HomeMy WebLinkAboutStation Pointe (2) 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: 5 Pool/SPA Certification Date: April 20, 2012
PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: April 19, 2017
Person Certified: SVETOSLAV A. KAZAKOU
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 [I Public 0 Semi -Public [:1 Special Purpose Pool
at: STATION POINTE APARTMENTS 2 - 9 FRANCIS AVENUE
Method of water treatment is CHLORINE
Bathing load not to exceed: 54 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Scott Leite, Heaah .Agent
Date Issued
MD
Town of Mansfield - Board of Health
Swimming -Pool Application
NAME OF OWNER: fill( mr, �Omrmm et J
r
ADDRESS:
ZIP:
TELEPHONE�C��
FAX:f?�"t`�/j�J
EMAIL: ���t(� �bl�l�►U.�CD��EU�1�COm
FED IDISS NO.
FEE. PER POOL: to 6 (_,:
Certification Expires Every 6 Years.
Permit Expires December 31stYearly.
PERSONCERTIFIEV�3v9fs (1v .iWA.KoV
Poo!/SPA Cortification Date; 4101wi
P001/SPA Corfittcatlon Expires Ly q ��
PERSON OERTIFIEn• �7
Pool/SPA Certification Dam.
Pool/SPA Certification Expires,
cortificMion romarks(if necessary):
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER
FEE: $125
H Public
POOL OPERATION: WSem(•Pub((c
0 Special Purpose Pool
POOL LOCATION.�II�i�
TYPE/POOL: "10 PON,
LI:NGTII:,I��r y-.!
VOLUME:(_
MINIMAX Dr-PTH:,�J'- r7
SWIM AREA;
WATER SOURCE: ton
WIW DIS POSAL:Awf f
WIDTH: V)
TYPE OF FINISH:11 U=1
SCUM GUTTER: 0A,
,
DECK TYPE: �,00o & ,
5KMMR WEIR 4EHGTH: � i ,
TREATMENT SYSTEM;
J
DISINFECT METHOD: C� l�ntl i�Qi
CHEMICAL TREATMENT: ft
NUMBER OF BATHERS:
DIVE AREA: n1k
REMARKS: "NO LIFEGUARD ON DUTY" 51911 Is required.
SIGNATURE:(�. -1d T -- — DATE; -
Please make pp �opriato changes, Sign, date and enclose check payable to Town of Mansfield. Mail to; Board of
Health, Town at, ansfield, Six Park Row, MansJleld, MA 17204(3.
N
31 5 Lo,
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Sivinuning Pool Application PERMIT NUMBER
FEE: $125
NAME OF OWNER:
10
ADDRESS.' �j A
CITY:
STATE: ZIP,
TELEPHONE:
N
FAX:
EMAIL.` 4i Ii t
It
FED IDISS NO: ffr
4,
FEE PER POOL
Certification Expires Every 6 Years.
Permit Expires December 31st Yearly.
PERSON CERTIFIED.
poolISPA Ceiffication Date: ' � 1- 1
PoolISPA Certification Expires
PERSON CERTIFIED; lviictl,i,I Ii
U
poolISPA Certification Date: G
poo[ISPA Ceilifloation Expires: 'f,
1,kj
certification rainarks(If necessary):
REMARKS:
"No LIFEGUARD ON DUTY" sign is required.
[] Public
POOL OPERATION: MSemi-Pubf(c
EB Special Purpose Pool
POOL LOCATION '!! 11 I tt.
Ji P", fl-IYj !,,- i, ,f
"I I
:'l
TYPEIPOOL:
WIDTH,
IDTH:i
VOLUME.
MIN/MAX DEPTH;
SWIM AREA,
WATER SOURCE:
WIWDISPOSAL .
TYPE OF FINISH:
SCUM GUTTER:
DECK TYPE*
SKMMRVJ0RtE9GT"*.
TREATMENT SYSTEM:
DISINFECT METHOD:
CHEMICAL TREATMENT.
4
NUMBER OF BATHERS' f
DIVE AREA
Ar
6
SIGNATURE:r ji DATE:
Please make appiopfiate changes. Sign, date and enclose check payable to Town Of Mansfield. Mall to: Board of
Health, Town OffiAnslield, 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.
{
Signature of Individual or
r
Corporate Name (Mandatory)
By: C - orate Officer
(Mandatory, if applicable)
*" Social Security Number (Voluntary) or
Federal* Identification Number
* This license will nbt 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
International Life-guard TraininqPro ram TM
I 1�
Personal Information
Last Name:
First Name:
Middle Name:
Date of Birth:
Certificate Number.
1-O��(a Ci)V-0V
1rkrj=C�rG
L ;1t1
iC �l'3 j�,-;�..
