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HomeMy WebLinkAboutStation Pointe (1) 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: 6 Pool/SPA Certification Date: April 20, 2012 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: April 19, 2017 Person Certified: SVETOSLAV A. KAZAKOV 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: BEACON COMMUNITIES, LLC for the operation of a ❑ Public V Semi -Public ❑ Special Purpose Pool at: STATION POINTE APARTMENTS 1 - FRANCIS AVENUE Method of water treatment is CHLORINE Bathing load not to exceed: 71 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Scott l Bite, 9-featth .Agent -Cl cif Date Issued Town of Mansfield f Townof MansfieldBoardof I�teartlr G Park Flow y Mansfield, MA 02048 r ,{ Sfvi nlilring Pool ool Applr ication PERMIT NUMBER FEE: $125 Public NAME OF OWNER:f���,�i tf���J �� POOL OPERATION: Q�Seml-Pub((c JJ11�� i}/�� p� `��I/1 b [L EB Special Purpose Pool ADDRESS-* 9 f rltl,r),& Avmub CITY: �/tUf111�� 1d STATE: N��{ ZIP: TELEPHONE; `�t� FAX: _.20 R+A to FED IDISIS~NO: 52 to qM FEE PER POOL:' 12.jr�2Q Certification Exuires Eyery !; Years, Permit Expires December 31stYearlY, PERSON CER7(F(ro's etelav K41awv Pool/SPA Codifiontlon Dato: , Ff J /Vo i I/ f?oollSt'A Corllftcallon Explies: ;j 1lgf avi,7 PERSON CERTIFIED: I Poo!/SPA Certification pate: POOUSPA Certification Expires: corlilicavon romarks(if necessary): REMARKS: "No LIFEGUARD ON DUTY" 91911 is required. POOL LOCATION&f1ho' n Voi* 'pomw I. TYPE/POOL: main poo( LENGTH: 4`61 VOLUME: Y. q MINIMAX DEPTH: i SWIM AREA:��� WATER SOURCE•. tow n W/W DISPOSAL:C�mf TYPE OF FINISH: 1 imr SCUM GUTTER: n/01 DECKTYPE: W umi t' SKMMfi W GiR L1wNGTH,. 0 WIDTIi: 'I / TREATMENT SYSTEM: b C• DISINFECT METHOD: CHEMICAL TREATMENT: to a NUMBER OF BATHERS: 1' DIVE AREA: 010, SIGNATURE:._ ,..-/%I tii�. _�l_ DATE — Please make pp oprialo, changes. Sign, date and enclose check payable to Town of Mansfield. Mall to: Board of Health, Town f jilsfield, Six Park Row, Mansfield, MA 02048. P Town of Mansrie rd of Health Id - Boa 00 IN/ A A Swimming Pool Application NAME OF OWNER: 'o ADDRESS:� qq� i", V CITY STATE -" ZIP: TELEPHONEV, FAXtt -1 r EMAIL - U -A FEE PER POOL: Certification Expires Every 6 Years. Permit Expires December 31sf Yearly. IN PERSON CERTIFIED. kv tk ,I �k PoO11SPA Certification Date: PoolISPA Cotiffication Expires. ', f VE Y 't PERSON CERTIFIED, ;&: j 3 v poolISPA Certification Date: Ii" 1- 14 poomSPA Certification Expires., certification remarks(If necessary): REMARKS .No LIFEGUARD ON DUTY" sign is required. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $125 H Public POOL OPERATION: MSeml-Pubfic [g Special Purpose Pool POOL LOCATION:,_ TYPEIPOOL: fA LENGTH: J44! VOLUME -'- -All T MIN/MAX DEPTH:, 15 - SWIM AREA: f J WATER SOUROE-. WIW DISPOSAL : ­4 d TYPE OF FINISH:'q-B SCUM GUTTER: DECK TYPE: "W SKMMR WF`IR L'Et4GTiA*. TREATMENT SYSTEM: �4 DISINFECT METHOD: "I A', CHEMICAL TREATMENT: NUMBER OF BATHERS:i')Ji I WIDTH, DIVE AREA fi/yf— DATE; SIGNATURE:, ;4- Z Please make opprbpliate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of*ansfield, Six Park Row, Mansfield, MA 02046, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State fax returns and paid all State taxes required under law. Signatureof "individgal or Corporate Name (Mnda 63 Y: Co o ate Officer (M ndatory, if applicable) ** Social Security Number (Voluntary) or pederaf 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. Ellis & Associates ILTPTM Course Completion nternational Lifeguard Trainim Prog rain TM Personal Information Last Name: i First Name: Middle Name: Date of Birth; Certificate Number: can, l on s -j 11,-1-/IntA* 1 �{ a�3 101-300-1033-2960 Mailing Address: City: State/Province: Postal Code: Country: Email 7 Home Phone: Work Phone: Course Information ILTP Course Type: (Please Check One) Training Course Type: ❑ Shallow Lifeguard [Pool Lifeguard [] Special Lifeguard New - Original I [I Renewal ❑with Open Water Shallow Lifeguard Training includes conscious, unconscious and suspected neck and back rescue skills forwater depths not to exceed 5 feet, excluding open water environments. AAOS/ACEP (Emergency Care & Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Pool Lifeguard Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet -excluding open water environments. AAOSIACEP (Emergency Care & Safety Institute- ESCI_org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Special Facilities Lifeguard Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet including wave pools and open water environments. AAOSIACEP (Emergency Care & Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Administration & Standard First Aid training included. City: State: ILTP - Continental Pools, Inc Savage I MD Completion Date: Expir tion Date: 0b C) l b ��21 �20 "7 1LTPT11 Course Completion Acknowledgment I acknowledge that I have received and understand the ILTPT` Training Program curriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPTM course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM does not provide any protection whatsoever to my employer or myself. Lifeguard Name (Please Print): Lifeguard Signature: i.