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HomeMy WebLinkAboutHoldiay Inn 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: 15 December 31, 2018 Person Certified: STEVEN M. PASCALE Pool/SPA Certification Date: November 09, 2016 Pool/SPA Certification Expires: November 09, 2021 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: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a [ 1 Public C Semi -Public [_I Special Purpose Pool located at., 31 HAMPSHIRE STREET Method of water treatment is SALINE 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. Amy Donovan-PaCmer, Wealth Agent 7tf Date Issued 3Fb fOW e TOWn of Mansfield Town of Mansfield - Board of Health _.__._-_--s Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 15 FEE: $125 Public NAME OF OWNER: VISION HAMPSHIRE LLC HOLIDAY INN POOL OPERATION: 1 1, Semi -Public Special Purpose Pool ADDRESS: 31 HAMPSHIRE STREET POOL LOCATION: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TYPE/POOL: SEMI-PUBLIC TELEPHONE: (508)339-2200 LENGTH: 62 WIDTH: 23 VOLUME: 42,666 GALS FAX: EMAIL: MIN/MAX DEPTH: 375' FED IDISS NO: 47-3112140 SWIM AREA: 1,426 SQ. FT. DIVE AREA: N/A WATERSOURCE: TOWN Certification Expires Every 5 Years. W/W DISPOSAL: TOWN Permit Expires December 31 st Yearly. TYPE OF FINISH: FIBERGLASS PERSON CERTIFIED: STEVEN M. PASCALE SCUM GUTTER: N/A Pool/SPA Certification Date: 11/9/2016 DECK TYPE: CONCRETE Pool/SPA Certification Expires: 11/9/2021 SKMMR WEIR LENGTH: 14' PERSON CERTIFIED: TREATMENT SYSTEM: SALINE POolISPA Certification Date: DISINFECT METHOD: SALINE POolISPA Certification Expires: CHEMICAL TREATMENT: CHLORINE SAND FILTER certification remarks(if necessary): NUMBER OF BATHERS: 83 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. No lifeguard on duty. Sign is required. 0SIGNATURE: DATE: 11 / 30/ % Please make appropriate changes. Sign, date and 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 Individual or Corporate Name q'Z ^ 311 21 **Social Security No. (Voluntary) or Federal Identification Number p-, � By: Corporate Officer (Mandatory, if Applicable) *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. =� � Vision Na.m shire LLC „ . ��;t 31 Hampshire Street _ ittte';Ati1'ds% 800 Superior Avenue East, 21st Floor V"Wft Cleveland OH 44114 :.-. . [Cr'todiv Gp ciQG. 9§ U1ra KlSpOIAt.lrCin,`bgC}i' 1� �36dwd of Kenitti 2 w�ditig 11 t flr ent" 3. tyao" `ork: 4 1 �,1,op!1;`1af�;;�q#rti. a �eta�lmr�ly��1Y�iCe,; G.4dfer -- GLOBVIS-01 JHOGAN ACoizo" CERTIFICATE OF LIABILITY INSURANCE D11/30/201TE 1'YI `./ 11I30/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on PRODUCER Roblin Insurance Agenc 144 Gould Street Suite 160 Needham, MA 02494 INSURED Vision Hampshire LLC dba Holiday Inn 31 Hampshire Street Mansfield, MA 02048 INSURER(S) AFFORDING COVERAGE __.. NAIC N INSURER A: Travelers Insurance Co 36161. INSURERB Travelers Indemnity & Affiliates _ ,25658__. INSURER C ACE American Insurance Co.. __. 122667. rnvcon ncc rcoTIClrnTC Kit M IMCD• Rc\ASIr1M NI IMRCR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR lADDLBUBR; POLICY NUMBER i POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE SD D 0 A X co MMERCIAL GENERAL LIABILITY ! EACH OCCURRENCE $ 1,000,000 GLAIMG MADE Xl OCCUR IP-630-9H994609-TIL-17 06124/2017 i 06/24/2018 I DAMAGES( RENTED ,PREM15E6 (Efloaaartence) 300,000 I_$ Liquor Liability $1M X q tY _ I MED EXP(Any one person) I$ 6,000 _ (PERSONAL&ACV INJURY 1,000,000 OEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ I$ 20,000,000 X POLICY F 1 PEo- I LOC PRODUCTS COMPIOP AGG $ 2,000,000 _ !I LIQUOR LIABILIT 1,000,000 OTHER: B AUTOMOBILE LIABILITY I X-] ANY AUTO IBA-9H986394.17-CAG 06/24/2017 06/24/2018 (Ea aaBI aBDU SINGLE LIMIT — BODILY INJURy Par ersonL_ $ 1,000,000 $ BO�DIeLYaINJURY (Per acclderu _ OWNED I SCHEDULED AUTOS ONLYAUTOS I AUTEpNLY 6011ELp SO IF ( ACE .. -_ $ C XUMBRELLALIAB X_ OCCUR I OCCURRENCE . $ 125,000,000 LIAB PUMBI6-A-G26786789 06/24/2017 O6/2412018 EACHAE 125,000,000EXCESS $ DED RETENTIONS I g D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY X PER STATUTE.