101-300-1033-2953
Mailing Address:
City:
State/Province:
Postal Code:
v.1~c��h�C�1�
�J:c.�hrc3p
KkA
02t52,
Country:
Email:
Home Phone: Work Phone:
Course Information
ILTP Course Type: (Please Check One) Training Course Type:
❑ Shallow Lifeguard [Pool Lifeguard ❑ Special Lifeguard 0 New - Original ElRenewal
I
❑with Open Water
Shallow Lifeguard Pool Lifeguard Special Facilities Lifeguard
Training includes conscious, unconscious and Training includes conscious, unconscious and suspected Training includes conscious,unconscious and
suspected neck and back rescue skills forwater depths neck and back rescue skills for water depths not suspected neck and back rescue skills for water
not to exceed 5 feet, excluding open water exceeding 16 feet -excluding open water environments. depths not exceeding 16 feet including wave pools
environments. AAOSlACEP (Emergency Care & AAOS/ACEP (Emergency Care & Safety Institute- and open water environments. AADS/ACEP
Safety Institute-ESCi.org) Healthcare Provider ESCLorg) Healthcare Provider CPR, AED, Oxygen (Emergency Care & Safety Institute-ESCI-org)
CPR, AED, Oxygen Administration and Standard First Administration and Standard First Aid training included. Healthcare Provider CPR, AED, Oxygen
Aid training included. Administration &Standard First Aid training included.
Training Center of Record: City; State:
ILTP - Continental Pools, Inc Savage MD
Completion Date:
Expiration Date:
ILTPTM Course Completion Acknowledgment.
I acknowledge that I have received and understand the ILTP ",1 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 R Associates and/or ILTPT"' does not
provide any protection whatsoever to my employer or
myself.
Lifeguard Name (Please Print):
Lifegua i41nforf�atioj�
ro
ILTPT11 InstructorValid _ ion
I hereby certify that the holder of this ILTP TM Course Completion Credential has successfully met all required skills competencies (including but not
limited to Prerequisite screening, rescue skills, BLS Skills, written
and practical exams) and curriculum requirements as prescribed by the
Intemational Lifeguard Training ProgramTM for the lifeguard classification indicated above. I have also reviewed the ILTPT'" Course Completion
Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment.
Max Water Depth:
ftJm updated Max Water Depth: ft/m Instructor Name: InstructorID:_ _ Date:
Instructor Name (Please Print):
Instructor Signature:
/V i`v in
For additional information regarding the International Lifeguard Training Program"N 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(ld)ieliis.com
Distribution: This certificate is issued from Jeff Ellis &Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 1/2011
=r Ellis & Associates ILTPTM Course Completion
International Lifeguard Trainin Pro ram TM
Course Information
ILTP Course Type: (Please Check On) Training Course Type:
[] Shallow LifeguardPool Lifeguard [] Special Lifeguard 0 New -Original
❑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.
i raining center of Record:
iLTP - Continental Pools, Inc
Completion Date:
Pool Lifecluard
Training includes conscious, unconscious and suspected
neck and back rescue skills for water depths not
exceeding 16 feet -excluding open water environments.
AADS/ACEP (Emergency Care & Safety Institute-
ESCI_org) Healthcare Provider CPR, AED, Oxygen
Administration and Standard First Aid training included.
Special Facilities Lifeguard
Training includes consdous,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: State:
Savage I MD
Expiration Date: --ti
ILTPTM Course Completion Acknowledgment
I acknowledge that I have received and understand the ILTPTM 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
ILTPTra 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 ILTPI does not
provide any protection whatsoever to my employer or myself.
Lifeguard Name (Please Print): Lifeguard Si nature:
ILTPTM Instructor Validation Information
---- '"•••r•"`"'•• --- 1n—I „tea auk. t.p b, u„y Ier du requlreo slcflls competencies (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 ProgramTM for the lifeguard classification indicated above. I have also reviewed the ILTPT"' Course Completion
Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment.
Max Water Depth: ft/m Updated Max Water Depth: ft/m Instructor Name: InstructorID; Date:
Instructor Name (Please Print): Instructor Signature:
��(%C..�=- i V f •> - ��L'`�Y'L54�_�-1 TCS 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: businesslaDiellis.com
Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 1/2011
Personal Information
Last Name:
rte`
First Name:
Middle Name:
Date of Birth:
Certificate Number:
aiMailing
a
06 � ci%hi�'_
101-300-1033-2956
Address: _
City:
=State/Province:
Postal Code:
Country:
Email:
Home Phone:
Work Phone:
r
Course Information
ILTP Course Type: (Please Check On) Training Course Type:
[] Shallow LifeguardPool Lifeguard [] Special Lifeguard 0 New -Original
❑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.
i raining center of Record:
iLTP - Continental Pools, Inc
Completion Date:
Pool Lifecluard
Training includes conscious, unconscious and suspected
neck and back rescue skills for water depths not
exceeding 16 feet -excluding open water environments.
AADS/ACEP (Emergency Care & Safety Institute-
ESCI_org) Healthcare Provider CPR, AED, Oxygen
Administration and Standard First Aid training included.
