HomeMy WebLinkAboutMansfield Depot II 12/31/2007TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
In accordance with the provisions of Chapter II L 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:
Village at Mansfield Depot II
for the operation of a ❑ Public ; Semi -Public ❑ Special Purpose Pool
at:
Mansfield Depot II
Method of water treatment is: Automatic Chlorinator
Bathing load not to exceed: 43 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Permit No.: 6
Date of Expiration: December 31, 2007
Name of Owner: Village at Mansfield Depot II
Address:
14 Page Terrace
City:
Stoughton
State: MA
Zip:02072
Telephone:
508-339-3533
Fax:
Cement Slab
Fed ID/SS No.:
04-2995014
Pool Location:
Mansfield Depot II
Type/pool:
Semi -Public
Length: 40'
Width: 20' Volume: 27,000
Min/Max. depth:
4' to 5'
Swim Area:
20x40'
Dive Area:
bone
Water Source:
Town
W/W Disposal:
Town Sewer
Type of Finish:
Printed Vinyl
Scum Gutter:
N/A
Deck Type:
Cement Slab
Skmmr weir length:
2 skimmers
Treatment System:
Hayward DE -3600 Earth Filter
Disinfect Method:
Chlorinating Sticks, Ph Minus and Plus,
Chemical Treatment:
Automatic Chlorinator
No. of Bathers:
43
Name of Certified Pool Operator: C�
Permit No.:6
Fee per pool: $75.00
Permit. Expires December 31s` yearly
SIGNATURE:
DATE: �lD
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, MA 02048.
RAHealthTafs DocumentsTERMU APPLICAMNSVSWIMMING POOLS APP.doc
certify under the penalties of penury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
Signature Individual or
Corporate Name (Manila
,orpo e Officer
(MghdAtory, if applicable)
Social SecurityNumber (Voluntary) or
� ry) �
Federal Identification Number
* This license will not be issued unless the ceifflication 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 dbligations. 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office et1INVS99890fi s
600 Washington Street' 7`h Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit - General Businesses
N
V
I am a sole proprietor and have no one Business e: LJ Retail Lj Restaurant/Bar/Eating Establishment
working iii any capacity. OfSice 0 Sales (including Real Estate, Autos etc
I am an employer with employees (M & part time). E' -Other _M011 once ]'
an employer providing workers' compensation for my employees working on
0
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 #:
insurance co. olic #
On rs`.�.M, �dev
company name:
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 $1,540.00 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 hereby certify an the s a n of perjury that the information provided above is true nd correct.
Signature Date
Print name 1 Phone # O a
official use only do not write in this area to be completed by city or town official
city or town: permit/license # OBuilding Department
QLicensing Board
❑ check if immediate response is required OSelectmen's Office
❑Health Department
contact person:
tceviscd Scpt 2003)
phone #;
bvE2 ��
NAME OF CITY OR TOWN
STATE SANITARY CODE : CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
TVDR !V: D!1!N • T)TTRT TO f T-1 QPXAT-PT TRT T(` C1 CPR('.TAT. PTTRT)MV Ph( -1T. rl
NAME OF POOL
` .
ADDRESS
p\j&
OWNER
f5cink ,,-4
ADDRESS
N 'rterrVG
DATE OF
P OL CAPACITY
INSPECTED 13Y
INSPECTION
L'
# OF GALS'r
METHOD OF WATER
TREATMENT
L—
BATHER
LOAD
# OLIFEGUARDS
WATER SOURCE:
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.
.p3 Adequate enclosure around pool. Gate self -latching w/
latch 4 ft above ground.
.04 Sewage Disposal
.05 Location, structural stability, finish.
.06 Water circulatioition systems. Filter Effluent flow
meter reading: pm. # 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
�x C Q
.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
Water Temp. I 1040F_
ladders.
* pails per million I
.15 Diving equipment in safe condition.
Other
.29 Pool water tested with appropriate frequency.
.17 Pool supervision - Pool supervision provided.
.30 Water testing equipment. DPD kit provided for
Jan. 1, 1999, pool supervisor certified as pool
VEffective
operator from YMCA or NSPF.
special purpose pools.
.21 Permit requirements - Permit issued. Adequate
.31 Water clarity
maintenance and testing records maintained. Records
.32 Water clarity maintenance. Filtration system operating
initialed by person making tests.
22 Health regulations: Signs posted. He, althwam ng
continuously.
.32 Special purpose pool drained, cleaned and every 14
signs posted for special purpose pools.
days.
.23 Lifeguards required: Yes ❑ No
Maximum Operating Temperatures for Special Purpose
If lifeguards required. Proper credentials, proper suits
Pools. (SPP).
and garments worn. Whistle and bullhorn provided
.33 a. Thermostatic control provided for each SPP.
.24 Safety equipment. Ring buoys and rescue hook
b. Thermostatic control only accessible to the pool
provided. Rescue tube and backboard with straps at
operator
pools attended by a lifeguard.
.38 General sanitation
.25 First Aid equipment provided.
.25 Emergency Communication System at the pool and in
working order. Emergency communication device in
V
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
READINGS
Alkalini 50450 Vin Free Chlorine 1 1.0-3.0 ' m
Cyanuric Acid (30-100 ppm= Comb.
Water Temp. I 1040F_
H level
* pails per million I
Other
.29 Pool water tested with appropriate frequency.
k-
.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
r
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