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Home My WebLink AboutMansfield Children's 12/31/2004TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD0 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: Mansfield Children's Ctr. for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: 1100 School Street Method of water treatment is: 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.: Date of Expiration: December 31, 2004 Scott Leite, Health Agent Date ssued Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 41' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: Deck Type: Skmmr weir length: Treatment System: Disinfect Method: Chemical Treatment: No. of Bathers: Remarks: Permit No.:8 Fee per pool: SIGNA' DATE: TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL 1 ,,1 Mansfield Children's Ctr. 1100 School Street Mansfield Zip:02048 508-339-9211 1100 School Street Semi -Public Width: 21' 3.5' to 6' 400sf None Town Private Liner Volume:1 C 2' Cement 3 skimmers Diatomacious Earth Chlorine 43 $75.00 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. R\Hea(th\Pafs AocumentAPERWT APPLICATIONS\SWIMMING POOLS APP.doc The Commonwealth of Massachusetts T - — Department of Industrial Accidents ofceof►nresugodens �' -- 600 Washington Street, 7r" Floor —4 Boston, Mass. 02111 �—1-1 Workers' Compensation Insurance Affidavit - General Businesses Applicant information: Please PRINT Ie 'bl ci state: i hone # WUlx J1tc rvt.auvaa �u.a ......•�..� . ❑ I am a sole proprietor and have no one BusinessT pe: F] Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. Office ❑ Sales (including Real Estate, Autos etc.) ❑ I am an employer with employees (full & part time). ❑ Other ❑ I am an employer providing workers' compensation for my employees working on this job. company name address: city: hone #• insurance co. nnliev # ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address: city: hone #• insurance co. rinlicy # company name: address: city: hone #- insurance co. nniiev # Attach additional sheet if necessary 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 cert{�y der t pa' n en ofperjury that the information provided above is true and correct. Signature `' Date �1 f Phone # Print fl'�e �' �� "`�. � official use only do not write in this area to be completed by city or town official city or town permit/license # QBuili ing Department QLicensing Board Q check if immediate response is required QSelectmen's Office QHealth Department contact person:phone #; QOther (revised Sept. 2003) CIA, IONAL N'SURANCE GROUP w'UT [CA NAT WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AMENDED INFORMATION PAGE EFFECTIVE 10/07/03 DUE TO THE APPLICATION OF A REGULATORY RATE CHANGE SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD NCCI CO #k15717 2066058 10/07/03 10/07/04 2066058 UTICA MUTUAL INSURANCE COMPANY ......................::::::::::::::::..:::::::::::.. . :. ....:.:... U�f��7sABUT;�:::::M�1:L1#SECi.:.t1[3F3E��S.::::::::.:::.:.:::::::::::::.::::.::.::::::::::::::::::.:::::::::.�.::::.:::::..:�::::.::::::::::...:.:...................................................................................... f CENTER BORHEK INS AGY 77377 • INC 311 PLYMOUTH ST 1100 SCHOOL STREET HALIFAX MA 02338 MANSFIELD MA 02048 (781) 293-6331 FEIN 042725454 RISK ID. 165573 SEE ATTACHED SCHEDULE ENTITY OF INSURED - CORPORATION 2. POLICY PERIOD - 10/07/03 TO 10/07/04 12:01 AM STANDARD TIME AT THE INSUREDS MAILING ADDRESS. 3A. WORKERS COMPENSATION INSURANCE:PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: MA. 3B. EMPLOYERS LIABILITY INSURANCE:PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT 3C. OTHER STATES INSURANCE:PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,LISTED HERE:ALL STATES EXCEPT:ND,OH,WA,WV,WY AND STATES DESIGNATED IN ITEM 3A. 3D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS FORMING PART OF THIS POLICY. 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. 