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Home My WebLink AboutCedar Heights 12/31/2013Commonwealth 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: 13 Pool/SPA Certification Date: March 20, 2013 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: March 20, 2018 Person Certified: MICHAELLA J. JOHNSON 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: for the operation of a ❑ Public at. Method of water treatment is Bathing load not to exceed: CEDAR HEIGHTS ❑ Semi -Public 10 CONNORS AVENUE CHLORINE 61 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health .Agent ❑ Special Purpose Pool None k2_13k_ Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 13 NAME OF OWNER: CEDAR HEIGHTS ADDRESS: 10 CONNORS AVENUE CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 337-0040 FAX: (508) 337-0042 EMAIL: FED ID/SS NO: 56-2332456 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: AMANDA TURNER Pool/SPA Certification Date: 3/2/2007 Pool/SPA Certification Expires: 3/2/2012 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: ❑ Public POOL OPERATION: F./I Semi -Public ❑ Special Purpose Pool POOL LOCATION: 10 CONNORS AVENUE TYPE/POOL: GUNITE/PLASTER LENGTH: 42'6" WIDTH: 27' VOLUME: 27,510 GALLONS MINIMAX DEPTH: 375' SWIM AREA: 917 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: PLASTER SCUM GUTTER: NONE DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8 1/2" TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 61 'NO LIFEGUARD ON DUTY" sign is required. MICHALLA JOHNSON - AGENT OF CEDAR HEIGHTS SIGNATURE: _ _ ❑ DATE: eus Please make approate chanes' ign, date an, ''enc fose 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. co-�c * Signature of IndividL@1 or Corporate Name (Mandatory) By: Corpora Pfficer (Mandatory, if applicable) , l� i L 3 5,,� 4,�-I, ** 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 Business/Organization Name: i11/J1/�'I/�/►C a �'�Z I ' Mll�/�[i �71i� Are ou anemployer? Check the appropriate box: Business Type (required): am a employer with �_ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no T Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• 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. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers'. comp. insurance req.] 1 workers' compensation policy information. *Any applicant that checks box #1 must also fill out the section below showing their **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 Insurer's Address: 02 13 C /Mate/zip: � /� 7/ /%� of � U cy orSelf-ins. Lia # C � c3t�®7 `7" `7 qExpiration Date: ch a copy of the workers' compensation policy declaration page (showing the policy number expir tion date). Failure to secure coverage as required ander 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 daya ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DI for insurance coverage verification. I do hereby certify, u r th pains a d penalties ofper' ry tha he 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: Phone #: www,mass.gov/dia Workers' Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Company Policy Number CEWC357479 Renewal of CEWC245767 NCCI No.[25844] Policy Information Page [1] Named Insured and Mailing Address Cedar Heights, LLC 34 Bellows Road Raynham, MA 02767 Federal Employer's ID 56-2332452 Risk ID Number 000520296 Agency EASTERN INSURANCE 233 West Central Street Natick, MA 01760 Agency Code: MAEAIN10 Insured is Limited Liability Co. (LLC) [2] Policy Period From August 25, 2012 to August 25, 2013, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 1,475 Total Surcharges/Assessments $ 47 Total Estimated Cost $ 1,522 INTERNAL USE FU Page - 1 - Information Page MGA : CEWC357479 WC 000001A Date :08/28/2012 MANOTE 16 South River Street • P.O. Box A -H • Wilkes-Barre, PA 18703-0020 • www.guard.com April 3, 2013 Michaella Johnson 185 Phillips Street Attleboro, MA 02703 Dear Michaeila, Pool Operation Management Congratulations upon your successful completion of the CERTIFIED POOL/SPA OPERATOR course in NORWOOD, MA from 3/19/2013 to 3/20/201311 hope that your experience was a positive one. You will be receiving your certification from the National Swimming Pool Foundation within 6-8 weeks. You can use this letter as proof of certification until your certificate arrives. The networking through your classmates can be a valuable resource to you and visiting www.pooloperationmanagement.com. You are also invited to enhance your knowledge