Loading...
HomeMy WebLinkAboutCanoe River CG 12/31/2004TOWN OF MANSFIELD B OARD OF HEALTH SIX PARK ROW91 02048 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 Ifor the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: 137 Mill St. Method of water treatment is: Automatic 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, 2004 �S/0_6 /. / , Scott Leite, Health Agent Name of Owner: Address: City: State: MA Telephone: TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Canoe River Campground 137 Mill St. Mansfield Zip:02048 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' Min/Max. depth: 3'-10' Swim Area: 57100' Dive Area: None Water Source: Town W/W Disposal: Private Leach Type of Finish: Cement Scum Gutter: /i .�j Deck Type: Cement Skmmr weir length: 4 Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: Automatic No. of Bathers: 94 Remarks: Permit No.:I Fee per pool: $75.00 Volume: 60,000 Permit Expires December 3151 yearly SIGNATURE: DATE: 1 �3 Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. R:\Heaith\Pat's DocumentAPERMIT APPLICATIOWSWIMMING POOLS APP.doc ,� The Commonwealth of Massachusetts Department of Industrial Accidents ' Off►C® Of 1H OSlfgad©AS 600 Washington Street, T Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit -General Businesses Applicant information: Please PRINT legibly name• /' (�- r` A 137 /,/l t L.., L 57- city Al A ASS r—/ [.Z-- state: /�'� zip: O Y S) phone # S U1' ` 3 "1- W t/6 ;)— work site location (full address) / 3 -2 �A�l / I- L, S / , (/(I -I �� � ) LZ -_c> /t414 , C)-:)- o y/,' ❑ I am a sole proprietor and have no one BusinessT pe: E] Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. L�/ [.Office ElSales (including Real Estate, Autos etc.) I am an employer with' employees (full & part time). / Other C -AELf �« c�c c •tiL� ❑ I am an employer providing workers' compensation for my employees working on this job. company name: S !_r%2 L, l - J C I R f UES C1�G-.��c�CTic%L� address / ' 7 jt'1 L_ L :5-r . City: iV(,y_ /= I tZ / /t,1 /q - O � 0 YX phone #. SU c? 3 `j - IA. insurance co k(DY +L- 15VI%1{ L Lc ILV(�- LOS . C 2 , policy # 6, j� a3 V( (3 — 8 &, s- U 3 ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: address: city phone #• insurance co policy # company name: address: city phone #• insurance co policy # 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 Signature Wpai s ofperjury�at the information provided above is true and carr et. Date {��o� �/ G Print name /f/[A2K /7, 1, Phone # �-Oy ` 3 3 0, - 6 1/6 �_ official use only do not write in this area to be completed by city or town official city or town: ❑ check if immediate response is required contact person: (revised Sept. 2003) permit/license # ❑Building Department ❑Licensing Board ❑Selectmen's Office ❑Health Department phone #; ❑Other TOWN ON MANSFIELD BOARD OF H ALTH SIX PARK ROW MANSFIELD, IV,A 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL. INSPECTION REPORT .n n G+MRAI M1101 If, i CDf=f'IAi PI iRP(1CF PClnl �I NAME OF POOL ADDRESS OWNER ADDRESS DATE OF INSPECTION a POOL CAPACITY # OF GALS. INSPECTED BY ` METHOD OF WATERBATHER f . , # OF LIFEGUARDS WATER SOURCE: TREATMENT t` LOAD f Regulation 105 CMR 435.000 i ne items marKeo Deiow win an __A inuicaie the viuiateu piuvisiurls ui Iva %..mrn It') v. Items marked with a "4' are satisfactory. REGULATION xlq VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. ------ ---- -------------------------------------------------- ------- -------------------------------------------------------------------------� .03 Adequate enclosure around pool. Gate self -latching w/latch 4 ft above ---ground----------------------------------------------------------- ------ ---------------- 04 Sewage Disposal------------------------------------------------ -------------------------------------- -- -- -------------- --- - - __05 Location, structural stability,_finish------------------------------------ 06W t __________________________________ 06Wate circulation & filtration systems1 liter effluent flow meter reading: gpm_ _# of turnovers _06 Suitable automatic equipment for disinfection of poo! water_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ---- --------------------------------------------------------- I -- --- -(:" ------------------------------------------------------- .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders anchored_ Inaccessible to public, adequate ventifation provided, .08 Inlets and outlets- Inlets located to produce uniform circulation. Over rim VX fill spout 6' above maximum water level _ Property_ 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 ... pj9yided. .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 um switch Accessible and rominentl marked 41 ----------------------------------------------------------------------- T tal Chlorine -~ Alkalinity ree Chlorine w _------ssconnections:Potablewatersuppliedthrouphair_gap______________ _`" _____-___________________-______________------------------------------ Comb. Chlorine it 10Skimmin,&cilifies_`�0% of recirculation drawn from surface of pool. _ ____________________i______________________--__________-_____-___-____-_-__ � I .12 Line with floats separates non -swimmer area from deeper water. _________________________________________________________________________ Other .12 Water depth markings on deck and walls. Properly spaced. Boundary line 1� i ... onpoolfloor and walls_ StepedAismarked with contrastinacolor_.......... ______________________________________________________________________ __13 Walkway and decks4 feet ------wide, safe condition. ------------------------ ---R--- ---------------------------------------------------------------------- .14 Ladders steps — one per 75 feet Not less than -2 ladders ------------------------------------- ----------=--------- -----. -- ----- --------------- ---------- --------------------------------- .15 nq egupmentin safe condition --------------------------------------------------- ----- ------------ ---- --- - - - -----t ------- ----------- ---------------- ------------------------- - .17 Pool supervision — Pool supervision provided. Effective Jan 1, '1999, pool .17 --supervisor cerii_fi_ed @spool operator from YMCA or NSPF: -- -- ---------------------------------------------------------------------- .21 Permit requirements — Permit issued. Adequate maintenance and testing ------------------V________________________________________________________________________- ___recordsmain-----.