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HomeMy WebLinkAboutHoliday Inn 12/31/2006TOWN 1 BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02049j 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 Realty Limited Partnership f a ❑ for the o of Public F-1LSI Semi -Public special Purpose Pool p at: Method of water treatment is: Bathing load not to exceed: 31 Hampshire St. 10 lb Chlorinator 6 to 8 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 4 Date of Expiration: December 31, 2006 p Scottie, Health Agent Date Issued TOWN OF 1 BOARD OF HEALTH SIX PARK ROW9 MANSFIELD 02048 PERMIT O 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: Mansfield Realty Limited Partnership for the operation of a ❑ Public Semi -Public ❑ Special Purpose Pool at: 31 Hampshire St. Method of water treatment is: 301b auto feed chlorinator Bathing load not to exceed: 83 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 3 Date of Expiration: December 31, 2006 Scott Ldite, Health Agent ),- ) ? -O Date Issued Name of Owner: Address: City: State: MA Telephone: Fax: Fed ID/SS No.: Pool Location: Type/pool: Length: 76' Min/Max. depth: Swim Area: Dive Area: Water Source: W/W Disposal: Type of Finish: Scum Gutter: Deck Type: Skmmr weir length TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Mansfield Realty Limited Partnership 31 Hampshire St. Mansfield Zip:02048 508-339-2200 04-3282038 31 Hampshire St. Semi Public Width: 26' 3'to5' 1,976 sf None Volume: 40,000 Town Town Sewer Fiberglass over gunite Lower and Upper Plaster 1611 Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: 301b auto feed chlorinator No. of Bathers: 83 Remarks: Permit No.:3 Fee per pool: $75.00 Per 'Expires December I' yearly p its General Partner, Mansfield Realty MansfieZk�i mitd P tnershi , by Corporation SIGNAT Daniel Frank, Vice President DATE: / �f �{�� p o Please make appropriate changes. Sign, date and d enclose hec�J�bl e t Town of Mansfield. Mail to: Board of Health, Town of Mansfield, S RAHealthTafs Docnments\PERMrP APPLICATIONS\SW 1MN11NG POOLS APP.doc TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Name of Owner: Mansfield Realty Limited Partnership Address: 31 Hampshire St. City: Mansfield State: MA Zip:02048 Telephone: 508-339-2200 Fax: N/A Fed ID/SS No.: 04-3282038 Pool Location: 31 Hampshire St. Type/pool: Hot Tub Length: 15' Round Width: Min/Max. depth: 41 Swim Area: N/A Dive Area: N/A Water Source: Town WAV Disposal: Town Sewer Type of Finish: Marble with Tile Scum Gutter: N/A Deck Type: Brick Skmmr weir length: 16" Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: 10 lb Chlorinator No. of Bathers: 6 to 8 Remarks: Permit No. A Fee per pool: $75.00 Volume: 500 P dbn'j'4 Expires December 31st yearly Mansfield Be ty Limit rt ership, b --G en PArtner, Mansfield Re Corporation SIGNATURE: ante Fran , Vice President DATE: 1-,2 / C/ 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.\Health\Pafs DocumentsTERMU APPLICA'ROWSWEVM1ING POOLS APP.doc name: Mansfield Realty Limited PArtnership d/b/a noliaay 11111 rla--- address: 31 Hampshire Street MA 02048 hone# 508-339-2200 ci Mansfield state: k site location full address I am a sole proprietor and have no one Business Type: ❑Retail ❑ RestaurantBar/Eating Establishment Sales (including Real Estate, Autos etc.) WO g m any capacity. tune Other Ho t e l I am an em 1 0 7er with em to ees (full &part ); ©,, . ; ' - I am an employer providing workers' compensation for my employees working on this job. Company name Holiday Inn Mansfield address• 31 Ham shire Street ci Mansfield hone#• 508-339-2200 ican Home Assurance -Co. WC9685605 h ++ I am a sole proprietor and have hired the independent contractors listed below who have the following workers compensation polices. tom an n m : • address: hone # ci tom an name• address• hone #: ci - W IRAN andl ir NOW ii RUN i 111MISMI F=iiore is secure Coverage as required ander Section 25A o€MGI,152 can lead to the imposition of criminal penalties of a fine >.p to demand that a' one years' imprisonment as well as Civil Penalties i 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 ce of Investigations of the DIA for coverage verifiation. Ido he reb c i under the n aloes of perjury drat the information provided above is true and co 12/14/2005 Date Signature ner an field ea y Cor oration Mansfield alty Limite Par nership, by Its Ge---___ M-1108 'H Printname Daniel Frank, Vice President Phone# rcityortown: se only do not