HomeMy WebLinkAboutRed Roof Inn 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
[Pe�rttto Operate a Swimming Pool
PERMIT NUMBER: 10 Pool/SPA Certification Date:
PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires:
Person Certified: HILARY EASTER
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:
for the operation of a ❑ Public
at:
Method of water treatment is
Bathing load not to exceed.
BW RRI LLC
❑ Semi -Public
60 FORBES BLVD.
AUTOMATIC CHLORINE
55 bathers
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
Scott Leite, Health .Agent
❑ Special Purpose Pool
None
(,-
Date Issued
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Swimming Pool Application PERMIT NUMBER 10
FEE: $125
NAME OF OWNER: BW RRI LLC
ADDRESS: THE RED ROOF BUILDING 605 S. FRONT ST
CITY: COLUMBUS
STATE: OH ZIP: 43215
TELEPHONE: (614) 744-2600
FAX: (614) 225-5214
EMAIL: KMORGAN@REDROOF.COM
FED ID/SS NO: 47-3368497
Certification Expires Every 5 Years.
Permit Expires December 31st_Yearly
.
PERSON CERTIFIED: RICHARD A. WARDELL
Pool/SPA Certification Date: 5/15/2015
Pool/SPA Certification Expires: 5/15/2020
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pooj/SPA Certification Expires:
certification remarks(if necessary):
REMARKS: "NO LIFEGUARD ON DUTY" sign is required.
❑ Public
POOL OPERATION: Semi -Public
Special Purpose Pool
POOL LOCATION: 60 FORBES BLVD.
TYPE/POOL: CONCRETE IN -GROUND
LENGTH: 40' WIDTH: 20'
VOLUME: 22,000
MINIMAX DEPTH: S to 8'
SWIM AREA: 800 sq. ft. DIVE AREA: NONE
WATER SOURCE: TOWN
W/W DISPOSAL: TOWN SEWER
TYPE OF FINISH: GUNITE
SCUM GUTTER: NONE
DECK TYPE: NONE
SKMMR WEIR LENGTH: TWO BASKETS
TREATMENT SYSTEM: DIATOMACEOUS
DISINFECT METHOD: AUTOMATIC CHLORINE
CHEMICAL TREATMENT: MANUALLY AS REQUIRED
NUMBER OF BATHERS: 55
SIGNATURE �pDATE:
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.
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.
`" (;ea rd
* Signature -of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
� � " 3-�)(P84 1 t �
** 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 aUthorityr of Mass. General Laws; Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
02 Department of Industrial Accidents
Office of Investigations
9 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legjbly
Business/Organization Name:
Address: 6i) V70 rbe5 —?_-Aud
City/State/Zip: MASA6 f' M4- W®lj K Phone #: 6 K " 33 q " 03a3
Are you an employer? Check the appropriate box:
1. [�1 am a employer with cQ O 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. ❑ RestaurandBar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
IL n Health 4;t�
12.L Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
**Ifthe 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: UD 11 � (S � ��' �C t J_A C
Insurer's Addre
City/State/Zip:
Policy # or Seli
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, under the pains and penalties of perjury that the information provided above is true and correct,
Signature Date:
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/dja
Client#' 64975
4WESTGLO
mull./rxuDATE
CERTIFICATE OF LIABILITY INSURANCE
(MM/DDIYYYY)
03/4/2016
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
Willis of Oregon, Inc.
CALIC#0464609 (503) 224-4155
222SW Columbia Suite - 600
CONTACT
NAME:
503 224 TSS— -----503-274--2455
AIC No Ext):
E-MAIL
ADDRESS:-----
DDRESS;_222
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A. The First Liberty Insurance Corporation 33588
Portland, OR 97201
INSURED
Red Roof Inns, Inc.
