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Home My WebLink AboutHoliday Inn 12/31/2016Commonwealth 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: 14 Pool/SPA Certification Date: March 19, 2013 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: March 19, 2018 Person Certified: MARCIO B. TAKIMOTO 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: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a ❑ Public at: Method of water treatment is ❑ Semi -Public 31 HAMPSHIRE STREET SALINE Bathing load not to exceed: bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health .Agent W Special Purpose Pool None Date Issued Town of Mansfield -Board of Healtii acs ' Town of Mansfield 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 14 FEE: $125 ❑ Public NAME OF OWNER: VISION HAMPSHIRE LLC, HOLIDAY INN POOL OPERATION: El Semi,PUbGC ADDRESS: 31 HAMPSHIRE STREET Fv] Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 TYPEIPOOL: SPECIAL PURPOSE LENGTH: 7 WIDTH: 7 I FAX: (608) 339-1040 VOLUME: 863 EMAIL: MINIMAX DEPTH: 3' j FED ID/S$ NO: 47-3112140 SWIM AREA: 154 Sq It DIVE AREA: N/A WATER SOURCE, TOWN Certification Expires Every 5 Years Permit Expires December 31St Yeariv W1W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS PERSON. CERTIFIED: MICHAEL 8CHAMI3URG SCUM GUTTER: NIA Pool/SPA-Certification Date, - 4128/2011-- - - DECK TYPE: BRICK w ISE -- � - Pool/SPA Certification Expires: 4/28/2016 SKMMR WEIR LENGTH: 14' i PERSON CERTIFIED: TREATMENT SYSTEM: SALINE Pool/SPA Certification Date: DISINFECT METHOD: SALINE Poral/SPA Certification Expires: CHEMICAL TREATMENT: CHLORINE SAND FILTER certification remarks(if necessary): _._ �___. ....._ _. _ _............. . . NUMBER OF BATHERS: I LIFEGUARD ON DUTY" sin Is required. ,. . REMARKS: �� _. ... _ .... , NO LIFER g "No Lifeguard on Duty" sign SIGNATURE: ...._. � _ DATE: Please make appropriate changes, Sign, da e 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 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. i * Signature of Individual or Corporate Name (Mandatory) j� By; Corporate Officer I (Mandatory, if applicable) `7 11 2_1 q C) I Social Security Number (Voluntary) or i FederalJdentification Number * This license will not be issued unless the certification clause is signed by i - ; - --- the applicant--- Your pplicant. -Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have metAax filing or tax Payment obligations. Licensi;es 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 620, Section 45A. The Commonwealth ofMassachusetts Department of industrial ticcidents Office of Investigations 600 Washington Street Boston, M,4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Dame:, lira'si o -A 9,q 0 0, j k `i rye LCC.. Address: 1 d191nA;h 1i(" -e, �+ City/State/Zip: i`n #0 --�t e j a . P)h Phone #: '721 Are you an employer? Check the appropriate box: Business Type (required): 1.9 1 am a employer with employees (full and/ 5, ❑ Retail or part-time),* 2. ❑ 1 am a sole proprietor or partnership and have no b, [� Restaurant/Bar/Eating Establishment employees working for me in any capacity. 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) [No workers' comp, insurance required] 8• ❑ Non-profit 3, D We are a corporation and its officers have exercised 9, ❑ Entertainment their right of exemption per c, 152, § 1(4), and we have 1p,[] Manufacturing no employees. (No workers' comp. insurance required]* 4, [ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. (No workers' comp, insurance req.) 12.90ther *Any Applicant that checks box N I must also fill ouk the scotion below showing ihcir *«lf ilio corporate ofrJcers have exempted themselves, but the corporation has other workers' compcn$ation policy information. employees, a workers' compensation is organization should chcck boxfl, • - policy required and such An I am an employer that is pro' P ding workers' compensation Insurance for my employees, Belotp is the policy information. Insurance Company Name:_. _Te C - k#)10( y _k)�ur.4.n C_,C C" ,fin _/ in C Insurer's Address; !ROD LJ 9-4 0 d,, V A Policy # or Self ins, Liu,# i C, 3 3t s I Expiration Date: ! �' 1 r -7 Attacb 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, do hereby cerafy, un der the pain�ndpenaltres Ofpedury that the information provided above is true and correct lM P}tone M off1clat use only, -Do not write in this area, to be completed by city or town official City or Town; Pcrmit/License # T Issuing Authority (circle one): 1. Board of T-Tealth 2. Building Department 3, City/Town