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HomeMy WebLinkAboutCedar Heights 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: PERMIT EXPIRES: 13 December 31, 2018 Person Certified: MICHAELLA J. (JOHNSON) SAMPSON Pool/SPA Certification Date: March 20. 2013 Pool/SPA Certification Expires: March 20, 2018 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: CEDAR HEIGHTS for the operation of a l Public ] Semi -Public f J Special Purpose Pool located at: 10 CONNORS AVENUE Method of water treatment is CHLORINE Bathing load not to exceed: 61 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan -Palmer, Health .Agent Date Issued JAN 1 16 2""Wt Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 13 FEE: $125 I Public NAME OF OWNER: CEDAR HEIGHTS POOL OPERATION: lV Semi -Public I I Special Purpose Pool ADDRESS: 10 CONNORS AVENUE POOL LOCATION: 10 CONNORS AVENUE CITY: MANSFIELD STATE: MA ZIP: 02048 TYPEIPOOL: GUNITE/PLASTER TELEPHONE: (508) 337-0040 LENGTH: 42' 6" .. WIDTH: 27' FAX: (508) 337-0042 VOLUME: 27,510 GALLONS EMAIL: MSAMPSON@CEDARHEIGHTSMANSFIELD.COM MIN/MAX DEPTH: 376' FED ID/SS NO: 56-2332456 SWIM AREA: 917 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN Certification Expires Every 5 Years. WIW DISPOSAL: TOWN Permit Expires December 31st Yearly. TYPE OF FINISH: PLASTER PERSON CERTIFIED: MICHAELLA J. (JOHNSON) SAMPSON SCUM GUTTER: NONE Pool/SPA Certification Date: 3/20/2013 DECK TYPE: CONCRETE Pool/SPA Certification Expires: 3/20/2018 SKMMR WEIR LENGTH: 8 1/2" PERSON CERTIFIED: TREATMENT SYSTEM: CHLORINE PoolISPA Certification Date: DISINFECT METHOD: CHLORINE PoollSPA Certification Expires: CHEMICAL TREATMENT: CHLORINE certification remarks(if necessary): NUMBER OF BATHERS: 61 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. MICHALLA JOHNSON - AS AGENT OF CEDAR HEIGHTS, LLC j SIGNATURE: l'rldC�EAlt DATE: 11111le_ _ Please make appropriate c nges. ign, d�e n, d enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. TAX CERTIFICATION FORM 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 Individ&l or Corporate Name By: Corporate f is (M datory, if '� e© ," ' 5 b-a33cy51k **Social Security No. (Voluntant) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. �\ The Commonwealth of Massachusetts Department oflndustrialAccidents IV I Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Name: l Address: I0 )0_1`)a" City/State/Zip: Are y an employer? Check the ppropriate box: 1. XIam a employer with employees (full and/ or part-time).-- 2: ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required] 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone Business Type (required): 5. ❑Retail 6. �❑RestaurantBar/Eating Establishment L 7. j/Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11. ❑ Health Care 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate of5eers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing workers' connWensation insurance for my employees. Below is the policy information. Insurance Company Na9me: Q/D ✓Gl2 — ���/ /t / lGi SG�12L LLtC e rt Insurer's Address: l �P )2(Aq o Ci�hz,a�J7 7 �y City/State/Zip: ,� ' /�������n�l��Yl IA- L 61 y2 �� Policy # or Self -ins. Lie. #���- `/e���b�����.' tt ' O� Expiration Date:" Attach a: copy of the workers' compensation policy declaration page (showing the policy number and expiration: date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, underjke paids aryd,�enaldes ofperjury that the information provided above is true and correct. d Official use only. Do not write in This area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Phan TRAVELERS J~ WORKERS COMPENSATION ONE TONER SQUARE AND HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY TYPE v INFORMATION PAGE WC 00 00 01 ( A) POLICYNUMBER: UB-4J410941-17-42-G RENEWAL OF (IEUB-2D63148-7-16) INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 1. INSURED: CEDAR HEIGHTS,LLC DBA THE VILLAGE AT CEDAR HEIGH TS; 34 BELLOWS RD RAYNHAM, MA 02767 NCCI CO CODE: 12637 PRODUCER: GLOVER-PADULA INS INC 16 MAIN ST EAST GREENWICH, RI 02818 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-25-17 to 08-25-18 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500,000 Each Accident Bodily Injury by Disease: $ 500, 000 Policy Limit Bodily