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Home My WebLink AboutMansfield Children's C. 12/31/2007TOWN OF D BOARD OF 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 CMR 435.00). permit is hereby issued to: Mansfield Children's Ctr. for the operation of a ❑ Public [2/Semi-Public ❑ Special Purpose Pool at: 1100 School Street Method of water treatment is: 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.: 8 Date of Expiration: December 31, 2007 t J yy 6 Scott Leit$, Healt Agent Date Issued lam_ Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 41' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: Deck Type: Skmmr weir length: TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIAIMI[NG POOL APPLICATION Mansfield Children's Ctr. 1100 School Street Mansfield Zip:02045 508-339-9211 042-425-454 1100 School Street Semi -Public Width: 25' 3.5' to 6' 400sf None Town Private Liner Volume: 30,000 5' Cement 2 skimmers Treatment System: Diatomacious Earth Disinfect Method: Chlorine Chemical Treatment: No. of Bathers: 43 Name of Certified Pool Operator: PN__ Permit No.:8 Fee per pool: $75.00 SIGMA DATE: Permit Expires December 31St yearly Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfteld. Mail to: Board of Health, Town ofMansfreld, Six Park Row, Mansfield, MA 02048. RAHealfliTaPs Documents\PERMIT APPLICAUONS\SWIMMING 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. f Individual or Name (Mandatory) a e Officer atory, 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 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 _ wee ofHrveseaGons 600 Washington Street, 7`h Floor ss* Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - General Businesses }y t _ z name: 4 41 i /-v Fca(a work site location (full address):--- ❑ I am a sole proprietor and have no one Business Type: ❑Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. 0 Office ❑ Sales (including Real Estate, Autos etc F1 I atm an employer with A employees (full & part time). ❑ Other u . y;—ee, b I am an employer providing workers' compensation for my employees working on this job. ee I am a sole proprietor and have hired the independent contractors listed bctow who have the following workers' compensation polices: company name: - address: city phone #: insurance co .. company "me: address: city: nhone #: Failure to secure Coverage as required ander Section 25A ofMGL 152 can lead to the imposition of criminal penalties of a fine up to $1,50.00 a adfor 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 Meg." Investigations of the DIA for coverage verification. I do hereby certify u W1 he pains owdpen o that the information provided above is true and correct Signature Date 11.7,91,17 Print name „ r�J �Gc U!'� Phone # official use only do not write in this area to be completed by city or town official city or town: _ permitllicense # (]Building Department []Licensing Board ❑ check if immediate response is required QSelectmen's Office []Health Department contact person: phone #; (]Other (-Yi-d SepL 2003) her R, - r - mmazusliblo . INFORMATION PAGE- RENEWAL 2066058 10/07/06 10/07ZO71 2066058 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY NCC I CO #15717 UTICA MUTUAL INSURANCE COMPANY -14ANSFIELD CHILDREN' b t.ntv-iFn INC 1100 SCHOOL STREET MANSFIELD MA 02048 ...•.. a . ............ __.- ---- ---- 311 PLYMOUTH ST HALIFAX MA 02338 .(781) 293-6331 FEIN 042725454 ..RISK ID. 165573 SEE ATTACHED SCHEDULE ENTITY OF INSURED - CORPORATION 2. POLICY PERIOD - 10/07/06 TO 10/07/07 12:01 AM STANDARD TIME AT 3A. THE INSUREDS MAILING ADDRESS. WORKERS COMPENSATION INSURANCE:PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: 3B. MA. EMPLOYERS LIABILITY INSURANCE:.PART TWO OF THE POLICY APPLIES TO WORK-IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT 3C. OTHER STATES INSURANCE:PART THREE OF THE POLICY APPLIES TO THE STATES,..,. ANY,LISTED HERE:ALL STATES EXCEPT:ND,OH,WA,WV,WY AND STATES DESIGNATED' IN ITEM 3A. 3D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS FORMING PART OF THIS POLICY. 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES; CLASSIFICATIONS, RATES, AND;RATING PLANS. ALL INFORMATION REQUIRED BELOW::I SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. 