HomeMy WebLinkAboutMansfield Meadows 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: 7 Pool/SPA Certification Date: October 28, 2009
PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: October 28, 2014
Person Certified: MARTIN PEKAREK
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 MEADOWS ASSOCIATION
for the operation of a ❑ Public
at:
Method of water treatment is
Bathing load not to exceed
V Semi -Public
12 BONNEY LANE #9
❑ Special Purpose Pool
CHLORINATING STICKS, PLUS TO INCREASE PH
43 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
23
_0
Date Issued
Town of Mansfield - Board of Health
Swimming Pool Application
NAME OF OWNER: MANSFIELD MEAOOWS-A hS i0
ADDRESS: 12 BONNEY LANE #9
CITY: MANSFIELD
STATE: MA ZIP: 02048
TELEPHONE: (508) 339.3357
FAX: (508) 339-9761
EMAIL;
FED ID/SS NO d Cf ,7t LU Z(
FEE PER POOL; $76.00
Certification Expires Every 5 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED: MARTIN PEKAREK
Pool/SPA Carliflualiun Dale. 10/28/2009
Poo!/SPA Certification Expires: 10/28/2014
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(If necessary):
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER: 7
0 Public
POOL OPERATION: Fvj Semi -Public
0 Special Purpose Pool
POOL LOCATION: 12 BONNEY LANE #9
TYPEIPOOL: RESIDENTIAL
LENGTH: 40' WIDTH; 22'
VOLUME: 42,9000
MINIMAX DEPTH: 3.5' to 9'
SWIM AREA; 40'x22' DIVE AREA; NONE
WATER SOURCE; TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH: CONCRETE
SCUM GUTTER;
Dr -CK TYPE: CFNI[NT OLA13
SKIMMR WEIR LENGTH:
TREATMENT SYSTEM: HEYWARD EARTH FILTER 4800
DISINFECT METHOD: CHLORINATING STICKS, PLUS TO INCREASE
PH
CHEMICAL TREATMENT: CALLS 8, IRON REMOVER. AUTOMATIC
NUMBER OF BATHERS: 43
REMARKS: .No LIFEGUARD ON DUTY" sign Is required.
+
SIGNATURE DATE.
Please make appy priate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of
Health, 'lawn of Mnn,sfin/d, Six Park Row, Mansfield, MA 02048,
I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
Signature of Individual or
Corporate Name (Mandatory)
i
BY: Corpor Officer
I {i111a ptory, 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.
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