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Home My WebLink AboutWest Village Apts 12/31/2014Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Ope��ate a Swimming Pool PERMIT NUMBER: 16 Pool/SPA Certification Date: December 09, 2011 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: December 08, 2016 Person Certified: HANSEL RIVERA Pool/SPA Certification Date: Pool/Spa Certification Expires: Person Certified: 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: BEHRINGER HARVARD WEST VILLAGE PROJECT OWNER, LLC for the operation of a ❑ Public at. Method of water treatment is Bathing load not to exceed: Ov Semi -Public 792 WEST STREET ❑ Special Purpose Pool CHLORINE/CHLORINATOR RAINBOW 300 93 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health .Agent None Date Issued Swimming Pool Application PERMIT NUMBER 16 FEE: $125 ❑ Public NAME OF OWNER: BEHRINGER HARVARD WEST VILLAGE POOL OPERATION: Semi -Public PROJECT OWNER, LLC ❑ Special Purpose Pool ADDRESS: 792 WEST S T REE I CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: LAURA.PREBLE@BHRES.COM WWW.LIVEWESTVIL FED ID/SS NO: 45-1501972 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MICHAEL MASON Pool/SPA Certification Date: 5/13/2011 Pool/SPA Certification Expires: `/ 5/13/2016 PERSON CERTIFIED: t10,V..5VFii, j Pool/SPA Certification Date: Pool/SPA Certification Expires: � ��6 _' ^_.""'� certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. POOL LOCATION: 792 WEST STREET TYPE/POOL: GUNITE SEMI-PUBLIC LENGTH: 56' VOLUME: 42,000 GALLONS MIN/MAX DEPTH: 4 ft. SWIM AREA: 1,400 sq. ft. WATER SOURCE: TOWN WIDTH: 25' DIVE AREA: N/A W/W DISPOSAL: I -OWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: ASTRAL SAND FILTER DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 93 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. Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health [Permit to Operatea Swimming Pool PERMIT NUMBER: 18 Pool/SPA Certification Date: December 09, 2011 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: December 08, 2016 Person Certified: HANSEL RIVERA Pool/SPA Certification Date: Pool/Spa Certification Expires: Person Certified: 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: BEHRINGER HARVARD WEST VILLAGE PROJECT OWNER, LLC for the operation of a ❑ Public ❑ Semi -Public 0 Special Purpose Pool at. 792 WEST STREET Method of water treatment is CHLORINATORISAND FILTER Bathing load not to exceed: 8-10 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 18 FEE: $125 NAME OF OWNER: BEHRINGER HARVARD WEST VILLAGE PROJECT OWNER, LLC ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: LAURA.PREBLE@BHRES.COM WWW.LIVEWESTVIL FED ID/SS NO: 45-1501972 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MICHAEL MASON Pool/SPA Certification Date: 3/13/2011 Pool/SPA Certification Expires: p 3/13/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS:" NO LIFEGUARD ON DUTY" sign is required. No lifeguard on duty. Sign is required. SIGNATURE: ❑ Public POOL OPERATION: ❑ Semi -Public Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL: SPA/HOT TUB LENGTH: N/A WIDTH: N/A VOLUME: 1500 GAL. MINIMAX DEPTH: 3.5 FT. SWIM AREA: NIA DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINATOR/SAND FILTER CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 8-10 4axly)ay �. 01930 11-7�v 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. 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. Xignature of Indio dual 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 subiect to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. IIIIIIII�II�I — Ili�l�l'�'II'VuV�ll�!�� hi�llll'�'lill'I'dyllllb� = I ��I�'Ill�llll�li!�I�uu�� I IIIPIIIII'IIII'I�I�IIIPI(j _— IIIIIII�III',dludul'I� --_ �II��IIiI,II�IIIIIIU,I, _ —_ �I�I�I�II�IIIIIIIIIII - _ - �II�I�ll�ll�llil�l��l�l SII - �I I I,I,,;uI�IIIIIIIV�', I �Iddl;ll,l�l�lllll,l mmo �." / lu i Llui The Commonwealth of Massachusetts ID Department of Industrial Accidents jJj Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information pp tt-'' / Please Print Legibly Business/Organization Name:(j('��r);I'% 1lcyt�C% U+Jf`>j U%ll�� . 1=CC Address: I � Nt"j. 6Y City/State/Zip: clove Ar y, n ara employer? Check the appropriate box: 1. u 1 am a employer with 15 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.] *Any applicant that checks box tl I 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 requited and such an organization should check box tt 1. I an an employer that is providing workers' compensation insurance for my employees. Below is the policy information. 