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HomeMy WebLinkAboutCedar Heights 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: 13 Pool/SPA Certification Date: March 20, 2013 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: March 20, 2018 Person Certified: MICHAELLA J. (JOHNSON) SAMPS 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. CEDAR HEIGHTS ❑� Semi -Public 10 CONNORS AVENUE Foroffluoya-0114 61 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 o Town of Mansfield - Board of Health G. �. 14 Swimming Pool Application NAME OF OWNER: CEDAR HEIGHTS ADDRESS: 10 CONNORS AVENUE CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 337-0040 FAX: (508) 337-0042 EMAIL: FED ID/SS NO: 56-2332456 Certification Expires Every 5 Years. Permit Expires December 31st Yearly PERSON CERTIFIED: MICHAELLA J. (JOHNSON) SAMPSON Pool/SPA Certification Date: 3/20/2013 Pool/SPA Certification Expires: 3/20/2018 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 13 FEE: $125 ❑ Public POOL OPERATION: Semi -Public ❑ Special Purpose Pool POOL LOCATION: 10 CONNORS AVENUE TYPE/POOL: GUNITE/PLASTER LENGTH: 42'6" WIDTH: 27' VOLUME: 27,510 GALLONS MIN/MAX DEPTH: 375' SWIM AREA: 917 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: PLASTER SCUM GUTTER: NONE DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8 1/2" TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 61 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. MICHALLA JOHNSON - AGENT OF CEDAR HEIGHTS SIGNATURE:...�'��'_`e�/✓�'��2'C.,.--_ d DATE: t { ru L L r, t 4 (E ti�vbC fG( 4 Please - Please make appropriate changes. Sign, date and e%iclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: '/ Ln t-& t- City/State/Zip: I_ Phone 4: C 33 7 " QJL t employer? Check the appropriate box: Ar7111at Business Type (required): 1. a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ R taurant/Bar/Eating Establishment 2. F]I am a sole proprietor or partnership and have no 7, ice and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity, 8, Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. [_1 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] 1 *Any applicant that checks box # I must also fill ouf 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: C)h (Z- F - Insurer's Address: � LZ, Policy # or Self -ins. Lic. # Expiration Date: 5 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 here certify, under t(re pains and !ties of perjury that the information provided above is true and correct. Qionahire• &I 6 Date: Z% 81 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 Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www,mass.gov/dia Phone #: TRAVELERS ONE TOWER SQUME HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-2D63148-7-15) RENEWAL OF (IEUB-2D63148-7-14) INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 1. INSURED: CEDAR HEIGHTS,LLC DBA SEE ENDORSEMENT WC 99 06 01 34 BELLOWS RD RAYNHAM MA 02767 NCCI CO CODE: 12637 PRODUCER: GLOVER-PADULA INS INC 16 MAIN ST EAST GREENWICH RI 02818 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-25-15 to 08-25-16 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 07-15-15 GS OFFICE: BOSTON SOUTH MA 853 PRODUCER: GLOVER-PADULA INS INC 32964 DIRECT BILL 011 l { i 4 � f S _,7%`"-3. i5'J� ii.: ( �t }•, _"'a '`a„',_' Did§ �t� yff��-�j! 'Tt;r �i�s"'t t k��T���.J��� r t; t 3 ,. i •� �� ii9 � fri xr..C.§""Z3'.-.�•:er'kj'i�tiyr i5ss:; { i f MAY AT ays +A SQA ''i t ,� _c4 �•- .� W . �' .�' � �tr •ter - p a POW l � 1 The Village at Cedar A Thrner Properties Apartment Community www.CedarHeightsMansfield.com December 18, 2015 Board of Health Town of Mansfield Attn: Jane Doucette 6 Park Row Mansfield, MA 02048 Certified Mail, Return Receipt Requested RE: 2016 Swimming Pool Permit Enclosed please find a completed Swimming Pool Application, Worker's Compensation Insurance Affidavit, Insurance Policy Declaration Page, a copy of my CPO Certificate, tax Certification Form and a check in the amount of $125.00. Should you have any questions or require anything further, please feel free to contact the office. Thank you, Michaella J. Samps , , Property Manager NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 'TVPP nP PnnT _• PT TRT .TC` 171SRMT-PT TRT .IC SPE.CTAT. PT IR POSE POOL ❑ NAME OF POOL ADDRESS OWNER ADDRESS DATE OF POOL CAPACITY INSPECTED BY {{ L INSPECTIONN1, # OF GALSt`` Tt METHOD OF WATER A BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENTOAD - Regulation 105 CMR 435.000 The items marked below with an "X'indicateqhe 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 tv .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 wamin 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 m Free Chlorine 1.0-3.0 rn Cyanuric Acid (30-100 ppm Comb. Chlorine (0.0-0.2 ppm) , Water Temp. 104°F. pH level (7.2-7.8) *parts per million I Pther .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( I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED Operator SIGNED Board of Health/Health Department 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°< a * Signature of Individual or ' Corporate Name (Mandatory) 1-a 61— i By: Corporate ff' er I > (Mandatorycif applicable) ��'���� ����� ���� � � �� s u ** 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.