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Home My WebLink AboutMansfield Children's C. 12/31/2006TOWN OF MANSFIELD C'i•1 OF HEALTH SIX pARK ROW9 MANSFIELD 1 2048 I" TO OPERATE A sWIMMINGPOOL In accordance with the provisions b 1 the Massachusetts]]. Section 127ADepaf the Massachusetts tment of Public General Laws, and Regulations establishedY Health (105 CMR 435.00). permit is hereby issued to: Mansfield Children's Ctr. for the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool at: 1100 School Street Method of water treatment is: Bathing load not to exceed: 43 bathers Number of Lifeguards required at all times the pool is open is: None 14NO LIFEGUARD ON DUTY" sign is required. Permit No.: 8 Date of Expiration: December 31, 2006 Scott Leite, TOWN OF MANSFIELD, BOARD OF SIX PARK ROW, MANSFIELD 02048 SWIMMINGPOOL APPLICAI1 Name of Owner: Mansfield Children's Ctr. Address: 1100 School Street City: Mansfield State: MA Zip:02048 Telephone: 508-339-9211 Fax: i *Cement Fed ID/SS No.: y.2 - Pool Location: 1100 School Street Type/pool: Semi -Public Length: 41' Width: IV Volume Min/Max. depth: 3.5' to 6' Swim Area: 400sf Dive Area: None Water Source: Town WAV Disposal: Private Type of Finish: Liner Scum Gutter: f Deck Type: S� (v i *Cement Skmmr weir length: ;L*skimmers Treatment System: Diatomacious Earth Disinfect Method: Chlorine Chemical Treatment: No. of Bathers: 43 Remarks: Permit No.:8 Fee per pool: $75.00 3,f &V 0 Pe mit Expires December 315` yearly SIGNATURE: DATE: res' 1(JN 2 0 206 :U 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 DocumentsTERMff APPLICATIONS\SwIMMING POOLS APP.doc 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 oucPF_CT10N REPUK I LUAU h "X" indicate the violated provisions of 105 CMR 435.000. Regulation 105 CMR 435.000 The items marked below wit an items marked with a'1' are satisfacto VIOLATIONS /COMMENTS REGULATION .03 Bathouse and sanitary facilities adequate lighting; ventilation; sanitary condition. -------------- ---- -- ----------------------------------------------------------- - ------------ 03Adequate enclosure around pool. Gate self -latching wllatch 4 ft above -- --- round. -------------------------------- ---- -.04 Sewag--------- - p ----------------- ------ ----------------------------------------- a Dis osal________________________________ .05location, structural stability, _firnsh.__________________________________ - ------ ------------------------- .06 Wat r rculation & filtration systems. Filter effluent flow meter reading: m # oftumovers------------------------------------------------------------------- -------------- ----------------- p - - ----------------------------------------------------------------- _06 Suitabl--e automatic ui ment for disinfection of pool water. _ _ _ _ _ _ _ _ _ _ ------ _ .06 Carbon dioxide (CO2) equipment for pH control adequate. (CO2) cylinders anchored_ Inaccessib_etopublic, adequateventilationprov-ided__-__----__ .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 useof 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, pj9pe0yjI9qatqq and lumbed - -- -------------- .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 renairs are made. .08 Special purpose pool and wading pools equipped with emergency shut ott _---____ um switch. -Accessible and -prominently marked - ------------------------------------ __09 Cross connections_Potablewatersuppliegthrougharr_gap_ ____________ ______ ____________________ -------------------------------------------------- 10 Skimmingfacilities_50% 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. Properly spaced. Boundary line on I floor and walls Ste ed es marked with ----- - color ________________ ------------------------------------------------------ ------poo-------------=--- P---g--marke -w------ast-nR----=-------- ---- ------------------------------------------------------ --------------- -.13 Walkway and decks4feetwide,safecondition------------------------- ------ _14Ladders,steps-oneper75feet._ otlessthan2ladders._ __________ ___ --- ---------------------------------------------------------------- _15 Diving egupment in safe condition___________________________________ .17 Pool supervision — Pool supervision provided. Effective Jan 1, 11999, pool supervisor certified aspooloperatorfromYMCAorNSPF_ ______________ _ .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 --purpose pools -----------------------------%------------------------ .23 Lifeguards required; Yes ❑ No Lit' If Lifeguard required; proper credentials, proper suits and garments worn. Whistle and bullhorn rovided------------------------------------- -- .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps atpools attended py_a lifeguard________________ .25 First aidequipmentprov_ided First aid kit Complete._____________________ --a--------------------------------------- .