HomeMy WebLinkAboutCanoe River CG 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:
Canoe River Campground
for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool
at:
137 Mill St.
Method of water treatment is: Automatic
Bathing load not to exceed: 94 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Permit No.: 1
Date of Expiration: December 31, 2008
Scott Leite, Health Agent,
Date Issued
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Canoe River Campground
Address: 137 Mill St.
City: Mansfield
State: MA Zip:02048
Telephone: 508-339-6462
Fax: 508-339-5237
Fed ID/SS No.: 04-2375571
Pool Location: 137 Mill St.
Type/pool: Cement
Length: 57' Width: 30' Volume: 60,000
Min/Max. depth: 3'-10'
Swim Area: 57x30'
Dive Area: None
Water Source: Town
W/W Disposal: Town Sewer
Type of Finish: Cement
Scum Gutter:
Deck Type: Cement
Skmmr weir length: 4
Treatment System: Sand
Disinfect Method: Chlorine
Chemical Treatment: Automatic
No. of Bathers: 94
Name of Certified Pool Operator: /Y .4/0-_ 4,4 �
Permit No.:l
Fee per pool: $75.00
_? Permit Expires December 31St yearly
SIGNATURE: g
DATE: l `�'
Please snake appropriate changes. Sign, date and enclose checkpayahle to Town of Mansfield. Mail to:
Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
R: HealtWane's Documents\PERMIT 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.
Signature of Individual or Corporate Name
*Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*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.
RMealthUane's Documents\Food Permit Forms\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 5 / -die./ -t-'
Address: 1 37 Al / L-- L -
City/State/Zip:A'1 /4<'
3�Z
—6-
e�� (��' Phone #: �, � ;� .__ .� � V (-,
Are you an employer? Check the appropriate box:
1. I am a employer with 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
Other1!`'C�i1c.t.�__
12
*Any applicant that checks box # I 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 ant an employer that is providing workers' compensation insurancefor my employees. Below is the policy information.
Insurance Company Name: Z to 4 ! C 0 — / �14 i E'' -/Z ( C 4 IU
Insurer's Address: 'Ie". C). '?o X 116 t
City/State/Zip:
Policy # or Self -ins. Lic. # C, -ZZ (-A z, `y � `� � ��� � � —� Expiration Dater �1 ✓ /y �
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 MGI, 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 WORI< 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 coverage verification.
I do hereby certify, under t9pains a rlpenalties of perjury�lrat the information provided above is true and correct.
/( / V, 107
Phone #: <6 �, ip, _ 1) 6 `716 -�>_
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 Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/clia
P
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
PERMIT TO OPERATE A SWIMMING POOL
In accordance with the provisions of Chapter I H. 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:
Canoe River Campground
Ifor the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool
at:
137 Mill St.
Method of water treatment is: Automatic
Bathing load not to exceed: 94 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Permit No.: 2
Date of Expiration: December 31, 2008
Scott Leite, Health Agent
Date Issued
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Canoe River Campground
Address:
137 Mill St.
City:
Mansfield
State: MA
Zip:02048
Telephone:
508-339-6462
Fax:
508-339-5237
Fed ID/SS No.:
04-2375571
Pool Location:
137 Mill St.
Type/pool:
Cement
Length: 40'
Width: 22' Volume: 22,440
Min/Max. depth: 3'
Swim Area: 40'x22'
Dive Area: None
Water Source: Town
W/W Disposal: Town Sewer
Type of Finish: Cement
Scum Gutter: None
Deck Type: Cement
Skmmr weir length: 2
Treatment System: Sand
Disinfect Method: Chlorine
Chemical Treatment: Automatic
No. of Bathers: 94
Name of Certified Pool Operator: A ,$Z
Permit No.:2
Fee per pool: $75.00
Per, Expires December 31s` yearly
SIGNATURE:r / =
DATE:
Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield Mail to.-
Board
o:Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
R:\Health'Jane's Docuntents\PERMIT APPLICATIONS\SWIMMING POOLS APP.doc
COMMONWEALTH OF MASSACHUSETTS
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
CAMPGROUND PERMIT
This is to certify that: JOSEPH & EMMA GONSALVES & FAMILY
Is hereby granted a permit for: CANOE RIVER CAMPGROUND
137 MILL STREET, MANSFIELD
250 SITES
This permit is granted in conformity with the Statutes and Ordinances relating thereto, and
expires December 31, 2008, unless sooner suspended or revoked.
