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Home My WebLink AboutMansfield Depot II 12/31/2004TOWN OF MANSFIELD BOARD 1 SIX PARK .1 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 ❑ Semi -Public ❑ Special Purpose Pool at: Method of water treatment is: Bathing load not to exceed: Mansfield Depot H Automatic Chlorinator 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, 2004 m: Scott Leite, (H alth Agent Date Issued TOWN OF 1VIANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Name of Owner: Keith Properties, Inc. Address: 532 Page Street City: Stoughton State: MA Zip:02072 Telephone: 508-339-3583 Fax: Fed ID/SS No.: 04-2995014 Pool Location: Mansfield Depot II Type/pool: Semi -Public Length: 40' Width: 20' Volume: 27,000 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.:6 Fee per pool: $75.00 SIGNA' DATE: 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. RAHealthtPat's DowmentsTERMIT APPLICATIONS\,SW>t*' WG POOLS APP.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office offnfestiffaaons 600 Washington Street, 7th Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - General Businesses address 73 n p state zip phone # ❑ I am a sole proprietor and have no one Business Type: ❑ Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. n Office ❑ Sales (including Real Estate, Autos etc.) ❑ I am an employer with employees (full & part time). E]Other NN I am an employer providing workers' compensation for my employees working on this job. companyname �� ih 1 ;Y ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address: City: Rhone M insurance co Policy # address: city Rhone #: insurance co policy # Attach additional sheet if necessary Failure to secure coverage as required under' Section 25A of 1AGL 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 rtify, and r the sins and penalties of perjury that the information provided above is true and correct. 1`! � 1t oS Signature Date TOWN ON MANSFIED BOARD OF HEALTH i SIX PARK ROW MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT .r. a rte.....n CD1Zf'1 AI DI IRDfIG'F P001 n 1 1rr-%JF rVVL. r- -- --- NAME OF POOL ADDRESS OWNER ADDRESS w fit,, DATE OF INSPECTION POOL CAPACITY # OF GALS. INSPECTED BY METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT _ LOAD -- '-°--- -s enr nnn Regulation 1U5 GMK 435.000 i ne nems marKeu De1UW WILT) d11 A u1U1G0l1= UIC vwiaacv N.vv.Q'w'' wl lww—• Items marked with a °fin are satisfactory. REGULATION X14 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 --_ 91999d. _ .04 Sewage Disposal -------------------------------------------------Y ------------------------------------------------------------------ �,s .05 Location, structural stability, _finish.---------------------------------- - --------------------------------------------------------------------- -------------------------- ----- - .06 Water circulation & filtration systems. Filter effluent flow meter reading: 0 _qpm. # ofturnovers Le. ----------------------------------- t �- _06 Suitable automatic equipment for disinfection of pool water ----------------- .06 ____________.06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders anchored_ Inaccessible to public, adequate_v_entilation provided_ .08 Inlets and outlets- Inlets located to produce uniform circulation. Over rim fill sp _qt 6° above maximum water level _ Properly_ shielded and located ------------- ------------- .08 _ _ _ _ - _ -- _ _ .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. ° .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.--------------------------------------- 2 ------ .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 int ° repairs are made. .08 Special purpose pool and wading pools equipped with emergency shut off ---pump switch_ Accessible and prominently marked'---------------------- ` . , ---- ---------- ---------------- ---------- ----------- --- ----- __09Crossconnections_Potablewatersupplie9t11rou9hair_gap______________ _ __ _____ ---------------- ------------------------------------------------ _10 Skimminnfacilities_50% of re circulation drawn from surface of pool. ------------- --------- ------ --------- - I _12Linewithfloatssepar-ates no -mer -----nsw----------ea from------deepe-------------water. - _______�t` 1- --------------------------------------------------- .12 =______________________________--------------- .12 Water depth markings on deck and galls. Properly spaced. Boundary line 9T pool floor and walls__Stepogge inocolor_ marked with contrast ________ ___------------ ------- _ ----- --- ---- _13 Walkway and decks -4 feet widq,-safe condition .------------------------ ------ --------------------------------------------------------------------- 14 Ladders steps — one per 75 feet Not less than 2 ladders -- -------------------------------------------------------------------- 15 Divin ui mentin safe condition - -- --------- -/�' _) --------------------------------------------------------------------- -' ----o�-p-----------------=----- ---- ------- 17 Pool supervision — Pool supervision provided. Effective Jan 1,1999, pool ... supervisorcertified aspool-operator fromYMCAorNSPF---------------- - -------------------------------------------------------------------------- .21 Permit requirements — Permit issued. Adequate maintenance and testing records-mntaned.----------Records Initialed byperson making tests. ___________ ________ ------- .22 Health Regulations: Signs Posted. Health warning signs posted for special ,- - - Purpo§e_pqqls---------------------- "--purposepools----------------------------------------------------- I ---------------------------------------------------------------------------- .23 Lifeguards required; Yes ® No ❑ If Lifeguard required; proper credentials, proper suits and garments wom. r ---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 equipmentprov_ided_ 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 4p otal Chlorine Alkalinit Free Chlorine Comb. Chlorine .' = Cyanuric Acid > .� — Water Temp. ff .. � pH Level —*parts per million Other _.29 Poolwatertested with appropriatefreguency__________________________ ____---------------------------------------------- .30 ____________________________________________.30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable -thermometer forsPecialpurpose pools.____________________ __________________________________________________ _.31 Waterclarity--------------------------------- ---------------------- ------ ------------------------------------------- 232 Water clarity maintenance. Filtration system operating continuously_ _32 special purpose pool drained, cleaned and ev_----- 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. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE i XW .34 Closure of the pool. POOL AMIUST BE CLOSED UNITL IT MEETS THE STANDARDS OF 195 CMR 435.39 THROUGH 435.31. SIGNED SIGNED Operator Board of Health/Health Department j