HomeMy WebLinkAboutDepot I & II 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: 6 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:
THE VILLAGE AT MANSFIELD DEPOT I -KEITH PROPERTIES
for the operation of a ❑ Public W Semi -Public ❑ Special Purpose Pool
at: THE VILLAGE AT MANSFIELD DEPOT I/FRANCIS AVENUE
Method of water treatment is CHLORINATING STICKS, Ph MINUS & PLUS
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
Date Issued
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Swimming Pool Application PERMIT NUMBER 6
FEE: $125
NAME OF OWNER: THE VILLAGE AT MANSFIELD DEPOT (-
KEITH PROPERTIES
ADDRESS: 14 PAGE TERRACE
CITY: STOUGHTON
STATE: MA ZIP: 02072
TELEPHONE: (508) 339-3583
FAX:
EMAIL:
FED ID/SS NO: 04-2946285
FEE PER POOL:
Certification Expires Every 5 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED: MARTIN PEKAREK
Pool/SPA Certification Date: 10/28/2009
Pool/SPA Certification Expires: 10/28/2014
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
HIGH SIERRA POOLS 2704 COLUMBIA PIKE, ARLINGTON, VA
REMARKS: I "NO LIFEGUARD ON DUTY" sign is required.
❑ Public
POOL OPERATION: Semi -Public
❑ Special Purpose Pool
POOL LOCATION: THE VILLAGE AT MANSFIELD DEPOT I/FRANCIS
AVENUE
TYPE/POOL: SEMI-PUBLIC
LENGTH: 40' WIDTH: 20'
VOLUME: 27,000
MIN/MAX DEPTH: 4' to 5'
SWIM AREA: 20x40' DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH: PRINTED VINYL
SCUM GUTTER: N/A
DECK TYPE: CEMENT SLAB
SKMMR WEIR LENGTH: 2 SKIMMERS
TREATMENT SYSTEM: HAYWARD DE -3600 EARTH FILTER
DISINFECT METHOD: CHLORINATING STICKS, Ph MINUS & PLUS
CHEMICAL TREATMENT: AUTOMATIC CHLORINATOR
NUMBER OF BATHERS: 43
SIGNATURE: / DATE:
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.
* Sidi 1f@4f IndiMual or &7
Corporate Name (Mandatory) `
By: Corporate Officer
(Mandatory, if applicable)
VIA
** 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.
4 LIN The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
j www.mass.gov/dia
. Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address:
City/State/Zip:
Are 1you an employer? Check the propriate box:
1. I am a employer with employees (full and/
Q
or part-time).* C 1p1 „ 11
2. ❑ I am a sole proprietor or partnership and havb 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.]
Phone #:
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 /n
12. gOthe4-M �VA�
*Any applicant that checks box #1 must also fill out the section below showing their workerk compensation policy informati& U
**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.
lam an employer thatisproydItigwor ' coPensaponinsiirtinceformyAnWloyees. Bemis the policy information.
0 011
Insurance Company Name: r / p�
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
Investieations of thelDIA for insurance coverage verification.
I do hereby certijjyfiidej the pos and penalties of perjury that the information provided abovg is true
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:
www.mass.gov/dia
Phone
This recognizes that
s recognize; that
(�
Jul-ii 2nanlens{CII
'
)urll znanle
nShll
iib
has completed the requirements for
U 0
has completed the reyuiremenls for
Bloodborne pathogens Training
..
Lifeguarding/First Airs/CPR/AEp
conducted
conducted by
by
High Sierra pools
High Sierra Pools
Pate completed: 83/24/2013
l9
pate completed: 03/24/2013
The American Red Crus, recognizes
The American Red Cross recognizes
this certificater is valid from
-
this certificate is valid from
tt
completion date for: 1 Year
compiotion date for: 2 Years
NATIoNAI. SWMMMoGn Po)
v{np/09
QATF CeAlIfIED
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
q'V PF nF DnnT _ DT TRT TO r1 SF,MT-PUBLIC ❑ SPECIAL PURPOSE POOL ❑
NAME OF POOL
ADDRESS
OWNER
ADDRESS
DATE OF
POOL CAPACITY
INSPECTED BY
t�
INSPECTION
/ �e i
# OF GALS
METHOD OF WATER
BATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATMENT
LOAD
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/COMMENTS
.03 Bathhouse and sanitary tacntties aaequaie ugnung;
ventilation; sanitary condition.
