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HomeMy WebLinkAboutWillow Crossing 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 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: Cottages at Willow Crossings LP for the operation of a ❑ Publicemi-Public ❑ Special Purpose Pool 11 at: 25 Cobb St. I Method of water treatment is: Bromine I Bathing load not to exceed. 22 bathers I Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. IN Permit No.: 11 Date of Expiration: December 31, 2004 Scott Leite, Heath Agent 4ZI:s�ssued Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 32' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Cottages at Willow Crossings LP 25 Cobb Street Mansfield Zip:02048 508-261-1333 05-0520927 25 Cobb St. Gunite Concrete Width: 14' 3' 6" to 3'9" 448 sf None Town Town Sewer White Marbleite None Volume: 12,544 Deck Type: Concrete Skmmr weir length: 8.5" Treatment System: Hayward C-50OLF Brominator Disinfect Method: Bromine Chemical Treatment: Bromine No. of Bathers: 22 Remarks: Permit No.: 11 Fee per pool: \\ $75.00 Permit Expires December 3lsl yearly SIGNATURE: DATE: 11) 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. RAHealthTafs DocumentsTERMIT APPLICATIOWSWIMMING POOLS APPAOC The Commonwealth of Massachusetts Department of Industrial Accidents office ofimresugo ions 600 Washington Street, /.,th Floor Boston, Mass. 02111 }4 9 Workers' Compensation Insurance Affidavit - General Businesses Applicant information: Please PRINT lehibly name: 1*& 4it-WOL, \ale �PaI4�n�ce3 address: (C��� �;Vzk ) city y t1 kkie D state: tloL zip: GrU!*!k phone # l ml work site location (full address): MSL ❑ I am a sole proprietor and have no one Business_Type: e: ❑ Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. [Office E] Sales (including Real Estate, A tos etc.) I am an employer with employees (full & part time). -S) Other S i -(t✓ �t I am an employer providing workers' compensation for my employees working on this job. company name: alai v't t. a(41. N< �-Sl L Rs:�t K145%010 J address: 6.'�©t 2 / city: phone#: insurance co. 6-X% t- S � AA ci,4 �►i i t7 t (n,J _ (Jpolicy # 60 n a) wi ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address: insurance co. policy # company name: address: city phone #• insurance co. policy # Attach additional sheet if necessary Failure to secureoverage 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' impris ent 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 statem may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify ukder thepains andpenalties ofperjury that the information provided above is true and correct ail al�� Print name Ik �e ®- ti`s, Phone # official use only do not write in this area to be completed by city or town official _- city or town: permittlicense # ❑Building Department ❑Licensing Board ❑ check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone #; ❑Other (revised Sept. 2003) INSURER: FAIRFIELD INSURANCE CO 695 EAST MAIN ST STAMFORD, CT 06904 ITEM 1. NAMED INSURED AND MAILING ADDRESS VILLAGE AT WILLOW CROSSING CORPORATE OFFICE 715 PUTNAM PIKE GREENVILLE RI 02828-1428 WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY - INFORMATION PAGE POLICY NO: 1100001077 RENEWAL OF: 1100000766 NCCI Company No: 32530 Account No: 51 RISK ID #380143143 PRODUCER NAME AND ADDRESS: BMIC SERVICES CORP ONE BEACON CENTRE WARWICK RI 02886 PRODUCER NO.: 0000110 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM2. POLICYPERIOD: From: 04-05-03 To: 04-05-04 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 500,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MI MN MS MO MT NE NV NH NJ NM NY NC OK OR PA RI SC SD TN TX UT VT VA WI D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Minimum Premium: $ 223 Audit Period: ANNUAL Issued 10 Date: 04-08-03 Total Estimated Annual Premium: $ 26,692 At: Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance wa iaFn rnPv 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 TYPE nF Pnni • Pt IRI IC F-1 SFMI-PHRLIC M SPECIAL PURPOSE POOL rl NAME OF POOL ADDRESS OWNER ADDRESS DATE OF INSPECTION POOL CAPACITY INSPECTED BY # OF GALS. METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT I LOAD Regulation 105 CMR 435.000 The items marked below with an "K indicate the violated provisions of 105 CMR 435.000. Items marked with a '1' are satisfactorv. I REGULATION XN VIOLATIONS/COMMENTS I .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. I -- -- -- - - -- -- - --------- - --- - -----------f-- ---------- -- --- --------- ------------------- - --- ------ -- - ------------------------------------------------- .03Adequaenclosure around pool. Gate self -latching wllatch 4 ft above round. --------------------------------------------------------------------- ------------------------------------------------------------- ----- ------ - :04 Sewage Disposal ------------------------------------------------ 05 Location, structural stability, finish------------------------------------ .06 Water circulation & filtration systems. Filter effluent flow meter reading: _______________gpm_1-of-turnovers _____ _.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_ventiiation provided. 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, ---propedy_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 Cross connections. Potable watersupplied through air_gap_ ----------------------------------- 10 Skimminpfacilities_50% of -re -circulation drawn from surface of pool. .12 Line with floats separates non -swimmer area from deeper water_ ------------------- --------------------- .12 Water depth markings on deck and walls. Property spaced. Boundary line ___ on pool floor and walls. _Step edges marked with contrastinpcolor________- -.13 Walkwand decks 4 feet wide,_ safe condition._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ----------y a - - - - _.14 Ladders, steps --one per 75 feet. -Not less than -2 ladders. -------------- _15 Di v_inpegupment in safe condition. --------------------------------- .17 Pool supervision — Pool supervision provided. Effective Jan 1, 1999, pool ... supervisor certified as j= 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 ❑ If Lifeguard required; proper credentials, proper suits and garments wom. Whisfle and bullhorn proyided._ _ _ _ -------------------- ---------------------------------- .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 property discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. -------------------------------------------------------------------- .29Chemical standards. -----------------------------------------------------------------I -------------------------------------------------------------I -------------------------------------------------------------------- ---------------------------------------------------------------------I POOLSIDE READINGS Bromine Alkalinity 2(i _6�i }sem _ 5tF _!__+ Total Chlorine"." Free Chlorinet _ Cyanuric Acid 3( 1 t ,.:' Comb. Chlorine 0 . Water Temp. �f4 ,,, - pH Level *parts per million Other 29 Pool water tested with appropriate freguency_ ------------------------ ------ ---------------------------------------------------------------------- .30 Water testing equipment. DPD kit provided for chlorine and bromine. --- Unbreakablethermometerforspecialpurpose pools.-------------------- ----------------------------- ----------------------------------------------- 31 Waterclarity.----------------------------------------------------- - -------------- ----- ---------------------------------------------------------------------- 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 only accessible to the pool operator ------------------------------------------------- .38 General sanitation. REGULATION NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE .34 iClosure of the pool. POOL MUST BE CLOSED UNITL IT MEETS THE STANDARDS OF 105 DI' -_'IR 43-5.29 THROUGH 435,31. SIGNED SIGNED Board of Health/Health