Fee: $75.00 plus $1.00 per site = $325.00
Permit Number: 1
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
APPLICATION FOR CAMPGROUND PERMIT
I hereby make application for a CAMPGROUND PERMIT, which expires
on December 31St of each year.
Name of Business: CANOE RIVER CAMPGROUND
Address: 137 MILL STREET
Owner: JOE & EMMA GONSALVES 1'A,411 /-
Telephone No.: (508) 339-6462
Fax No.: (508) 339-5237
S.S./FID No.: 04-237-5571
Number of Sites: 250
Fee: $75.00 Plus $1.00 Per Site
Permit No.: 1
g
Signature , >( ? rZ Y It _ C
Date !� ��
Please make appropriate changes. Sign, date and enclose check payable to Town of
Mansfield Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA
02048.
RAHealthUane's DocumentsTERMIT APPLICATIONSTAMPGROUND.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.
14
yPu
By: Corporate Officer (Mandatory, if
Signature of Individual or Corporate Name Applicable)
0 Ll '), -�? �; (
"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 securitynumber will be farr..shed 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.
R:\Hea]thUane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: `7t r r / % a C^'
Address:
City/State/Zip: /c 1,4 �U
:)-O `l Y
Phone #:
Are you an employer? Check the appropriate box:
I am a employer with i"% 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 (- /kt't4 /1 le 0 t
*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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Z(A A I C t .1 r A"I L"2- ( CAAJ
Insurer's Address: /0.0.
City/State/Zip: 0 2
ov `/%G
Policy # or Self -ins. Lic. # 6 Z', 1-4 F al % V Expiration Date:
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 coverage verification.
I do hereby certify, under tie pains on penalties of pert that the information provided above is true and correct.
r.
Finn afiira•-'..6� , ...,: C;, y e-r;.:+'u.t. �' Date:
c
Phone #: t —C) ? � _Z 1, . — 6 V (, . L
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: Phone #:
www.mass.gov/dia
mtjlwlew)
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
-PXMr. iW TVv-NT . nrMT V1 r'1 CT)POTAT. PTTRPORV PC)( -)T. rl
NAME OF POOL
"tf
ADDRESS f
OWNER
ADDRESS `
DATE OF
--
POOL CAPACITY
INSPEGrED BY
INSPECTION
C
4 OF GALS
i
METHOD OF WATER
BATHER
4 OF LIFEGUARDS
j WATER SOURCE:
TREATMENT
LOAD
Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of I0 (;MK 43J.000.
Items marked with a "✓" are satisfactory.
REGULATION X/✓ VIOLATIONS/COMMENTS
.03 Bathhouse and sanitary facilities adequate lighting;
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 circulatio filtration systems. Filter E ue 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. Alf
.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
until repairs can be made.
.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.
V
.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
V
initialed by person making tests.
Health Signs Health
.22 regulations: posted. 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 fitter
backwash water.
.29 Chemical standards
POOLSIDE READINGS
Bromine f2:U 6 0nnmi
Cyanuric Acid
Water T
.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
V
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
Total Chlorine
Free Chlorine
Comb.
Chlorine
pH level
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.
SIGN SIGNED
Operator Board of
TOWN OF MANSFIELD
BOARD OF HEALTH
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:
Canoe River Campground
for the operation of a El Public Semi -Public ❑ Special Purpose Pool
at:
137 Mill St.
Method of water treatment is: Automatic
Bathing load not to exceed: 94 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
red.
