HomeMy WebLinkAboutMilhaus 12/31/2007TOWN OF MANSFIELD
BOARD
SIX 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 CAM 435.00). permit is hereby issued to:
ilhaus @ MansCondo 'frust
for the operation of a ❑ Public Ze-Public ❑ Special Purpose Pool
at:
150 Rumford Ave.
Method of water treatment is: Sodium Hypochlorite
Bathing load not to exceed. 70 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
I Permit No.: 9
Date ofE.xpiration: December 31, 2007
Scott Leite, Health Agent
117z,
Date I sued L
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Milhaus @ MansCondo Trust
Address:
150 Rumford Avenue
City:
Mansfield
State: MA
Zip:02048
Telephone:
508-339-7531
Fax:
Automatic Chlorinator Marc Mac, 22 psi
Fed ID/SS No.:
04-6551192
Pool Location:
150 Rumford Ave.
Type/pool:.
Gunite
Length: 60'
Width: 30' Volume: 66,000
Min/Max. depth:
4', 7', 10',14'
Swim Area:
18,000sf
Dive Area:
None
Water Source:
Town
W/W Disposal:
Town sewer
Type of Finish:
Concrete
Scum Gutter:
yes
Deck Type:
Concrete 16'
Skmmr weir length:
4, 8' apart
Treatment System:
Haywood 3000
Disinfect Method:
Automatic Chlorinator Marc Mac, 22 psi
Chemical Treatment:
Sodium Hypochlorite
No. of Bathers:
70
Name of Certified Pool
Operator: c :
Permit No.:9
Fee per pool:
$75.00
Permit Expires December 31St yearly
SIGN T
G
DATE:
IAN 0 '2 OUI
Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield. Mail to:
Board ofHealth, Town ofMansfreld, Six Park Row, Mansfield, MA 02048.
RAHeaith\PaPs DocumentsTERMIT APPLICATIONSISWIMMING POOLS APP.doc
I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
*r re bT Individual or
orate Name (Mandatory)
VT 6�ep� A-�1� 0- _
By: 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
payment obligations. Licensees who fail io correct their non Tiling 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
OPCSS HMS9%9ddow
^ 600 Washington Street, 7`s Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit - General Businesses
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I am a sole proprietor and have no one Businesse: E] Retail ❑ RestaurantBar/Eating Establishment
wooing in any capacity. [Office [] Sales (including Real Estate, Autos etc.)
I am an employer with _— employees (full & part thme). El Oti:er
I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city 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 #•
insurance co. olic #
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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.
Ido hereby certify under the pains and p n 'hies ofperjury that the information provided above is true and correct
Sigiature g� f; fit G v ° : Date b1'
print
official use only do not write in this area to be completed by city or town official
city or town:
❑ check if immediate response is required
contact person:
(revised SepL 2003)
permit/license # []Building Department
(]Licensing Board
QSeleetmen's Office
[]Health Department
phone #; (]Other
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SHOul,D ANY OF THE AEOVr OESCRI13FO POLICIS9 BE CANCELLED P9FOR2 THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDRAVOR TO MAIL
10 DAYS wmlT im NOTICF. To THE CERTIF1CATC HOLDEN NAMED TO THE t -EFT, BUT
FAILURE TO DO SO $HALL IMPOSE NO OBLIGATION OR LIABILITY GF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRE$ENTATIVP8,
AUrHORILFE1 ASPRLSENTATIVE
Bath E, Sheehy .
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ALL SEASONS POOL&SPA
PAGE 02
0045(lelib
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
rvn�
CIV T)nry . DT MT Tn rt QMAT-T)TMT TO -qPRC.TA1. PTTRP0SR POOT. ❑
NAME OF POOL
OWNER
ADDRESS
DATE OF
POOL CAPACITY
SPE BY
INSPECTION
# OF GALS
,. _ fT61
METHOD OF WATERBATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATMENT
LOAD
7
- �
Regulation 105 CMR 435.000 The items marked below with an "X" mdicate the violated provisions or tui Unnx 4s:).wv.
Items marked with a "✓" are satisfactory.
REGULATION X/✓ VIOLATIONS/COMWNTS
ventilation; sanitary condition.
.03 Adequate enclosure around pool. Gate self4atching w/
latch 4 ft above ground.
.04 Sewage Disposal
.05 Location, structural stability, finish.
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: in. # 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 pod 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 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. Property
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 wom. Whistle and bullhom 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 property
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..
Total Chlorine
Alkalin 50=10 . tin
Free Chlorine
Cyanuric Acid
Comb. (fl U=fl� ppin} A
_
Chlorine
Water Temp. 1049F. -
pH level
* arts per million
Other
.29 Pool water tested with appropriate frequency.
.30 Water testing equipment. DPD kat 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
i
REGULATION
NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
34 I I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED I SIGNED
Operator Board of Health/Health Department