HomeMy WebLinkAboutMansfield Meadows 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: 7 Pool/SPA Certification Date: September 14, 2012
PERMIT EXPIRES: December 31, 2016 pool/SPA Certification Expires: September 13, 2017
Person Certified: DARKO STANKOVIC
Pool/SPA Certification Date:
PoollSpa 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:
BEACON COMMUNITIES, LLC
for the operation of a ❑ Public
at:
Method of water treatment is
Bathing load not to exceed:
❑� Semi -Public
12 BONNEY LANE #9
CHLORINE TABLET
51 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
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Swimming Pool Application PERMIT NUMBER 7
FEE: $125
❑ Public
NAME OF OWNER: BEACON COMMUNITIES, LLC POOL OPERATION: W Semi -Public
❑ Special Purpose Pool
ADDRESS: 12 BONNEY LANE #9
POOL LOCATION: 12 BONNEY LANE #9
CITY: MANSFIELD
STATE: MA ZIP: 02048
TYPE/POOL: MAIN
TELEPHONE: (508) 339-3357
LENGTH: 40' WIDTH: 22'
VOLUME: 36,300 GAL.
FAX: (508) 339-9761
EMAIL: INFO@CONTINENTALPOOLS.COM
MINIMAX DEPTH: T- 8'
FED ID/SS NO: 52-2069090
SWIM AREA: 440 DIS
WATER SOURCE: TOWN
Certification Expires Every 5 Years.
W[W DISPOSAL: TOWN SEWER C
Permit Expires December 31st Yearly.
TYPE OF FINISH: PAINT
0
S eou/c
PERSON CERTIFIED:
SCUM GUTTER: N/A
`i
Pool/SPA Certification Date:`311L la
DECK TYPE: CONCRETE
Pool/SPA Certification Expires:atj3'd `
SKMMR WEIR LENGTH: 8"
PERSON CERTIFIED:
TREATMENT SYSTEM: DE
Pool/SPA Certification Date:
DISINFECT METHOD: CHLORINE TABLET
Pool/SPA Certification Expires:
certification remarks(if necessary):
CHEMICAL TREATMENT: CL220 FEEDER
NUMBER OF BATHERS: 51
REMARKS: "NO LIFEGUARD ON DUTY" sign is required.
SIGNATURE: `_ C - --- - _ 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.
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.
f
cc �`
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Offi er
(Mandatory, if applicable)
* -,�20,f;J-,2 c),3 J
** 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
1 Congress Street, Suite 100
Boston, MA 02114-2017
s ,•W www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: High Sierra Pools Inc
Address:
City/State/Zip:
2704 Columbia Pike
Arlington, VA, 22204 Phone #: 703-920-1750
Are you an employer? Check the appropriate box:
I. ❑ 1 am a employer with employees (full and/
or part-time),*
2. ❑ 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.0 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. nRestaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.0 Health Care
12.❑ Other
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation poucy uuormauon.
"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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: HMS Insurance Associates Inc
insurer's Address:
20 Wight Ave Suite 300
City/State/Zip: Hunt Valley, MD, 21030
Policy # or Self -ins. Lic. # 30WELJ4825 Expiration Date. 03/01/2017
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, r toter the p, j a r allies �` 'nry that tine information provided abov is true and correct.
1-605-8337
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.guvium
American
Red Cross
Certificate of Completion
Dmitrij Zvizdeckij
has successfully completed requirements for
Bloodborne Pathogens _ valid 1 Year
Training
Lifeguarding/First _ valid 2 Years
Aid/CPR/AED
conducted by
American Red Cross
❑ ❑
Date Completed: 02/22/2016
Instructors: Michal Gasko, Simona 0�4
Nekorancova Certificate ID: GSVPEG
To verify, scan code or visit:
redcross.org/confirm
American
Red Cross
Certificate of Completion
Michal Chovan
has successfully completed requirements for
Bloodborne Pathogens _ valid 1 Year
Training
Lifeguarding/First _ valid 2 Years
Aid/CPR/AED
conducted by
American Red Cross
D
Date Completed: 02/22/2016
Instructors: Michal Gasko, Simona 0.0
Nekorancova Cerlificate ID: GSVPDW
To verify, scan code or visit:
redcross.org/Confirm
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
mcrnr nn -��T . nTTnT Tn n QVA4T_D1TRT Tf- i QPF('TAT. PT TRP()QF. POM. n
NAME OF POOL
a mc*W • ,P
ADDRESS
OWNER
ADDRESS
DATE OF
INSPECTION
f a7#
POOL CAPACITY
OF GALS
INSPECTED BY
I t l
METHOD OF WATER
TREATMENT
-
BATHER
LOAD14
# OF LIFEGUARDS
WATER SOURCE:
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: n 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
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
Alkalin 50-150
m
ee Chlorine
1.0-3.0 m
ii
Cyanuric Acid (30-100 ppm)
Comb.
Chlorine
(0.0-0,2 pp );oo
Water Temp. 104°F.
pH level
(7.2-78)
* parts per million I
Uther
.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
i
J
REGULATION
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
Operator
SIGNED
of Health/Health Department