by participating in future CERTIFIED POOL/SPA OPERATOR courses. As a POM student, you are eligible for discounted services. You can have one of our CPO instructors aid you in making your job easier and your facility safer. Call us to schedule an inspection of your facility. Also, be sure to visit our website to find all the CPO products and services you need to run a safe facility. Thank you for your participation. If you should have need of our services in the future, please contact us. Sincerely, Trevor Sherwood Vice President 68 EDWARDS ROAD 9 BRICK, NJ 08723 • PHONE (732) 451-1040 • FAX (732) 451-1630 www pooloperationmanagement.com. � Village ® mH Cedar Heig A Thnier Properties Apartment Community www.CedarHeightsMansfield.com April 3, 2013 Board of Health Town of Mansfield Attn: Jane Doucette 6 Park Row Mansfield, MA 02048 RE: 2013 Swimming Pool Permit Per my correspondence dated 12/6/12 which included a 2013 Swimming Pool Application for Cedar Heights, LLC, I stated I would forward CPO Certificate once available. Enclosed please find the letter from Pool Operation Management confirming that I have successfully completed the Certified Pool/Spa Operator course in Norwood, MA on 3/19/13 to 3/20/13. Please accept this as proof of completion in lieu of actual certificate. I will be receiving the certificate from the National Swimming Pool Foundation in 6-8 weeks and will forward once available. Should you have any questions or require anything further, please feel free to contact the office. Thank you, 1. Michaella J. Johnson Property Manager The Village a Cedar Heights A Mumer Properties Apartment Community www.CedarHeightsMansfield.com December 6, 2012 Board of Health Town of Mansfield Attn: Jane Doucette 6 Park Row Mansfield, MA 02048 RE: 2013 Swimming Pool Permit Enclosed please find a completed Swimming Pool Application, Worker's Compensation Insurance Affidavit, Insurance Policy Declaration Page and a check in the amount of $75.00. Also included is our current Certified Pool Operator Certificate. We are aware that this certificate is expiring and will no longer be valid for the upcoming season. This letter confirms that I will personally be taking the Pool Operation Management course on March 19-20, 2013 in Norwood, MA. I will forward my valid Certificate upon completion of the class. Should you have any questions or require anything further, please feel free to contact the office. Thank you, Michaella J. Johnson Property Manager �IIIIUIIIIIIIIIIIIIIIIiIIi' � ��"I LI The Village Cedar Heights r A Turner Properties Apartment Community April 25, 2013 Board of Health Town of Mansfield Attn: Jane Doucette 6 Park Row MA �� r.��sF�'�:id, "JiA :1204i 8 RE: 2013 Swimming Pool Permit www.CedarHeightsMansfield.com This is a follow up to my letter dated 4/3/13, which included the letter from Pool Operation Management confirming that I have successfully completed the Certified Pool/Spa Operator course in Norwood, MA on 3/19/13 to 3/20/13. Enclosed please find a copy of my actual CPO certificate. I have also included a copy of my CPO Certification card. Should you have any questions or require anything further, please feel free to contact the office. Thank you, Michaella J. Johnson Property Manager 1 0LO NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 'rypp nF pnnT • PT MT Tr ri SEMI-PUBLIC (13,,~` "° SPECIAL PURPOSE POOL ❑ 1 1 1 L V NAME OF POOL ADDRESS `"_ OWNER ADDRESS DATE OF ' POOL CAPACITY INSPECTED BY --' Jack -- �cv,7L--' — INSPECTION (ZZ k,, # 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 CMR 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 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 until repairs can be made. b,,, 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. 2.0-6.0 m* Total Chlorine Diving equipment in safe condition. Alkalinity 50-150 ppm Pool supervision - Pool supervision provided. Cyanuric Acid Effective Jan. 1, 1999, pool supervisor certified as pool Comb. (0.0_1.2' 0.0- • .2 ppm) Chlorine a' operator from YMCA or NSPF. 104°F. pH level (7.2-7.8) Permit requirements - Permit issued. Adequate * parts per million I 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 ppm Free Chlorine 1.0�3.0 m. Cyanuric Acid (30-100 ppni Comb. (0.0_1.2' 0.0- • .2 ppm) Chlorine 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 y t V REGULATION 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 435.31. Operator SIGNED Board of Health/Health Department