.03 Adequate enclosure around pool. Gate self -latching w/
latch 4 ft above ground.
.04 Sewage Disposal 4-1
.05 Location, structural stability, finish.
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: 4oD 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.
.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*
Total Chlorine
Alkalin
50-150 m
F hlorine1.0-3.0 m.
Cyanuric Acid
(30-100 ppm)
Comb. (0.0- . 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
REGULATION
NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
X/V
.34I I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED SIGNED
Operator Board of Health/Health Department
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: 5 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:
THE VILLAGE AT MANSFIELD DEPOT II -KEITH PROPERTIES
for the operation of a ❑ Public ❑� Semi -Public ❑ Special Purpose Pool
at: THE VILLAGE AT MANSFIELD DEPOT II -FRANCIS AVENUE
Method of water treatment is
Bathing load not to exceed:
GPM 75 BACKWASH 60
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
6
Date Issued
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Swimming POOL Application PERMIT NUMBER 5
FEE: $125
NAME OF OWNER: THE VILLAGE AT MANSFIELD DEPOT II -
KEITH PROPERTIES
ADDRESS: 14 PAGE TERRACE
CITY: STOUGHTON
STATE: MA ZIP: 02072
TELEPHONE: (508) 339-3583
FAX:
EMAIL:
FED ID/SS NO: 04-2946285
FEE PER POOL: $"75":00"` l 4�
Certification Expires Every 5 Years.
Permit Exaires December 31st Yearly.
PERSON CERTIFIED: MARTIN PEKAREK
Pool/SPA Certification Date: 10/28/2009
Pool/SPA Certification Expires: 10/28/2014
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
HIGH SIERRA POOLS 2704 COLUMBIA PIKE, ARLINGTON, VA
REMARKS: I "NO LIFEGUARD ON DUTY" sign is required.
SIGNATURE:
❑ Public
POOL OPERATION: F./I Semi -Public
❑ Special Purpose Pool
POOL LOCATION: THE VILLAGE AT MANSFIELD DEPOT II -FRANCIS
AVENUE
TYPE/POOL: SEMI-PUBLIC
LENGTH: 48' WIDTH: 24'
VOLUME: 65,000 GALLONS
MIN/MAX DEPTH: T to 9'
SWIM AREA: 36'x24' DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH: VINYL PRINT
SCUM GUTTER: N/A
DECK TYPE: 24' CONCRETE
SKMMR WEIR LENGTH: 2 SKIMMERS
TREATMENT SYSTEM: 1 Hayward 3600/1 Hayward 4800 Bath Filter
DISINFECT METHOD: GPM 75 BACKWASH 60
CHEMICAL TREATMENT: HAYWOOD CHLORINE FEEDER/TABS/CH
200
NUMBER OF BATHERS: 70
DATE: 6h*,
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.
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
*
Signa ure of Individual or
Corporate 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
Business/Organization Name:
Address:
City/State/Zip:
Phone #: ( 15� n c.J
A you an employer? Check the appropriate box: Business Type (required):
1. 1 am a employer with employee (full and/ 5. ❑ Retail
or part-time).*C 6. ❑ Restaurant/Bar/Eating Establishment
2. El am a sole proprietor or partners ip an a no 7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑Non-profit
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]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care
with no employees. [No workers'.comp. insurance req.] 12. Other
*Any applicant that checks box # I must also fill out the section below showing their worke s' compensation- pollcy info on.
**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 pro 'd' g wo ke s' ompensa 'o insurance for my e loy es. Below is the policy information.
Insurance Company Name: EK
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. # ID1X) -!O�xl �r, I ; - U r Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number a d expiratio/ 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
Investigations of the DJA for insurance overage verification.
