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Home My WebLink AboutMilhaus 12/31/2014Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Fier to Operate a Swimmin=Pool PERMIT NUMBER: 9 Pool/SPA Certification Date: February 26, 2009 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: February 26, 2014 Person Certified: JOHN M. BURKETT 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: MILHAUS @ MANSCONDO TRUST - DAVID DOUCETTE for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed W Semi -Public 150 RUMFORD AVENUE ❑ Special Purpose Pool AUTOMATIC CHLORINATOR MARC MAC, 22 PSI 70 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent None Date Issued { _ Town of Mansfield - Board of Health �a r Swimming Pool Application NAME OF OWNER: MILHAUS @ MANSCONDO TRUST ADDRESS: 20 CABOT BLVD. CITY: MANSIFELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-3078 FAX: EMAIL: FED ID/SS NO: 04-6551192 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: JOHN M. BURKETT Pool/SPA Certification Date: 2/26/2009 Pool/SPA Certification Expires: 2/26/2014 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. V Town 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 9 FEE: $125 ❑ Public POOL OPERATION: Semi -Public ❑ Special Purpose Pool POOL LOCATION: 150 RUMFORD AVENUE TYPE/POOL: GUNITE LENGTH: 60' WIDTH: 30' VOLUME: 66,000 MIN/MAX DEPTH: 4', T, 10', 14' SWIM AREA: 18,000sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CONCRETE SCUM GUTTER: YES DECK TYPE: CONCRETEI6' SKMMR WEIR LENGTH: 4, 8' APART TREATMENT SYSTEM: HAYWOOD 3000 DISINFECT METHOD: AUTOMATIC CHLORINATOR MARC MAC, 22 PSI CHEMICAL TREATMENT: SODIUM HYPOCHLORITE NUMBER OF BATHERS: 70 (508) 339-7531 TRUSTEE NUMBER SAMANTHA CONTACT PERSON c S NATURE: _ DATE: Please m priate 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. gna re of Individual or orporate 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 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Av licant Information Please Print Lezibly Business/Organization Name: Address: J,!!0"mn City/State/Zip:1)jaZk.H i t IOC 006y.Ll Phone #: 67) 60 3.3 iL3a 7S Are you an employer? Check the appropriate box: 1, Y I am a employer with / 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.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing IL ❑ Health Care 12.V1 Other J Mr dJ6j6 C k ensation olicy intormation. *Any applicant that checks box tl l must also till out the section oeiow snuwuig LIM r wor Us comp p **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 i11. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: It City/State/Zip: � '« Policy # or Self -ins. Lic. #, ero / .i ff I j Expiration Date: ! i 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 Investigati o the DIA for insurance coverage verification. I do under the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write it, 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 Contact Person: Permit/License # 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office www,mass.gov/dia Phone ACC? CERTIFICATE OF LIABILITY INSURANCE DAT> `I ,D 1/6/ 1/6/14 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 Win ADDITIONAL INSURED, the policy(les) 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 110 the certificate holder in lieu of such endorsemenf s). PRODUCER Hardy Insurance Agency, Inc 31 Tosca Drive, Suite 2 Stoughton, MA 02072 INSURED Millhaus at Mansfield Condo Trust 150 Rumford Ave Mansfield, MA 02048 CONTACT NAME: Sand PHONE 781 341-8300 AIX No: (781) 341-8302 a -SE. sandy@hardyinsurance.net INSURE S AFFORDING COVERAGE NAIC# INSURERA:Liberty Mutual INSURER B: INSURERC: INSURER D: INSURER E: 1 INSURER F: UUVtKAUI=Q OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES 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. _-I -- - ---- --- POLICY EFF POLICY EXP ILTR TYPEOFINSURANCE INSR ADDLSUBR POLICY NUMBER MMIDD/Y MMIDD/YYYY UMTS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GENERALLIABIUTY ACCORDANCE WITH THE POLICY PROVISIONS, 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 EACHOCCURRENCE $ DAMAGE TO RENTED $ PREMISES (Ea g=rrLn Sandy Trat.1 ewey . wnnnn �� DATIAIJ All .in hoc a vnrl COMMERCIAL GENERAL LIABILITY MED EXP (Ary one person) $ CLAIMS -MADE FIOCCUR PERSONAL& ADV INJURY $ GENERAL AGGREGATE $ PRODUCT S-COMP/OPAGG $ GEN'LAGGREGATE LNITAPPLIES PER $ C E IRIT POLICY PRO- JECTLOC AUTOMOBILE LIABILITY a acccidert $ BODILY INJURY (Per person) $ ANY AUTO ALLOWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE or accident $ HIRED AUTOS _ AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ IXCESSLIAB CLAIMS -MADE $ DED RETENTION $ WORKERS COMPENSATION WC2-31S-600449-013 12/20/13 12/20/14 WCSTATU- OTH- A AND EMPLOYERS' LIABILITY YIN E.L.EACHACCIDENT $ LOO OOD ANY PROPRIETORIPARTNERIEXECUTNE ] NIA OFFICE RMIEMBEREXCLUDED7 E.L. DIS EASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) E.L. DISEASE-POLICYLIMfi $ 5500 000 Ii yyes descnbeunder DESCRIPTION OF OPERATIONS below DESCRIPTION OFOPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space is required) GEK 111-IGA 1 t MULUtK --- — 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 AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Sandy Trat.1 ewey . wnnnn �� DATIAIJ All .in hoc a vnrl ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: N-t"�6 �-p NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 'rvn-Q n� nnnT . DTTPT Tr n gF.MT-PTTRT.TC SPECIAL PURPOSE POOL ❑ NAME OF POOL a §' ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION # OF GALS METHOD OF WATER BATHER # OF EGUARDS WATER SOURCE: TREATMENT LOAD` Regulation 105 CMR 35.000 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 Tacimies adequate ugnung; ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching wl 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 2.06,0 m* Total Chlorine Alkalinity 50-150 m Free Chlorine 1.0-3.0 m Cyanuric Acid (30-100 ppm} Comb. Chlorine (0.0-0.2 ppm) Water Temp. 104°F. pH level (7.2-7.8) * parts 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 X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. r 1f SIGNED ( r ✓ y ;` Y f SIGNED -- 0 erator Board of Health/Health Department