety Act • Compliance with the Americans with Disabilities Act %. • Model Aquatic Health Code Updates • Articles & Research Links Pool operators can be more -efficient by downloading the Pool Service Manager Ap foruPhones ;4 and Androids. Just go to the Google Play Store or iTunes and search for National wimming pool,_ Foundation. Download and -use at no, charge for the-firsf-month. { Please inform us if you change your contact information by sending anjemail to se�yic�e(ns ,f.org. Thanks for all you do to keep pool environments safe. nom y (7CPQ} CertfiM. Lachocki, Ph.D. -�� f Name:rKeA .! F a� Chief Executive Officer pfeer#�e� . K REGULATION I NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE w� .34I I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED Operator SIGN of Health/Health Department Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 S`0+4 Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL- PURLTC ❑ SF,MT-PUBLIC ht SPECIAL PURPOSE POOL ❑ NAME OF POOL cvnN\c) r� ADDRESS \\0(3 OWNER v'�v1� ADDRESS DATE OF INSPECTION c U POOL CAPACITY # OF GALS gg �""`- V00 INBY CX"KI METHOD OF WATER TREATMENT , ,.ca*roY1 cvw; I`� BATHER LOAD , ` # OF LIFEGUARDS W�TER SOURCE: N kj r\ 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:Aj'N)_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. � ycx�\ S_e�C_ be- .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 pur o pools. .23 Lifeguards required: Yes No E]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,Q=6 6-0-6-M"J'. Cyanuric Acid Water *parts per 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 Ick M \00 `'Z. 0" \ mac 5 Y\ �� G��u C12L, �� °�",Ckjc