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HomeMy WebLinkAboutCanoe River CG 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: 1 Pool/SPA Certification Date: October 25, 2013 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: October 25, 2018 Person Certified: MARK A. BURMEISTER Pool/SPA Certification Date: October 25, 2013 Pool/Spa Certification Expires: October 25, 2018 Person Certified: PHILIP J. CARROLL 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: CANOE RIVER CAMPGROUND for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: F./I Semi -Public 137 MILL STREET 94 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 i -`�,-- Date Issued ,4 r ; J DEC 1'& 2015 Town of Mansfield Town of Mansfield - Board of ! �k`��h�a�,t�;� ` ``�� 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 1 FEE: $125 NAME OF OWNER: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-6462 FAX: (508) 339-5237 EMAIL: FED ID/SS NO: 04-2375571 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARK A. BURMEISTER Pool/SPA Certification Date: 10/25/2013 Pool/SPA Certification Expires: 10/25/2018 PERSON CERTIFIED: PHILIP J. CARROLL Pool/SPA Certification Date: 10/25/2013 Pool/SPA Certification Expires: 10/25/2018 certification remarks(if necessary): REMARKS:"NO LIFEGUARD ON DUTY" sign is required. ❑ Public POOL OPERATION: 0 Semi -Public ❑ Special Purpose Pool POOL LOCATION: 137 MILL STREET TYPE/POOL: CEMENT LENGTH: 57' WIDTH: 30' VOLUME: 60,000 MINIMAX DEPTH: 3'-10' SWIM AREA: 57'x30' WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CEMENT SCUM GUTTER: DECK TYPE: CEMENT SKMMR WEIR LENGTH: 4 TREATMENT SYSTEM: SAND DISINFECT METHOD: CHLORINE DIVE AREA: NONE CHEMICAL TREATMENT: AUTOMATIC NUMBER OF BATHERS: 94 E'- ti�� DATE: °L �� X s SIGNATURE: _. 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. ` _- NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTAON REPORT r -i CL`T.TT DTTUT It- 1QPPr1A1 PTTRP()QF PC)C)T. rl NAME OF POOL P G ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY a— INSPECTION # OF GALS METHOD OF WATER BATHER # IFEGUARDS I WATER SO CE: 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 & P)tfation systems. Filter Effluent flow meter reading: gpm. # of turnovers .06 Suitable automa is 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 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 Free Chlorine 1A-3. m Cyanuric Acid (30-100 ppm Comb. Chlorine (0.0-0.2W 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 w✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED L SIGNED Operator Board of Health/Health Department 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. 5­7—A/le-LlNJ )A)G. * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 0V -,) 37.s. 71 ** 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 Washing ton Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legjbly Business/Organization Name; 1-;T 4+2 -LI -0 J.-)6 Address: I .3 City/State/Zip: MILL M d k,, C-A-.1J0C 21 U&2 6.)_Oi'SPhone #: Are you an employer? Check the appropriate box: l I am a employer withemployees (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.] ,o.?_ 333 -6`/6__L *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy inrormation. **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; Insurer's Address: a Li, ® L— ✓4- Kim o u 'T AVL . City/State/Zip / _4-A,)D0 , FL. Policy # or Self -ins. Lic. # (D ZZ O q 9 S/V 7 0 0 % 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. Ido hereby certify, under t e pains and penalties of erjury that the information provided above is true and correct Simature: /.