write in this area to be completed by city or town official permit/ticense #77MMM Beildhng Department []Ucensing Board QSdectmeu's Office ❑ Check if immediate response is required []Hesith Department contact person: phone #; (]Other (revised SWL 2003) s. — I certify under the penalties of perjury than (State taxes, xestrequired underknowledge dlaw!1ef, have filed all State tax returns and paid Mansfield Realty Limited Partnersh * Signature of Individual or Corporate Name (Mandatory) Corporate Officer Daniel Frank, Vice (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number 04-3282038 sident * 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 Section nest is made under the authority of Mass. General Laws, Chap Client#: 1462 ACORD.CERTIFICATE OF PRODUCER T.E. Penn Insurance Agcy, Inc. 50 Cabot Street P.O. Box 920444 Needham, MA 02492-0005 INSURED Fine Hotels Corporation And Fineberg Management, Inc. One Washington Street, #402 Wellesley Hills, MA 02481 FINEHOTE E(MMIDDYY DATM LIABILITY INSURANCE 05/03/05 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURERA: American Home Assurance Co. INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR BY THE POLICIES DESCRIBED OTHER DOCUMENT WITH HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN, THE INSURANCE AFFORDED POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICYEFFECTIVE POLICY EXPIRATION LIMITS IN D TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MMIDD LTR NSR EACH OCCURRENCE $ GENERAL LIABILITY DAMAGE TO RENTED $ E en e COMMERCIAL GENERAL LIABILITY CLAIMS MADE F—I OCCUR PREMIE u MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE. $ PRODUCTS -COMP/OPAGG $ 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 HIREDAUTOS BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY- EA ACCIDENT $ GARAGE LIABILITYOTHER THAEA ACC $ N ANY AUTO AUTO ONLY: AGG $ EACH OCCURRENCE $ EXCESS/UMBRELLA LIABILITY CLAIMS MADE AGGREGATE $ OCCUR $ $ DEDUCTIBLE $ RETENTION $WC WC9685605 STATU- OTH- 05/01/05 05/01/06 X TRY LIMIT ER A WORKERS COMPENSATION AND E.L. EACH ACCIDENT $1,000,000 EMPLOYERS' LIABILITY ANPROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $1,000,000 FICER/ EX E.L. DISEASE - POLICY LIMIT $1,000,000 ifyes,desenbeunder SPECIAL PROVISIONS below OTHER OF OPERATIONS / LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS DESCRIPTION Re: Holiday Inn Mansfield, 31 Hampshire Street, Mansfield, MA 02048 CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_ DAYS WRITTEN Holiday Inn Mansfield H HHampshire NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Street 31 Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Mansfield, MA REPRESENTATIVES. AUTHORIZED REPRESENTATIVE KCO © ACORD CORPORATION 1988 ACORD 25 (2001108) 1 of 2 #12480 ACORD 25-S (2001108) 2 of 2 #12480 fine Washington street, quite 402 Wellesley, Massachusetts 02481 Tel: 781-431-1108 ® Fax: 781-431-7130 Via UPS Overnight December 14, 2005 Board of Health Town of Mansfield Six Park Row Mansfield, MA 02048 Licensee Mansfield Realty Limited Partnership Location Holiday Inn Mansfield Re: 2006 Annual License Renewal Applications To Whom It May Concern: Enclosed please find the following documents in connection with the renewal for the above referenced property: 1) Swimming Pool Permit Renewal Application, 2.) Application fee in the amount of $75.00 3.) Hot Tub Permit Renewal Application 4.) Application fee in the amount of $75.00 5.) WC insurance affidavit and certificate and Tax Certification. Please do not hesitate to contact me if you have any questions. Sincerely, I ara - lin gf Encls. TOWN ON MANSFIELD BOARD OF HEALTH SIX PARK ROW MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMI SWIMMING POOL INSPECTION REPORT TYPE OF POOL: PUBLIC❑ SEMI-PUBLIC SPECIAL PURPOSE POOL NAME OF POOL I j f ` _� ,,, ,� ADDRESS tYYS�I�� DATE OF INSPECTION (� -� (4 # OF GALS. METHOD OF WATER �L- I BATHER TREATMENT LOAD Regulation 105 CMR 435.000 The items marked below Items marked with a "4" are satisfactory. REGULATION and sanitary facilities adequate lighting; ventilation; sanitary l i bLi _ �- ADDRESS t� L130 INSPECTED BY 'L�) - Lt i Ce # OF LIFEGUARDS WATER SOURCE: with an "X" indicate the violated provisions of 105 CMR 43 VIOLATIONS/COMMENTS M condition. I ------------ -------------------- ----------- --- ---- ------------------- .03 Adequate enclosure around pool. Gate self -latching wAatch 4 ft above - --------------- ---ground ------------------------------------------------------------- - 04 Sewa Di I ---- - --------------------------------------------------------------------- -.05 Location, structural stability, finish_ - - .06 Water circulation & filtration systems. Filter effluent flow meter reading: # ofturnovers------------------------------------------ ---------------------------------------------------------------------- _06Suiitableautomaticequipmentfordisinfectionofpoolwater-------------- --►/__ ---------------------------------------------------------------------- .