HomeMy WebLinkAboutMansfield Children's C. 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: 8 Pool/SPA Certification Date: April 16, 2014
PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: April 16, 2019
Person Certified: KEVIN J, FALLON
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 CHILDREN'S CENTER
for the operation of a ❑ Public
at:
Method of water treatment is
Bathing load not to exceed:
Fvj Semi -Public
1100 SCHOOL STREET
CHLORINE
43 bathers
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
Scott Leite, Weaah .Agent
❑ Special Purpose Pool
►=G m
Date Issued
Town of Mansfield
Town of Mansfield - Board of Health s Park Row
Mansfield, MA 02048
Swimming Pool Application PERMIT NUMBER 8
FEE: $125
NAME OF OWNER: MANSFIELD CHILDREN'S CENTER
ADDRESS: 1100 SCHOOL STREET
CITY: MANSFIELD
STATE: MA ZIP: 02048
TELEPHONE: (508) 339-9211
FAX:
EMAIL:
FED ID/SS NO: 042 725 4541
Certification Expires Every 5 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED: KEVIN FALLON
Pool/SPA Certification Date: 4/16/2014
Pool/SPA Certification Expires: 4/16/2019
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS:, "NO LIFEGUARD ON DUTY" sign is required.
❑ Public
POOL OPERATION: 0 Semi -Public
❑ Special Purpose Pool
POOL LOCATION: 1100 SCHOOL STREET
TYPE/POOL: SEMI-PUBLIC
LENGTH: 41' WIDTH: 25'
VOLUME: 30,000
MIN/MAX DEPTH: 3'
SWIM AREA: 1000sf DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: PRIVATE
TYPE OF FINISH: LINER
SCUM GUTTER:
DECK TYPE: 5' CEMENT
SKMMR WEIR LENGTH: 2 SKIMMERS
TREATMENT SYSTEM: DIATOMACIOUS EARTH
DISINFECT METHOD: CHLORINE
CHEMICAL TREATMENT:
NUMBER OF BATHERS: 43
SIGNATURE: ,. B-� DATE:
Please make appropriate changes. Sign, date and enclose check payable to To n 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.
:ign*6fe of Individual or
Corp fate 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, IMA 02111
Iwww.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:IMAs di "e(A ��il1'(��•����J' ('. �r—
Address: [10(f
City/State/Zip:
r� I dt-,SAI&V Met 00-0 Phone #:
Are you an employer? Check the appropriate box:
1. �I am a employer with r 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, auto, etc.)
B. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
II.❑ Health Care
12.EOtheric �'r^
*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.
Insurance Company Name: U f-t'e a M"
Insurer's Address: 1Uf Ftz��xr¢ ,IRt' �crl
City/State/Zip;
Policy # or Self -ins, Lic. # U 66 6-i- Expiration Date: de 6'
Attach a copy of the workers' compensation policy declaration page (showing the policy number a d 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 cerl5p6K er the�aws
Si ature: //
Phone #: 5 v _ _73 !k —
�gs of perjury that the information provided above is true and correct
r,arA. l 21,12 // Ir -
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
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Utica Mutual Insurance Company
NAME OF INSURANCE COMPANY
201 Edgewater Place, Suite 295 Wakefield, MA 01880
ADDRESS OF INSURANCE COMPANY
2066058 10-07-2015 10-07-2016
POLICY NUMBER EFFECTIVE DATES
Wm. F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 781-293-6331
NAME OF INSURANCE AGENT ADDRESS PHONE #
MANSFIELD CHILDREN'S CEN 1100 SCHOOL STREET MANSFIELD MA 02048
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
WC 7506h (8-10) Wolters Kluwer Financial Services I Uniform Forms TM
Rev. 8/00
Massachusetts
Form ST -5 Department of
Sales Tax Exempt Purchaser Certificate Revenue
Part 1. Exempt taxpayer information
To be completed by exempt government or 501(c)(3) organization.
Name H. i2ead Inc. /dtal Nanzl eM Cht.2dAen'z CenteA
Address
9100 SchooX St2ee.t
city State Zip
!'lans��e2d NA 02048
Exemption number
042-725-454
Issue date Certificate expires on (date)
07/29/06 071 9196
Certification is hereby made that the organization named above is an exempt purchaser under Massachusetts General Laws, Chapter 64H, sections 6(d)
or 6(e). All purchases of tangible personal property or services by this organization are exempt from taxation under said chapter to the extent that such
property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or
any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation.
Signature Ti Date
Warni9j.: Wi)(ful misuse of this/certificate may result in criminal tax evasion sanctions of up to one year in prison and $10,000 ($50,000 for
corpo atio s) in fines.
Part 2. Agent information
To be completed by agent of exempt government or 501(c)(3) organization.
Name of agent's organization
Address
City State Zip
Agent's name
Address
City State Zip
I certify that in making this purchase. I am acting as an agent for the exempt organization named above (select one):
❑ Government organization (local public school, city/town government, state agency, etc.).
Attach Form ST -2, if available. If Form ST -2 is not available, enter exemption number, if known:
❑ 501(c)(3) organization (parochial school, Scout troop, etc.). Form ST -2 must be attached.
Signature Title Date
Part 3. Vendor information
Signature Title Date
Check applicable box:
❑ Single purchase certificate (attach detailed receipts or complete Part 4, on reverse)
❑ Blanket certificate
This form is approved by the Commissioner of Revenue and may be reproduced.
