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HomeMy WebLinkAboutMansfield Depot I 12/31/2004TOWN 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: Keith Properties, Inc. for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: The Village at Mansfield Depot I Method of water treatment is: Haywood Chlorine Feeder/Tabs/CH 200 Bathing load not to exceed. 70 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 5 Date of Expiration: December 31, 2004 Scott Lute, ealth Agent Dat Issue 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.: 04-2946285 Pool Location: The Village at Mansfield Depot I Type/pool: Semi -Public Length: 48' Width: 24' Volume: 65,000 Min/Max. depth: 3' to 9' Swim Area: 36'x24' Dive Area: None Water Source: Town W/W Disposal: Town Sewer Type of Finish: Vinyl Print Scum Gutter: N/A Deck Type: 24' concrete Skmmr weir length: 2 skimmers Treatment System: Disinfect Method: GPM 75 Backwash 60 Chemical Treatment: Haywood Chlorine Feeder/Tabs/CH 200 No. of Bathers: 70 Remarks: Permit No.:5 Fee per pool: $75.00 Permit Expires December 31St yearly l o' SIGNATURE: ' 6 DATE: \ rIPI 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. RAHeaith\Pafs Documents\PBRMIT APPLICATIONS\SWft^flNG POOLS APP.doc The Commonwealth of Massachusetts Department ofIndustrial Accidents Office OHMSH98flons 600 Washington Street, 7"h Floor kt Boston, Mass. 02111 Workers' Compensation insurance Affidavit - General Businesses Applicant informatio ri: Please PRINT le 'bl name: —G -N 't N address: 0-1%6-161 . 6ty (A state: zip: phone # work site location full address ):.\;ii ❑ I am a sole proprietor and have no one Business T e. L] Retail n Restaurant/Bar/Eating Establishment working in any capacity. Office n Sales (including Real Estate, Auto etc) V\c ❑ I am an employer with employees (full& part time). [DOther �my--,iA 1 am an employer providing workers' compensation for my employees working on this job. company name 16 i n address: F1 I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: com an n in : address city: hone #• nniiev insurance co. company name: address: nhnnp. city: ninsurance co. nfiev It Attach additional sheet if necessaryand/or 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.Q0 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 DU for coverage verification. I do hereby certify under theinsandPenallies ofperjury that the information provided above is true and correct. Signature Date Print name �We Phone# official use only do not write in this area to be completed by city or town official _lBuilding Department permit/license # f city or town: FILIcensing Board ❑ ElSelectmen's Office check ❑ if immediate response is required E]Health Department phone #; E]Other_ contact person: (revised Sept. 2003) OP ID R1 DATE (MMIDDIYYYY) c®RD. CERTIFICATE OF LIABILITY INSURANCE KEITH -3 11/07/03 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Associates Inc.HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Thomas Gregory AssocALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 601 Edgewater Drive iate Wakefield MA 01880 Phone: 781-914-1000 Fax: 781-246-2601 INSURERS AFFORDING COVERAGE NAIC #` INSURED INSURER A: Atlantic Charter Insurance rp INSURER B: Keith Properties Inc. INSURER C: Christine Farrell 532 Pa a Street INSURER D: Stough on MA 02072 INSURER E: I COVERAGES LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING THE POLICIES OF INSURANCE ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE MMIDDIYY DATE MMIDDIYY LTR NSR TYPE OF INSURANCE EACH OCCURRENCE $ GENERAL LIABILITY PREMISES (Ea occurence) $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- LOC POLICY JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ GARAGE LIABILITY EA ACC $ ANY AUTO OTHER THAN AUTO ONLY: qGG $ EACH OCCURRENCE $ EXCESSIUMBRELLA LIABILITY $ OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLE RETENTION $ ER ftACCIDENT WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCE00307501 06/30/03 06/30/04 T $ 500000ANY A PROPRIETOR/PARTNER/EXECUTIVE MPLOYEE $ 500000OFFICER/MEMBER EXCLUDED?If CY LIMIT $ 500000 yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Swimming permit Evidence of Workers Compensation.coverage for 2004 pool Mansfield RE: Mansfield Meadows, Village at Mansfield Depot I and Village at Depot II. CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MANSOO 1 INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN DATE THEREOF, THE ISSUING Town of Mansfield NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Attn : Pat Byrnes IMPOSE -NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 6 Park Row REPRESENTATIVES, Mansfield MA 02048 1 AUTHORIZEDAWRESENTATI ©ACORD CORPORATION 1988 ACORD 25 (2001108) TOWN ON MANSFIELD � BOARD OF HEALTH SIX PARK ROW i MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 905 CMR 435.000 SWIMMING POOL. INSPECTION REPORT TYPE OF POOL: PUBLIC SEMI-PUBLIC SPECIAL PURPOSE POOL ❑ NAME OF POOL r ADDRESS OWNER - �' ADDRESS POOLCAPACITY INSPECTED BY DATE OF INSPECTION # OF GALS. METHOD OF WATER B R # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD f� Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 106 CMR 435.000. Items marked with a "4" are satisfactory. VIOLATIONS/COMMENTS REGULATION X/4 .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. --- ------------------------------------------------------------ .03 Adequate enclosure around pool. Gate self -latching wllatch 4 It above ---ground_--------------- :04 Sewage Disposal ------------------------------------------------- 05 Location, structural stability, finish.-----------------------------------. .06 Water circulation & filtration systems: filter effluent flow meter reading: gpm, #oftumovers___- _ _06 Suitable automaticequIpment for disinfection of pool water--------------- . .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders anchored_ Inaccessible to public, adequate v_enflation provided____ ------- .08 Inlets and outlets- Inlets located to produce uniform circulation. Over rim fillspout 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 --- gy0i d. ------------------------- .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. --------------- ------------------------------------------------------------- ----------- I-------------------------------------------------------------------- p ----------------------------------------------------------- ---------------- --a------------------------------------------------------------- .08 Special purpose pool and wading pools equipped with emergency shut off pump switch_Accessibl�andprominentlymarked.--------------------- _ _09 Cross -connections, Potable watersupplied through air gap_ _ _ _ _ _ _ __ _ ___ _. .10 Skimmingfacilities:50% of re circulation drawn from su6ce of pool. .12 Lane with floats separates non -swimmer area from deeper water ---------- ------------- 12 _________.12 Water depth markings on deck and walls. Properly spaced. Boundary line ... on pool floor and walls_ Step edges marked with contrasting color--------- _13 Walk}vaY and decks 4 feet wide, safe condition _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 14 Ladders, steps - one per 75 feet _Not less than 2 ladders. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 15Divingegupmentinsafe-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 by person making tests. ------------ 22 Health Regulations: Signs Posted. Health warning signs posted for special _ ---purposepools_-------------------------------------- ----- --- - --------------------- - - -- - - - - - --- -- .23 Lifeguards required; Yes ❑ No t If Lifeguard required; proper credentials, proper suits and garments wom. Whistle and -bullhorn rov-de-d ---------------------------------------- --------------------------------------------------------------------- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with stra s at _ ols attended b a -- ---- --------------------------------------------------------------------- -------- -------------p---p°-----------y----g----=----------- --- ---- - .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 property discharged. No direct connection to sewer system. Separation tank provided for diatomaceous / earth filter backwash water. ------------------------------------------------ ------------------------------------------------------------ .29 Chemical standards. POOLSIDE READINGS Bromine . /Total Chlorine Alkalinity5t} =3 Free Chlorine Comb. Chlorine C anuric Acid Water Temp.U4 ., pH Level 3 *parts per million Other .29 Pool water tested with appropriatetreguency_ _________________ .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools--------------------- _.31 WatercIOty.----------------------------------------------------- _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 onl accessible to the ooI o erator ------- -y-------------p-- -p -- --------...... -- - -------------------------------------------------------------- ------ 38 General sanitation.