0 Phone #: OOF ° o� 40 ' 05-22 Business Type (required): 5. ❑ Retaii 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing I I.❑ Health Care 12.❑ Other Insurance Company a7 ``,� i )) Y Insurer's Address: J75- (1J C'-Pr 1 — City/State/Zip: Policy # or Self -ins. Lic. 9 WG0®,'29C9 1 L _3'7 Expiration Date: -31/1� 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 S i OP 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 ifisurance coverage verification. I do hereby Phone #: tit ffdpains and penalties of perjury that the information provided abov i�true and correct. Date: 3/7/4 )0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 11 Contact Person: Phone #: www.mass.gov/dia NOTICE iffy EMPLOYEES NOTICE The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided f or payment to our injured employees under the above-mentioned chapter by insuring with: New Hampshire Insurance Company % AIG NAME OF INSURANCE COMPANY 175 Water Street, 18th Floor New York, NY 10038 ADDRESS OF INSURANCE COMPANY WC002921139 3/1/2014 to 3/1/2015 POLICY NUMBER EFFECTIVE DATES Marsh USA Inc. Comerica Bank Tower, 1717 Main St. Dallas, TX 75201 214 303 8450 NAME OF INSURANCE AGENT ADDRESS PHONE # Behringer Harvard Holdings, LLC 15601 Dallas Parkway, Ste. 600 EMPLOYER ADDRESS Addison, TX 75001 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 furnish 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 w�d g NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT mc�nn nn r.��r . r�rror rn n QQAAT_DTMT Tt' RPRCTAI. P1TRP()C1R. P()nl. NAME OF POOLADDRESS k,. 4 OWNER "� V l.� ADDRESS DATE OFPOOL INSPECTION~ CAPACITY # OF GALS INSPECTED BY METHOD OF WATER TREATMENT C*LLOAD BATHER #GUARDS I 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. REGULATION X/✓ 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 & i tfation systems. Filter Effluent flow meter reading: gpm. # of turnovers i .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 .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 bullhom 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 m* otal Chlorine chlorine and bromine. Unbreakable thermometer for Alkalin 50-150 m Free Chlorine 1.0-3.0 m Cyanuric Acid (30 -100 ppm) .31 Water clarity Comb. (0.0-02 ppm) Chlorine Water Temp. 304°F. pH level (7.2-7.8) continuously. * arts per million Other .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 REGULATION I NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 34 I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. a SIGNED SIGNED Operator Board of Health/Health Department NLA" NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT „rmr rr. r-1 r LIU RAT nTTOT Tr r'7 QPRf'TAT PTTRP00,12 Pn()T_ NAME OF POOL ADDRESS f �/ OWNER ADDRESS DATE OFPOOL 1 CAPACITY f , t INSPECTED BY ! a INSPECTION # OF GALS METHOD OF WATER 9 11BATHER LOAD # OF LIFEGUARDS I WATER SOURM: TREATMENT 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" v" ' are satisfactory. REGULATION X/✓ 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 �Itration 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 .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 .15 .17 .21 .22 .23 .24 .25 .25 .26 .29 Ladders, steps - one per 75 feet. Not less than 2 ladders. Diving equipment in safe condition. Pool supervision - Pool supervision provided. Effective Jan. 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. Permit requirements - Permit issued. Adequate maintenance and testing records maintained. Records initialed by person making tests. Health regulations: Signs posted. Health warning signs posted for special purpose pools. Lifeguards required: Yes ❑ No If lifeguards required. Proper credentials, proper suits and garments worn. Whistle and bullhorn provided Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. First Aid equipment provided. 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. Waste and backwash water disposal properly discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. Chemical standards POOLSIDE READINGS Bromine 2.0-6.0 m* ;Total Chlorine Alkalinity 50-150 m Free Chlorine 1.0-30 pm Cyanuric Acid (30-100 ppm) Comb. Chlorine (0.0-0.1p m)' Water Temp. 104°F, pH level (7.2-78 * arts per million Other .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 REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE w✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED 4—L SIGNED Operator Board of Health/Health Department