Loading...
HomeMy WebLinkAboutMansfield Depot I 12/31/2006TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 In accordance with the provisions of Chapter Ill. 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: Village at Mansfield Depot I for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: The Village at Mansfield Depot I Method of water treatment is: Haywood Chlorine Feeder/Tabs/CH 200 Bathing load not to exceed. 70 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 5 Date of Expiration: December 31, 2006 Date Issued TOWN ON MANSFIELD BOARD OF HEALTH SIX PARC ROW MANSFIELD, MA 02048 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT r -i r: -l✓ CD1=1-1A1 Pi ippngF: Pnni n 1 irC lJr rVVL. rVuuv NAME OF POOL LJ `•' u - ADDRESS OWNER /P�� ADDRESS DATE OF INSPECTION POOL CAPACITY/ # OF GALS. INSPECTED BY Loou C' METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT I LOAD Regulation 105 (;MR 435.UUU i ne items marKeu Deluw wnn du A Mum -LC L!M YWlalcu Nr vvt�rvr� yr rvv �+... _•+�•� +�• Items marked with a "-1' are satisfactory. REGULATION x11 VIOLATIONS/COMMENTS .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. 03 Adequate enclosure around pool. Gate self latching w/latch 4 ft above ---------------------- ...91999d . I_'P Sewage Disposal---------------------------------------------- --- I ------ A --------------------------------------------------------------------- 05 Location, structural stability, finish. ---------------------------------------V - ------ --- - -- - ------ - - - -- ---------- - -- ------ .06 Water circulation & filtration systems. Filter effluent flow meter reading: gpm,_#oftumovers------ - - - - ----' _06 Suitable automatic equipment for disinfection of pool water. 106 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders -7anchored. 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 _ Properly; 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 pump switch. Accessible and -prominently marked ______________________ .09 Cross connections_ Potablewatersuppliedthroughair_gap_ ______ 10 Skia n facilities 50% of re -circulation 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, -safe condition,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _14 Ladders, steps — oneper 75 feet:Not less than -2 ladders. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _15Divin_egu4mentinsafecondition- ________________________________ 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 ____________ .22 Health Regulations: Signs Posted. Health warning signs posted for special ... p-mose pools ------------------------------------------------------ ,23 - -- -- ---- - - -- - - - --------------- ,23 Lifeguards required; Yes ❑ No If Lifeguard required; proper credentials, proper suits and garments wom. Whistle and bullhorn provided.______ _____________________________ .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended b ---------------------------- First a lifeguard_ _ ____ First equipment provided_ _First aid kit complete._ _ _ _ -------------- Aid _ _ -------------------------------------------------------------------- -----`'-`------------------------------------------------- .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 V --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 4 &i3; p Total Chlorine Alkalinity , > 5th 1© ttr Free Chlorine '��,sMAL C anuric Acid ¢ ?6{ m Comb. Chlorine fl Water Temp. :.its_ , . ,,.` pH Level *parts per million Other 12 _pP P �- - c>t---------------- 29 Pool water tested with a ro natefr_guency__________________________ ______________________________ �-_ ----- .30 Water testing equipment. DPD kit provided for chlorine and bromine. fj --- Unbreakable -thermometer forspecialpurpose pools._____ -------------------/ __________________________--_________-------------------- 31 Water clarity.----------------------------------------------------- ------------ __32 Water -clarity maintenance_ Filtration system operating continuously_______ ----------- .A _____I,�"________________________________________________________________________I Maximum Operating Temperatures for Special Purpose Pools. (SPP). An .33 a. Thermostatic control provided for each SPP. b. Thermostatic control only accessible to the pool Operator____________ _____________________________________________________________________________ .38General sanitation. TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION /A p \ Name of Owner: a ��� �G Address: et �- i�AGYfrCcG� City: Stoughton; _ State: MA Zip:02072 AYaaa Telephone: 508-339-3583 Fax: 1 P Fed ID/SS No.: 04-2946285 Pool Location: The Village at Mansfield Depot I Type/pool: Semi -Public Length: 48' Width: 24' Volume: 65,000 Min/Max. depth: 3' to 9' Swim Area: 36'x24' Dive Area: None Water Source: Town W/W Disposal: Town Sewer Type of Finish: Vinyl Print Scum Gutter: N/A Deck Type: 24' concrete Skrmnr weir length: 2 skimmers Treatment System: 1 Hayward 3600 & 1 Hayward 4800 Bath Filter 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 WMM - �1AFj.%,M DATE: 1� / 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. RAHealth\Pafs Documents\PERMTT APPLICATIONS\SMN1?,4ING POOLS APP.doc 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: Sknmir weir length: Treatment System: Disinfect Method: Chemical Treatment No. of Bathers: Remarks: Permit No.:6 Fee per pool: SIGNATURE: DATE: TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION • nc. �i �/�(®C= CLQ" /�l�lF��%� D� t � Stoughton Zip:02072 508-339-3583 04-2995014 Mansfield Depot II Semi -Public Width: 20' 4' to 5' 20x40' None Town Town Sewer Printed Vinyl N/A Cement Slab 2 skimmers Volume: 27,000 Hayward DE -3600 Earth Filter Chlorinating Sticks, Ph Minus and Plus, Automatic Chlorinator Elc1 $75.00 Expires December 31St yearly Please make appropriate changes. Sign, date and enclose checkpayable to Town ofMgnsfield Mail to: Board of Health, Town ofMansfield, Six Park Row, Mansfield, MA 02048. R\Health\PaPs Documents\PERMITAPPLICATTONS\SNVID4M1NG POOLS APP.doc The Commonwealth of MassachuseUs -- - = Department of Industrial Accidents office OfIRYQWOUGHS 600 Washington Street, 7rh Floor ,a Boston, Mass. 02111 Workers' Comensation Insurance Affidavit - General Businesses w V a,EMO ai city state hone # I am a sole proprietor and have no one Business Type: ❑ Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity, sa �/ ❑ Office�❑�ales (in ding R 1 Estate, Autos etc.) I am an em�loyer wide capacity loyees (full & art time). i,drOther h-� - x . I am an employer providing orkers' compensation for Wy employees working on this job. ❑ T am a sole proprietor and have hired the independent contractors listed below who have the following workers compensation polices. company Mine: : imm Companyname: address: Fa7ure 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 an or 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 DTA for coverage verification. I do hereby c� fy/� der tthe ��nd peenalties penury that the information provided above is true and corned e:.... h— C 01" i i/ n//1 �[ U/.f.(_�/!'S/� _ Bate '6-11--d Ll t�� Phone # ':7M 'ZAK -e)- official use only do not write in this area to be completed by city or town official city or town: permitllicense # 011ailding Department []Licensing Board ❑ check if immediate response is required ElSelectmen's Office []Health Department contact person: phone #; DOther (gid sops. 2003) 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. IG VI II 1%49V 4"--- - ate Name (Mandatory) By: Corporate 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.