The Red Roof Building
605 S Front Street
Columbus, Ohio 43215
INSURER B :
-
INSURER C : __
-"
INSURER D:_
INSURER E
- —
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 CONTRACTOR 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 INSURANCE
ADDL
INSR
POLICY NUMBER
WVD _
POLICY EFF
MM/DDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITYOF
EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES (Ea occurrenceL$
MED EXP (Any one person) $
_
CLAIMS-MADEI I OCCUR
PERSONAL & ADV INJURY $
GENERAL AGGREGATE I$
PRODUCTS -COMP/OP AGG $
GEN'L AGGREGATE LIMIT APPLIES PER:
COMBINED SINGLE LIMIT
Ea accident _ $
RO-
1POLICY JEO CT _! LOC
AUT
AUTOMOBILE LIABILITY
Irr I_ _-$
BODILY INJURY (Per person) $
ANY AUTO
BODILY INJURY (Per accident) $
_i ALL AUTOS OWNED F _.. SCHEDULED
AUTOS
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE $
Per accident)
-
UMBRELLA LIAB i
OCCUR
--
-
EACH OCCURRENCE 1$
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
�. DED_ RETENTION $
T
!'
N / A
WC6-641-437760-015
I I
I I'I
A
-
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y!N
ANY PROPRIETOwaARTNER,EXECunve
09/06/2015
09/06/2016
WC STATU ! OTH-
X TORY LIMITS ER
E.L. EACH ACCIDENT $1,00(],000
OEnCERAEMUER EXCLUDED? N
�
(Mandatory In NH)
E.L. DISEASE -EAEMPLOYEE $1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
__..-.. _.
-
E.L. DISEASE -POLICY LIMIT $1,000,000
—._
-1 _ -._- ______
III III
I
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
"Workers Comp Information"
Voluntary Compensation; Other States Coverage
RE: Evidence of Insurance
LOC: 60 Forbes Blvd Mansfield, MA 02048
CERTIFICATE HOLDER
Red Roof Inns #10274
C/O Hilary Easter
60 Forbes Blvd.
Mansfield, MA 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD
T' ,
POOL OPERATIoM MAMAGEMENTO
May 20, 2016
Hilary Uastcr
6 Mee.tinglaouse Patit
)4iddleborn. MA 02346
Dear Tlilary,
t`t�nruzl,tttnns italitrt vt tri°sttc essiUl coEttlaietiitin ol'tiit ('t ft'i"IFII;Is i'00IJSFF
,)PEltATOR Course! 1 httl% that y�rta XI)c6 tt "t u r :: pmm ec one You will hi
re o iviug your c;erhficaiton 1,110M ihr V itit?141! SiviMU Mw Riot Psruntliitiou %vi(hi i
rr-S t'ee ks.
YOU i11) use this letie.r;ts proor of tcrtiii atitxt until Your ("-rtifi at.~;arrives,
The ne.ttisoiking through Yate classtt m";'all ht' a v;rltrable Ic"cml'e to you and visiting
��ivea ,j�t� lopc titiizritttl ut;tgernt=.Wxoiu. YOU ttrC also i11vit0d It- your knowledge. by
1?sirttc.tpatjnp to (tuutr t,`k:RTIFIFT3 1'00USPA C)E'FR IT)k courses.
As a 110tyi student, you are eligible for discounted services_ 'You can have. one of our CPO
instructors aid you in making yourjob easier and your facility safer. Call ug to schedule. an
inspection of your facility. Also, he sure to visit our website to find all the C110 products and
services you need to run a sale facil ity.
Thank you for your participation. If you should aced aur Services it) the fuwle,
please cojitact us.
Sincerely.
Trevor Sherwood
Vice President
68 ff—MM OS ROAD a BRICK, NJ C
23 0 1'1-10(111; -iT2-,15 1--1040-d FAX T32-4Si.
�II�I%tliHlti3Cl�t�lCtSl.t;ptll
Jane Doucette
From:
Kristen Morgan <KMorgan@RedRoof.com>
Sent:
Thursday, April 21, 2016 12:54 PM
To:
Jane Doucette
Subject:
RE: MANSFIELD POOL PERMIT
Attachments:
Fw: CPO INFORMATION - NEEDED
Hi there, Jane:
Just as a matter of following up, I wanted to shoot you over a copy of the confirmation e-mail our General
Manager, Hilary Easter, received for registering for the course. She is all set to take the training on May 19-20.
Let me know if you have any questions.
Thank you,
Ra poor Iza
Kristen N. Morgan I Legal Assistant
P 614.744.2683 1 F 614.225.5214
Red Roof Inns, Inc. • The Red Roof Building • Red Roof Building
605 South Front St. • Columbus, OH 43215
kmorgan(LOredroo£com ( redroof.com
BEST
Confidentiality Notice
This electronic mail transmission is privileged and confidential and is intended solely for the party to whom it is
addressed.
