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Home My WebLink AboutCanoe River CG 12/31/2013Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Armito Operate a Swimming Pool PERMIT NUMBER: 1 Pool/SPA Certification Date: November 12, 2008 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: November 12, 2013 Person Certified: MARK A. BURMEISTER Pool/SPA Certification Date: November 12, 2008 Pool/Spa Certification Expires: November 12, 2013 Person Certified: PHILIP J. CARROLL 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: CANOE RIVER CAMPGROUND for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: W Semi -Public 137 MILL STREET CHLORINE 94 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaaii .Agent ❑ Special Purpose Pool None 9tDatefissu: 2012 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 1 NAME OF OWNER: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-6462 FAX: (508) 339-5237 EMAIL: FED ID/SS NO: 04-2375571 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARK A. BURMEISTER Pool/SPA Certification Date: 11/12/2008 Pool/SPA Certification Expires: 11/12/2013 PERSON CERTIFIED: PHILIP J. CARROLL Pool/SPA Certification Date: 11/12/2008 ❑ Public POOL OPERATION: W Semi -Public ❑ Special Purpose Pool POOL LOCATION: 137 MILL STREET TYPE/POOL: CEMENT LENGTH: 57' WIDTH: 30' VOLUME: 60,000 MINIMAX DEPTH: 3'-10' SWIM AREA: 57'x30' WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CEMENT SCUM GUTTER: DECK TYPE: CEMENT SKMMR WEIR LENGTH: 4 TREATMENT SYSTEM: SAND DISINFECT METHOD: CHLORINE Pool/SPA Certification Expires: 11/12/2013 CHEMICAL TREATMENT: AUTOMATIC certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. NUMBER OF BATHERS: 94 DIVE AREA: NONE 7 - SIGNATURELL A _ f a 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 Operate a Swimming Pool PERMIT NUMBER: 2 Pool/SPA Certification Date: November 12, 2008 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: November 12, 2013 Person Certified: MARK A. BURMEISTER Pool/SPA Certification Date: November 12, 2008 Pool/Spa Certification Expires: November 12, 2013 Person Certified: PHILIP J. CARROLL 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: CANOE RIVER CAMPGROUND for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: ❑ Semi -Public 137 MILL STREET CHLORINE 94 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health Agent 0 Special Purpose Pool None A ddi Date Issued a Town of Mansfield -Board of Health Swimming Pool Application NAME OF OWNER: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-6462 FAX: (508) 339-5237 EMAIL: FED ID/SS NO: 04-2375571 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARK A. BURMEISTER Pool/SPA Certification Date: 11/12/2008 Pool/SPA Certification Expires: 11/12/2013 PERSON CERTIFIED: PHILIP J. CARROLL Pool/SPA Certification Date: 11/12/2008 Pool/SPA Certification Expires: 11/12/2013 certification remarks(if necessary): REMARKS: .NO LIFEGUARD ON DUTY" sign is required. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 2 E] Public POOL OPERATION: L] Semi -Public F./I Special Purpose Pool POOL LOCATION: 137 MILL STREET TYPE/POOL: CEMENT LENGTH: 40' WIDTH: 22' VOLUME: 12,000 MIN/MAX DEPTH: 3' SWIM AREA: 40'x22' WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CEMENT SCUM GUTTER: NONE DECK TYPE: CEMENT SKMMR WEIR LENGTH: 2 TREATMENT SYSTEM: SAND DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: AUTOMATIC NUMBER OF BATHERS: 94 SIGNATURE:r�' �... _ ✓„ �_= i� DATE: If J DIVE AREA: NONE 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. : I. I".0 /-v C:. ; r--AJI.` C.'Alve; k�__ f(I V&Y� C-.A/u1.06L..(t 0c—Li ° * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 01/ 1 ._ 3 -? ._ � � -7 t ** 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. EMI �i H v A O u � a 00 4-4 00 w 00 ,� N A N \ ® O � O � v N v1 � O U w ® O cno p y 0 00 w �� I�b'N ADO 0-4. N A Poiov � N 0 O a� O c4 0 U The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1W www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: S' /L C®t / •'j o -J C,41ve' � ,/Q 1 �� C'4/�t�G�"�C7�,d.-v � Address Al t 10. L S;. -r-, City/State/Zip: M,W c, r-1 E t®. �>, A14 : &AG°,Phone #: .a'-0? - 3� `?, 'j r, 6 t,r (; Are you an employer? Check the appropriate box: 1. 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.] *An a licant that checks box #1 must also fill out the section below showing thei 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. ❑ Manufacturing 11.❑Health Care 12.NrOther Cm/'�°ct �I' �` - r workers' compensation policy information. y pp **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' compensation insurance for my employees. Below is the policy information. Insurance Company Name: l'i .Z i C H _ /`]`M t C't A) Insurer's Address: `� l� K !UI U` �. i AVL/ City/State/Zip: 0 iG l_AtJJ 0., Policy # or Self -ins. Lic. #, (o'Z Z- (AB . L) 1_/ 5 S /y � �� " � -- 1 � Expiration Date: A 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, undeVYh�,Nins and penalties jfperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 11% /D_ Issuing Authority (circle one): 1. Board of Health 2. Building, Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other 11 Contact Person: Phone #: 11 www, mass. govraia 19 ZURICH INSURED'S NAME AND ADDRESS STARLIN, INC. DBA CANOE RIVER CAMPGROUNDS 137 MILL ST MANSFIELD MA 02048 POLICY NUMBER: (6ZZUB-0495N75-0-12 ) RENEWAL OF (6ZZUB-0495N75-0-11) POLICY PERIOD FROM: 05-13-12 TO 05-13-13 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ PREMIUM DISCOUNT 0900-20 EXPENSE CONSTANT TERRORISM TOTAL ESTIMATED PREMIUM TAXES AND SURCHARGES DEPOSIT AMOUNT DUE Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: AMERICAN ZURICH INSURANCE COMPANY 6226 NONE 338 72 6636 367 7003 Adjustments of Premiums shall be made ANNUALLY ******************************* Deposit Amount Due: $ 7003 ****************************** POLICY NUMBER: (6ZZUB-0495N75-0-12) DATE OF ISSUE: 03-16-12 WC ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: COLONIAL INS SERVICES IN 75W2J NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 9'XMU nT7 unnT DT MT TO r_1 SRMf-PTTRUC.. ❑ SPECIAL PURPOSE POOL NAME OF POOL ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION `� iL' i # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMK 435.000. Items marked with a "✓' are satisfactory. 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 circulationXgpm. ation systems. Filter Effluent flow meter reading: # 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 2.0-6.0 m* To i Chlorine Alkalin 50-150 m ree 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 I 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 DREG NOTION I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 34 SIGNED Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 43 Operator SIGNED Board of Health/Health Department NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT -rwF ng pnnT • pT TRT T(' n-F.MT-PT TBLTC SPECIAL PURPOSE POOL ❑ NAME OF POOL s ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY --� — INSPECTION :> # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD -l' 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. REGULATION X/✓ VIOLATIONS/COMiVIENTS .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 flow meter reading: fID 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* gid. Total Chlorine Alkalin 50-150 m Free Chlorine (1.0-310 m Cyanuric Acid (30-100 p Comb. Chlorine (0.0-0 2 ppm Water Temp. 104°F. pH level (7.2-7. * parts per million I 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 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 S I G N E-0 Board of Health/Health Department