�Gi�:xlj i�c�nTr,�ian2 s7V Gr��{ ILTPTM Instructor Validation Information I hereby certify that the holder of this ILTP T'" Course Completion Credential has successfully met all required skills competencies (including but not limited to Prerequisite screening, rescue skills, BL.S Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramT'A for the lifeguard classification indicated above. I have also reviewed the ILTPT"l Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment. Max Water Depth:_,!L_ft/m Updated Max Water Depth:_ ft/m Instructor Name: InstructorID: Date: Instructor Name (Please Printf: Instructor Signature: For additional information regarding the International Lifeguard Training ProgramTm please call or write to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business(abiellis.com Distribution: This certificate is issued from Jeff Ellis & Associates. Inc. Corporate Headquarters, Kingwood, TX. Revised 112011 r Ellis & Associates ILTP TM Course Completion International Life uard Training Pro ram TM L t H Course Type: (Please [] Shallow Lifeguard Shallow Lifeguard Course information Pool Lifeguard Special Lifeguard Owith Open Water Pool Lifeguard Training includes conscious, unconscious and suspected neck and back rescue skills forwaterdepths not to exceed 5 feet, excluding open water environments. AADS/ACEP (Emergency Care & Safety institute-ESCLorg) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. I raining Center of Record: ILTP - Continental Pools, Inc Completion Date: Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet -excluding open water environments. AAOS/ACEP (Emergency Care & Safety institute- ESCl,org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Iraining Course Type: 1 New - Original I ❑ Renewal Special Facilities Lifeguard Training includes conscious,unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet including wave pools and open water environments. AAOS/ACEP (Emergency Care & Safety Institute-ESCLorg) Healthcare Provider CPR, AED, Oxygen Administration & Standard First Aid training included.. City:I State: Savage MD Expiration Date: 312 G/Zo; 7 ILTPT"' Course Completion Acknowledgment I acknowledge that I have received and understand the IL I PTM Training Program curriculum and demonstrated said skills and knowledge to required competencies. 1 further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPTM course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM does not provide any protection whatsoever to my employer or myself. Life card Name (Please Print): j u I I a'-) St tv'-' Lifeguard Signature- �j- %4'��.r►aa. -A ILTPTM Instructor Validation Information I hereby certify that the holder of this ILTP TM Course Completion Credential has successfully met all required skills competenctes (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training Program"" for the lifeguard classification indicated above, I have also reviewed the ILTPTM Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment, Max Water Depth; S --ft/m Updated Max Water Depth; ft/m Instructor Name: InstructorID: Date: Instructor Name (Please Print}; Instruct IgnatUre: jS., y For additional information regarding the International Lifeguard Training Program TM please call or write to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business(rjellis com Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 1/2011 Personal Information Last Name: i 1 V ( First Name: Middle Name: Date of Birth: Certificate Number: J CO Y-) 2 NZ 101-300-1033-2958 Mailing Address: W u'e, 5i City: . i tlu t7 to r7 State/Province: (��- G Postal Code: 02-7 1 b Country: „ U 5 r`- Email: Jul, (Zvi srt iv200cc Ycaioo-C Home Phone: .'� Work Rhone: L t H Course Type: (Please [] Shallow Lifeguard Shallow Lifeguard Course information Pool Lifeguard Special Lifeguard Owith Open Water Pool Lifeguard Training includes conscious, unconscious and suspected neck and back rescue skills forwaterdepths not to exceed 5 feet, excluding open water environments. AADS/ACEP (Emergency Care & Safety institute-ESCLorg) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. I raining Center of Record: ILTP - Continental Pools, Inc Completion Date: Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet -excluding open water environments. AAOS/ACEP (Emergency Care & Safety institute- ESCl,org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Iraining Course Type: 1 New - Original I ❑ Renewal Special Facilities Lifeguard Training includes conscious,unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet including wave pools and open water environments. AAOS/ACEP (Emergency Care & Safety Institute-ESCLorg) Healthcare Provider CPR, AED, Oxygen Administration & Standard First Aid training included.. City:I State: Savage MD Expiration Date: 312 G/Zo; 7 ILTPT"' Course Completion Acknowledgment I acknowledge that I have received and understand the IL I PTM Training Program curriculum and demonstrated said skills and knowledge to required competencies. 