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HomeMy WebLinkAboutHockomock Y 12/31/2004Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 38' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: Deck Type: Skmmr weir length: SIX PARK , MANSFIELD 02048 I..... SWIMMING POOL APPLICATION Hockomock Area YMCA -Mansfield 40 Balcom Street Mansfield Zip:02048 508-339-3066 04-2131749 40 Balcom Street Above -ground Width: 18' 3' to 4'6" 38' x 18' None Town Septic System Steel w/vinly liner None Wooden 1.5 to 2 ' Treatment System: Sand Filter Disinfect Method: Chlorine Chemical Treatment: Chlorine No. of Bathers: 40 Remarks: Permit No.: 12 Fee per pool: $75.00 SIGNATURE. DATE: /Z -3 -" Volume: 10,000 gal Permit Expires December 31st yearly 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. R1HealthkPat's Docutnents\PMUT APPLICATIONSGSWIMMING POOLS APPAOC The Commonwealth of Massachusetts Department of Industrial Accidents i Office OURNISITYSUGHS 600 Washington Street, 7`h Floor %Y Boston, Mass. 02111 z, Workers Compensation Insurance Affidavit -General Businesses nu -t Please PRINT lee bly asoma• 1C®1 �/ ltx-^ l�_" address:/ qeo / r 67 ey �- =.<�,rl,r� state: -1 zin' -6`00' 5 phone # e' E64) ' i 3101' ❑ I am a sole proprietor and have no one BusinessT pe: ❑ Retail F]Restaurant/Bar/Eating Establishment working in any capacity. [ Offic Sales (including Real Estate, Autos etc.) ❑ I am an employer with employees (full & part time). 0 Other ❑ I am an employer providing workers' compensation for my employees working on this job, company name: city phone #: insurance co. noliev # ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address: city phone #: insurance co. policy # company name: address: city phone It - Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Print name official use only do not write in this area to be completed by city or town official city or town: permittlicense # ❑Building Department OLicensing Board O check if immediate response is required ❑Selectmen's Office OHealth Department contact person: phone #; OOther (revised Sept. 2003) October 27, 2003 TOWN OF MANSFIELD, MASSACHUSETTS Hockomock Area YMCA -Mansfield 40 Balcom Street Mansfield, MA 02048 RE: 2004 Swimming Pool Permit Six Park Row, Mansfield, MA 02048 Your current Swimming Pool Permit with the Town of Mansfield expires December 31, 2003. Enclosed are the applications for 2004. Please review the information I have on file and make any additions or corrections. All items on the application must be completed. Please return the signed applications to my attention no later than November 28, 2003. Sign, date, and enclose check payable to Town of Mansfield, and mail to: Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 If you have any questions or require additional information, please contact me at (508) 261-7366 orcs{ scfd a.ccs Thank you, Pat Byrnes Administrative Secretary Board of Health Enclosed TOWN ON MANPRELD BOARD OF HEALTH SIX PARK ROW MANSFIELD, MAS 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TVPt= rlF Pnni • PI IRI I('. n RFMI_Pt IRI IC SPECIAL PURPOSE POOL M NAME OF POOL ADDRESS OWNER ADDRESS DATE OF INSPECTION _ F . POOL CAPACITY # OF GALS.` INSPECTED BY METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD > Regulation 105 CMR 435.000 The items marKed below with an "A" indicate the violated provisions or i uo L;mK 4so.uuu. Items marked with a "4' are satisfactory. REGULATION XN VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting;'ventilation; sanitary condition. -----------------------------ool------------------------------------ ------ --------------------------------------------------------------------- .03 Adequate enclosure around pool. Gate self -latching watch4 ft above _ _ 91999d. _.04 Sewage Disposal__________________________ ----------------------- ------ ---------------------------------------------------------------------- _.05 Location, structuralstability,_finish._________________________________ - - ------ ----------------------------------------------------------------- _____ .06 Water circulation & filtration systems. Filter effluent flow meter reading: --------------- gpm__#oftumovers_____ -.0606 Suitable automatic equipment for disinfection of pool water_ Suitable automatic ---- ------ ---------------------------------------------------------------------- .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 use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain ... p1qvided. --------------------------------------------------------------------- .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 are made. .08 Special purpose pool and wading pools equipped with emergency shut off ... pu_mpswitch_ Accessible and -prominently marked ------------------------------------------------------------ ---------------------------------------- -.09 _______________________---------------------------------------------------------------------------- _.09 Cross connections_ Potable water suppliedthrough air_gap------------- --------------------------------------------------------------------------- .10Skimmin,qfacilities_50.1�of recirculation drawn fromsu_rfaceofpool............................. --------------------------- ------------------------ I .12 Line with floats separates non -swimmer area from deeper water_ ------------------- - -------- ------ ---------------------------------------------------------------------- .12 Water depth markings on deck and walls. Properly spaced. Boundary line I ... on pool floor and walls_ Step edges marked with contrasting color------------------------------------ ---------------------------------------------------- --------------------- — --------- !rAsK -.13 ______________--------------------------------------------------------------------- 13 Walkway and decks 4 feet wide, safe condition ---------------------------------------------------------------------- ----------- - - --- ------ ---------------------------------------------------------------------- _._14 Ladders, steps --one-per 75 feet. -Not less than -2 ladders. _ _ _ _ _ _ _ _ _ _ _ _ -- ------ ---------------------------------------------------------------------- ,15 Diving egupment in safe condition, _____________ ------------- ----------------------------------------------- ----------------------------- �P�iyipq_e ef�t in safe condition. gy!RE ------------------------------------------------- V ----- ---------------------------------------------------------------------- .17 Pool supervision —Pool supervision provided. Effective Jan 1, 1999, pool ... supervisorcertified as pool operator from YMCA or NSPF_-------------------------------------- ------------ ------ -------------------------------- .21 Permit requirements — Permit issued. Adequate maintenance and testing ___records maintained._ Records initialed byperson-makingtests.___________ _______ --------------------------------------------------------------------- .22 Health Regulations: Signs Posted. Health warning signs posted for special ---purposepools----------------------------------------------------- - ,23 Lifeguards required; Yes ❑ No ❑ If Lifeguard 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. -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 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. -------------------------------------------------------------------- ------ ---------------------------------------------------------------- .29Chemical standards. POOLSIDE READINGS Bromine tt —tJ Total Chlorine V Alkalinity Cyanuric Acid 5Q r Free Chlorine Comb. Chlorine " Water Temp.;3t4� v,x H Level x *parts per million Other -29 Pool watertested-with appropriatefreguency-------------------------- -------------- -------------------------------------------------------------- ---------------------- - .30 Water testing equipment. DPD kit provided for chlorine and bromine. _ _ _ Unbreakable thermometer for special purpose pools. _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ ----- ---------------------------------------------------------------------- -31-Water- cla--rity. --------- ----------------------------------------------------- ------ ---------------------------------------------------------------------- _.32 Water clarity maintenance. Filtration system operating continuously_ __ _ _ _ ------ ---------------------------------------------------------------------- _.32 specialpurpose 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.