Loading...
HomeMy WebLinkAboutHockomock Y 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: 12 Pool/SPA Certification Date: October 27, 2010 PERMIT EXPIRES: December 31, 2013 pool/SPA Certification Expires: October 27, 2015 Person Certified: JEFFREY D. LALIBERTE Pool/SPA Certification Date: November 18, 2012 Pool/Spa Certification Expires: November 17, 2017 Person Certified: BRITTANY A. MORIN-MEZZADRI 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: HOCKOMOCK AREA YMCA -MANSFIELD for the operation of a W Public at: Method of water treatment is Bathing load not to exceed. ❑ Semi -Public 40 BALCOM STREET CHLORINE 30 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott l Bite, Health .Agent ❑ Special Purpose Pool None Date Issued ��E44NCf til. °„ �a Town of Mansfield - Board of Health w G :r Swimming Pool Application NAME OF OWNER: HOCKOMOCK AREA YMCA -MANSFIELD ADDRESS: 40 BALCOM STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-3066 FAX: (508) 337-8479 EMAIL: FED ID/SS NO: 04-2131749 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: JEFFREY D. LALIBERTE Pooi/SPA Certification Date: 10/27/2010 Pool/SPA Certification Expires: 10/27/2015 PERSON CERTIFIED: Pool/SPA Certification Date: POOUSPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: Town of Mansfield 6 Park Row Mansfield, MA 02048 3 PERMIT NUMBER: 12 0 Public POOL OPERATION: ❑ Semi -Public ❑ Special Purpose Pool POOL LOCATION: 40 BALCOM STREET TYPE/POOL: ABOVE GROUND LENGTH: 89" WIDTH: 70" VOLUME: 10,000 gal MINIMAX DEPTH: 4' SWIM AREA: WATER SOURCE: TOWN W/W DISPOSAL: SEPTIC SYSTEM TYPE OF FINISH: PLASTIC SCUM GUTTER: NONE DECK TYPE: WOODEN SKMMR WEIR LENGTH: 1.5 to 2' TREATMENT SYSTEM: SAND FILTER DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 30 DIVE AREA: NONE /24 DATE: _1 Please make` rppr�pri 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. * Signature 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 UIV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Nal Address: `i City/State/Zip: Ie, Phone #: , z7 r-- `U'2 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I 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. [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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 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 workers' compensation policy information. **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 p yer that is providing workers' compensation insurance for my e»rployees. Below is the policy information. Insurance Company Name: Insurer's Ad 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 Investigations of the DIA for insurance coverage verification. I do hereby certify,tlepins penalties of perjury that the information provided above is true and correct. -'r.mss=_rG n _ _...w...... t79t0. 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/aia Phone 06/1112013 14:09 5006435220 HOCKOCK-AREA YMCA PAGE 02 • i The Conifflontoealth of Massirchttset(s pepartment of Induytritri Accidents � I offsee of Invcstigaiiotts 600 WasG.inglon Street i Boston, Mil. 02111 j ttnvw.ttrusc,gov�tlra iI Vitolrlteirs' Compen9ation insurance, Affidavit: General Businesses 1 A lic�ttttInfarmtttit*n Please Print Le' i /051 BusitteworgattizAtion.Name : �G�G Le i A.. -., 444ii -Sr Ac(dress:_ dip `/i , 'i,��n VW City/State/Zip; Phone 9;' Are you an employer? Check (lie appmprislte box: _ Rusiness Type (required): i.f�Cl I am a employer with {p .. employees (hill and/ 5• © Relail or part-time),* fi. Restavrant/BarfRating Establishment 2. ❑ I arts; a sole prnprietosor.pbrttlotship find )have no 7. ❑ ffiac. sinrf/ar 5.alcs (mel. reAl catttie,:swto,.eto.) . ertx�iloste� �uts�c#;ts��4tr:tttlk if' �y'>r:tp;�ity. s. NNun-profit {'tato workers' comp. insurance required] 3.0 We aro a corporation and its officers have excrriscd 9. [] Enlertairmerit their right of'cxemption per c. 1.52, § i(4), and we have 10,E] Manufacturing no omployees: [ate=wlirltets' coiiip. insuranccmquired]* tl.F1 HeAh Care 4. n We are a non-profit organization, staffed by votlintecM.' with no einptoym. [No workers' comp. ingmace req] t2f] Other +Any npplicant that checks box #I must alsn rill out the scrtlon Wow showirr� ilid tvaikcrs' cntnponselioo ptllicy infnrmation. 'i'(f tic corporate aificeis have exempted 1110m3elvac, but the entporrtian hAs nihrr crnployres, a 1rrrnkar5' tae KRX'1tlon policy iv requirai And ¢aeh en orgnnimtian shnukl check box H1. I atrt ax �1+iildycr fhpt is providing wurlcrrr' canrpensntinn r'nrnrence,for tnji tntjrtupeer ;ac�lnw is tlte.pali,:y infnrtnatidn. Insurance Company NRme: '�%v rrti ,Gkra : �r.ri(R j— i "" ►r`" ``fi _ 'insurer's Address: l � 1-10M.N Or, -_ City/51ate/Tip: N . ,�7i''•2 � l7 �'7U � .,,.,.._.._,�.. Policy // or Self ins. Lic.119,-71 G l'0-- X71 0`� _ Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing tine policy nurnber ntut! exp"flon date.), railure to securo aovtrtago w requited under Section 75A of MGL c. 152 aAn lead to the frttpasition of criminal penalties OCR li>xc up to $1,500.00 and/or one-year imprisoment, As well as civil penalties in the form of a STOP WORK ODDER Aad a One oCup to $750.00 a day Against the violli or. lie advised that a copy orthis statement may be forwarded to the Office of tnvesti ations ofthe DIA for imurancc coverage verification. Ida. thereby.. ,�erti2AA j under die p itm and penaldav of per, jury that the informafiatt provided above is 1tue rmd edrme _ mature: '� ' ., .- 1_ _ 17ate: Y/r tlffcinrl mve o>rty, JJa not wry in flus arca, to br: compleled by,c> or town oPeial City or Town- _ _ _ _ _ Pcrmit/Licouse fl— Issuing Authority (circle one): 1. Board of fferiith I Building Department 3. City/Town Clerk 4. Licensing t#oard 5. Selectmen's Office 6. Other Contact Person: PIlene #f:�^ • +vww.mnss:gnvlein . • . 06111/1013 14:09 5086435280 DOWU TRAVELERS�T INSURER: THE TRAVELERS INDEMNITY COMPANY 1. INSURED: MOCK©MOCK YOUNG MEN'S CHRISTXAN ASSOCIATION INC Sof] ELMWOOD sT N ATTLEBORO MA 02760 Insured Is A CORPORATION HOCKOCK-AREA YMCA PAGE 03 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: ($KUB -471 GPOS-2-12 ) RENEWAL OF (GKUB-4716P05-2-11) NCCI CO CODE: 11347 PRODUCER: HENRY L NEWBURY INS AGCY i GEORGE LEVEN DR N ATTLEBORO MA 027GO Other work places and Identifivation numbers are shown In the schedules) attached, 2. The polioy period Is from o7-01-12 to 07-01-13 12:01 A.M. at the Insured's mailing address, 3. A, WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE, Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A 0. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this polloy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: OG -1 8-12 WC ST ASSIGN: MA OFFICE,. ORLANDO INDUS AFF 1 G1 PRODUCER. HENRY L NEWBURY INS AGCY 24XGY La ®U ii, MIM z cd 0 1T F� v Ra r� .if r�� � r,,nN1,i➢III,t,IIlI010 � _ - n ..i r ..'a.,,. uuunuomum+ima �'alllPhlP,Y�+, IO'���,�; - mxv IL 8u11l�iipi i81,�uII11111i1 - z— _ _ �— t Y,�. . iliiNlllll�llllul'�lul' _.