1 further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPTM course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM does not provide any protection whatsoever to my employer or myself. Life card Name (Please Print): j u I I a'-) St tv'-' Lifeguard Signature- �j- %4'��.r►aa. -A ILTPTM Instructor Validation Information I hereby certify that the holder of this ILTP TM Course Completion Credential has successfully met all required skills competenctes (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training Program"" for the lifeguard classification indicated above, I have also reviewed the ILTPTM Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment, Max Water Depth; S --ft/m Updated Max Water Depth; ft/m Instructor Name: InstructorID: Date: Instructor Name (Please Print}; Instruct IgnatUre: jS., y For additional information regarding the International Lifeguard Training Program TM please call or write to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business(rjellis com Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 1/2011 The Commonwealth of Massachusetts Department of Industrial Accidents Office,of Investigations 600 Washington Street Boston, MA 02111 UTSN www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeLribly Business/Organization Name: Address City/State/Zip:,t Are you an employer? Check the appropriate box: l." I am a employer with tt` 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.] Phone #Iq :d�� Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit Q. ❑ Entert,alnrnent 10. ❑ Manufacturing 11.❑ Health Care Other, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy in ormation. **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. Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: :�ity/State/Zip r` # y Expiration Date: ?olic # or Self -ins. Lic. #. - €F kttach 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 .me 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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to.the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify, under (lepains and penalties of perjury that the information provided above is true and correct P >iQnature�` ¢ Date 3` 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 S. Selectmen's Office 6. Other Contact Person: Phone #: ,-- , ® A R� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/22/2015 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 Alliant Insurance Services, Inc. 2415 East Camelback Rd Suite 420 CONTACT NAME: PHONENo 602-707-1900 FAX 480-333-6973 E-MAIL AnnPFqR- INSURERS AFFORDING COVERAGE NAIC # Phoenix AZ 85016-4266 INSURERA:AXIS Surplus Insurance Company 26620 10/25/2016 - INSURED INSURER B: First Mercury Insurance Company 10657 INSURER C:Navi ators Insurance Company 42307 Continental Pools, LLC INSURERD:Ohio Casualty Insurance Company 24074 8520 Corridor Rd., #B Savage, MD 20763 INSURER E:Liberty Mutual Fire Ins. Co. 23035 INSURER F: Liberty Surplus Insurance Corp10725 Policy Aggregate $$10,000,000 r-nvcoArncc CERTIFICATE NUMBER' 1770808447 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS rF x COMMERCIALGENERALLIABILITY CLAIMS -MADE ❑X OCCUR 100001724606 10/25/2015 ' 10/25/2016 - EACH OCCURRENCE $1,000,000 DAMAGE TO PREMISES EaENT-Ewocence $1,000,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY a j RO- CT I—XI LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 Policy Aggregate $$10,000,000 E AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X X NON AUTOS -OWNED HIRED AUTOS AS2661066678025 10/25/2015 10/25/2016 CEO aBBI EDccid'n SINGLE LIMIT $1,000,00_0 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROaPE de DAMAGE $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE ELU790250012015 10/25/2015 10/25/2016 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED I I RETENTION $ $ E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY - Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OF EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WA766DO66678015 I 10/25/2015 10/25/2016; X STATUTE ETH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 B C D Excess GL/EL Excess Auto Excess Liability NJEX000005872901 SFI5EXC7613611V ECO1656322216 10/25/2015 10/25/2015 10/25/2015 10/25/2016 10/25/2016 10/25/2016 Each Oce/Aggregate $10,000,000 Each Occ/Aggregate $10,000,000 Each Occ/Aggregate $10,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof Of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. Continental Pools, LLC 8520 Corridor Road, Ste B AUTHORIZED REPRESENTATIVE Savage MD 20763 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD .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' Alkalinity 50-150 m` Cyanuric Acid (30-100 ppm) Water Temp. 1040x. *parts 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 M VIN ')total Chlorine Free Chlorine Comb. Chlorine vH level NAME OF CITY 01t TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 'PV -DV nD DnnT • DT TRT TO 1-1 RFT AT -PT TRT Tr CPFCTAT. PTTRWAR PnnT. 11 NAME OF POOL e*hl birJ SS OWNER ADDRESS DATE OF �=+ POOL CAPACITY INSPECTED BY INSPECTION # OF GALS METHOD OF WATER BATHER # OF LIFjEGUARDS WATER SOURCE: TREATMENT LOAD ( 1 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: 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 REGULATION NO, THE SPACE BELOW DESCRIBES VIOLATIONS fAARKED ABOVE X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. t SIGNED OP er�ator SIGNED Board of Health/Health Department