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HomeMy WebLinkAboutRed Roof Inn 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: 10 PERMIT EXPIRES: December 31, 2017 Person Certified: HILARY EASTER Pool/SPA Certification Date: May 20, 2016 Pool/SPA Certification Expires: May 20, 2021 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: BW RRI LLC for the operation of a L Public n Semi -Public [_) Special Purpose Pool located at: 60 FORBES BLVD. Method of water treatment is AUTOMATIC CHLORINE Bathing load not to exceed: 55 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 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 10 FEE: $125 ❑ Public NAME OF OWNER: BW RRI LLC POOL OPERATION: Semi -Public ❑ Special Purpose Pool ADDRESS: THE RED ROOF BUILDING 605 S. FRONT ST. POOL LOCATION: 60 FORBES BLVD. CITY: COLUMBUS STATE: OH ZIP: 43215 TELEPHONE: (614) 744-2600 FAX: (614) 225-5214 EMAIL: KMORGAN@REDROOF.COM FED ID/SS NO. 47-3368497 Certification Expires Every 5 Years. Permit Expires December 31st Yeariv. PERSON CERTIFIED: HILARY EASTER Pool/SPA Certification Date: ffb6l 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. TYPE/POOL: CONCRETE IN -GROUND LENGTH: 40' WIDTH: 20' VOLUME: 22,000 MIN/MAX DEPTH: 3' to 8' SWIM AREA: 800 sq. ft. DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: GUNITE SCUM GUTTER: NONE DECK TYPE: NONE SKMMR WEIR LENGTH: TWO BASKETS TREATMENT SYSTEM: DIATOMACEOUS DISINFECT METHOD: AUTOMATIC CHLORINE CHEMICAL TREATMENT: MANUALLY AS REQUIRED NUMBER OF BATHERS: 55 SIGNATURE: _ _ _ DATE: Please make appropriate cha es. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. I 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 dividual or Corporate 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. aN 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 �yPlease Print Legibly Business/OrganizationName: c l `�­­o Address: oc) (,� S �� V ' City/State/Zip: Ma O S -e� 6 m A 0Z4&Phone #: 668 " 1-1- �Q 3 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 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. EQ Retail 6. FlRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing I 1. ❑ 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 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' co rmppe1nssaat—ion ins fu'rance for my employees. Below is the policy information. Insurance Company Name: "'ei" A � � )_i Insurer's Address: n 5 lIt° K I q i\\A City/State/Zip:. Policy # or Self -ins. Lic. # L� `► 1 I "" V �ll� 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 certifyr..pnder the pains 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 # 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 #: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYLibgjyMutual. INSURANCE INFORMATION PAGE 175 Berkeley street Boston, MA 02116 Issued by The First Liberty Insurance Corporation (a stock company) 27359 Policy Number WC6-641-437760-016 Issuing Office Lewiston, ME Renewal Of WC6-641-437760-015 Issue Date 09/26/2016 Account Number 4-437760 Sub Account 0000 1. Insured and Mailing Address FEIN Red Roof Inns, Inc. NJ TIN The Red Roof Building, 605 South Front St Risk ID COLUMBUS OH 43215 MI Risk ID Status Corporation Other workplaces not shown above: See Item 4. Premium - Extension of Information Page 2, Policy Period: The policy period is from 09/06/2016 to 09/06/2017 12:01 A.M. standard time at the Insureds mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AZ CA CT DE FL GA IL IN KY LA MD MA MI MN MS MO NV NH NJ NY NC PA SC TN TX UT VA WV WI 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 $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 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 and the States of. ND OH WA WY D. This policy includes these endorsements and schedules: See Item 3. Coverage D - Extension of Information Page 4. Premium: The premium for this policy will bedetermined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per $100 Estimated Annual Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page . Minimum Premium $1,962 (DE) Total Estimated Annual Premium $ Premium will be billed Annual Deposit Premium $ Deposit Tax/Surcharge/Assessment $ Producer 0002 006162 Countersigned by Authorized Rep. (AZ) WILLIS OF OREGON, INC -PORTLAND 222 SW COLUMBIA ST STE 600 (, PORTLAND OR 972016645 Producer BOATRIGHT 8726 Portland, OR -LN RECEIVE® SEPI 8 2016 Willis Of Oregon WC 00 00 01 A ©1987 National Council on Compensation Insurance, Inc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Bank # Pkt#t TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: BOARD OF HEALTH Date: 4/5/2017 Schedule: JD4517 From Whom Account Number Amount THE RED ROOF BUILDING 01512-445006 $ 125.00 r --- -_. -- __---- - — – Cash $ 125.00 Checks $ Total $ 125.00 Online or Wire Receipt $ TOTAL: $ 125.00 Mansfield, MA 4/5/2017 To The Officer Making the Payments: The above is a detailed list of moneys collected by me, amounting in the aggregate to:------ __ _ $1z5.00 for the period ending 4/5/2017 which I have paid to the Town Treasurer whose receipt I hold therefor. Employee or Dept Head Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 10 FEE: $125 NAME OF OWNER: BW RRI LLC ADDRESS: THE RED ROOF BUILDING 605 S. FRONT ST CITY: COLUMBUS STATE: OH ZIP: 43215 TELEPHONE: (614) 744-2600 FAX: (614) 225-5214 EMAIL: KMORGAN@REDROOF.COM FED ID/SS NO: 47-3368497 li"A&,} - z o Q -t U Le r -e d rbv(: t cry Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: HILARY EASTER Pool/SPA Certification Date: ff 6l f ra Pool/SPA Certification Expires: �e�a PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: 'NO LIFEGUARD ON DUTY'sign is required. ❑ Public POOL OPERATION: Semi -Public ❑ Special Purpose Pool POOL LOCATION: 60 FORBES BLVD. TYPE/POOL: CONCRETE IN -GROUND LENGTH: 40' WIDTH: 20' VOLUME: 22,000 MIN/MAX DEPTH: 3' to 8' SWIM AREA: 800 sq. ft. DIVE AREA: NONE WATER SOURCE: TOWN WNW DISPOSAL: TOWN SEWER TYPE OF FINISH: GUNITE SCUM GUTTER: NONE DECK TYPE: NONE SKMMR WEIR LENGTH: TWO BASKETS TREATMENT SYSTEM: DIATOMACEOUS DISINFECT METHOD: AUTOMATIC CHLORINE CHEMICAL TREATMENT: MANUALLY AS REQUIRED NUMBER OF BATHERS: 55 WleSIGNATURE: DATE: _ Please make approprias. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Ce - \ C 0 X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED i SIGNED leraiKr Boar of ealth/Heal Department v Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 g 508-261-7366 Av. °'�A4 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 TV -PF nP vnnT • PT TRT TC' r1 CRTAT_PTTAT TC' 14 CPF( TAT. PT TRPnCF. PnnT. rl NAME OF POOL ADDRESS_ OWNER ADDRESS DATE OF �y POOL CAPACITY INSPECTED BY INSPECTION (n r1E # OF GALS ��� METHOD OF WATER BATHER # OF LIFEGUARDS W TER SOURCE: TREATMENT `"� LOAD "\ 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 atisfactory. 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 flowr.- 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 r(16-64_661 W 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 V,- Y Total Chlorine Free Chlorine Comb. Chlorine pH level Other