= - uil8lll��ll'IIIiI' a� ILII@,°',u,��11 pp 11 A&M_ — - X. _ _ = LL r -I -N, - s,� F K J GOAh cr 01W6 All I • U, c U � iUIIIllllildl�llul� Iulu�N�l1111111,1u1 I Nlluul Il�llulllilultp{il��� ��tf't'[IIUiih�,,,. I +, p i�1u11111u1, _� II'lilli'�illi' 1111111i1+l i'�ulldi�llilullll,�l�l': _ ,�-' . — �uullllulllull��lll�1N� I,p1111111'+V;Illu,, `� �,, II111111111u11'IIII"11� II � � ,III' ; ; � I���IIIIIIhu111011�I1'� 111,1 iI� ,ao 66 66MV'6 LL 1e �AcISN;auoydaLa; 'u01�e9yi'i'��''; u�p, E 0 the v� FOR YOUTH DEVELOPMENT® FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY Brittany Morin-Mezzadri 300 Elmwood St North Attleboro, MA 02760 Dear Brittany, Congratulations on successfully completing a YMCA of the USA training certification. Please review the information on your attached certification card. Please use this form to correct or update your contact information or to request a duplicate card. OThe information that appears on my records is incorrect. I have marked the changes above. OI have enclosed $20 for a duplicate card request for my certification. To obtain a copy of your official training transcript, please register on, www.ymcaexchange.org (User ID is YMCA and Password is 9622) and create an account under the heading "My Account." Questions? Please contact us at event. registrations@ymca.net or call our Contact Center at 800-872-9622. ®® TRAINING CERTIFICATION j the YMCA OF THE USA F� 12MAAQ711 BY062 Brittany Morin-Mezzadri Lifeguard 2011 Expires 12/29/2014 YMCA OF THE USA 101 N Wacker Drive, Chicago IL 60606 161003 8/10 P 800 872 9622 F 312 279 4492 W ymca.net NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPEC ION REPORT rrAmU f-%UnnnT . DTTDT TO n 4ZRTAT_-DTTT2T T(I RPFC..TAT. PTTRPC)CF. Pn(-)T. ❑ NAME OF POOL A4 ADDRESS OWNER ADDRESS DATE OF INSPECTION !!�-/Qy5j'Z POOL CAPACITY # OF GALS PSPECTED BY METHOD OF WATER TREATMENT BATHER LOAD # OF LIFEGUARDS WATER SOURCE: 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 L�� 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 (20-6.0 ppm Cyanuric Acid Water Temp. 104°F� *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 AAa b- k(4b k L)�1 Total Chlorine Free Chlorine Comb. Chlorine pH level Other REGULATION NO. I 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. 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 Li QT rA4Y DTMT It' 1711-` QP-PCTAT. PTTRP(lCF PC)( -)I. ❑ NAME OF POOL } ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY INSPECTION f 9 O 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 ano sanitary Tacaaues aaequate ugnung, 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. .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 .10 .12 .12 .13 .14 .15 .17 .21 .22 .23 .24 .25 .25 .26 .29 gap. Skimming facilities. 50% of recirculation drawn from surface of pool. Line with floats separates non -swimmer area from deeper water. Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. Walkway and decks 4 feet wide, safe condition. Ladders, steps - one per 75 feet. Not less than 2 ladders. Diving equipment in safe condition. Pool supervision - Pool supervision provided. Effective Jan. 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. Permit requirements - Permit issued. Adequate 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 Q- 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. .1 First Aid equipment provided.-/,,1)�` 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 -6" r_ i Li f0 POOLSIDE READINGS Bromine 2.0-6.0 m* Total 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 [REGULATION I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE I w✓ 34 ( ( 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