From: Jane Doucette[mailto:Jdoucette@mansfieldma.com]
Sent: Friday, April 01, 2016 10:23 AM
To: Kristen Morgan <KMorgan@RedRoof.com>
Subject: RE: MANSFIELD POOL PERMIT
Yes I need the individual certification papers,
From: Kristen Morgan [mailto:KMorgan{-)RedRoof,coin]
Sent: Friday, April bI, 2016 10:01 AM
To: Jane Doucette
Subject: RE: MANSFIELD POOL PERMIT
Hi there, Jane:
Are you looking for copies of the individual's certification papers? I apologize, but I'm new to assisting with
this permit, and just want to be sure we're getting you exactly what you need.
Thank you,
��� ri• '. _'� PIS.,...
Kristen N. Morgan I Legal Assistant
P 614.744.2683 1 F 614.225.5214
Red Roof Inns, Inc. • The Red Roof Building • Red Roof Building
605 South Front St. • Columbus, OH 43215
I<morgannredroof.com redroo£com
l l
yt4t.
BEST
ux�ron+x r<:,
w
Confidentiality Notice
This electronic mail transmission is privileged and confidential and is intended solely for the party to whom it is
addressed.
From: Jane Doucette [mai Ito: Jdoucette(@,n-iansfieIding. coin
]
Sent: Friday, March 25, 2016 8:36 AM
To: Kristen Morgan <KMorganr RedRoo£com>
Subject: MANSFIELD POOL PERMIT
Just to let you know I cannot process the pool permit for the Red Roof Building until I receive copies of the
pool/spa certificate for the person certified. Thanks, Jane
Jane Doucette
From:
I0274 <I0274@RedRoof.com>
Sent:
Thursday, April 21, 2016 12:43 PM
To:
Kristen Morgan
Cc:
Mark Aston
Subject:
Fw: CPO INFORMATION - NEEDED
see attached
Hilary Easter I General Manager Inn #274
P 508.339.2323 F 508.337.6733
Red Roof Inns #i0274 • 60 Forbes Blvd.• Mansfield, MA 02048
i0274(o)redroof.com I www.redroof.com
Confidentiality Notice
This e-mail message is intended by Red Roof Inns, Inc. for use only by the individual or entity to which it is addressed.
From: Kimberly Sherwood <pom4info@gmail.com>
Sent: Tuesday, April 19, 2016 11:18 AM
To: 10274
Cc: Latoya Proctor
Subject: CPO INFORMATION - NEEDED
PLEASE - Note our book policy below. You must either respond to this email with a home address or a written
statement saying you accept our book policy. Until we receive either, the book will not be sent.
We have received your registration for Pool Operation Management's CPO course
ON: MAY 19-20,2016
AT: DAYS INN MIDDLEBORO, 30 E CLARK STREET, MIDDLEBORO, MA
Once a home address is provided or the book policy is accepted, the handbook, directions, sample schedule and
confirmation letter will be mailed. In the event that it is within 2 weeks of the scheduled class, you will receive your book
the first day of class from the instructor. Class is from 8:30 am - 5 pm. Please bring a photo ID, basic calculator
(CELLPHONE CALCULATORS ARE NOT PERMITTED DURING THE EXAM), pen and paper. You can also visit our
website at www.pooloperationmanagement.com to check out sample problems from the exam. Any questions, please call
me at 732-451-1040.
REFUND POLICY: In the event that you cannot attend, a efuod may be requested 14 days before the course. However,
there is $35 cancellation fee. Within 14 days of the course or if you fail to attend, no refund will be given. ONLINE
TRAINING IS NON-REFUNDABLE.
BOOK POLICY: Books are only shipped to the home address. If the book is lost by the recipient when shipped to the
home address, a new book must be purchased for $65.00.If you want the materials shipped to the business address and
they are lost by either the shipper or recipient, a new book must be purchased for $65. Books will not be sent during the
late period, which is the two weeks before the start of the class.
FOR MORE POLICIES: Please visit: http://pooloperationmanagement.com/about/policies/
Thanks,
Kimberly Sherwood
Manager
Pool Operation Management
Brick, NJ 08723
732-451-1040
www.pooloperationmanagement.com
Please take notice of our new email addresses. Please add POM41NFO(pD_GMAIL.COM to your safe sender's list.