-Records initialed bypersonmakingtests. .22 Health Regulations: Signs Posted. Health warning signs posted for special LZ le --- purpose_pools=----------- --------------------------------------------------------------------------- ,23 Lifeguards required; Yes ❑ No If Lifeguard required; proper credentials, proper suits and garments wom. ---Whistle and bullhorn proyided.-------------------------------------- ---------------------------------------------------------------------------- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube ___and backboard with straps atpools attended by @lifeguard_______________ _ ____ _____________________________________________________________________ .25First aid equipmentprovided 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 ti# {per T tal Chlorine -~ Alkalinity ree Chlorine w Cyanuric, Acid - = Comb. Chlorine it Water Temp. X41 s„nom pH Levelt -Varts per million Other .29 Pool water tested with appropriate_ eguency------------------- ------ ------ ---------------------------------------------------------------------- .30 Water testing equipment. DPD kit provided for chlorine and bromine. --- Unbreakablethermometerforspecialpurpose pools----------------------------- --------------------------------------------------------------------- 31 Waterclarity.----------------------------------------------------- ------ ---------------------------------------------------------------------- __32 Water clarity maintenance, Filtration system operating continuously____-_ _ ---------------------------------------------------------------------- __32specialpurposepooldrafined,cleanedandevery14days.______________ 1`' ---------------------------------------------- ___-_-___------------------ 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.................. ______________________________________________________________________ .38General sanitation. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE i X14 •34 Closure of the pool. POOL MUST BE CLOSED UNITL IT MEETS THE STANDARDS OF 195 CMR 435.29 THROUGH 435.31. SIGNED SIGNED Operator Board of Health/Health Department j 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 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 Vfor the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: 137 Mill St. Method of water treatment is: Automatic 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, 2004 Scott Leite, Health Agent Issued Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No. Pool Location: Type/pool: Length: 40' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: Deck Type: Skmmr weir length: TOWN 1MANSFIELD, BOARD OF I SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL 1 Canoe River Campground 137 Mill St. Mansfield Zip:02048 508-339-6462 508-339-5237 04-2375571 137 Mill St. Cement Width: 22' 3' 40'x22' None Town Private teach Cement None Cement 2 Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: Automatic No. of Bathers: 94 Remarks: Permit No.:2 Fee per pool: $75.00 Volume: 22,440 Permit Expires December 31St yearly z-� SIGNATURE: DATE: 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-,\Health\Pat's DocumentAPERMIT APPLICATIONS\SWIMMING POOLS APP.doc ` The Commonwealth of Massachusetts — Department of Industrial Accidents t -- Office OfI msdoanO/IS - 600 Washington Street, 7rh Floor Y Boston, Mass. 02111 v Workers' Compensation Insurance Affidavit - General Businesses A liPlease PRINT le bl c name ✓l/14 /, 1 < % G ('J / L L S .I City !V i �( S /= f L I� state: /ul A ?,i,2: O -)- 0 Y P 12hne # S v S - -) S 9 - G WOTK Slit; IMULIVII ,uu auvi— — --- ❑ I am a sole proprietor and have no one BusinessT e: [:]Retail ❑ Restaurant/Bar ating Establishment working in any capacity. [ Office ❑ Sales (including Real Estate, Autos etc.) I am an employer with _Y_ employees (full & part time). P Other CA Al /°C /- ° u /"I-� ❑ I am an employer providing workers' compensation for my employees working on this job. D R'4 C A UoC-- address: % 3 i At / L 5 '! ..:t.,. ,�i�r�S�-/�Z� �V1� U.�.fJ yc�' phone#• SCJ. -.'S J'�%� G �i�6 y/�L f"JS . C ❑ 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. voticy # -/_U3 address: city: hone #• insurance co. otic # 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 certify under #e pai s and talties of perjury th the information provided above is true and carr t. Signature ' . CEJ ` ` " Date // / ' V, C� .3 v � r Print name 41 f� (3(�/i�M �-7 S % Z� Phone# SU� '" 3 j - V6 official use only do not write in this area to be completed by city or town official city or town permit/license # ❑Building Department Licensing Board ❑ check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone #; Other (revised Sept. 2003) 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 CDGr'IAI P1 IPPf1<,'F P()C)l n i Yrr- Vr" r'VVL. r-Ui7L11✓ LJ .,i..... .. u - NAME OF POOL fiflspout6"ahovemaximumwaterlevel Properly_ shielded and located -------------------------------------------- ADDRESS __________________________________ .08 Main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without use of tools. Open area does not drain OWNER ... proyided.