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Home My WebLink AboutWillow Crossing 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 PERMIT EXPIRES: Person Certified: PAUL J. MILLER Pool/SPA Certification Date: May 15, 2015 Pool/SPA Certification Expires: May 15, 2020 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 17 December 31, 2017 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: B -X MANSFIELD, LLC dbaTHE VILLAGE AT WILLOW CROSSINGS for the operation of a Public [ Semi -Public L41 Special Purpose Pool located at: 25 COBB STREET Method of water treatment is BROMINE Bathing load not to exceed: 22 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 — s Date Issued '6L �e ddSNauoydauotin3die aa$bl6'ob9 OCKLAND' v 1:011304L,?81: t 0 I'll 0 6 12 REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE OICA C OLLcy . w� .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNEDSIGNED Operator Board of Health/Health Department TMs 3 $` BFT p.x e `4 L, 3 Town.of-ManSfield Town of Mansfield - Board of HeaA ,n � � 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 17 FEE: $125 NAME OF OWNER: B -X MANSFIELD, LLC dbaTHE VILLAGE AT WILLOW CROSSINGS ADDRESS: 25 COBB STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-1333 FAX: (508) 237-4663 at e c,iI EMAIL:.MSOHOL@BENCHMARKQUALITY.COM FED ID/SS NO: 27-4452440 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAUL J. MILLER Pool/SPA Certification Date: 5/15/2015 Pool/SPA Certification Expires: 5/15/2020 PERSON CERTIFIED: Pool/SPA Certification Date: �.vvit�,n.. �h`f, r�tsE"rr'iifl%,"ai1C)i) C:tF7ir65: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: ❑ Public POOL OPERATION: ❑ Semi -Public W Special Purpose Pool POOL LOCATION: 25 COBB STREET TYPE/POOL: GUNITE CONCRETE LENGTH: 32' VOLUME: 12,544 MINIMAX DEPTH: 3'6" to 3'9" SWIM AREA: 448 sf WATER SOURCE: TOWN WIDTH: 14' DIVE AREA: NONE W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: BLUE MARBLEITE SCUM GUTTER: NONE DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8.5" TREATMENT SYSTEM: HAYWARD C-50OLF BROMINATOR DISINFECT METHOD: BROMINE CHEMICAL TREATMENT: BROMINE NUMBER OF BATHERS: 22 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) ':;9"7- '//V5A Z/ V0 ** 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 a 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 Ledbly Business/Organization Name: a -x M t� Com' cilkl i :z&yAla° ,4 (fosslvz5'1 Address: A'S Phone #: S�8"- 2b1-1333 Are ou an employer? Check the appropriate box: Business Type (required): II am a employer with6 employees (full and/ 5. ❑ Retail or part-time).* 6. nRestaurant/Bar/Eating Establishment 2:0 1 am a sole proprietor or partnership and have no 7, Office and/or Sales (incl. real estate, auto, et( employees working for me in any capacity. [No workers' comp, insurance required] 8• Non-profit 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,E] Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, t with no employees. [No workers' comp, insurance req.] 12 *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 prove ng workers' compensation insurancefor my employees, Below is the policy information. Insurance Company Name:_W' j��.(,tVolnCe' C.�tYJ��7 Insurer's Address: 3111—/% Qf'I �'/jMeQ. ; City/State/Zip: S+. �ssto ) Policy # or Self -ins. Lic. # • W G f! `?'t e / 163 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 ihis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiify(�(/,ynder theepp/Jain�s an. penalties of perjury that the information provided above is true and correct. CicrostnrP' V'T��"/u � Date: Phone #: S08"•2i-1333 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 #: BENCASS-02 BURRAI �✓ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 4/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS -^ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES :LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ,<EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Willis of Illinois, Inc.PHONE c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 NCONTACT AME:Willis Towers Watson Certificate Center NAME: A!c No Ext (g77) 945-7378 ac No): (888) 467-2378 EMAIL certificates@willis.com ADDRESS: INSURERS) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY CLAIMS OCCUR INSURERA:Arch Insurance Company 11150 INSURED INSURER B: Lloyd's B7874 INSURER C: Benchmark Senior Living LLC 201 Jones Road Suite 300 West Waltham, MA 02451 INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 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 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 SHnVVN MAY HAVE RFFN RFni icGn PV oAin ci Ainec INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER MM/DDY MM/DD//YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED -MADE PREMISES Ea occu rence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY PRO LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ OTHER: A AUTOMOBILE LIABILITYEa ANYAUTO X 41CAB4987703 04/01/2016 04/01/2017 LIMIT $ 1,000,00 accident) X BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS Coll Ded $1,000 X Comp Ded $1,000 PROPERTY DAMAGE Per accident $ X $ B X UMBRELLA LIAB EXCESS LIAB Fx OCCUR CLAIMS -MADE SB-LTCAX-01356-16 04/01/2016 04/01/2017 EACH OCCURRENCE $ 20,000,001 AGGREGATE $ 20,000,001 DED RETENTION $ $ A WORKERS COMPENSATION_ AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N❑ N/A 41 WCI4987903 04/01/2016 04/01/26,47 X STATUTE EERH E.L. EACH ACCIDENT $ 1,000,001 E.L. DISEASE - EA EMPLOYEE $ 1,000 001 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT 1 $ 1,000,001 DESCRIPTION OF OPERATIONS below A Business Auto 41CAB4987803 04/01/2016 04/01/2017 Any Auto/CSL 1,000,001 ---•— •.— — —• _�� • I-- • I—, , -- o tt umu ,u,, Auumona, KemarKs bcneowe, may be attached if more space is required) Certificate Holder is included as an Additional Named Insured. Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE B -X Mansfield LLC d/b/a The Village at Willow Crossings 25 Cobb Street Mansfield, MA 02048 CuKSU C� Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Pal 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 TYPR OF POOT,- PTTRLTC ❑ SF.MT-PTTRLTC ❑ SPF.CTAT, PTTRPOW POOT. ❑ NAME OF POOL ADDRESS OWNER ADDRESS DATE OF f POOL CAPACITY INSPECTED BY INSPECTION # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD.vit I (_�,,--% 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.; n REGULATION IX/✓ VIOLATIONS/COMMENTS 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. .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 POOLSIDE READINGS Bromine Cyanuric Acid Water ( *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 M Total Chlorine Free Chlorine Comb. Chlorine pH level Other