HomeMy WebLinkAboutHockomock Y 12/31/2003TOWN OF MANSFIELD
BOARD OF HEALTH
SIX PARK . ! 1 0204-V
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:
for the operation of a ❑ Public
at:
Method of water treatment is:
r
❑ Semi -Public ❑ Special Purpose Pool
Sand Filter
Bathing load not to exceed: 40 bathers
Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
Permit No.: 12
Date of Expiration: December 31, 2003
Scott Leite, ealth Agent
610"1" /6->
Date Issued
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Hockomock Area YMCA -Mansfield
Fax:
Fed ID/SS No.:
04-2131749
Pool Location:
40 Balcom Street
Type/pool:
Above -ground
Length: 38'
Width: 18'
Min/Max. depth:
3' to 416"
Swim Area:
TV x le
Dive Area:
None
Water Source:
Town
W/W Disposal:
Septic System
Type of Finish:
Steel w/vinly liner
Scum Gutter:/-)dAi-
Deck Type:
Wooden
Skmmr weir length:
1.5 to 2'
Treatment System:
Sand Filter
Disinfect Method:
Chlorine
Chemical Treatment:
Chlorine
No. of Bathers:
40
Remarks:
Permit No.: 12
Fee per pool:
$75.00
Volume: to, oco �Hl
Permit Expires December 31S` yearly
SIGNATURE: �•.�
;1
DATE: °/ r/t
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.
R:\Jieaith\PaPs DocumentsNPERMIT APPLICATIONSISNVB&,flNGPOOLS 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.
* Signature of Individual or
Corporate Name (Mandatory)
By: Corp rat Officer
(Mandatory, if applicable)
* * Social Security Number (Voluntary) or
Federal Identification Number
* 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.
• • A
STATE SANITARY CODE: CHAPTER V, MINIMUM STA
105 CMR 435.000
FOR
CDGr'IAI bi IRPr1SF Pool I-1
I YNt UI- t'UUL: VuCSLlu
NAME OF POOL
I__I ���-���••,
fAj
-
ADDRESS
OWNER
ADDRESS
DATE OF INSPECTION
POOL CAPACITY
# OF GALS.
-'
INSPECTED BY
METHOD OF WATERBATHER
`
# OF LIFEGUARDS
W TER SOURCE:
TREATMENT
'" Val>,
LOAD
-f IAA, I KAP A35 (inn
Regulation 1U5 GMK 435.000 I ne I[errl5 nidinGu uvivw vviuI an I-- a
Items marked with a " 4' are satisfacto .
REGULATION X14 VIOLATIONS/ OMMENTS
.03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary
condition.
-------------------------------------------------------------------- -- 1:;;';'
-------------------------------------
.03 Adequate enclosure around pool. Gate self -latching wllatch 4 ft above
... pround----------------------------------------------------------------------------------------------- ---------------------------------------
_.04 Sewage Disposal----------------------------------------------------- -------- -' --- - ----- -4 = - - -
_.05 Location, structural stability, _finish.----------------------------------- - -- -- -°-`------------ - ----- - --- --- ---- -----------
.06 Water circulation & filtration systems. Filter effluent flow meter reading: -
----gpm__#ofturnovers - - �`L -L- V1-----------------
1
`_ ---- ?
---- ------ ----------------------------- -- -
.06 Suitable automatic a ui ment for disinfection of pool water------------------ "`
.06 Carbon dioxide (1302) equipment for pH control adequate. (CO2) cylinders
anchored. Inaccessible to public, adecquateventilationprovided.______---_ _______ _____ ____ _ ___ ____ ____ ----------------
.08 Inlets and outlets- Inlets located to produce uniform circulation. Over rim t t,
fills out 6" above maximum water level Pro erl shleldedandlocated _ ____, ___ ___________________ _____________
p - = p y----------------- ---- - -
.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 t
--- 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 ` t
repairs are made.
.08 Special purpose pool and wading pools equipped with emergency shut c
pump switch._ Accessible and prominently parked --------------------
_09 Cross connections. Potable water supplied through air_gap._ _ _ _ _ _ _ _ _ _ _ _ _ _
_10 Skimminpfacilities_50% of recirculation drawn from surface of pool. _
.12 Line 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 Walkway _
and decks 4 feet wide, condition._ _ _ _ _ _ _ _ _ _ _ _ _ -----------
_14 Ladders, steps - one per 75 feet. -Not less than -2 ladders-----------------
------
-------------------------------------------------------------------
tp
vl`=---------------------------
---------- - -- -
;. F
------------------ - - - --
__15 Div_ingegupmentin safe -condition ----------------------------------- --"— '--------- ------------------------------------------------------------
.17 Pool supervision — Pool supervision provided. Effective Jan 1, 1999, pool {
- - spisorcifiedas- ooloperator fromYMCAorNSPF -------------------------------------------------------------
u ev--er- ------------------------------------------- -----
------
.21 Permit requirements — Permit issued. Adequate maintenance and testing
... recordsmaintained. Records_ initialedbypersonmakingtests. ____________________________________________________________________________
.22 Health Regulations: Signs Posted. Health warning signs posted for special
... purposepools------------ ---------------------------------------- ----------------------------------------------------------------------------
.23 Lifeguards required; Yes ❑ No
If Lifeguard required; proper credentials, proper suits and garments worn.
-- Whistle and -bullhorn provided.--------------------------------------- --------------------------------------------------------------------------
.24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube
POOLSIDE READINGS
and backboard with straps at pools attended by a lifeguard_______________
____________________________________________________________________________
_.25First aid equipmentprovided. -First aid kitcomplete.____________________
_V ----------- -----------------------------------------------------------
.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
Alkalinit 50 -15Q: m
---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.
Water Tem . 1'04 F
29 Pool water tested with appropdptefreguency--------------------------
.30
_______________________
.30 Water testing equipment. DPD kit provided for chlorine and bromine.
Unbreakable thermometer for special purpose pools. _ _ _ _ _ _ _ _ _ _ _ _ _
__31_Waterclarity.-----------------------------------------------------
-.32 Water clarity maintenance_ Filtration system operating continuously_ ......
_.A2 specialpurpose pool drained, cleaned and every_ 14 days----------------
Maximum
_______________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.
4 --
t
QX
---- ------
----- --- --
---
POOLSIDE READINGS
Bromine (2,0-6,0 R m*)
Total Chlorine
Alkalinit 50 -15Q: m
Free Chlorine3,0 m
Cyanuric Acid 30 -100 m '
Comb. Chlorine 0.0 = 0.2 rri
Water Tem . 1'04 F
pH Level 7,2 7:8)
*parts per million
Other
29 Pool water tested with appropdptefreguency--------------------------
.30
_______________________
.30 Water testing equipment. DPD kit provided for chlorine and bromine.
Unbreakable thermometer for special purpose pools. _ _ _ _ _ _ _ _ _ _ _ _ _
__31_Waterclarity.-----------------------------------------------------
-.32 Water clarity maintenance_ Filtration system operating continuously_ ......
_.A2 specialpurpose pool drained, cleaned and every_ 14 days----------------
Maximum
_______________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.
4 --
t
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----- --- --
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