"WI-Ift-Ift
MASSACHUSETTS DEPT. OF REVENUE
PO Box 7010
Chelsea, MA 02150-7010
ill#Ili##Illi#I .ti
.ALAN LeBOVIDGE, COMMISSIONER
TERESA O'BRIEN-HORAN, DEPUTY COMMISSIONER
H READ INC $7oc No lee 30048
1100 SCHOOL STEx
, ion
MANSFIELD MA 02048-2036 lnl_ : `ber 042 725 454
Da a i31i/05/D6 �
Bu p au T5D MGT t;ERV
Phone (617) 887-6367
Dear Taxpayer,
A review of our records indicates that the Massechusetis sales/tise .t x exemption for .REAi31NC , a
tax-exempt 501(c) (3) organization, will expire on 7,201136;
The Department of Revenue is issuing this notice in lieu of a new�Fpr 1'St=2, "Certificate of Exemption".
The notice verifies that the Massachusetts Department of Revenue ;(gas ,mewed the sales/use tax
exemption for H READ INC subject to the conditions stated in Massachirsatts General Laws, Chapter
64H, sections 6(d) or (e), as applicable.
The organization remains responsible for maintaining its exempt status and for reporting any loss or
change of its status to the Department of Revenue. Absent the Department of Revenue's receipt of
information from the taxpayer by the expiration date of the current certificate that the entity no longer
holds exempt status under the above provisions, the taxpayer's certificate is renewed. This renewal will
expire on. 07/29/96.
The taxpayer's existing Form ST -2, in combination with this renewal notice may be presented as evidence
of the entity's continuing exempt status. Provided that this requirement is met, all purchases oftangible
personal property by the taxpayer are exempt from sales/use taxation under Chapter 64H or I
respectively, to the extentAhat such property is used in the conduct of the purchaser's business.
Any abuse or misuse of this notice by any tax-exempt organization or any unauthorized use by any
individual constitutes a serious violation and will lead to revocation. Willful misuse of this notice is
subject to criminal sanctions of up to one Year in prison and $10,000 in fines ($50,000 for
corporations),
This notice may be reproduced.
Sincerely,
Alan LeBovidge
Commissioner of Revenue
7 `<m m
a=0In--
0 A
N WR
0
o$OmxQ.�
CD
o� o °am
a � CD
0 CD
m "mac
o=ID 0-00
>3
03�r-
�C
O m ::r
IN
..oc'-tea
0.• a °
v M C m p D
7 i= m N
M 1 7 —VD
7 •~—� 0
a N m a
!.op m n
cn® a='0 m
m0a'=amm
m X o o a.
» CO a m
CL
oi0 m "-m
CD � � � %D— :
CD 34D
fn G g m M W m
O < 3
0
:3 CD
o��
C,
, - 0 m
< w m CD
"�
m f'ccn
X
m
m c m m
fr C)
O's m'.Qc
\ rn
A! Km
o D m a
O
h `o.
-u
.r C) Ar. >
mss -
O
_ m -0
f+U)
m rt
s
z
�mO13c_
O
X
K
° m r
m
m
DI
vroD"�
w
oo�o-
r0
m`ow
Z
° a-0
mm5mm
m
m
z
�n w �A
w+c
9jmaS
K
m �Q�S
o F rov
� =m
April 30, 2014
Kevin J. Fallon - Certification Number: CPO -188453
1132 School Street
Mansfield, MA 02048
Hello, Kevin
Congratulations on achieving your Certified Pool / Spa Operator® (CPO®) certification. We are proud
you have earned a CPO® certification, the most widely accepted training program in the world! Please
continue to use the NSPF® Pool & Spa OperatorTM Handbook to expand your knowledge, and to
maintain high standards to keep the pools you care for open and safer.
NSPF is here to help!
While your instructor should be a constant source to answer questions and provide resources in your
community, NSPF also provides several resources to help you become more effective.
3 You will receive the periodic Prevention AdvisorTM eNewsletter that provides information on
prevention topics, emerging issues in the industry, and the health benefits of aquatic activity. If
you did not include your email address on the CPO Certification exam, please sign up at
www.nsp£org under the Resources tab.
Q The Resources section of the NSPF website has lots of information to -help you stay ahead:
• State and County Codes
• RWI Prevention Toolkit
• Compliance with the VGB Pool & Spa Safety Act -
• Compliance with the Americans with Disabilities Act
• Model Aquatic Health Code Updates
• Articles & Research Links -
Pool operators can be more -efficient by downloading the Pool Service Manager ADor'lPhones
and Androids. Just go to the Google Play Store or iTunes and search for National Tolimming Pool
Foundation. Download and use at no charge for the -first -month.
f
Please inform us if you change your contact information by sending an mail to service2c ns�f.org. Thanks -
for all you do to keep pool environments safe.
1
Sirely, {_
� 0 s
CPW Certification
oma M. Lachocki, _
Chief Executive Officer ` Name.c Kevin-J.17,166�
D#e Certified: April 11
Certific�atior(Number 0188453 ,
x
Instructor. Name=}ReR elrg
CertifirCatrdin x�ir-ps^ �S r�l�
n .
REGULATION I
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
SIGNED
Board of Health/Health Department
P
M
P
"NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
T'VPF nF AnnT • PTTPT Tr, n -,PMLPTTTtT.T(' RPF.C'.TAT. PTTRPOQF. POOL ❑
NAME OF POOL
DRESS
OWNER
ADDRESS
DATE OF
POOL CAPACITY
INSPECTED BY
INSPECTION
# OF GALS
}
f"
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 "v"' 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 circulatio ation systems. Filter Effluent flow
meter reading: fipm. # 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.
1
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 warnin
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
TPKI Chlorine
Bromine 2.0-6.0 m*
4ree Chlorine
Alkalinity 50-150 m)
Comb.
Cyanuric Acid (30-100 ppm)',
Chlorine
vH level
Water Temp. 104°F.
*parts per million 1
.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