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Home My WebLink AboutMansfield Children's Center 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: 8 Pool/SPA Certification Date: April 22, 2009 PERMIT EXPIRES: December 31, 2013 pool/SPA Certification Expires: April 22, 2014 Person Certified: KEVIN FALLON 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 CHILDREN'S CENTER for the operation of a ❑ Public at: Method of water treatment is ❑v Semi -Public 1100 SCHOOL STREET *290W mil ❑ Special Purpose Pool Bathing load not to exceed: 43 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 ��6 f 3 Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 8 NAME OF OWNER: MANSFIELD CHILDREN'S CENTER ADDRESS: 1100 SCHOOL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-9211 FAX: EMAIL: FED ID/SS NO: 042-725-454 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: KEVIN FALLON Pool/SPA Certification Date: 4/22/2009 Pool/SPA Certification Expires: 4/22/2014 PERSON CERTIFIED: PooIiSPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. ❑ Pubhc POOL OPERATION: W Semi -Public ❑ Special Purpose Pool POOL LOCATION: 1100 SCHOOL STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 41' WIDTH: 25' VOLUME: 30,000 MINIMAX DEPTH: 3' SWIM AREA: 1000sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: PRIVATE TYPE OF FINISH: LINER SCUM GUTTER: DECK TYPE: 5' CEMENT SKMMR WEIR LENGTH: 2 SKIMMERS TREATMENT SYSTEM: DIATOMACIOUS EARTH DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: NUMBER OF BATHERS: 43 SIGNATURE: DATE: Please make approp rate changes. ign, date and enclose check payable to Town of Ma sfield. 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. RLIL't * Si nature of Individual or Corporate Name (Mandatory) F, C� By: Corporate Officer (Mandatory, if applicable) `fir 72 Social ** 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 Applicant Information /, �t Please Print Legibl /�y Business/Organization Name: a �vl�� - ��/ 1 � ,� s ►eXG� l r -e ls a''rl`e%— Address: OCL) c/X_aw( 5`1 City/State/Zip:.��t �. T l e , e,_Phone #: �_6 V `33 %-_61 .2- i 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.] 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.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy mtormarion. **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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information, Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. #, Expiration Date: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investivations of the DIA for insurance coverage verification. I do hereby certify ,I the Phone #: f6c_ that the information provided above is true and correct. .2 611 Official use only. Do not write In this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone 06/2012013 11:29 17812931300 BLIRHEK INS PAGE 01/01 DATE (MMIDDIYYYY) �`'► '�'° CERTIFICATE OF LIABILITY INSURANCE 1 0612012013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, les must be endorsed. If SUBROGATION 1$ WAIVED, subject to IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(• ) the terms and conditions of the policy, certain policies may raquire an endorsement. A statement on this certiticate does not confer rights to the e,artifleatu- holder in lieu of such endorsement(s). PROhUCER Phone,. 781-293-6331 -N ' 9E:- FAx WM. F. Surhek Insurance Agency Fax: 781-293-2171 �cNr o.,.W);_.. _ -�-(Ale, _ 311 Plymouth Street E-MAIL Halifax, MA 42336 Merle D. Ott ADDRE39; PROD DER MANSE -1 CUST.01%C� ID il: 1NBURER(3) APfORD,ING DOVERAG6 NAS A: Utica National Insurance Group 25976 INSURED Mansfield Children's INSURER Center Inc. INSURER B ; _ - 1100 School St. I291JRER C I, _ Mansfield, MA 02058 INSURER D: ... .. •• - INSURER E 1 .. - OVERAGES CERTIFICATE NUMBER: ""' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L13TED BELOW HAVE @EEN ISSUED TO THE INSURED NAMMEDED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS G8R7IFiCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU$JECT TO ALL THE TERMS, EXCLUSIONS ANIS CONDITIONS OF .^SUCH POLICIES, LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, _ POLICY IFF POLIOT EXP I LIMITS W GENERAL LIABILITY COMMERCIAL GENERAL LIASII_ITY 1 CLAIMS-MAOr F-1 OCCUR GE146 AGGREGATE LIMIT APPLIES PER: 7 POLICY I I i[C LOG AUTOMOBILE LIABILITY ANY AUTO _ ALL OWNED AUTOS SCHEDULrD AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIA11 OCCUR EXCESS LIAR — CLAIMS DEDUCTIBLE WORKERS COMPENSATION AND EMPLOYERS' klABILITY ANY PROPRIETORIPARTNERr:XECUTWE Y� I NIA OFFMI IOEREMBER EXCLUDED9 I EACH OCCURRENCE }5 ASA '�Rl`NTEu j _PREM�^ES L OC/.'U ranee _ . 3 MEI) EXP Any mn pareon) $ PERSONALSADV INJURY 4 �GENERALAGGREE RODUCTS - COMPIOP AGG $ 7L COMBINED SINGLE, LIMIT S (Enatoid8n1) BODILY INJURY (Por parcan) B BODILY INJURY (Per ACM100hl) 9 PROPERTY DAMAGE S ` (Par at ident) jl EACH OCCURRENCE �v� x CRY 10/07/2012110107120131 C.L. EACH DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AiWch ACORD 101, ArldItIonel Romorks Schedule, It more xpata Is required) TU - 1()0,001 g 100,001 EA FMPLOYE S 100,00 MANSFIE SHOULD ANY of THE ABOVE, DE30RIBI=0 POLICIES HE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 19E DELIVERED IN TOWN OF MANSFIELD ACCORDANCE WITH THE POLICY PROVISIONS, Health Agent 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Merle D. Ott c(719BO.2009 ACORD CORPORATION. All rights reserved. ACORD 26 (2009/09) The ACORD name and 1090 are registered marks of ACORO , -L5w, 4N T4p- CPOF ftegistratM N.. Fa&ow 02-251997he . is hereby Cenified and Registered NATIONAL SWIMMING POOL FOUNDATION on 4/22/09 DATE CERTIFIED 7/— W(. C.E.O. NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT -rvnV nV nnnT & PTTUT Tr, n RF.M1-P1TRI,Ic ❑-''°`- SPECIAL PURPOSE POOL ❑ NAME OF POOL y _ r ADDRESS OWNER .04 Sewage Disposal ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION t `t # 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. F .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 securer 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 warmn 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* Total Chlorine special purpose pools. Alkalin 50-150 m Free Chlorine 1.0-3.0 m g .. Cyanuric Acid (30-100 ppm) Comb. Chlorine (0.0-0.2 ppm) days. Water Temp. 104°F. pH level (7.2-7.8) * arts er million f Other operator .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. f .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. f 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. 114, C SIGNED �" a SIGNED Operator Board of Health/Health Department