Special Facilities Lifeguard
Training includes consdous,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: State:
Savage I MD
Expiration Date: --ti
ILTPTM Course Completion Acknowledgment
I acknowledge that I have received and understand the ILTPTM 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
ILTPTra 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 ILTPI does not
provide any protection whatsoever to my employer or myself.
Lifeguard Name (Please Print): Lifeguard Si nature:
ILTPTM Instructor Validation Information
---- '"•••r•"`"'•• --- 1n—I „tea auk. t.p b, u„y Ier du requlreo slcflls competencies (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 ProgramTM for the lifeguard classification indicated above. I have also reviewed the ILTPT"' Course Completion
Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment.
Max Water Depth: ft/m Updated Max Water Depth: ft/m Instructor Name: InstructorID; Date:
Instructor Name (Please Print): Instructor Signature:
��(%C..�=- i V f •> - ��L'`�Y'L54�_�-1 TCS 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: businesslaDiellis.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 ofInvestigations
600 Washington Street
Boston, MA 02111
,Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeLibly
Business/Organization Name:
Address:
City,
Are you an employer? Check the appropriate box:
1. ❑/ I am a employer with 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 co_*poration 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 #:
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11. ❑ Health Care
12❑"xOthery �� f/i�'�€�.f:� �.�.'�`z_
'Any applicant that checks box #1 must also fill out 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.
r am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company N
Insurer's
:�ity/State/Zip:
?olicy # or Self -ins. Lic. #
Expiration Date.
kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
::�ailure 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
)f 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 the pains and penalties ofperjury that the information provided above is true and correct.
ii afore
Qn it 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 S. S61ectmen's Office
6. Other
Contact Person:
Phone #:
1 0
A" R'D CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIODNYYY)
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•
PHONE , 602-707-1900 FAx 480-333-6973
E-MAIL
INSURERS AFFORDING COVERAGE NAIC #
Phoenix AZ 85016-4266
INSURERA:AXIS Surplus Insurance Company 26620
EACH OCCURRENCE $1,000,000
INSURED
INSURER B: First Mercury Insurance Company 10657
INSURER c:Navigators Insurance Company 42307
Continental Pools, LLC
8520 Corridor Rd., #B
Savage, MD 20763
INSURER D: Ohio Casualty Insurance Company 24074
!NSURERE:Liberty Mutual Fire Ins. Co. 123035
INSURER F: Liberty Surplus Insurance Corp10725
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOSAUTOS
NON -OWNED
X HIRED AUTOS rAUTOS
r-nveDAn=Q CGDTIFICATF NIIMRFD• 1770808447 RFVISION Nl1MRFR-
vTHIS 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 i
LTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EFF
MMIDD
POLICY EXP
MMIDD
LIMITS
F
x COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
100001724606
10/25/2015
10/25/2016
EACH OCCURRENCE $1,000,000
DAMAGE TORENTED
PREMISES Eaoccunerice $1,000,000
MED EXP (Any one person) $
PERSONAL & ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY � PES a LOC
OTHER:
GENERAL AGGREGATE $2,000,000
PRODUCTS -COMP/OPAGG $2,000,000
Policy Aggregate $$10,000,000
E
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOSAUTOS
NON -OWNED
X HIRED AUTOS rAUTOS
AS2661066678025
10/25/2015
10/25/2016
Eo MB�NBED ent)SINGLE LIMIT $1,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Peraccldent
$
A
X
UMBRELLA IAB
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
ANY PROPRIETORIPARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WA766DO66678015
10/25/2015
10/25/2016x
---
PER OTH-
STATUTE ER
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
SF15EXC7613611V
EC01656322216
10/25/2015
10/25/2015
10/25/2015
10/25/2016
10/25/2016
10/25/2016
Each Occ/Aggregate $10,000,000
Each OcdAggregate $10,000,000
Each Occ/Aggregate $10,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
rFDTIGIceTF t401 nFR CANCELLATION
O 1988-ZU14 AC:UKL] I:UKVUKA I IUN. AH rlgnts reservea.
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
Savage MD 20763•-
AUTHORIZED REPRESENTATIVE
O 1988-ZU14 AC:UKL] I:UKVUKA I IUN. AH rlgnts reservea.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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
SIGNED
Board of Health/Health Department
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
TVPP !lP P(1(lT • PT TRT T(' rl CPTifT-PT TRT T(' rl CPP( TAT. PT TRP(ICP. POOT. rl
NAME OF POOL
ADDRESS
OWNER
ADDRESS
DATE OF
POOL CAPACITY
INSPECTED BY
INSPECTION
�}
# OF GALS
METHOD OF WATER
BATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATMENT
LOAD
I
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" V" 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 circulati 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
.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 unm*1 I I Total Chlorine
Cyanuric Acid (30-100 ppm)
omb.
Chlorine
pH level
Water Temp. 1040F,
Other
* arts 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