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Home My WebLink AboutMansfield Depot I 12/31/2003TOWN OF 1 ', ! • 1 OF SIX PARK ROW, MANSFIELD 02048 1 11 7111'!1111 i 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, Inco for the operation of a ❑ Public emi-Public ❑ Special Purpose Pool at: The Village at Mansfield Depot I Method of water treatment is: 2 Sand Filters/jacuzzi MFM24 F Bathing load not to exceed: 70 bathers Number of Lifeguards required at all times the pool is open is: None "N® LIFEGUARD ON DUTY"' sign is required. Permit No.: 5 Date of Expiration: December 31, 2003 toDate fssued TOWN OF MANSFIELD, 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.: P2 Pool Location: The Village at Mansfield Depot I Type/pool: Semi -Public Length: 48' Width: 24' Volume: Min/Max. depth: 3' to 9' Swim Area: 361x24' Dive Area: None Water Source: Town W/W Disposal: Town Sewer Type of Finish: Vinyl Print Scum Gutter: N/A Deck Type: 241 concrete Skmmr weir length: 2 skimmers Treatment System: 2 Sand Filters/jacuzzi WA124 F 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 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, AM 02048. RAHealffiPat's DocumentAPERNUT APPLICATIONSNSWMWNG POOLS APP.doc I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. 1///4 64� kgl-y- Signature of Individual or Corporate Name (Mandatory) By: �orporate Officer Mandatory, if applicable) * * Social Security Number (Voluntary) or r 4 Federal Identification Number /P� t r-� * This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. 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 TVDI= nF Pnnl • PI IRI Ir. r1 SFMI-PURI_IC F_1 SPECIAL PURPOSE POOL M NAME OF POOL t='�°�` � �°� ADDRESS OWNER 'r `-r-'L � ADDRESS ------ --------------------------------------------------------------------- A v-, ------ ---------------------------------------------------------------------- DATE OF INSPECTION . POOL CAPACITY_ # OF GALS.' r. INSPECTED BY METHOD OF WATER BATHER ----------- -- ate. #ofturnovers-----------------------------------------------t # OF LIFEGUARDS WATER SOURCE: TREATMENT.n_ ---------------------------------------------------------- LOAD `I I Regulation 105 CMR 435.000 The items marked below with an "x" Inalcate the vlolatea provisions or i uo urviK 4sz).uuu. Items marked with a N" are satisfactory. REGULATION XN VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. -----------------------oun---------------- --------- ----------- - ---- .03 Adequate enclosure around pool. Gate self -latching w/latch 4 ft above ------ --------------------------------------------------------------------- ---ground. -------------------------------------------------------------- ------ ---------------------------------------------------------------------- 04 Sewage Disposal------------------------------------------------ - -------------------------------------------------------------------------- 05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter effluent flow meter reading: ----------- -- ate. #ofturnovers-----------------------------------------------t .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 ventilation provided. ............. _ _ --------------------------------------------------------------------- Inlets and outlets- Inlets located to produce uniform circulation. Over rkn .08 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 provided. ---------------------------------------------------------------------- --------------------------------------------------------------------- .08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump,`r' ... properlylocated 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 water supplied through -air -gap .............. - ------------------------------------ 10 Skimming facilities_50% of -re -circulation drawn -from surface of po_ _ _ _ _ ----------- PPRI. .12 Line with floats separates non -swimmer area from deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color_ --------------------------------------------------------------------- .13 Walkway and decks4feet wide, safe condition --------------------------- _ /_ 14 Ladders, ste s one _ _ _75 feet _Not less than 2 ladders. - -- -- - -- P- - ------------------------------------ `- 15 Diving equipment in safe -condition ----------------------------------- 1 °---------------------------------------------------------------------- 17 Pool supervision - Pool supervision provided. Effective Jan 1, 1999, pool supervisor certified aspool 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 _ _ u ose ools. ---------------------------------- .23 Lifeguards required; Yes ❑ No Il If Lifeguard required; proper credentials, proper suits and garments worn. ---Whistle andbullhornprovided.---------------------------------------- ----- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube -and backboard with straps atpools attended by alifeguard_-- ------ - --------------- -- - ---------- ---------------- ---------------- .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 properly discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. ------ ----------------------------------------------------------------- ---------------------------------------------------------------------- 29 Chemical -standards. 29 Pool water tested with appropriate frequency__________________________ .30 Water testing equipment. DPD kit provided for chlorine and bromine. _ - Unbreakable thermometer for special purpose pools. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ q, - 31 Water clarity. 32 Water clarity maintenance. Filtration system operating continuously_ ...... _32 special purpose 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 5 ssible to the pool operator _ _ _ _ _ _ _ _ _ _ _ 38 General sanitation. ---------------------------------------------------------------------I POOLSIDE READINGS Bromine - = - tal Chlorine Alkalinity "Free Chlorine Cyanuric Acid Comb. Chlorine Water Temp. ry . , ._� H Level472—W 1090=1 arts per million Other 29 Pool water tested with appropriate frequency__________________________ .30 Water testing equipment. DPD kit provided for chlorine and bromine. _ - Unbreakable thermometer for special purpose pools. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ q, - 31 Water clarity. 32 Water clarity maintenance. Filtration system operating continuously_ ...... _32 special purpose 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 5 ssible to the pool operator _ _ _ _ _ _ _ _ _ _ _ 38 General sanitation. ---------------------------------------------------------------------I REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE XIII .34 Closure of the pool. POOL MUST BE CLOSED UNITL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. PAWSIGNED / SIGNED Op ator B6prd of Health/Health Department