HomeMy WebLinkAboutMansfield Children's C. 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 II L 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 emi-Public ❑ Special Purpose Pool
at:
1100 School Street
Method of water treatment is: Diatomacious Earth
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, 2002
e I sued
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Mansfield Children's Ctr.
Address:
1100 School Street
City:
Mansfield
State: MA
Zip:02048
Telephone:
508-339-9211
Fax:
Fed ID/SS No.:
Pool Location:
1100 School Street
Type/pool :
Semi -Public
Length: 41'
Width: 21' Volume:
Min/Max. depth:
3.5' to 6'
Swim Area:
400sf
Dive Area:
None
Water Source:
Town
W/W Disposal:
Private
Type of Finish:
Liner
Scum Gutter:
Deck Type:
2' Cement
Skmmr weir length:
3 skimmers
Treatment System:
=sand -filter /-? ; et re m at e
Disinfect Method:
Chlorine
Chemical Treatment:
No. of Bathers:
43
Remarks:
Permit No.:
Fee per pool:
$75.00
SIGNA'
DATE:
rQ rY1X
,r 31 st yearly
B
r c- r
i ; fr P tI
{i
101 0 2 ill
?(Q i
Please make appropriate changes. Sign, date and enclose check payable to Town ofMansfield. Mail to:
Board ofHealth, Town of Mansfield, Six Park Row, Mansfield, MA 02048.
CAPats Documents\PERMU 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.
�11K L
�4*Sig nature of Indivi or
Corporate Name (Mandatory)
*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.
We build strong kids,
strong families,
a strong communities.
KEVIN FALLON
1132 SCHOOL ST
MANSFIELD, MA 02048
Dear KEVIN FALLON
Congratulations on successfully completing it YMCA of the USA training certifcatiion- 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
0marked 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 CertifIication
99EFA0103B9027
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 tree: 800-872-9622 • fax: 312-977-9063 • www.ytnca.ne.t
YMCA mission: To put Christian principles into practice throiigh program; that build heallhy spiril, mind a"d NON for all.
'�111g't�1
Tt f
Dear KEVIN FALLON
Congratulations on successfully completing it YMCA of the USA training certifcatiion- 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
0marked 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 CertifIication
99EFA0103B9027
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 tree: 800-872-9622 • fax: 312-977-9063 • www.ytnca.ne.t
YMCA mission: To put Christian principles into practice throiigh program; that build heallhy spiril, mind a"d NON for all.