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Home My WebLink AboutHockomock Y 12/31/2006TOWN OF MANSFIELDBOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048it 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: Hockomock Area YMCA -Mansfield Ifor the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: 40 Balcom Street Method of water treatment is: Chlorine 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, 2006 Scott Leit , ealth Agent Date Iss e TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK 1 02048 SWIMMINGPOOL APPLICATION Name of Owner: Hockomock Area YMCA -Mansfield Address: 40 Balcom Street City: Mansfield State: MA Zip:02048 Telephone: 508-339-3066 Fax Fed ID/SS No.: 04-2131749 Pool Location: 40 Balcom Street Type/pool: Above -ground Length: 38' Width: 18' Volume: 10,000 gal Min/Max. depth: 3' to 4'6" Swim Area: 38'x 18' Dive Area: None Water Source: Town W/W Disposal: Septic System Type of Finish: Steel w/vinly liner Scum Gutter: None 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 SIGNA' DATE: nber 31" yearly 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\PapsDocuments\PER OF APPLICATIONS\SWIM IINGPOOLSAPP.doc The Commonwealth of Massachusetts Department of Industrial Accidents G CE 01IfI(MtiONORS 600 Washington Street, 7`h Floor Boston, Mass, 02111 • e A.. d _ r naval nn cin P_CCP.S address: `�' � state' M f zia' a`k� phone # '%'— z3o� ct I am a sole proprietor and have no one working in any capacity. I am an employer with'' cm�lo e( Business e: ❑ Retail ❑ Restaurant/Ear/Eating Establishment El Office ❑ Sales (including Real Estate, Autos etc.) At & part time). ❑ Other M I am an employer providing workers' compensation for my employees working on this job. —,(-v t1 A ' ( ( ,r., i'`(ti- C..� o -`7CaG uhone #• L ' C..�, city l 1 1(} <•�c Y'� `1 G -+LJ ❑ I am a sole proprietor and have hired the independ%nt contractorslistedho have the following workers' compensation polices: comnan n m cam an name• address: hone #: OM - p to $1,soo.00 and/or I understand that a' one years' imprisonment as welt as etvii penataes In me "'Jim o.. �_.-_ •. --.--_ -- _-- copy of this :t :t, n eat may he forwarded to Me voce of Investigations of the DIE, for coverage verification. permit/license # ClBaitding Department city or town: []Licensing Board Qselectmen's Office ❑ check if immediate response is required []Health Department contact person: phone #; (]Other (revised Scat 2003) 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) gt.,A-4 0 AA, A By: Cor rate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number 4; y aL * This license will not be issued unless the certibcation 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 TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC SPECIAL PURPOSE POOL ❑ NAME OF POOL ADDRESS 140 OWNER ADDRESS /v �c r r� POOL CAPACITY INSPECTED BY j w� DATE OF INSPECTION �- V I O iw # OF GALS. U �� METHOD OF WATER IBATHER i f # OF LIFEGUARDS WATER SOURCE: TREATMENT � n _C16 LOAD —�-1-- �� 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 '1' are satisfactory. VIOLATIONSICOMMENTS REGULATION .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. ---- -- ------------------------------------------------------------ 03 Adequate enclosure around pool. Gate self -latching wllatch 4 ft above ground.--------- ------------------------------------------------------------- _04 Sew a a Disposal -------- -------------------------- ---- --- -- -- ----------- - --- ----- _05location, structural stability, finish._ ---------------------------- ----------- -------- ------------------------------------ --------------------- .06 Wate irculation & filtration systems. Filter effluent flow meter reading: --- --- - ----ppm- # ofturnovers--------------------------------- _ _06 Suitable automatic equipment for -disinfection -of pool water ---------------- ,06 --------------- ,06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders 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. 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 ... provided---------------------------------------------------------- ----- I -------------------------------- --------------------------------------I ----- A---------------------------------------------------------------------- I -----I---------------------------------------------------------------------- 08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump, ---pro _rl located and lumbed------------------------------------ -pe-y-----------p------=-------------------------------------- 08 Suction outlet covers in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet . . -- __ t.- anti .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_Vp --------------- .10 _____________.10 Skimminefacilities_50% of re circulation drawn from surface of pool._ _ .121-i 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_ Stepedges marked with contrasting color_ _ .13 Walkway and decks4feet wide,safecondition ---- ____________________ _14 Ladders, steps —oneper 75 feet. Not less than 2 ladders. _ _ _ _ _ _ _ _ __15 Diving eguipmentin safe -condition -- -------------------------------- ------------------------------------------------------------------- --- .17 Pool supervision — Pool supervision provided. Effective Jan 1, 1999, pool sup rvisor certified as I o rator 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 secols ----- --------------------------------------------------------------------- .23 Lifeguards required; Yes ❑ No ❑ If Lifeguard required; proper credentials, proper suits and garments wom. Whistle and bullhorn rovided ----- ---------------------------------------------------------------------- .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 _ sted ------------------ .26 Waste and backwash water disposal property discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water.------ ------------- _____________________ -- ------------------------- .29 Chemical standards. POOLSIDE READINGS R Bromine - Total Chlorine �m Alkalinity� ii Free Chlorine -. � Comb. Chlorine 0- - Cyanuric Acid C Level Other Other Water Temp. w _" w "parts per million .29 Poolwatertested with ap_proprtatefrequency-------------------------- ------ ---------------------------------------------------------------------- .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable -thermometer for special u se Is-------------------------------------------------------------------- __31 Waterclarity.----------------------------------------------------- ------ ------------------ -------------------------------------------------- .32 Water clarity maintenance_ Filtration system operatingcontinuously------------------------------------------------------------------------------------ _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.