HomeMy WebLinkAboutRed Roof Inn 12/31/2007TOWN OF MANSFIELD
BOARD OF HEALTH
0X PARK ROW, MANSFIELD 02048
In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts
General Laws, and Regulations established by the Massachusetts Department of Public
Health (105 CMR 435.00). permit is hereby issued to:
Red Roof Inn, Inc. #7274
for the operation of a ❑ Public 12`Semi-Public ❑ Special Purpose Pool
at:
60 Forbes Blvd.
Method of water treatment is: Manually as required
Bathing load not to exceed. 55 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
I Permit No.: 10
Date of Expiration: December 31, 2007
Lo7
Date IssuOP
October 31, 2006
Red Roof Inn, Inc. #7274
P.O. Box 117508
Carrolton, TX 75011
RE: 2007 Swimming Pool Permit
E€„, 2111 Gy 20H
Your current Swimming Pool Permit with the Town of Mansfield expires December 31,
2006. Enclosed are the applications for 2007.
New this year: Please provide Certified fool Operator name and certificate with
license application. Please also review the information I have on file and make any
additions or corrections. All items on the application must be completed.
Please return the signed applications to my attention no later than November 29, 2006.
Sign, date, and enclose check payable to Town of Mansfield, and mail to:
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
If you have any questions or require additional information, please contact me at
(508) 261-7366.
Thank you,
Karen Doucette
Administrative Secretary
Board of Health
Enclosed
Name of Owner: Red Roof Inn, Inc. #7274
Address:
P.O. Box 117508
City:
Carrolton
State: TX
Zip:75011
Telephone:
508-339-2323
Fax:
Operator:
Fed ID/SS No.:
31-1393666
Pool Location:
60 Forbes Blvd.
Type/pool:
Concrete, In -ground
Length: 40'
Width: 20' Volume: 22,000
Min/Max. depth:
3' to 8'
Swim Area:
800sf
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
No. of Bathers:
55
Name of Certified Pool
Operator:
pool maintained.
Permit No.:10
Fee per pool:
$75.00
Permit Expires December 31s' yearly
SIGNATURE: �b-
DATE: ,
RAHealth\Pays Documents\PERMIT APPLICATIONS\SWIMMING POOLS APP.doc
Per daily testing
The Commonwealth of Massachusetts
Department of Industrial Accidents
afte0flayawaffon
600 Washington Stree4 7 h Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit - General Businesses
name ,
address: 1°
city state zip: phone #.
I am a sole proprietor and have no one Business e: M Retail ❑ Restaurant/Bar/Eating Establishment
working in any capacity. 0 Office ❑ Sales (including Real Estate, Autos etc.)
1 m an cm-,!wre-- S'�itii empi^�]ier5 {f ui &pal: tiMe . ❑ t1ii:.eZ
I am an employer providing workers' compensation for my employees working on this job.
company name:Inns,
lyv-
address:
city -° 1 phone #:
❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices:
company name:
address:
city phone M
insurance co. oli # _
companyname:
address•
city phone #: —
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereky certify under *e pains and penalties of perjury that the information provided above is true and correct.
Print name
official use only do not write in this area to be completed by city or town official
city or town: permit/license # (]Building Department
QLicensing Board
❑ check if immediate response is required (]Selectmen's Office
[Health Department
contact person: phone #; ❑Other
(revised SepL 2003)
avL R-
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.
F
sok�nns, Ino -,.
Signature of Individual or
Corporate Name (Mandatory)
Corporate Officer
(Mandatory, if applicable)
** 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
payr ent 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.
r
.! Crrrl/iee! Poo! / spa Operzeroro
as an opr/wrpr Aquatic Rteilirie:� i
CPO®RePistration No 02 Rx i",grl ,is hereby Certified and Registered
by the
NATIONAL SMMMING POOL FOUND.A,TIONon
I
4/30/03
DATECERrV'ltD76a SNW4
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0010646
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
Ti7pF n-17 IXInT • PT TRT Tf' r i RMAT PT TRT .TCOr 4PPMAT . PT TRPnSR 77 77. . n
NAME OF POOL
I IV
ADDRESS
6b 6ieKs
OWNER
ADDRESS
DATE OF
POOL CAPACITYSPE
BY
INSPECTION
3L
# OF GALS
Z Z/
METHOD OF
L
BATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATNIENI'
LOAD
S�5
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 I
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 & ation systems. Filter Efts en ow
meter reading: pm. 00f
turnovers
.Oft 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. Property 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 pod immediately if outlet covers missing,
broken, loose or can be removed without tools
Special purpose pool and wading pools equipped
emergency shut off pump switch. Accessible and
prominently marked.
.09 Cross connections. Portable water supplied through air
gap.
.10 Slimming 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.
pA
.17 Pool supervision - Pool supervision provided.
Effective Jan. 1, 1999, pool supervisor certified as pool
l/
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
Bromine _ ftTo Chlonne_ -
Alkaiini} $_ ree Chlorine
Cyanuric Acid 0400M" A Comb. f1
Water Temp. =1!44° pH level
*parts per million Other
.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 Yk
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
34 (Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
1105 CMR 435.29 THROUGH 435.31.
SIGNEDI SIGNED
Operator Board