4. CLASSIFICATIONS PREM BASIS RATE EST 5T LOC CODE TYP EST TOT ANN PER $100 'ANNUAL NO REMUN REMUN PREMIUM SEE ATTACHED SCHEDULE $4,,'117 MINIMUM PREMIUM $165 (MA) EXPENSE CONSTANT(MA) $264 TOTAL ESTIMATED ANNUAL PREMIUM $4,381 DEPOSIT PREMIUM $4,381 THE FOREGOING AMENDMENT RESULTS IN AN ADDITIONAL PREMIUM OF: $18 ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. COMPANY OF ER ZOUNTERSIGNED THIS 16TH DAY OF FEBRUARY,2004 PREMIUM AMOUNT TO BE REFLECTED ON NEXT BILLING NOTICE JNI-BILL NO. 100362146 DB- IC ISSUE DATE 02/16/04 4C 00 00 01A W 2066058 08 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AMENDED INFORMATION PAGE EFFECTIVE 10/07/03 DUE TO THE APPLICATION OF A REGULATORY RATE CHANGE ;UPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD NCCI CO #15717 2066058 110/07/03 10/07/041 2066058 1 UTICA MUTUAL INSURANCE COMPANY INC 1100 SCHOOL STREET MANSFIELD MA 02048 FEIN 042725454 RISK ID. 165573 311 PLYMOUTH.,ST� ., HALIFAX MA 02338 (781) 293-6331 NFO **SCHEDULE OF OPERATIONS" AGE 2 4. T LOC CODE TYP NO CLASSIFICATIONS A 0001 8868 SCHOOL: PROFESSIONAL EMPLOYEES & CLERICAL TOTAL FOR LOCATION 0001 0002 8868 SCHOOL: PROFESSIONAL EMPLOYEES & CLERICAL TOTAL FOR LOCATION 0002 9740 TERRORISM RISK INSURANCE MA ASSESSMENT CHARGE TOTAL FOR MASSACHUSETTS IC ISSUE DATE 02/16/04 SCHEDULE PAGE 1 PREM BASIS RATE EST EST TOT ANN PER $100 ANNUAL REMUN REMUN PREMIUM 560,000 0.68 3,808 $3,808 IF ANY 0.68 ",0 $0 .0300 x.168 .0370 1,41 $4,117, TOWN ON MANSFIELD BOARD OF HEALTH SIX PARK ROW MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT ,— I. 1-1 CDF- IAI PI IPP().qF- P()(il I-i I YF't Ut- VUUL: rUtSLlu LJ -- NAME OF POOL 1G , , - .ADDRESS t wz-° OWNER ADDRESS DATE OF INSPECTION /t*_ POOL CAPACITY Lr INSPECTED BY ' �"`�'� .� # OF GALS. � �' METHOD OF WATER BATHER % l # OF LIF GUARDS WATER SOURCE: TREATMENT LOAD !'nAD AAI-, nM Regulation 105 GMK 435.000 i ne Items marKeu uelvw wi l cm 1%,0LU u,c V JW1 v r• .. �• •� _..... . _ _. _ _ _ _ items marked with a are satisfactory. REGULATION X/4 VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. .Os Adequate enclosure around pool. Gate self -latching wllatch 4 ft above ---- ---------------------------------------- round. --------------------------------- --------------------------- __04 Sewage Disposal------------------------------------------------ - --------------------------------------------------------------------- __05 Location, structuralstability,finish.---------------------------------- ------------------------------------------------------- ------------------- .06 Water circulation & filtration systems. Filter effluent flow meter reading:` iu gpm_ #oftumovers---------- __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 __-__----- .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 _ _ _rovided. -----a--------- ------- ----------------------------------------------------- OB 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 ... pump switch _ Accessible and prominently marked ------------------------ -.09 _________________________09 Cross connections: Potable water supplied through air_gap ............... _10 Skimminpfacilities_50% of re circulation drawn from su_rf_ace 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 __________________________14 Ladders, steps --one-per-75 feet._Not less than -2 ladders._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _15Diyingequ4mentinsafecondition__________________________________ .17 Pool supervision — Pool supervision provided. Effective Jan 1, 1999, pool supervisor certified aspool 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 2 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. -------------------------------------------------------- --------------------------------------------------------------------------------- 29 Chemical standards. POOLSIDE READINGS ; Bromine 4 ;; 0" prz Y Total Chlorine Alkalinity(5t rrr Free Chlorine Cyanuric Acid Jp,= aE) t 4r Ct Jr omb. Chlorine Water Temp. t04_ l W. - pH Level 7 Z" —*parts per million Other _29 Pool water tested with appropriate freguency-------------------------- .30 _______________________.30 Water testing equipment. DPD kit provided for chlorine and bromine. _ _ _ Unbreakable thermometer for special purpose pools--------------------- - 31-Waterclari-ty.----------------------------------------------------- ----------- _32 Water clarity_ maintenance_ Filtration system operating continuously_ _32 specialpurpose pool drained, cleaned and ever _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.