I do hereby certify,l dq'lo pajn penalties ofNrjury that thfi infotnfktion provided above is que and
"i.7'!•-, %..s
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
This recognizes that
1pi
Nina Yaneva
has completed the requirements for
Bloodborne Pathogens Training
conducted by
E'aHigh
sierra Pools
d)
pate completed: 03/31/2013
The American Red Cross recognizes
this certificate is valid from
i
completion date for: 1 Year
This recognizes that
1pi
Nina Yaneva
has completed the requirements for
I_ifeguarding/First Aid/CPR/AEP
conducted by
High Sierra Pools
0)
pate completed: 03/31/2013
The American Red Cross recognizes
this certificate is valid from
completion date for: 2 Years
CFO, RtSlsir+ti�s Hn Z 2 C6 1� 8Qy Osc ATION
NATIONAL SW[MMING P-1' UNP
v^npffi9
DfjE CEATi F1ED
}T::FIG. 7L..F.. 7X. L•oxf•
insrnuC�P b:, _� r
This recognizes that
Yordanov
This recognizes chat
Daniel Yordanov
Daniel
l� ®
has completed the requirements for
, y
has t:onjpleted the requirements for
'
Lifeguarding/First Aid/CPR/AFD
by
'g;, �
F3loodborne Pathogens Training
by
l�1
conducted
0
conducted
High sierra Pools
High Sierra Pools
[)ate completed: 00/15/2013
1
Date completed: 03/15/201:3
The American Red Cross recognizes
The Ame.rlcan Red Cross recognizes
this certificate is valid from
this certlfk ate is valid from
completion date for'. 2 Years
completion dclte for: 1 Ye11*
i
F' e
AC" " CERTIFICATE OF LIABILITY INSURANCE
vvv�ivwa-v
YYY
7/10/ D/10/ 201IDD/Y3
3
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 is an 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 to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Eastern Insurance Group LLC
77 Accord Park Drive
Unit B1
Norwell MA 02061
CONTACT Daniel Duff
NAME: y
PHONE ]81-261-2012 FAX
AIC No
qoMDRESS•dduffy@easterninsurance.com
INSURERS AFFORDING COVERAGE NAIC #
INSURER A:Philadel hia Insurance Company
INSURED Beacon Residential Management LP
c/o Beacon Communities LLC
Two Center Plaza
Suite 700
Boston MA 02108
INSURERBNH Employers Insurance Co
INSURERCMEMIC Indemnity
INSURERD:
INSURER E:
INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
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.
ILTR TYPE
OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MM/DD/YYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100 000
PREMISES Ea occurtence $
X COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $ 1,000
A
CLAIMS -MADE Ix I OCCUR
PHPK998355
/1/2013
/1/2014
PERSONALBADVINJURY $ 1,000,000
X Terrorism
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
EBL $ $1,000,000
PRO-
POLICY JFQTX LOC
Eaa acccideBINntSINGLE LIMIT 1 000 000
AUTOMOBILE LIABILITY
BODILY INJURY (Per person) $
XANY
A
AUTO
ALL OWNED SCHEDULED
HPK998351
/1/2013
/1/2014
BODILY INJURY (Per accident) $
AUTOS AUTOS NED
NON-OPer
PROPERTY DAMAGE $
accident
HIRED AUTOS AUTOS
Medical payments $ 5,000
X Terrorism
X
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE $ 10,000,000
AGGREGATE $ 10, 000, 000
EXCESS LIAR
CLAIMS -MADE
A
PHUB415723
/1/2013
/1/2014
X 10,00
DED RETENTION$
WC 9LIMIT OTH-
TATU$
B
WORKERS COMPENSATION
CC -600-4000497-2013A
E.L. EACH ACCIDENT $ 1,000,000
AND EMPLOYERS'LIABILITYYIN
ass Only
/1/2013
/1/2014
ANY PROPRIETOR/PARTNER/EXECUTIVE
rN
N /A
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
OFFICER/MEMBER EXCLUDED?
BD
C
(Mandatory In NH)
E.L. DISEASE - POLICY LIMIT $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
on- Mass
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
RE: Village at Mansfield Depot I LLC, locations 1, 3, 5, 7, 9, 11, 15, 17 and 19 Francis Avenue,
Mansfield, MA.
Evidence of Insurance.
lya4112LN_1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Mansfield, Massachusetts
6 Park Row
Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE
Cleaves/DDUFFY�/u`
ACORD 25 (2010/05) v iaoo
INS025 nn1nm5 M Tho ARr1Rrl normo and innn nra ranicfararl mnrkc of Arr1Rr1
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
q --,Du r'%-rnrnnT . AT MT m r l CFMT-PT TRUC SPECIAL PURPOSE POOL O
1 11 L V
NAME OF POOL
--
ADDRESS
OWNER
ADDRESS
DATE OF
_ POOL CAPACITY
INSPECTED BY
-- 7—�—
INSPECTION
� ' dtij # OF GALS
y L��
METHOD OF WATER
BATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATMENT
OAD
'(�►
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/COMAIENTS
.03 Bathhouse and sanitary facilities adequate iignting;
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 circulationfiltration 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
2.0-6.0 m*
Total Chlorine
Alkalin
50-150 m
Free Chlorine
1.0-3.0 m
Cyanuric Acid
(30-100 pp
Comb.