Injury by Disease: $ 500,000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OR OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OF ISSUE: 07-14-17 SD OFFICE: BOSTON SOUTH MA 853 PRODUCER: GLOVER-PADULA INS INC 32964 � ? \� 4 ; .: ©- :` /Ck \ \/a The Village at Cedar Heights `Ly® A honer Properties Apartment Community January 11, 2018 Board of Health Town of Mansfield Attn: Amy Donovan -Palmer 6 Park Row Mansfield, MA 02048 Certified Mail, Return Receipt Requested RE: 2018 Swimming Pool Permit www.CedarHeightsMansfield.com Enclosed please find a completed Swimming Pool Application, Worker's Compensation Insurance Affidavit, Insurance Policy Declaration Page, a copy of my CPO Certificate, tax Certification Form and a check in the amount of $125.00. Also included is our current Certified Pool Operator Certificate. We are aware that this certificate is expiring and will no longer be valid for the upcoming season. This letter confirms that I will personally be taking the Pool Operation Management course on March 13-14, 2018 in Norwood, MA. I will forward my valid Certificate upon completion of the class. Should you have any questions or require anything further, please feel free to contact the office. Also, here is my email which was requested: msamoson(a)cedarheiehtsmansfield com Thank you, Michaella J. Sa Property Mani Department of Public Health — Community Sanitation Program STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.00 Naine of City/Town Type of Pool: ❑Public Name/Address of Pool: Un Inspection Date: Time: a �C) Owner/Operator: r ter \ S�ource: z6boO WATER QUALITY Water Test Results (Taylor DPD Test Kit # K-2006) Water Clarity Results (Secchi Disk) 435-Inspector Field Notes Page I $athhouse and sanitary facilities adequate lighting; ventilation; sanitary condition 111 10 Adeuuate enclosure around pool: Gate self-latchine w/ latch 4 ft above eround t/ Location, structural stability, finish Water circulation & filtration systems: Filter Effluent flow meter reading: `1gpm # of turnovers: e C' < Suitable automatic equipblent for pH control adequate; CO2 cylinders anchored. Inaccessible to Y L\ public, adequate ventilation provided 'I *is and outlets: Inlets located to produce uniform circulation; Over rim fill spout 6" above maximum water level; Properly shielded and located am drain suction outlets covered with suitable protective covers and grates. Cannot be removed without the use of tools; Open area does not provide entrapment of fingers, toes, etc; At least one ch system outlet provided against user entrapment by antivortex cover or other means.; Minimum of 2 suction outlets provided for each Damn. oronerIv located and plumbed. MZand mming facilities: 50% of recirculation drawn from surface of pool in with floats separates non -swimmer area from deeper water; Water depth markings on deck walls;Properly spaced; Boundary line on pool floor and walls; Step edges marked with trastingcolor lkways and decks 4 It wide, safe condition t aciciers, steps — one per i� it; Not less Man 2 taaaers v` G Diving equipment in safe condition Pool supervision: Pool supervision provided n �. Effective Jan. 1" 1999: Pool Supervision Certified as O erator from YMCA or NSPF Permit Requirements: Permit Issued; Adequate maintenance and testing records maintained; Records initialed b person makingtests Health ReQuIations: Siens posted: Health warnine siens posted for special purpose pools Lifeguard required: ❑ Yes [�Y o If lifeguard required: Proper credentials, proper suits, and 6garment worn; Whistle and bullhorn provided Safety Equipment: Ring buoy and rescue hook provided; Rescue tube and backboard with straps at pools attended by lifeguard 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 nnqted Waste and backwash water disposal properly discharged; No direct connection to sewer system; Separation tank provided for diatomaceous earth filter backwash water Chemical Standards Pool water tested with appropriate frequency �\ X Water testing equipment; DPD kit provided for chlorine and bromine; Unbreakable thermometer Water Clarity: Water 14 a. Thermostatic control provided for each SPP b. Thermostatic control only accessible to the pool operator General Sanitation 435-inspector Field Notes Page 2