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders L ) . anchored. Inaccessible to public,Oequateventil kc!! prov-ided___-___-__-_f------ ------------------------ ---------------------------------------------------------------------- Inlets and outlets- Inlets located to produce uniform circulation. Over rim .08 fill ut6 above maximum waterlevel. P-----edan------ed. Property " shielded and -- ---------------------------------------- - ------ --------------------------- -------------------------------'---'-- .08 Main drain suction outlets covered with suitable protective covers or Open does not grates. Cannot be removed without use of tools. area 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, proper) located and pjqmbed --------------------------------------------------------- .08 Suction outlet covers in place, unbroken and secure and cannot be / V 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_ Able and prominently marked_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -.09 Gross -connections. Potable water supplied through air_gap .............. --------------------------------- ------ 10 Skimming facilities. 5V/6 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 contrasting color --------- I_-______ _13 Walkway and decks -4 feet wide, safe condition --------------- 14 Ladders, steps — oneper 75 feet. - Not less than 2 ladders. 15 Divinffequipment in safe -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 byperson making tests. .22 Health Regulations: Signs Posted. Health warning signs posted for special --- pure----p°ols------------------------ --------------------------- ------ --------------------------------------------------------------------- .23 Lifeguards required; Yes ❑ No [ , If Lifeguard required; proper credentials, proper suits and garments wom. Whistle and bullhorn------ d. --------------------------------- _________________________ ------------- ------ ------------------------------------- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube l% __ and backboard with straps at----- attended by -lifeguard_--------------- -25 First aid equipment provided._Firstaid kit complete .___________________ __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 --- numbersposted------------------- ------------------------------ ------ ---------------------------------------------------------------------- .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. POOLSIDE READINGS Acid million .29 Pool water testedwith appropriate frequency_ ......................... 30 Water testing equipment. DPD kit provided for chlorine and bromine. / Unbreakable thermometer for specialpurpose pools. _ _ _ _ _ v ----------------------------- ------ .31 Water clarity. _ _32 Water clarity maintenance. Filtration system operating continuously_ _ _ _ _ _ _ (_ _32 special purpose pooldrained, cleaned and even 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. Comb. C Hp Level Other .34 u" w" I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE Closure of the pool. POOL MUST BE CLOSED OF 105 CMR 435.29 THROUGH 435.31. SIGNED SIGNED MEETS THE STANDARDS Board of Health/Health • • • A ' 1 i 1 1� STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC ❑ SPECIAL PURPOSE POOL NAME OF POOL ADDRESS OWNER t ADDRESS 2 r. POOL CAPACITY DATE OF INSPECTION # OF GALS. INSPECTED BY \e V METHOD OF WATER BATHER c 0owiLOAD # OF LIFEGUARDS WATER. SOURCE: TREATMENT Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000. Items marked with a "4" are satisfactory. x/4 VIOLATIONS/COMMENTS REGULATION Bathouse and sanitary facilities adequate lighting; ventilation; sanitary .03 condition. -------------------------------------------------------------------- .03 Adequate enclosure around pool. Gate self -latching w/latch 4 ft above - --- round. --------------------------------------------------------------------- 04 Sewage Disposal---------------------------------------------------- - - -- --- -------------.