Permit No
Date of Expiration: December 31, 2007
Date issued/
Name of Owner:
Address:
City:
State: MA
Telephone:
Fax:
Fed ID/SS No.:
Pool Location:
Type/pool:
Length: 57'
Min/Max. depth:
Swim Area:
Dive Area:
Water Source:
W/W Disposal:
Type of Finish:
Scum Gutter:
Deck Type:
Skmmr weir length;
Canoe River Campground
137 Mill St.
Mansfield
Zip:02048
508-339-6462
508-339-5237
04-2375571
137 Mill St.
Cement
Width: 30'
3'-10'
57'x30'
None
Town
Private -beach
Cement
Cement
4
Treatment System: Sand
Disinfect Method: Chlorine
Chemical Treatment: Automatic
No. of Bathers: 94
Volume: 60,000
M u.-JI C. j /?Acd � e-'yl�
Name of Certified Pool Operator:%' /C f `> /'j -'4I L�-
Permit No.:1
Fee per pool: $75.00
Permit Expires December 315` yearly
r
f
SIGNATURE:
DATE: l l / A- zo C
Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to:
Board of Health, Town ofMansfield, Six Park Row, Mansfield, MA 02048.
RAHea1di\Pafs Documents\PERMIT APPLICATIONS\SWIMMING POOLS APP.doc
TOWN 1
BOARD 1
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:
Canoe River Campground
for the operation of a ❑ Public Q'Semi-Public ❑ Special Purpose Pool
137 Mill St.
Method of water treatment is: Automatic
Bathing load not to exceed: 94 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Permit No.: 2
Date of Expiration:
Scott Leite,
December 31, 2007
Agent
Date Issued
Name of Owner: Canoe River Campground
Address:
137 Mill St.
City:
Mansfield
State: MA
Zip:02048
Telephone:
508-339-6462
Fax:
508-339-5237
Fed ID/SS No.:
04-2375571
Pool Location:
137 Mill St.
Type/pool:
Cement
Length: 40'
Width: 22' Volume: 22,440
Min/Max. depth:
3'
Swim Area:
40'x22'
Dive Area:
None
Water Source:
Town
W/W Disposal:
-PubmtezLeaelt
Type of Finish:
Cement
Scum Gutter:
None
Deck Type:
Cement
Skmmr weir length:
2
Treatment System:
Sand
Disinfect Method:
Chlorine
Chemical Treatment:
Automatic
No. of Bathers:
94
Name of Certified Pool Operator: Al ,4, - l<
Permit No.:2
Fee per pool:
$75.00
Permit Expires December 3Is` yearly
SIGNATURE:
j ' 'r r �LLetl.� •�...
l r�
DATE: It
Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfield. Mail to:
Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
RAHealdiTafs DocumentsTERMIT APPLICATION=VIMMING POOLS APP.doc
t
00� rtes
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CIVIR 435.000
SWIMMING POOL INSPECTION REPORT
mvnV n -V ITxvIT . DT MT TO r -i C'AAAT pTTRT TO qPP( ..TAT. PTTRPORP. POOL I -I
NAME OF POOL
AD SS
OWNER
ADDRESS
DATE OFPOOL
t ,
CAPACITY
p! `
SPE BY
INSPECTION
.
# OF GALS
METHOD OF WATER
[
S
BATHER
# OF LIFEGUARDS
WATER SOURCE:
TREATMENT
F'
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 "✓" are satisfactory.
REGULATION X/✓ VIOLATIONS/COMMENTS
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. Fitter Effluent flow
meter reading: m. # 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
.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 Slamming 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 QZ
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 property
discharged. No direct connection to sewer system.
Separation tank provided for diatomaceous earth filter
backwash water.
.29 Chemical standards
POOLSIDE READINGS
Bromine I(2 05.4 aur►'
Cyanuric Acid
Water
*parts per million 1
.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
Total Chlorine
Free Chlorine
Comb.
Chlorine
vH level
REGULATION
NO.
THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE
wl/
.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 HeatthMeafth Department
Operator