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Home My WebLink AboutHoliday Inn 12/31/2014Commonwealth 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: 14 Pool/SPA Certification Date: April 28, 2011 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: April 28, 2016 Person Certified: MICHAEL P. SCHAMBURG 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: MANSFIELD HOSPITALITY, LLC HOLIDAY INN for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed ❑ Semi -Public 31 HAMPSHIRE STREET CHLORINE 6 to 8 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent ❑ Special Purpose Pool None ¢` Date Issued N. �- - Town of Mansfield - Board of Health v r Swimming Pool Application NAME OF OWNER: MANSFIELD HOSPITALITY, LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: EMAIL: FED ID/SS NO: 26-1196350 Certification Expires Every 5 Years. Permit Expires December 31st Yearly• PERSON CERTIFIED: MICHAEL P. SCHOMBURG Pool/SPA Certification Date: 4/28/2011 Pool/SPA Certification Expires: 4/28/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): PERMIT NUMBER 14 FEE: $125 ❑ Public POOL OPERATION: ❑ Semi -Public ,o Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SPECIAL PURPOSE LENGTH: 7 WIDTH: 7 VOLUME: 863 MIN/MAX DEPTH: 3' SWIM AREA: 154 sq ft DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: BRICK RAISED SKMMR WEIR LENGTH: 141 TREATMENT SYSTEM: 10 Ib. CHLORINE DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: 6 to 8 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. "No Lifeguard on Duty" sign 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. Town of Mansfield Town Of Mansfield - Board Of Health 6 Park Row Mansfield, MA 02048 Swimming POOL Application PERMIT NUMBER 15 FEE: $125 NAME OF OWNER: MANSFIELD HOSPITALITY, LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: EMAIL: FED ID/SS NO: 26-1196350 Certification Expires Evert/ 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MICHAEL P. SCHOMBBURG Pool/SPA Certification Date: 4/28/2011 Pool/SPA Certification Expires: 4/28/2016 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 ❑ Public POOL OPERATION: Semi -Public ❑ Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 62 WIDTH: 23 VOLUME: 42,666 GALLONS MINIMAX DEPTH: 375' SWIM AREA: 1426 sq ft DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: 30 Ib. AUTO FEED CHLORINATOR DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: 83 SIGNATURE:_ _ 5r_ _ DATE: X }' I 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. LL * Signaturd of Individual or Corporate Name (Mandatory) orporate fficer (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. i ** 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 Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leizibly Business/Organization Name: MANSrIELD H°SFUT AQT t Address: -'->I Fi SHlR-' :g City Phone #: ;_6S — `1— City/State/Zip:OQT,LANP O IZ}z05 G Expiration Date; Policy # or Self -ins. Lic. # 3 y I®2aL � P Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure covcrage 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, yp#rjoe pains and penalties of perjury that the information provided above is true and correct. Phone fl: is i' &>I&' 99 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # N 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 Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail 1. ® I am a employer with ��s employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g, Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. Other n�L with no employees. [No workers'.comp, insurance req.] *Any applicant that checks box H 1 must also fill out the section below showing their **If the corporate officers have exempted themselves, but the corporation has other workers' compensation policy information. employees, a workers' compensation policy is required and such an organization should check box i{1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1?6IV% L L — IC�o (if ZNt"i Insurer's Address:pBX T41a%Ek City/State/Zip:OQT,LANP O IZ}z05 G Expiration Date; Policy # or Self -ins. Lic. # 3 y I®2aL � P Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure covcrage 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, yp#rjoe pains and penalties of perjury that the information provided above is true and correct. Phone fl: is i' &>I&' 99 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # N 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 q T ® CERTIFICATE LIABILITY i`-6co INSURANCE DATE (MMIDD/YYYY) 4/23/2013 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 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 Frank Crystal & Co of OR, Inc. CONTACT NAME: — PHON o Ex 971-222-3200 A/c No :971-222-3260 dba Crystal & Company Fox Tower,805 SW Broadway #480 Portland OR 97205 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE_ _ ___ _NAIC # __ INSURERA:National Union Fire Insurance Co of 9445 1/30/2013 INSURED INSURERB:Fireman's Fund Insurance Company 1873_ INSURERC:MEMIC Indemnity Company 1030 Linchris Hotel Corp 269 Hanover Street, Unit #2 INSURER D:Hartford Underwriters Insurance Com 0104 INSURERE:Liberty Mutual Fire Insurance Compa ._.__.. 3035 Hanover MA 02339 INSURER F: IY J Y■ 1=1N -M EME0In 11111:1 �:at LL'Y!L'Y�YYi!iG RGYIJIW IYV IPIVLI�. 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL,SUBR INSR WYD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS B GENERAL LIABILITY I 'OXX80944967 11/30/2012 1/30/2013 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 X COMMERCIAL GENERAL LIABILITY WE EXP (Any one person) $10,000 I j CLAIMS -MADE � OCCUR PERSONAL& ADV INJURY $1,000,000 GENERAL AGGREGATE � $2,000,000 — GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 $ POLICY PRO X LOC JEC I B AUTOMOBILE LIABILITY MXA07183676 11/30/2012 1/30/2013 COMBINED SINGLE LIMIT Ea accident 1 000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED X SCHEDULED IAUTOS AUTOS NON --OWNED x PROPERTY DAMAGE $1,000,000 Per accident HIRED AUTOS IX AUTOS i Comp/Coll Deds $1,000 A X UMBRELLA LIAB X OCCUR BE067339993 /1/2013 11(2014 EACH OCCURRENCE $30,000,000 AGGREGATE $30,000,000 EXCESS LIAB ' CLAIMS -MADE j t DED x RETENTION$10.000 $ I CTORY WORKERS COMPENSATION /1/2013 (112014 X CR STATU- OR LI ITS ER D AND EMPLOYERS' LIABILITY Y / N �10280269 4072 11/2013 /112014 E ANY PROPRIETORIPARTNER/EXECUTIVE❑ N N/ A j C231S390075013 /1/2013 /1/2013 11/2014 /1/2014 E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYE $500,000 E OFFICER/MEMBER EXCLUDED? (Mandatory in BE I WC231S390089013 C231 S390107013 /112013 /1/2014 E.L. DISEASE - POLICY LIMIT $500,000 E If yes, describe tinder DESCRIPTION OF OPERATIONS below B Liquor Liability MXX80944967 11/30/2012 1/30/2013 Each Common Cause $1,000,000 I Aggregate $2,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Evidence of coverage only, as respects Workers Compensation. Named Insured includes Mansfield Hospitality, LLC. Evidence of coverage as respects Holiday Inn Mansfield 31 Hampshire Street, Mansfield, MA 02048. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 0 co T=a U C A u) NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT "Tmy Tn n QVI11" W rEly F11 CPF(`TAT. PTTRP()RF. P(1f)T. n NAME OF POOL r ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION # OF GALS METHOD OF WATER BATHER # OF"LIFEGUARDS WATER SO CE: 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 satisfactory. REGULATION X/✓ VIOLATIONS/COMMENTS .03 Bathhouse and sanitary taciuties adequate iignung; 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 .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 2.0-6.0 m* Chlorine Lree Alkalinity50-150 m, ll, Chlorine 1.0-3.0 m Cyanuric Acid (30-100 ppm) I AComb. Chlorine (0.0-0.2 ppm) Water Temp. 104°F. pH level (7.2-7.8) *parts per million Xer .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 REG NOTION I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE I X/✓ .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 SIGNED Board of Health/Health Department