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HomeMy WebLinkAboutHoliday Inn 12/31/2007TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 PERMIT TO OPERATE A SWIMMING POOL In accordance with the provisions of Chapter 111. Section 127,4 of the Massachusetts General Laws, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00). permit is hereby issued to: Mansfield Realty Limited Partnership for the operation of a ❑ Public ❑ Semi -Public ❑ Special Propose Pool at: 31 Hampshire St. 11 Method of water treatment is: 10 lb Chlorinator 11 Bathing load not to exceed: 6 to 8 bathers I Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 4 Date of Expiration: December 31, 2007 Scott Leite, Health Agent Date Issued Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 76' Min/Max. depth Swim Area: Dive Area: TOWN IBOARD O SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Mansfield Realty Limited Partnership 31 Hampshire St. Mansfield Zip:02048 508-339-2200 04-3282038 31 Hampshire St. Semi Public Width: 26' 3' to 5' 1,976 sf None Volume: 40,000 Water Source: Town W/W Disposal: Town Sewer Type of Finish: Fiberglass over gunite Scum Gutter: Lower and Upper Deck Type: Plaster Skmmr weir length: 16" Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: 301b auto feed chlorinator No. of Bathers: 83 Name of Certified Pool Operator: Paul A. Robbins Permit No.:3 Fee per pool: $75.00 Per�rrut pares December 31St yearly Mansfield ReaAL*d Partn tt pi , by its General Partner, Mansfield Realty Corporation SIGNATURE: -- Daniel Frank, President DATE: 11/17/2006 Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, NIA 02048. RAHeaithTaPs DocumentAPERMIT APPLICATIONSXSNIMMING POOLS APP.doc Name of Owner: Address: City: State: MA Telephone: Fax: Mansfield Realty Limited Partnership 31 Hampshire St. Mansfield Zip:02048 508-339-2200 Fed ID/SS No.: 04-3282038 Pool Location: 31 Hampshire St. Type/pool: Hot Tub Length: 15' Round Width: Min/Max. depth: 4' Swim Area: N/A Dive Area: N/A Water Source: Town W/W Disposal: Town Sewer Type of Finish: Marble with Tile Scum Gutter: N/A Deck Type: Brick Skmmr weir length: 16" Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: 101b Chlorinator No, of Bathers: 6 to 8 Volume: 500 Name of Certified Pool Operator: Paul A. Robbins Permit No. A Fee per pool: $75.00 Mansfield ReVLimited eisp; ypi ss eReea�bVaitC YeY ' field Realty Corporation SIGNATURE Daniel Frank, President DATE: 11/17/2006 Please make appropriate changes. Sign, date and enclose check -payable to Town ofMansfteld. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. RAHealth\Pafs Docoments\PERMIT APPLICATIONS\SWIMMING POOLS APP.doc NAME OF CITY OR TOWN STATE SANITARY CODE : CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TV -DP nT: PnnT • Pt TRT TP n CFMI-PI TRT .W. qPF.('1A1.P1TRP0VV.P00T. n NAME OF POOL ADDRESS ._ OWNER ADDRESS DATE OF --7 POOL CAPACITY 1N$PEC ED BY INSPECTION 4� # OF GALS` METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT(r�,v <s LOAD. 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 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: qpm. # 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 C A-. .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. a " .17 Pool supervision - Pool supervision provided.jE 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 Q 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 Chlorine Cyanuric Acid Water Temp. 104°1. * artspr 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 :N` • �7 N3 Oow e W Q 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UUT Boston, MA 02111 wwiv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lel4ibly Business/Organization Name: Mansfield Realty Limited Partnership d/b/ai Holiday Inn Mansfield Address: 31 Hampshire Street City/State/Zip: Mansfield, MA 02048 Are you an employer? Check the appropriate box: 1. ® I am a employer with 150 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 #: 508-339-2200 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. El Health Care 12.® Other Hotel *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. I an: an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Liberty Mutual Insurer's Address: Riverside Office Park, 13 Riverside Road. City/State/Zip: Weston, MA 02493 Policy # or Self -ins. Lic. # WC7-111-257344-026 Expiration Date: 05/01/2007 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 covere verification. I do hereby cer , under the pai atq'p :allies of perjur that the information provided above is true and correct Mansfield Real t ited P rt ship its �enerai Part r,-MansfieldRealty Corporation Si anahrre- Date: 11/17/2006 781-431-1108 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: www.mass.gov/dia Phone #: One Washington Street, Suite 402 Wellesley, Massachusetts 02481 Tel: 781-431-1108 - Fax: 781-431-7130 Via UPS Overnikhht November 20, 2006 Board of Health Town of Mansfield Six Park Row Mansfield, MA 02048 Licensee Mansfield Realty Limited Partnership Location Holiday Inn Mansfield Re: 2007 Annual License Renewal Applications To Whom It May Concern: Enclosed please find the following documents in connection with the renewal for the above referenced property: 1.) Swimming Pool Permit Renewal Application, 2.) Application fee in the amount of $75.00 3.) Hot Tub Permit Renewal Application 4.) Application fee in the amount of $75.00 5.) WC insurance affidavit and certificate and Tax Certification. 6.) Certified Pool Operator Certificate for Paul Robbins. Please do not hesitate to contact me if you have any questions. Sincerely; A i Y a h m94r Encls.