--------------------------------------------------------- ADDRESS DATE OF INSPECTION POOL CAPACITYINSPECTED # OF GALS. BY METHOD OF WATER BATHER LOAD # OF LIFEGUARDS WATER SOURCE: TREATMENT ^s enc AMA 4F A(1rl Regulation 1U5 C:MK 4d5.000 I ne Items mdlKeu uclvW Wiui au ^ ,f,un.a.c Ll 1c VJWJ­ ................-- Items marked with a "4' are satisfactory. REGULATION xhl VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. 03 Adequate enclosure around pool. Gate self -latching wllatch 4 ft above ---ground_ ----------------------------------------------------------------- 04 Sewage Disposal------------------------------------------------- -------- ------------------------------------------------------------------- ,05LoGatl ---- --------------------------------------------------------------------- 05Location structuraistabilit finish ______ ______ ________________ y'---------------------------------- --- - -- ---- --- - --- C a� - .06 Water circulation & filtration systems. Flit effluent flow meter reading: (:� � j � � ------ _- gpm__#oftumovers __06Suitableautomaticequipmentfordisinfectionofpoo!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 fiflspout6"ahovemaximumwaterlevel 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 drain provide entrapment of fingers, toes, etc. At least one antivortex ... proyided.--------------------------------------------------------- ----------------------------------------------------------------------------- .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 ---V-------------------------------- ...pump switch_ Accessible and prominently marked .---------------------- -- -------------------------------------------------------------------------- Chlorine Free Chlorine __09Crossconnections_Potablewatersuppliedthroupbair_gap___ __________ ______ ______________________________________________________________________ C anuric Acid _10Skirnl innfacilities_50%ofrecirculationdrawnfrom surface ofpool._ _ s` __ ___________________________________________________________________ I _12 Line with floats separates non -swimmer area from deeper water------------ --------------------- jam_ _ .12 Water depth markings on deck and walls. Properly spaced. Boundary line _32Waterclaritymaintenance.Filtrationsystemoperatingcontfnuously____ I onpoolfloor and walls. _Step edges marked with contrastinpeolor________ _____________________________________________________________________________ __32 specialpurpose pool drained, cleaned and every 11 -On .-------------- �� _13 Walkway and decks 4 feet wide, safe condition .------------------ -- ---------------------------------------------------------------------- Operating Temperatures for Special Purpose Pools. (SPP). _14Ladders,steps_ oneper 75 feet. Not less than2ladders -------------------- .33 a. Thermostatic control provided for each SPP. ____________________-_________________________----------------------- _15 Div_inpegupmentin 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 byperson making tests-------------------------------------------- ---------------------------------------------- .22 Health Regulations: Signs Posted. Health warning signs posted for special VX --- purpose pools----------------------------------------------------- ------ - --------------------------------------------------------------------- .23 Lifeguards required; Yes ❑ No If Lifeguard required; proper credentials, proper suits and garments wom. --- Whistle and bullhorn proyide4-------------------------------------- ----------------------------------------------------------------------------- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube ___and backboard with straps at pools attended by a lifeguard______________ _"_--_ --------------------------------------------------------------------- .25FirstaidequipmentProv_ided_ First aidkitcomplete.____________________ _____________________________________________________________________________ .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. Separaflon tank provided for diatomaceous earth filter backwash water. ------ --------------------------------------------------------------------- -------------------------------------------------------------------- .29 Chemical standards. POOLSIDE READINGS ---V-------------------------------- Bromine/Total .30 Water testing equipment. DPD kit provided for chlorine and bromine. .30 Chlorine Free Chlorine _ Alkalinity C anuric Acid Comb. Chlorine _= — Water Temp. � __31 Waterclarity.----------------------------------------------------- *parts per million ------ Other __29 Poolwatertested with approptEtefrequency-------------------------- ---V-------------------------------- ----------------------------------------- ---------------------------------------------------------------------- .30 Water testing equipment. DPD kit provided for chlorine and bromine. .30 --- Unbreakable -thermometer forsPeciaipurposepools ----------------------------- ________________________ --- __31 Waterclarity.----------------------------------------------------- ------ --------------------------------- ------------------------------------- _32Waterclaritymaintenance.Filtrationsystemoperatingcontfnuously____ ___________________________________________________________________ __32 specialpurpose pool drained, cleaned and every 11 -On .-------------- �� A,,'O ------------------------------------------------------------------------ Operating Temperatures for Special Purpose Pools. (SPP). .33 a. Thermostatic control provided for each SPP. V b_Thermostaticcontrol onlyaccessibletothepooloperator __ _____________________________ 38 General sanitation. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/4 •34 Closure of the pool. POOL MUST BE CLOSED UNITL IT MEETS THE STANDARDS OF '195 CMR 435.29 THROUGH 435.31. SIGNED SIGNED Operator Board of Health/Health Department