HomeMy WebLinkAboutMansfield Depot II 12/31/2002TOWN 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:
Keith Properties, Inc.
for the operation of a ❑ Public �C-Public ❑ Special Purpose Pool
at:
Mansfield Depot II
Method of water treatment is: Hayward DE -3600 Earth Filter
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.: 6
Date of Expiration: December 31, 2002
Issued
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Keith Properties, Inc. J'
Address:
City: Stoughton
State: MA Zip:02072
Telephone: 508-338-3583
Fax:
Fed ID/SS No.:
Pool Location:
Mansfield Depot II
Type/pool:
Semi -Public
Length: 40'
Width: 20' Volume:
Min/Max. depth:
4' to 5'
Swim Area:
20x40'
Dive Area:
None
Water Source:
Town
W/W Disposal:
Town Sewer
Type of Finish:
Printed Vinyl
Scum Gutter:
N/A
Deck Type:
Cement Slab
Skmmr weir length: 2 skimmers
Treatment System: Hayward DE -3600 Earth Filter
Disinfect Method: Chlorinating Sticks, Ph Minus and Plus,
Chemical Treatment: Automatic Chlorinator
No. of Bathers: 43
Remarks:
Permit No.:
Fee per pool: $75.00
Permit Expires December 31St yearly
SIGNATURE:
DATE:
JAN
Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfteld. Mail to:
Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
C.\Pafs DocumentAPERMIT APPLICATIOWSWIMMING 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.
a,0,0� ff - A_s�cla-ks
*Signature of Individual orl
Corporate Name (Mandatory) ®' /® 0? nJ9�ko/
LO
, 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 621C, Section 49th.