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Home My WebLink AboutHockomock Y 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 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: Hockomock Area YMCA -Mansfield H for the operation of a ❑ Public at: Method of Water treatment is: [Semi -Public 40 Balcom Street Chlorine Bathing load not to exceed: 40 bathers ❑ Special Purpose Pool Number of Lifeguards required at all times the pool is open is: None Permit No.: 12 Date of Expiration: "NO LIFEGUARD ON DUTY" sign is required. December 31, 2007 Scott eite, H alth Agent Date sued We build strong kids, strong families, strong communities. June 14, 2007 Mansfield Board of Health Attn: Scott Leite 6 Park Row Mansfield, MA 02048 Dear Mr. Leite; �l JUN -11-8 zoos Q The Hockomock Area YMCA, Mansfield Branch would like to request a waiver on the fees for the License to conduct a Recreational Camp for Children, and Swimming Pool Permit. The Hockomock Area YMCA is a not-for-profit organization offering camp summer opportunities to the youth of Mansfield. Sincerely, Am owns Executive Director Hockomock Area YMCA 40 Balcom Street Mansfield, MA 02048 Hockomock AreaYMCA • Mansfield Branch • 40 Balcom Street • Mansfield, MA 02048 Tel. (508) 339-3066 • Fax (508) 337-8479 • www.hockymca.org TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Name of Owner: Hockomock Area YMCA -Mansfield Address: 40 Balcom Street City: Mansfield State: MA Zip:02048 Telephone: 508-339-3066 Fax: Fed ID/SS No.: 04-2131749 Pool Location: 40 Balcom Street Type/pool: Above -ground Length: 38' Width: 18' Volume: 10,000 gal Min/Max. depth: 3' to 4'6" Swim Area: 38' x 18' Dive Area: None Water Source: Town W/W Disposal: Septic System Type of Finish: Steel w/vinly liner Scum Gutter: None Deck Type: Wooden Skmmr weir length: 1.5 to 2 ' Treatment System: Sand Filter Disinfect Method: Chlorine Chemical Treatment: Chlorine No. of Bathers: 40 Name of Certified Pool Operator: Permit No.: 12 Fee per pool: $75.00 Permit Expires December 31St yearly SIGNATURE: DATE: Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to.- Board o:Board of Health, Town of Mansfield, Sia. Park Row, Mansfield, MA 02048. RAHealthUane's DocumentsTERMIT APPLICATIONS\SWIMMING POOLS APP.doc TAX CERTIFICATION FORM 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. E� fir.,, me z, Signature of Individual or Corporate Name By: Corpora e Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. RMealthVane's Documents\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street s Boston, MA 02111 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / ' /„ ,{ Please Print Leizibly Business/Organization Name: l J 0Q kO rlld c� k A (e !A A/ Address: -) u. V E, ( City/State/Zip: ^V- -P,i o -v, Phone #: a > Are you an employer? Check the appropriate box: 1. I am a employer with _7U0 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.] 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.❑ Health Care 12.❑ Other *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 arrr an employer tlrat is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: cu f Insurer's Address: g', ct ,K � City/State/Zip: 8 l' ` ` C o- ? o Policy # or Self -ins. Lic. # � � Z <., � 5 3Expirationl Date: +v 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 statetnent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby t�f , under tl pains and penalties of perjury that the information provided above is true and correct. Rionatnra• k;tst #, / r INt fI Date: li%7 Official use only. Do not sprite 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: www.mass.gov/dia Phone #: ISSUED BY THE STOCK INSURAN15012111111601MPANHEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER '• 1 AMERICAN HOME ''COMPANY 77209-0000 • • 13781 1 i 1 i• It NEW YORK HOCKOMOCK AREA YMCA, INC. 300 ELMWOOD STREET NORTH ATTLEBORO, MA 02760-0000 SEE NAME AND ADDRESS SCHEDULE - WC990610 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE INSURED IS CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME A ITEM 2 POLICY PERIOD 12:01 A.M. standard time at the insured's mailing address /gymMember Companies of American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 TREIBER AGENCY GROUP LLC 377 OAK STREET CS 601 GARDEN CITY, NY 11530-0000 PREVIOUS POLICY NUMBER NEW ESS SCHEDULE - WC FROM 07/01/o6 TO 07/01/07 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers compensation r_aW OT nrn scn.cs uaacu here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work In each state nsteo in n:ern a.m. The limits of our liability under Part Two are: Bodily Injury by Accident $ 10090 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below is subject to verification and change by audit. Classifications SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES EXPENSE CONSTANT MINIMUM PREMIUM EXCEPT WHERE APPLICABLE BY STATE) $284 MA Estimated Total Rate Per csr'maieo Code Number Remuneration $100 OF Re- Premium 11\1 Annual [13 Year muneratlon FRI Annual ❑ 3 Year TOTAL ESTIMATED PREMIUM If indicated below, interim adjustments of premium shall be made: 11 Semi -Annually 11 Quarterly 11 Monthly DEPOSIT PREMIUM ENDORSEMENTS (FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 07/25/06 PARSIPPANY 82 Issue Date Issuing Office 39967 INSIJ F—D'S ('OPY $3,529 Authorized Representative wC 00 00 01 NAME OF CITY OR TOWN STATE SANITARY CODE : CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT 1rVDV nR UnnT • pT TRT T(' 171 -'PMT-PT TRLTC SPF.CTAT. PTTRP09R Po7T. ❑ NAME OF POOL ,j,(,� �(AA i i ADDRESS OWNER ADDRESS DATE OF`f INSPECTION C� ! T A POOL CAPACITY # OF GALS INSPECTED BY . U� T METHOD OF WATER TREATMENT C--- BATHER LOAD # OF LIFEGUARDS 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/✓ VIOILATIONS/COMMENTS ventilation; sanitary condition. ,Q3 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: pm. # of tumovers .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 .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. .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 worn. -Whistle 'and-bullhorn-pravided.— .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 Cthe poohand 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 V, I W, 1L� ve'� et� Alkalin- 50-150 41 Free Chlorine 1-fl.0-3.0-ppm m Cyanuric Acid' (30-100 ppm)` Comb. Water Temp. 1 1040V: 1 I pH level 1"(7:2-7.$) *parts per 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 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 105 CMR 435.29 THROUGH 435.31. SIGNED SIGNED Board of Health/Health Department