Chlorine
(0.-0.2 p
Water Temp.
104°F.
pH level
(7.2-7.8)
* arts 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. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
w�
.34I I
Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED SIGNED
Operator
Board of Health/Health Department
�EG NOTION I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE I
X/✓
34 I I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED
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
TVPF CIF PCV1T • PT TRT T(` rl -,PMT-PT TRT T( RPF( TAT. PT TRPC)RF. PC)( -)T. rl
NAME OF POOL
PADDRESS
-- 1
OWNER
ADDRESS
DATE OF
POOL CAPACITY
INSPECTED BY
+
INSPECTION
# 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
.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 t2.0-6.0 nn -M,
Cyanuric Acid
Water Temp. 1p4°P,
*parts per million
.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
Tota}.C'hlonni
eee Chlorine
Comb.
Chlorine
pH level,
Other
Dear Madam/Sir,
Please find in this envelope the pool permit renewal application and payment.
Please feel free to contact me should you need anything further.
Thank you and best regards:
Tania Stancheva I Operations & Sales
High Sierra Pools, Inc. - SAFETY IS OUR FIRST PRIORITY
2704 Columbia Pike, Arlington VA 22204
P: (703) 920-1750 ext. 112 1 F: (703) 920-1753
2704 COLUMBIA PIKE VA,MD,DC 703-920-1750 NEW YORK 914-374-4099 RICHMOND AND TIDEWATER
ARLINGTON, VA 22204 FAX 703-920.1753 BOSTON 781-605-8337 804 869 2475
MFMRFR OF CONDOMINHIM ASSOCIATION INSTITUTF PROPFRTY MANAGFMFNT ASSOCIATION THF ASSOCIATION OF POCIt P. SPA PROFFSMONAIS NATIONAL SWIMMING POOL FOUNDATMON
Dear Madam/Sir,
Please find in this envelope the pool permit renewal application and payment.
Please feel free to contact me should you need anything further.
Thank you and best regards:
/ JGyF
Tania Stancheva I Operations & Sales
High Sierra Pools, Inc. - SAFETY IS OUR FIRST PRIORITY
2704 Columbia Pike, Arlington VA 22204
P: (703) 920-1750 ext. 112 1 F: (703) 920-1753
2704 COLUMBIA PIKE VA,MD,DC 703-920-1750 NEW YORK 914-374-4099 RICHMOND AND TIDEWATER
ARLINGTON, VA 22204 FAX 703.920-1753 BOSTON 781-605-8337 804 869 2475
MFMRFR OF CONDOMINtHM ASSOCIATION INSTITUTF PROPFRTY MANAGFMFNT ASSOCiATtON THF AS.WMATION OF POOi & SPA PROFFSSMNAtS NATIONAL SWIMMING POOL FOUNDATION
9 L&� YJ c;)o 13
III Lilt 329211' 1:25SO? 19811: 304430048711'
V14329L11' 1:2550?19811: 304430048711'
HIGH SIERRA POOLS, INC.