��i Date; a 3 / 1�> Phone #: S-09 - 3.37_ 6y6 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 11 Contact Person: Phone M 11 www.mass.gov/aia CERTIFICATE OF LIABILITY INSURANCE DATE (M 7/201 YYY) T TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX COLONIAL INS SERVICES IN 310 N MAIN ST #6 (A/C, No, Ext): (A/C, No): E-MAIL MANSFIELD, MA 02048 ADDRESS: 75W21 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY INSURER B: STARLIN, INC. DBA CANOE RIVER CAMPGROUNDS INSURER C: INSURER D: 137 MILL ST INSURER E: MANSFIELD, MA 02048 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE ADD L SUB R POLICY NUMBER POLICY EFF DATE (MM1DDIYYYY) POLICY EXP DATE (MMWDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS MADE 0 OCCUR. MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PROJECT ❑ LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) BODILY INJURY $ (Per person) ALL OWNED AUTOS SCHEDULE AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LIAB R CLAIMS-MADE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION ANDX EMPLOYER'S LIABILITY Y/N UB-0495N75D-15 05/13/2015 05/13/2016 WC STATUTORY LIMITS OTHER E. L. EACH ACCIDENT $ 100,000 ANY PROPERITOR/PARTNER/EXECUTIVE FN__� OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF MANSFIELD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED BOARD OF HEALTH IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED REPR TAAVE MANSFIELD, MA 02048 �C•— r ACORD 25 (2010/05) The ACORD name and logo are registerea marKS of AL;UKU Tao-zu,u m, ,vrcu 1.vmr•vrvwr wrv. mee rrynta ivovv vu. Aj - -1i „u ' i f M a� p� jk W v ® N Er >, CL © k,v,`Y $� Nps �V C �6T„ A .. 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'� .4 1by46 Aa+ 44f4 f tf 1 +�'��ye 1!!4. �4 �„� {{lb ¢A 1 {y 9�l4 A{114 J f1 y4 1 R L I4t ♦ f d<1d I141111Y `4i1�Qb1 Pr114riy 6 4 1 �I 1 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: 2 Pool/SPA Certification Date: October 25, 2013 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: October 25, 2018 Person Certified: MARK A. BURMEISTER Pool/SPA Certification Date: October 25, 2013 Pool/Spa Certification Expires: October 25, 2018 Person Certified: PHILIP J. CARROLL 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: CANOE RIVER CAMPGROUND for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: ❑ Semi -Public 137 MILL STREET CHLORINE 94 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent W Special Purpose Pool None PD=telssued h ? 4 Town of Mansfield - Board of Health Swimming Pool Application NAME OF OWNER: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-6462 FAX: (508) 339-5237 EMAIL: FED ID/SS NO: 04-2375571 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: MARK A. BURMEISTER Pool/SPA Certification Date: 10/25/2013 Pool/SPA Certification Expires: 10/25/2018 PERSON CERTIFIED: PHILIP J. CARROLL Pool/SPA Certification Date: 10/25/2013 Pool/SPA Certification Expires: 10/25/2018 certification remarks(if necessary): C l �, Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 2 FEE: $125 ❑ Public POOL OPERATION: ❑ Semi -Public [] Special Purpose Pool POOL LOCATION: 137 MILL STREET TYPE/POOL: CEMENT LENGTH: 40' WIDTH: 22' VOLUME: 12,000 MINIMAX DEPTH: 3' SWIM AREA: 40'x22' WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CEMENT SCUM GUTTER: NONE DECK TYPE: CEMENT SKMMR WEIR LENGTH: 2 TREATMENT SYSTEM: SAND DISINFECT METHOD: CHLORINE DIVE AREA: NONE CHEMICAL TREATMENT: AUTOMATIC NUMBER OF BATHERS: 94 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: J iz� _ e.. 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. r � NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT -T _ T TTTIT T! M QBILAT DTTRT T(' rl QPR(`TAT P1iRP(-10,F P(-lOT. NAME OF POOL ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY K INSPECTION # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WAUR SOURCE: TREATMENTCALF—OAD Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions or tv21 UMTc 4sD.uuu. 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. y .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulatiofi"ion 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 C/ 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 1 (2.0-6.0 ppm' Cyanuric Acid Water Temp. I 104°F. parts per 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 Tfital Chlorine tree Chlorine Comb. Chlorine pH level Other 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 e- SIGNED Operator Board of Health/Health Department