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Home My WebLink AboutMansfield Meadows 12/31/2004TOWN OF MANSFIELD BOARD i '` SIX PARK ROW,• 1 02041-, 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 Meadows Assoc I for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: Bonney Lane Method of water treatment is: calle and iron remover. Automatic chlori 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.: 7 Date of Expiration: December 31, 2004 Scott Leite, Health Agent Date 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: SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Mansfield Meadows Assoc 12 Bonney Lane #9 Mansfield Zip:02048 508-339-3357 508-339-9761 04-3083384 Bonney Lane Residential Width: 22' 3.5' to 9' 40'x22' None Town Town Sewer Concrete Cement Slab Volume: 55,000 Treatment System: Heyward Earth Filter 4800 Disinfect Method: Chlorinating sticks, plus to increase ph Chemical Treatment: calle and iron remover. Automatic chlori No. of Bathers: 43 Remarks: Permit No.:7 Fee per pool: $75.00 SIGNA DATE: ISt yearly 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 HeatthTat's Dowments\PERMTT APPLICAT[OWSWR AC'G POOLS APP.doc The Commonwealth of Massachusetts Department of Industrial Accidents t office NIMSI%9ONS - 600 Washington Street, 7th Floor Y Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - General Businesses Applicant information: Please PRINT le%dbiy t name: _. 11 f �( '� i` � address: 2, L`i'ILCLAI state f tO zip: 0) OLLK phone # r'ib 6 ` � ❑ I am a sole proprietor and have no one Business T pe: ❑Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. [Office ❑ Sales including Real Estate, Autgs ❑ I am an employer with employees (full & part time). EJ Other Refkk ® I am an employer providing workers' compensation for my employees working on this job. companv name address: ❑ 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 #: 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 andlor 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 t o pains and penalties of perjury that the information provided above is true and correct. Signature f i t- Date Print name , Phone # IG 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) OWN ON MANSFIELD BOARD OF HEALTH SIX PARK ROW i MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT rvoc nc onru • 01 tni it F-1 C1=11/II_D1 IRI ir'_ _ RPFCIAI Pt 1RPOSF POOL n NAME OF POOL ADDRESS ( lvcu OWNER ADDRESS DATE OF INSPECTION ` POOL CAPACITY # OF GALS. INSPECTED BY v..r ( METHOD OF WATER TREATMENT" BATHER LOAD # OF LIFEGUARDS WATER SOURCE: Regulation 105 CMR 435.000 1 ne items marKea deiow wjtn an --, Inuicaie ine vioiateu pi uvi5wus ui , uu %..,v,r% --j— Items marked with a "-,P are satisfactory. REGULATION X14 VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. -------------------------------------------------------------------- ------ ---------------------------------------------------------------------- .03 Adequate enclosure around pool. Gate self -latching wAatch 4 ft above ground_ ,04 Sewage Disposal tom`` , 05 Location, structural stability, finish. ------------------------------------- .06 ______________.06 Water circulation & filtration systems. Filter effluent flow meter reading: gpm, # of turnovers `--- _06 Suitable automatic equipment for disinfection of pool water. .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders ) h ed 1 W. t blic ad uate ventilation rovided -- --f=-------------------------------------------------------------- ------------------------------------------------------------- --- a"%, or____nacc ---- o Fu -_"y' -- -------------p---------------- ------ - --------------------------------------------------------------------- .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. .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 , iv- um switch Accessible and rominentl marked -p-- ---= ---------p--------y-----=--------------------------- =d, — __09 Crossconnections_ Potable water suppliedthrouRhair_Vp______________ _____ _10 Skimminpfacilities_50% of recirculation drawn from surface of pool._ -- - _12 Line with floats separates non -swimmer area from deeper water_ k. .12 Water depth markings on deck and walls. Property spaced. Boundary line Water Temp. on pool floor and walls, Steped,qes marked with contrastinpcolor_ pH Level Via_ Y -.13 Walkway and decks 4 feet wide, safe condition -------------------------- ____________________14 ---------------------------------------------------------------------- .14Ladders, steps _ oneper 75 feet. Not less than 2 ladders. 15 Divi nuegupmentinsafe condition. _______________________ -- ------------- _ f - .17 Pool supervision - Pool supervision provided. Effective Jan 1, 1999, pool _ ... supervisor cerii_fied as pool operator from YMCA or NSPF_ _ --- --- -- - - - - ---- - --- - -- - -- - - --- -- -- - .21 Permit requirements - Permit issued. Adequate maintenance and testing records maintained. Records initialed b erson makm tests. ------------------------------------ -YP--- ------g---------------- .22 Health Regulations: Signs Posted. Health warning signs posted for special --- pu_rpose p00ls----------------------------------------------------- ,23 Lifeguards required; Yes ❑ No E"' If Lifeguard required; proper credentials, proper suits and garments wom. _ --- Whistle and -bullhorn provided---------------------------------------------- ___________________________________________.24 .24Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps atpools attended by a lifeguard_ _.25First aid equtpmentprovided. -First aid kttcomplete-------------------------- _______________________.25 .25Emergency 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. ------------ -- - -.----------------------------------------------------- .29Chemical standards. _____________________________________________________________________I --------------------------------------------------------------I POOLSIDE READINGS Bromine =d, — Total Chlorine Alkalinit Sit _ ,Free Chlori C anuricAcd k. ne Comb. Chle Water Temp. ? .. pH Level Via_ Y *parts per million ---------------------------------------------------------------------- Other .29 Pool water tested with appropriatefrequency-------------------------- ----------------------------------------------------------------------------- .30 Water testing equipment. DPD kit provided for chlorine and bromine. --- Unbreakable -thermometer forsPecialpurposepoots--------------------- ______ _ --------------------------------------------------------------------- -31-Water- clarity. ---------------------------------------------------------------- —1°` ------ ---------------------------------------------------------------------- _32 Water artyclmaintenance. Filtrations stem o ratin oontinuousl _ _ _ ....................-Y -- -�-- g - - y ----------------------------------------------------------------------- --- 32 s ectal u _ se ool drained, cleaned and eve 14 da s._ _ _ _ _ _ _ _ _ _ _ _ _ --- p - -p m° P-- - ----- - -- -- - ry y _ - L-- --- --- -- - - - - ---- - --- - -- - -- - - --- -- -- - Maximum Operating Temperatures for Special Purpose Pools. (SPP). .33 a. Thermostatic control provided for each SPP. F - b_ Thermostatic control only accessible to the pool operator _ 38 General sanitation. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X14 .3$ Closure of the pool. POOL MUST BE CLOSED UNiTL IT MEETS THE STANDARDS OF 105 CMR 435.39 THROUGH 435.31. SIGNED SIGNED O erator Board of Health/Health De artment