4. CLASSIFICATIONS PREM BASIS RATE EST ST LOC CODE TYP EST TOT ANN PER $100 ANNUS NO REMUN REMUN PREMI1 SEE ATTACHED SCHEDULE MINIMUM PREMIUM $184 (MA) $5,512 EXPENSE CONSTANT(MA) $2'`84 TOTAL ESTIMATED ANNUAL PREMIUM $ 5; 796 DEPOSIT PREMIUM $5;;.796 ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. COUNTERSIGNED THIS 29TH DAY OF AUGUST,2006 PREMIUM AMOUNT TO BE REFLECTED ON NEXT BILLING NOTICE UNI -BILL NO. 100362146 DB- IC ISSUE DATE 08/29/06 WC 00 00 01A W 2066058 11 VVe hl.iild strong gids, stroi ig families, strong comm>_tniLies. KEVIN FALLON 1132 SCHOOL ST MANSFIELD, MA 02048 V miom'wjw Dear KEVIN FALLON Congratulations on successfully completing a YMCA of the USA (raining certificatiion. If you have any questions, call the YMCA of the USA certifications office at 800-872-9622. To correct or update your records or to request a script, a duplicate card, or a certificate, see directions below. Special requests: (Mark as many as apply) The information (e.g., name, address,certification information) that appears on my records is incorrect. I have 0 marked the changes. Please send me a free official transcript of all program training certifications I have received. Please send me a duplicate card for (Please enclose a check payable to the YMCA of the USA for $8, regardless of how many cards are involved.) Lifeguard Other certifications (please specify _-_ All my certifications Please send me a certificate for the following certification(s): (Please enclose a check payable to the YMCA of the USA for $8, regardless of how many certificates are involved.) YMCA of the USA �. Training Certification cation 99EFAQ103B9027 KEVIN FALLON Pool Operator on Location (POOL) Issued 06/02/1999 YMCA of the USA • 101 North Wacker Drive • Chicago, Illinois 60606 • 312-977-0031 • toll free: 800-872-9622 • fax: 312-977-9063 • w",myraca.net YMCA tnissiono To pw Christian principles into practice through programs Thal hnild hcalthy>.piril, wind aril bod, lin' all. Congratulations on successfully completing a YMCA of the USA training certification. If you have any questions, call the SCA of the USA certifications office at 800-411-9648 or 312-9770031. To correct or update your records or to request a transcript, a duplicate card, or a certificate, see directions on the reverse side. C a r c O' ' 1 k 9 95Ef=A�1C3i�-027 � � 02H-34-2174 KEITH LA! LOIS` � 'FAL"LCN 1132 SCHCOL ,ST A':RfS€IELi�� .MA C2G4� �?cci !Cp�rat4r .c�r_'Lt�:2tiar� tH(CL) Date Lwd: 61C2/99 October 31, 2006 TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 Mansfield Children's Ctr. 1100 School Street Mansfield, MA 02048 RE: 2007 Swimming Pool Permit 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 Pool 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 CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 CP-POTAT PTTRPIICF.PCX-)T. 171 'r YFE ()y 11("L: FUIJLH: u•7L'1V11-1 VLL1V .� NAME OF POOL r;, -ADDRESS €� zw` OWNER Fyy ADDRESS DATE OF POOL CAPACITY f INSPECTED BY INSPECTION # OF GALS METHOD OF WATERBATHER > F LIFEGUARDS WATER SOURCE: W TREATMENT ,.N K, LOAD ,.M. • , ... ,----�_.___ ._C Ina i-XAU AQC nnn Regulation 105 CMB 435MU l fie items marK0aceiow w1U1 au -N uiutLaw Items marked with a "✓" are satisfactory. REGULATION X/✓ VIOLATIONSICONIlV EMS ventilation; sanitary condition. ,03 Adequate enclosure around pool. Gate self -latching w/ latch 4 it above ground. .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulation & 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 vAthout tools until repairs can be made. .08 Special purpose pool and wading pools equipped with emergency shut off pump switch. Accessible and prominently marked. 1 01 .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 declot 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 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 r mine 2.0=6.0 m* tal Chlorine alin 50-150 m ree Chlorine 1,0-3:Unuric Acid {30-100 ppm) Comb. 0 ppm) Temp.104°F. pH levelrts [jaer er million ther .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 Ys.f , Maximum Operating Temperatures for Special Purpose] Pools. (SPP). .33 a. Thermostatic control provided for each SPP., b. Thermostatic control only accessible to the pool TO operator .38 General sanitation REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE wr .34 Closure of the pool. POOL MUST BE CLOSED UNTIL. IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED x JJ. i f SIGNED - s ` Op for d Board of HealflMealth Department