CAPITAL ONE BANK
143291
2704.COLUMBIA PIKE r
65-7198!2550
ARLINGTON, VA 22204
(703) 920-1750
a
PAY *k**ONE HUNDRED FIFTY AND 0/100 DOLLARS
d
m
DATE
AMOUNT
05-06-20 3
$**********.150.00
m
TO THE Town of Mansfield
ORDER 6 Park Row
8
OF. Mansfield, MA 02048
�:��
_
AUTHORIZED SIGNATURE NP
VOID AFTER SIX MONTHS
V14329L11' 1:2550?19811: 304430048711'
11' L4458411' 1:2 5 50 7198 111: 304430048711'
11' L4458511' is 2550? L98 0: 304430048711'
VILLAGE AT MANSFIELD
Town of Mansfield -- Board o f .Health
at O
Swimming Pool Application
NAME OF OWNER: THE VILLAGE AT MANSFIELD DEPOT (-
KEITH PROPERTIE$
ADDRESS: 14 PAGE TERRACE
CITY: STOUGHTON
STATE: MA ZIP: 02072
TELEPHONE: (508) 338-5513
FAX:
EMAIL:
FED ID/SS NO: 04-2995014
FEE PER POOL: $75.00
Certification Expires Every 5 Y ars
Permit Expires December 3151 Yeariv,
PERSON CERTIFIED: HOWARD R. KINTH
Poo!/SPA Certification Date: 5/16/2008
Pool/SPA Certification Expires, 5/16/2013
PERSON CERTIFIED:
POWSPA Certification Date:
P0011SPA Certification Expires:
cortNicatlon remarkslif necessary):
Town of Mansfield
6 Park RoW
Mansfield, MA 02048
PERMIT NUMBER: 6
[l Public
POOL OPERATION: W_ Seml-Pubilc
❑ Special Purpose Pool
POOL. LOCATION: THE VILLAGE Ar MANSFIELD DEPOT IIFRANCIS
AVENUE
TYPEIPOOL: SEMI-PUBLIC
LENGTH: 40' WIDTH: 20'
VOLUME: 27.000
MINIMAX DEPTH 44o 5'
SWIM AREA: 20x4V DIVE AREA: NONE
WATER SOURCE: TOWN
W1W DISPOSAL: TOWN SEWER
TYPE OF FINISH: PRINTED VINYL
SCUM GUTTER: NIA
DECK TYPE: CEMENT SLAB
SKMMR WEIR LENGTH: 2 SKIMMEFS
TREATMENT SYSTEM; HAYWARD DE -3600 EARTH FILTER
DISINFECT METHOD: CHLORINATING STICKS, Ph MINUS & PLUS
CHEMICAL TREATMENT: AUTOMA"IC CHLORINATOR
_..... .... �._._ .. ... ...... ... NUMBER OF BATHERS: 43
REMARKS: "NO LIFEGUARD ON DUTY" sign is required: _ u
SIGNATURE:�� v --
�._............... ....... ..__.... _... , DATE:W..._.._......�._.._..--
Please make apprOPrfata changes. ,sign, date and enclose check payable to Town of Mensfield. Mail to: Board of
Health, Town of Mansfield, Six Park Flow, Mansfield, MA 02046.
VILLAGE AT MANSFIELD
i I certify under the penalties of perjury that 1, to my best knowledge and belief,
have fled all State tax returns and paid all State taxes required under law.
Signatur of In v1 Ir
Corpora a Name or
.4ya�-� _- ?201)-e4� aA_j�
BY: Corporate officer
(Mandatory, If applicable)
rO
'� Social Security Number (Voluntery) or
Federal Identification Number
This license will not be Issued unless the certffication clause is signed by
the applicant
** Your Social Security number will he 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 -thing 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.
VILLAGE AT MANSFIELD
D,
Town of Mansfield - Board of Health
1
S'wimmi'ng Pool Application
NAME OF OWNER: THE VILLAGE AT MANSFIELD DEPOT II -
KEITH PROPERTIES
ADDRESS: 14 PAGE TERRACE
CITY: STOUGHTON
STATE: MA ZIP: 02072
TELEPHONE: (508) 339-3583
FAX:
EMAIL:
FED ID/SS NO: 04.2546285
FEE PER POOL: $75.00
Certification Exnires Every 3 Years.
Permit_ExWfe> _December 31st Yeariv.
PERSON CERTIFIED: HOWARD R. KEITH
PooUSPA Certificatlon Date: 511612008
Pool/SPA Certification Expires: 611612013
PERSON CERTIFIED:
PooUSPA Certification Date,
POOYSPA Certification Expires:
certification ramarks(Ir necessary);
REMARKS; "NO LIFIEGUARD ON DUTY' sign Is required.