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 Other - - --Pp p--------------------------------------------------------------- -,29 --------- - ------ _.29Poolwatertestedwitha ro natefreguency__________________________ ______ ___ .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakablethermometerfors ec1a4 u se ools -_--_ ---------------------------------------------------------------- 31 Water clarity. --------------------------------- _.31_W------------------------------------------------------------- ---- ri maintenance. Filtration system operating continuously_ __ V__________________________________ 32Water cla ty ----------------------------------- -- ry - ----- ------------------------------------- _32specialpurposepooldrained,cleanedandeve _14 ays._______________ _ 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------------- perator______ ----- _ _ _ --------------------------------------- _ _ _ _ _ _. I.38 General sanitation. REGULATION NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE �y .34 Closure of the pool. POOL MUST BE CLOSED UNIT L iT MEETS THE STANDARD% OF 105 CMR 435.29 THROUGH 435.31. SIGNED I SIGNED address: 1b. b < — � ^_ rr site location t nut auumn I am a sole proprietor and have no one Business Type: ❑ Retail ❑ Restaurant/Bar/Eating Establishment working any spa ty El office ❑ Sales (inclu ' g eaI Estate, Autos etc.) dam an em loser with � em to ees (full & time). ❑Other � _ I am an employer providing workers' compensation for my employees working on this job. an name: -- U I phone " city: ❑ I am a sole proprietor and have hired the independgnt contractors listed below who have the following workers' compensation polices: companyn m address: hone #• Ci insurance ce. _ _ oli # _ _ Company name: address: hone M. ci 0 Fa:iere to Imre eoverrge as required ender Sec#ion i5A of MGL ISZ can lead to the imposition of criminal penalties of a fine ap to $Iersta 0 and/or one yeas' imprisonment as rrcll as dvii penalfies in the foray of a STOP WORK ORDER and a fine of 5100.00 a day against me. T enderatand that a' copy o[ this statement maq�form►rded to the Office of Investigations of the DIA for coverage verification. 06/20/2006 08:20 FAX 7812931300 BORHEK INS. I OP ID S DATE (MMIDDIYYYYI ICATE ACORD,� CERTIFICATE O� LIABILITYTHNSUIRANCEEDASAM�TH CFEIN ORMATION 06 PRODUCER ONLY AND CONFERS NO RIGHTS UPON HOLDER- THIS CERTIVICATE DOES NOT AMEND, EXTEND OR k Ynsurgnce z,gency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. VM. 1:,!. Borhe 311 Plymouth street galifax MA 02338 Phone:781-293-6331 Fax:781-2932171 Mansfield Children's Center Inc. -Mansfseid NAOiO58 INSURERS AFFORDING COVERAGE INSURER A; Utica DTational INSURER B: INSURER C; INSURER D: INIQI IRER E: NAIC # nee ar COVERAGES URED NAMED ABOVE NOTWITi-isrAN NG IS SUBJECT'f0 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 'j p1E POLICIES OF INSURANOk CONDITION OF ANY CONTRAC OR OTHER DOCUMENT W 7H RESPECTFOR TOTHE WHICHPOLICY T IS GER or•ICATE pv1Y BE I SUED OR DI ANY REQUIREMENT, TERM DED BY TFIE POLICIES OESGRIOEO HEREIN _�_ MAY PERTAIN, TWE INSURANCE AFFOR Y NAVE BEEN REDUCED BY PAID CLAIMS, IGE P Y E%P ATION LIMITS pOLIC1E5, AGGREGATE LIMITB SHOWN MA �_.--�-- POL EFFE ,,,;.T---'--' • `— � POLICY NUMBER DATE MM100lYY DAT1r MM1DDlYY SACH OCCURtiENCE S GENERAL LIABILITY CorINIERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER; PRO- LOC POLICY ( i JECT Ll AUTOMOOILH LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS I1IRED AUTOS NON,OW NFD AUTOS GARAGE LIABILITY 7 ANY AUTO EXCESSIUMBREI.LA LIABILITY OCCUR C_I CLAIMS MADE DEDUCTIBLE I RETEN'rION $ WORKERS COI�PENSAYIDN ANTN _D 2 0 6 6 0 5 6 EMPLOYERS' LIAGILITY ANY OFFICHRIMEMBEk �XCLUO D9 J.XEUUTIVE II yyas, describe �nd0r ohc w PROVI$ION5beIOW BY OF CERTI� HOLDER MANOFIE TOWN OF bMNSFTrW Health Agent Scott Leite 6 Park Row 02048 Mansfield MA �rSr+fAG'��0'REfln=-D g pREIv11SES (Ea ocsurence MED Exp (Any Dna pera011) $ PERSONAL & ADV INJURY S GENERALACGREGATE b PRODUCTS - COMP/OP AGG S COMBINED SINGLE LIMIT I x (EBacddenp L BODILY INJURY $ (Per PmrsOn) BODILY INJURY $ (Per aaident) pROPERTY DAMAGE (1'er ecadant) AUTO ONLY - EA ACCIDENT S EA ACC S oYHER THAN AUTO ONLY: AGG 5 EACH OCCURRENCE $ -- AGGREGATE S ,.—�---•- S E.L. EACH ACCIDENT 5100000 10/07/05 10/07/06 --"—"—' 51. DIEA EMPLOYE S 10 0 0 0 0 F.L. DISEASE - POLICY LIMIT 5 5 0 0 0 0 0 CANCELLA I Ivry SHOULD ANY OF THE ABOVE DESCRIBED POUGIES 8E CANCELLED DEFORE THE EXPIRA DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 _ DAYS WRITTI NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFY, GUT FAILURE TO DO 50 SHS IMPOSE NO OBLIGATION OR LIA131LITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES, t ®ACORD CORPORA 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. 4ell of I dual or Name (Mandatory) orporate icer (Mandato , if applicable) ** Social Security Number (Voluntary) or Federal Identification Number S-- — Z -I -Tel * 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.