***********************
The contents of this email are to be used for informational purposes only. if you choose to use this information
for application at your own facility, it is at your own discretion. Pool Operation Management is not responsible
for any actions that you may take at your own facilities, at your place of work or your lives as a result of utilizing
this information. Recipient agrees to indemnify and hold harmless POM, its officers, agents and employees
against and from all occurrences, suits, demands, claims, damages or costs of suits including attorney's fees.
Jane Doucette
From:
10274 <10274@RedRoof.com>
Sent:
Thursday, April 21, 2016 12:43 PM
To:
Kristen Morgan
Cc:
Mark Aston
Subject:
Fw: CPO INFORMATION - NEEDED
see attached
Hilary Easter I General Manager Inn #274
P 508.339.2323 F 508.337.6733
Red Roof Inns A0274 + 60 Forbes Blvd.* Mansfield, MA 02048
i0274C%redroof.com I www.redroof.com
Confidentiality Notice
This e-mail message is intended by Red Roof Inns, Inc. for use only by the individual or entity to which it is addressed.
From: Kimberly Sherwood <pom4info@gmail.com>
Sent: Tuesday, April 19, 2016 11:18 AM
To: 10274
Cc: Latoya Proctor
Subject: CPO INFORMATION - NEEDED
PLEASE - Note our book policy below. You must either respond to this email with a home address or a written
statement saying you accept our book policy. Until we receive either, the book will not be sent.
We have received your registration for Pool Operation Management's CPO course
ON: MAY 19-20,2016
AT: DAYS INN MIDDLEBORO, 30 E CLARK STREET, MIDDLEBORO, MA
Once a home address is provided or the book policy is accepted, the handbook, directions, sample schedule and
confirmation letter will be mailed. In the event that it is within 2 weeks of the scheduled class, you will receive your book
the first day of class from the instructor. Class is from 8:30 am - 5 pm. Please bring a photo ID, basic calculator
(C LLPFI®NE CALCULATC►RS A E N®T PERMITTED DURING THE_EXAM pen and paper. You can also visit our
website at www.pooloperationmanagement.com to check out sample problems from the exam. Any questions, please call
me at 732-451-1040.
REFUND POLICY: In the event that you cannot attend, a refund may be requested 14 days before the course. However,
there is $35 cancellation fee. Within 14 days of the course or if you fail to attend, no refund will be given. ONLINE
TRAINING IS NON-REFUNDABLE.
BOOK POLICY: Books are only shipped to the home address. If the book is lost by the recipient when shipped to the
home address, a new book must be purchased for $65.00.If you want the materials shipped to the business address and
they are lost by either the shipper or recipient, a new book must be purchased for $65. Books will not be sent during the
late period, which is the two weeks before the start of the class.
FOR MORE POLICIES: Please visit: http://pooloperationmanagement.com/about/ policies/
Thanks,
Kimberly Sherwood
Manager
Pool Operation Management
Brick, NJ 08723
732-451-1040
www.Doolor)erationmanaqement.com
Please take notice of our new email addresses. Please add POM41NFO@,GMAIL.COM to your safe sender's list.
The contents of this email are to be used for informational purposes only. If you choose to use this information
for application at your own facility, it is at your own discretion. Pool Operation Management is not responsible
for any actions that you may take at your own facilities, at your place of work or your lives as a result of utilizing
this information. Recipient agrees to indemnify and hold harmless POM, its officers, agents and employees
against and from all occurrences, suits, demands, claims, damages or costs of suits including attorney's fees.
NAM OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPEQTION REPORT
mvnn nc nnnT . vrruT To n "'PAn-PTTRT T(' K3r gPFCTAT. PT TRP( -)CF. POOT, 171
NAME OF POOL
ADDRESS
OWNER
ADDRESS
DATE OF
POOL CAPACITY
I
INSPECTED BY
_
INSPECTION
- # OF GALS
METHOD OF WATER
V. IWO BATHER
# OF LIFEGUARDS
WATER SO E:
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/ 01
latch 4 ft above ground.
.04 Sewage Disposal oe
.05 Location, structural stability, finish. _
.06 Water circulationation systems. Filter Effluent flow
meter reading: ttqpm. # 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. Jz'
.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
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
*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
III pljjj�ii
Total Chlorine
Free 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.
,Y
SIGNED SIGNED
Operator Board of Health/Health Department