Clerk 4. Licensing Board S. Selectmen's Office 6, Other Contact Person: Phone www.mass.gov/dia GLOBVIS-01 JHOGAN CERTIFICATE OF LIABILITY I SURANCE DATE(MM/DD!YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 6/6/2016 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(ies) 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 Roblin Insurance AgencyPHONE 144 Gould Street Suite 100 Needham, MA 02494 CONTACT NAME: FAx A/c No Ext : (781 ) 455-0700 A/C No): (781) 449-8976 AIL ADDRESS: certificates@roblininsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Technology Insurance Company INSURED INSURER B : INSURER C: Vision Hampshire LLC dba Holiday Inn 31 Hampshire Street Mansfield, MA 02048 INSURER D: EACH OCCURRENCE $ DAMAGE TO RENTED INSURER E; INSURER F: -----"-"' I�ILVIJIVIV IV VIVI�CR. 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 RESPECTTO 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. INSR ADDL SUBR POLICY LICY EXP EFF PO LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMlDDIYEFF MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- ❑ LOC GENERALAGGREGATE $ PRODUCTS - COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ ' Ea accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _— EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION_ $ X AND EMPLOYERS' LIABILITY Y! N STATUTE EERH E.L. EACH ACCIDENT $ 500 1000 A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N / A TWC3562216 06/01/2016 06/01/2017 (Mandatory in NH)and If yes, describe under E.L. DISEASE - EA EMPLOYE $ 500,000 � E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) W.'I!JUU-ZUg4 ACURu GURPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD Lf1 1. - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield 6 Park Row THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE W.'I!JUU-ZUg4 ACURu GURPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Perm�toOperate aSwimming Pool PERMIT NUMBER: 15 Pool/SPA Certification Date: March 19, 2013 PERMIT EXPIRES: December 31, 2016 pool/SPA Certification Expires: March 19, 2018 Person Certified: MARCIO B. TAKIMOTO 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: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a ❑ Public at: Method of water treatment is ❑ Semi -Public 31 HAMPSHIRE STREET SALINE Bathing load not to exceed: 83 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah Agent ❑ Special Purpose Pool None Date Issued Jr 4 Town of Mansfield - Board of Health DASAf1�`, .y Swimming Pool Application If s3 Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 15 FEE; $125 CJ Public NAME OF OWNER: MANSFIELD HOSPITALITY, LLC HOLIDAY INN POOL OPEPATION: 91 Semi -Public ADDRESS: 31 HAMPSHIRE STREET Cl Special Purpose Pool CITY POOL LOCATION: 31 HAMPSHIRE STREET MANSFIELD STATE: MA ZIP; 0204$ TYPE/POOL; SEMI-PUBLIC TELEPHONE: (508) 339-2200. LENGTH: 62 FAX: VOLUME: 42,666 GALLONS EMAIL; MIN/ MAX DEPTH: 375' FED ID/88 NO_26-1195350- SWIM AREA: 1426 sq ft WATER SOURCE: TOWN Certification Expires Every 5 Years W/W DISPOSAL: TOWN Permit Expires December 31st Yearly_ TYPE OF FINISH: FIBERGLASS PERSON CERTIFIED: MICHAEL P. SCHAMB13URG SCUM GUTTER; NIA Pool/SPA-Certification-Date: --- -- -4/28%2011- - - -- DECKTYPE: CONCRETE Fool/SPA Certification Expires: 4/28/2016 SKMMR WEIR LENGTH; 14' PERSON CERTIFIED: TREATMENT SYSTEM: SALINE P001/SPA Certification Date: DISINFECT METHOD: SALINE Pool/SPA Certification Expires: WIDTH: 23 DIVE AREA: NIA certification remarks(if necessary); CHEMICAL TREATMENT: CHLORINE SAND FILTER _ NUMBER OF BATHERS: 63 REMARKS: ! "NO LIFEGUARD ON DUTY" sign is required, "No Lifeguard on Duty" sign - SIGNATURE: _.. _ _ DATE: , A, 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 o2o48, , -' C'(-, Com ) m NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TVPR OF Pool'. P1JBLIC ❑ SEMI-PUBLIC SPECIAL PURPOSE POOL NAME OF POOL ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY ' L INSPECTION / t # OF GALS METHOD OF WATER I 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. .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 warm g 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 Alkalinity 50-150 m Free Chlorine 1.0-30 m Cyanuric Acid (30-100 ppm) Comb. Chlorine (0.0-0.2 ppm) Water Temp. 1040F. pH level (7.2-78) * 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. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/✓ .34 Closure of he ool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 35.2 THROUGH 435.31. 4 SIGNED SIGNED ��s Ln Op for Board of Health/Health Department