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER: 5
❑ Public
POOL OPERATION: p Semi-Pt:bllc
❑ Special purpose Pool
POOL LOCATION: THE VILLAGE AT MANSFIELD DEPOT ll -FRANCIS
AVENUE:
TYPEIPOOL: SEMI-PUBLIC
LENGTH: 48' W 0TH: 24'
VOLUME: 65,000 GALLONS
MINIMAX DEPTH V to V
SWIM AREA: 36x24' DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH, VINYL PRINT
SCUM GUTTER: NIA
DECK TYPE: 24' CONCRETE
SKMMR WEIR LENGTH: 2 SKIMMEFtS
TREATMENT SYSTEM: 1 Hayward .60011 Hayward 4800 Bath Filter
DISINFECT METHOD: GPM 75 BACKWASH 60
CHEMICAL TREATMENT: HAYWOOD CHLORINE FEEDERrrABS/CH
200
NUMBER OF BATHERS. 70
.... ........
SIGNATURE: DATE: f 13 M
Please make appropriate changes. Sign, date and enclose check payable to Town of Mgnsfleld. Mail to: Board of
Health, Town of Mansfield, SIX Park Row, Mansfield, MA 02048.
VILLAGE AT MANSFIELD
Iceify under the penalties of perjury that I, to my best knowledge and belief,
avefiled all State tax returns and paid all State taxes required under Nw.
Signatur of In vi I or
Corpora a Name {Mandatory)
By: Corporate Officer _
(Mandatory, if applicable)
till i �{ Y3
Social Security Number(Voluntary) o
Federal'ldentification Number
This license will not be Issked unless the
the applicant certificption c(ausf- is signed by
"Your Social Security number will be fumished to the Massachus,:tts
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.
Mf 1N51 I ELL) f'1L-HUUW;�
Town of Mansfield
'own of Mans' eld ® Board of Health 6 Park Rover
Mansfield, MA 02048
Swimming
Pool Application PURMIT NUMSER: 7
❑ Public
NAME OF OWNER: MANSFIELD MEADOWS ASSOCIATION
POOL OPERATION: Serni-Public
C _) SP196al PUrpose Pool
ADDRE85: 12 BONNEY LANE 09
POOL LOCATION: 12 130NNEY LANE #9
CITY: MANSI`IELD
STa1TE' MA 7.IP; 02048
TYPEIPOOL! RESIDENTIAL
TELEPHONE: (508) 339-3357
LrNGTH: 40' WIDTH: 22'
VOLUME;: 42,9000
FAX: (508) 339-9761
EMAIL:
MINIMAX DEPTH 3.5' to 9'
FED IDIss N0; 04-3083384
SWIM AREA: 40'x22' DIVE AREA, NONE
rrF PER POOL: $75.00
WATErt SOURCE:: TOWN
Certification EXplres Every 5_.Years,
WIW DISPOSAL; TOWN SEWER
Permit Expires december 31st Yeah
TYPE OF FINISH: CONCRETE
PERSON CERTIFIED: HOWAr2D-R" :ITH �}Y tj(��E,� SCUM GUTTER:
Pool/SPA Certification Cate: 5/1 ifi68 I
Oj I DECK TYPE: CEMENT SLAB
Pool/SPA Certification Expires. 5/1,r,/2r013101
?�/ItbKMMR WEIR LENGTH:
PE,R$ON CPRTIFIED:
TREATMENT SYSTEM: HEYWARD EARTH FILTER 4800
Poo//SPA Certification Date;
DISINFECT METHOD: CHLORINATING STICKS, PLUS TO INCREASE
PH
PoolISPA Certification Expires.
CHEMICAL TREATMENT' CALLE & IRON REMOVER. AUTOMATIC
certification remarks(If nocassary):
J Q (h -...
-- NUMF3ERO' BATHERS! 43
' e
REMARKS; "NO LIF=EGUARD ON DUTY" sign Is required, (L7 I
I
SIGNATURE: C'� �._
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.
8
1 .11 i 11- IQ 1G 1 1' 1* J I Ir -111J1 I u. -L I Il.ntn.�w,.�
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,
' Signature Wridividual or
Corporate Name (Mandatory)
By: ori -I ieer tori e� �AsCc�
( andatory, if applicable)
to iJ�JC%TP.YI��. �.+llrlly�trTPf Vl31 �SJIUI I�U�`{�f"
Federal Identification Number
A This license will not be isssued unless the certification clause is signed by
the applicant.
as Your Social Security number will bre furnished to the Massachusetts
Department of Revenue to determine whether you have. rnet tax filing or tax
payment obligations. Licenseas who fail to correct their non -fling 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,