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Home My WebLink AboutMilhaus 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: 9 Pool/SPA Certification Date: March 19, 2014 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: March 19, 2019 Person Certified: JOHN M. BURKETT 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: MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE for the operation of a ❑ Public W Semi -Public ❑ Special Purpose Pool at: 150 RUMFORD AVENUE Method of water treatment is AUTOMATIC CHLORINATOR MARC MAC, 22 PSI Bathing load not to exceed: 70 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health .Agent ��j/ -- Date Issued Town of Mansfield - Board of Health t_. Swimming Pool Application NAME OF OWNER: MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE ADDRESS. T"" CITY: (tltMStF STATE: MA ZIP: 02048' C3 G` TELEPHONE: (508) 339-3078 FAX: EMAIL: FED ID/SS NO: 04-6551192 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: JOHN M. BURKETT Pool/SPA Certification Date: 3/19/2014 Pool/SPA Certification Expires: 3/19/2019 PERSON CERTIFIED: Pool/SPA Certification Date: Pocl/SPA Certification Expires: certification remarks(if necessary): Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 9 FEE: $125 ❑ Public POOL OPERATION: D Semi -Public ❑ Special Purpose Pool POOL LOCATION: 150 RUMFORD AVENUE TYPE/POOL: GUNITE LENGTH: 60' WIDTH: 30' VOLUME: 66,000 MINIMAX DEPTH: 4', 7', 10% 14' SWIM AREA: 18,000sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CONCRETE SCUM GUTTER: YES DECK TYPE: CONCRETE16' SKMMR WEIR LENGTH: 4, 8' APART TREATMENT SYSTEM: HAYWOOD 3000 DISINFECT METHOD: AUTOMATIC CHLORINATOR MARC MAC, 22 PSI CHEMICAL TREATMENT: SODIUM HYPOCHLORITE NUMBER OF BATHERS: 70 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. (508) 339-7531 TRUSTEE NUMBER SAMANTHA CONTACT PERSON SIG47-, E: _ y}? �. DATE: %G 110110 Pleasappropriate hanges. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Healtn of-Mansfi d, 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 i 49,x. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, IIIA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information IPlease Print Legibly Business/Organization Name: Address: Z,Lb 6mh& 4 City/State/Zip: fi l Phone #; ) c 3,02 Are you an employer? Check the appropriate box: 1. I am a employer with j 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, *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 that is providing workers' compensation insurance for my employees. Below is the policy information. il Insurance Company Name: 1 .Y 6 & i� -7 -7 0— Insurer's Address; ('_,4- Jej jdt,' ,-)el.,e City/State/Zip: Policy # or Self -ins. Lie. # d ' 7 7 Expiration Date:_ i(, 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�ainst they pi'ator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of tete `01A for insurance coverage verification. I do h"er ;<der the pains andpaniziti5s of perjury that the information provided above is true and correct, 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 ACa pR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 01/20/2016 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(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). PRODUCER01917 - 001 C & S Insurance Agency Inc PO BOX 406 Mansfield, MA 02048 NAME: CO TACT Branch 1917-1 (AJCNE (508) 339-2951 AX (508) 339-2307 A C. No. Ext : AIC. No.: EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: A.I.M. Mutual Insurance Company 33758 INSURED Millhaus At Mansfield Condominium Trust 2 Hampshire Street Ste 100E Foxboro, MA 02035 INSURER B I SURER C : INSURER D INSURER E INSURER F, COVERA GES CERTIFICATE NUMBER: REVISiviv rvurvlcr-rc. 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. LTR TYPE TYPE OF INSURANCE ADDL /NSR SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYY POLICY EXP MMIDDIYYYY LIMITS ACCORDANCE WITH THE POLICY PROVISIONS. GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY AUTHORIZED REPRESENTATIVE / n Annnn nnonnoArini.r All . nl•fc rncnninfi EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Anyone person) $ CLAIMS -MADE OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS - COMP/OP AGG $ NED Ea accidentSINGLE LIMIT $ POLICY EO-- OC AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS TY PerOa PEcRdenDAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ $ A yyoRKERg CYER SLS BILITY w EMPLO S IA YIN OiglCppya�6WUR&T&xECUTJVE[ in NH) NIA VWC-100-6020536-2015A 12120/2015 12/20/2016 X WC STAT U- ER TORY LIMITS ER E.L. EACH ACCIDENT $ 100,0000 E.L. DISEASE - EA EMPLOYEE $ 100,000.00 E.L. DISEASE -POLICY LIMIT $ 500,000.00 �(ffMandatory DYESSGRIPTION O�dOPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) (tAN!`FI I AT!0N t.crti irlklm 1c FIV LV...--_-. ..._._ Town Of Mansfield Attention: Board of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Six Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / n Annnn nnonnoArini.r All . nl•fc rncnninfi lJ 1.700 -LV 1v ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD I 10/26/2009 04:16 5086685201 ALL SEASONS POOL PAGE 02/02 ti - --ja Ik T 11 i. OA f� NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT me I- ter. "CW -%T . nTTnT Tn n Ql7AAT _-DT TRT TO QPP('TAT_ PTTRPORP P()OT. rl NAME OF POOL 011 ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPE INSPECTION V# OF GALS - METHOD OF WATER BATHER # OF IFEGUARDS 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 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: , `` pm. # 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 11No 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* To Chlorine Alkalinity 50-150 ppm Kree Chlorine 1.0-3 m Cyanuric Acid (30-100 ppm) Comb. Chlorine (0.0-0 pp 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 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 Operator SIGNED Board of Health/Health Department