----- -- --- - ------------------------ ' .05 Location, structural stability, finish. ------------------------------------------------------------------- ------------- ---- '------------------------------------- .06 Water circulation & filtration systems. Filter effluent flow meter reading: '1 1 li gpm # ofturnovers----- --------------------------------------------- .06Suitable automaticequipme_ntfor disinfection ofpoolwater_ _ _____________________________________________________________________________ .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders 0)'r4 anchored. Inaccessible to public, adequate ventilation provided. -------------------------- - ---------------------------------------------------------------------------- .08 Inlets and outlets- Inlets located to produce uniform circulation. Over rim fill spout 6" above maximum water level_ Properlyshieldedandlocated--- ----- ---------------------------------------------------------------------- .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 N 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 re airs 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 pool._ ------------ ------------------------------------ ---------------------------------------------------------------------- ------ .12 Line with floatsseparates deeper water. _ _ _ _ _ _ _ _ _ non -swimmer area frau �A 12 Water depth markings on deck and walls. Properly spaced. Boundary line �/y on pool floor and walls. Step edges marked with contrasting color, _ _ _ _ _ _ _ _ .13 Walkway and decks_4 feet wide, safe condition ........................ _14 Ladders, steps — one per 75 feet._Not less than_2 ladders. t -------------------------------------------------------------------- --- -q "" --k C-kk-,�-', ------------------------------- 15 Divingequpmentinsafecondition_------------------------------------" .17 Pool supervision — Pool supervision provided. Effective Jan 1, 1999, pool ,V/ supervisor certified aspool operator from YMCA or NSPF_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ----- --------------------------------------------------------------------- .21 Permit requirements — Permit issued. Adequate maintenance and testing t/ records maintained. Records initialed byperson making tests-------------- .22 Health Regulations: Signs Posted. Health warning signs posted for special ___purpose pools.______________ ------------ ------------------------ ------ ---------------------------------------------------------------------- .23 Lifeguards required; Yes ❑ Nc If Lifeguard required; proper credentials, proper suits and garments worn. --- Whistle andbullhomprovided.---------------------------------------------------------------------------------------------------------- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube z/ and backboard with straps atpools attended b_y 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 properly discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. -------------------------------------------------------------------------------------------------------------------------------------------------- .29 Chemical standards. POOLSIDE READINGS Bromine 2.t} -6.0 m* otal Chlorine Alkalinity 50-150 m Free Chlorine 1.0 —3.0 m Cyanuric Acid 30-100PP m Comb. Chlorine 0.0-0.2 m Water Temp. 104 F H Level (7.2-7.8) .parts per million Other 1.29 Pool water tested with appropriate frequency_ ......................... 30 Water testing equipment. DPD kit provided for chlorine and bromine. _ Unbreakable thermometer for special purpose pools._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _31_ Water clarity-.------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------- - - _32 Water clarity maintenance. Filtration system operating continuously_ _32 special purpose pool drained, cleaned and every 14 days._ _ _ _ _ _ _ _ _ _ _ V ----------------- --------------------------------------------------------------------------------- Maximum Operating Temperatures for Special Purpose Pools. (SPP). .33 a. Thermostatic control provided for each SPP. b. Thermostatic control only accessible to the pool operatq ----------------- ____________ f 38 General sanitation. REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE of x/J .34 Closure of the pool. POOL MUST BE CLOSED UNITL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. I 00,j SIGNED SIGNED Operator Board of Health/Health Department