HomeMy WebLinkAboutCanoe River CG 12/31/2002TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK RO-%V9 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 emi-Public ❑ Special Purpose Pool
at:
137 Mill St.
Method of water treatment is: Sand
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, 2002
Date Issued
<Scottte, Health Agent
TOWN OF MANSFIELD,BOARD 1;
SIX PARK ROW, MANSFIELD 02048
SWBUUIING 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:
Min/Max. depth:
3'
Swim Area:
40'x22'
Dive Area:
None
Water Source:
Town
W/W Disposal:
Private Leach
Type of Finish:
Cement
Scum Gutter:
Deck Type:
Cement
Skmmr weir length:
2
Treatment System:
Sand
Disinfect Method:
Chlorine
Chemical Treatment:
Automatic
No. of Bathers:
94
Remarks:
Permit No.:
Fee per pool:
$75.00
Z,Z( L-1
Permit Expires December 315` yearly
SIGNATURE:
DATE:
. .
E a#
NOV fo
Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfield. Mail to:
Board of Health, Town ofMansfield, Six Park Row, Mansfield, MA 02048.
CAPats Documents\PERMIT APPLICATIONS\SWIMMING POOLS APP.doc
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.
5 I Lt1UI/ //-Jc,
*Signature of Individual or
Corporate Name (Mandatory)
411 a
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 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.
JM6ezD—
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
OnTUITAT DTTR12(lQF P(-l(')T. r�
TYPE Ut' FUUL: ru"111k,
NAME OF POOL
u
a
ADDRESS
,
OWNER
ADDRESS
t C
DATE OF
POOL CAPACITY�ff
`t
INSPECTED BY
INSPECTION
;�
# OF GALS
(
d
METHOD OF WATER
BATHER#
I
OF LIFEGUARDS
WATER SOURCE:
TREATMENT
LOAD
_Ir
Inc tIlkAD A2< nOO`
Regulation 105 CMR 435.000 The items markea netow wnn an A uiu-Mr, uiv vi—a— F—.....__� �_ ��� -• _ . _._ _ _.
Items marked with a "✓" are satisfactory.
REGULATION X/✓ VIOLATIONS/COMMENTS
ventilation; sanitary condition.
03 Adequate enclosure around pool. Gate self -latching wl
latch 4 ft above ground.
.04 Sewage Disposal
.05 Location, structural stability, finish.
.06 Water circulation & filtration systems. Filter Effluent flow
meter reading: _Apm. # 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
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 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 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
V
�I
V/
off
POOLSIDE READINGS
.30 Water testing equipment. DPD kit provided for
Bromine
2'0I 0 m a
Total Chlorine
Alkalin -
3Q 150,
Free Chlorine
V m
Cyanuric Acid
(0 100,
Comb.
0 0 0 2ppm
days.
Chlorine
t �,
Water Temp.
1Q4F 4 _
pH level
tip
*parts per million
Other
f
.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.
tip
b. Thermostatic control only accessible to the pool
operator
f
.38 General sanitation
REGULATION I
I NO. I THE SPACE BELOW DESCRIBES VIOLATIONS_ MARKED ABOVE
X/-./
.34 Closure of the pool. PPOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF
105 CMR 435.29 THROUGH 435.31.
SIGNED SIGNED i
Operator Board of Health/Health Department
TOWN 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 127,4 of the Massachusetts
General Laws, and Regulations established by the Massachusetts Department of Public
Health (105 CAM 435.00). permit is hereby issued to:
Canoe River Campground
for the operation of a ❑ Publicemi-Public ❑ Special Purpose Pool
at:
137 Mill St.
Method of water treatment is: Sand
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, 2002
AA'� D
Scott Leite, health Agent
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048 5,
SWIMMING POOL APPLICATJON
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:
Min/Max. depth:
3'-10'
Swim Area:
57'x30'
Dive Area:
None
Water Source:
Town
W/W Disposal:
Private Leach
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
Remarks:
Permit No.:
Fee per pool:
$75.00
Permit Expires December 31St yearly
51��%�
SIGNATURE. %
DATE: /C) / 3
Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfield. Mail to:
Board of Health, Town ofMansfield, Six Park Row, Mansfield, MA 02048.
CAPaPs Documents\PERMU APPLICAMNS\SWIMMING POOLS APP.doc
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 (Mandatory)
1
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 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.
APPENDIX 12
NAME OF CITY OR TOWN
STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS,
105 CMR 435.000
SWIMMING POOL INSPECTION REPORT
TVPF nF Pnnl • PI IRI ir. n �FMI-pl IRI I SPECIAL PURPOSE POOL ❑
NAME OF POOLADDRESS
t -�
j,
OWNER
L t�
ADDRESS
DATE OFPOOL
CAPACITY
�
INSPECTED BY
L
INSPECTION
4:5 -Z Z �� # OF GALS.
METHOD OF WATER
BATHER
j
# OF LIQ RDS
WATER SOURCE:
TREATMENT
LOAD
�`
°=
Regulation 105 CMR 435.000 The items marked below with an "A" maicate the violatea provisions or 1u5 UMK 430.uuu.
Items marked with a "✓" are satisfactory.
ventilation; sanitary condition.
...................................... ............................................... ........ ................................................................................... ...............
.
.03 Adequate enclosure around pool. Gate self -latching w/
...... )atQb.4 ft.ah4vP,amMCtd...............•-----....------•---.................... .............. •-----......................------•-•-----..........-----.............-•-------.....
:04 -Sewage Disposal.....................•---•--.........--•---------.............. .......... .......................................................................... ..............
.05 Location, structural stability, finish.
............................................................. ......................... ........ .............. .......................................................
.06 Water circulation & filtration systems. Filter effluent flow
meter reading: 42� 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.ventil; tion.Grovided...................................................................................... ...............................................
.08 Inlets and outlets - Inlets located to produce uniform
circulation. Over rim fill spout 6" above maximum
water level. Properly shielded and located.
........ ................................................ ......................................... I.........
.08 Main drain suction outlets covered with suitable
protective covers or grates. Cannot be removed
without use of tools. Open area does not provide
entrapment of fingers, toes, etc. At least one
...... antNprtex.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
...... locatedand.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
until repairs are made.
.ua - speciai purpose pool ana waaing pools equippea witn
emergency shut off pump switch. Accessible and
prominently marked.
................................................................................
.09 Cross connections. Potable 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 poc
operator from YMCA or NSPF.
.21 Permit requirements - Permit issued. Adequate
maintenance and testing records maintained. Record;
initialed by person making tests.
................................................................................
.22 Health Regulations: Signs Posted. Health warning
signs posted for special purpose pools.
........................................... ............ . .................
.23 Lifeguards required: Yes � No
If lifeguard required; proper credentials, proper suits
and garments worn. 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. First aid kit complete
................................................................•--...---........
.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 tt
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
Bromine m , -
Total Chlorine
Alkalinity
Free Chlorine
Cyanuric Acid
Comb. Chlorine
Water Temp.
pH Level
*parts per million
Other
.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.
..................................................................................•-
REG'JLATION
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.
SIGNEDperator ( SIGNED
Board of HealthiHealth Department