( �RH YIN 'TWC3638151 06/01/2017 06/01/2018 500,000 ANY PROPRIETORIPERTNERIE%ECUTNE N IA EL EACH ACCIDENT CIManGEqq/MHEXCLUDED? as.n EL DISEASE -_EAEMPLOYEE, 500,000 S I II yes,"ITIOe under ' DESCRIPTION OF OPERATIONS below : 500,000 E.LDISEASE- POLICY LIMIT . DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached it more apace is required) Issued as evidence of Insurance. ncoT¢trn Tc unI nco rAMrc1 I ATInNI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Issued as Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �iullllllllllllllllllpo �IIIIIIIIIII� �" — Iiliill�IlluNlulllllllu,AMD- ` , dllllllllillllllllllll'lIP I Illl��lllllllllllllll�llli Illllllillllllllll�'' `" tllllllllllllllllliip �uiuuNlplill11111� —�� � I � � Illl��lllllllllllll i�� +, ? d ' � �" I'�NIIIIIIIIPIIIII re �IIII�IIIIIiII� �, M� IN III�IIIIIIIIIIIV 1 Ali u Zi dllf f. Nhlli CommClU. aty e s o o I a �I�ulZ�il — c dll IIIIIIIIP I" ` dlllllll � �' � II �IIIIIIIII i� � I � d �IIIIIIIIIIIIIIII' i '��� —gip tllllllllllllllll�l BOOM dIV � � INlllllllllp �IIIIIIIIIIII '�', � �71 � d IIII�LLI � d' I t �__,�'■„ _= I�I��II�IIIIIIIIIIIIi � IIIIIIIIIIIIIII' V I�� �I � W IIIIIIIII�IIIil��lll� I ' 1 II���IIIIIIVII ,� � iNllllllllllll � � �' tlllflplllillll �� _ �iiiuN�uiu�illllll�llAli _ �iliuiliiNluullllflllVlRaw p�lllllllllll�ln, Illl���iluiiuuil u�� �� � ,IiiiiNiiillululuNllu�V ;, dlllllllllillllllllpllll4 o NIINNIIN � , , a IiuiNiilN ulll���N�u�N�l���lllli'— I � = I�Ill��l�l�ulu�lllllli ,IiuiiilNluiuiiuiiiuu" � � I �NlliuilNlNuiuuNlNl Illl�NIIIIilllllllllll � ;, pIIIIIIIIIIIIINIIiI llum�uuuii���l III�INNiI�N�llmlul lih uiulllll l�- ': ��I�II'lil ��,1,�,1��'6tl�ib��.lLleddSNeuoydala� �ol�eo�y��ll��,J� 0 NSF International OFFICIAL LISTING NSF International Certifies that the products appearing on this Listing conform to the requirements of ANSI/APSP 16 (ASME/ANSI A112.19.8) - Suction Fittings for Use in Swimming Pools, Wading Pools, Spas, and Hot Tubs This is the Official Listing recorded on March 14, 2012. Triodyne Safety Systems LLC 3054 North Lake Terrace Glenview, IL 60025 347-486-9641 Facility: Addison, IL Design Orientation (Wall Flow Suction Fitting Model Sump Model or Field Type and/or Floor) Rate (SIM) Main Drain Cover - TSS-2800 Anti -Hair Snare Plus[1] (21 [3] [4] Sta-Rite 8" Round WC 73-1P Floor 68.8 (11 Only the drain cover has been Certified by NSF International to ASKS A112.19.8-2007 and NSF/ANSI Standard 50. The drain cover was evaluated to the requirements of the standard with the sump stated above. The sump is not Certified under this specific Listing. Installers of the drain cover should ensure the sump and fasteners meet the requirements of ASME A112.19.8 and the sump has dimensions equivalent to the test sump stated above. [2] Per ASME A112.19.8-2607, the use of the suction fitting with a field fabricated sump built in accordance with Figure 2 of that standard shall be permitted when specified and designed by a Registered Design Professional. Installers should also ensure that the drain cover is installed, fastened, and secured according to the drain cover and the sump manufacterer's instructions. (31 NSF Listed unit is white. [41 Testing assembly included use of ADP 2000 collar. NOTE: ANSI/APSP 16-2011 has replaced ANSI/ASME A112.19.8-2007, and addenda A112.19.8a-2008 and A112.19.8b-2009 which have been withdrawn. 041 Note: Additions shall not be made to this document without prior evaluation and acceptance by NSF International. 1 of 1 OC260 789 N. Dixboro Road, Ann Arbor, Michigan 48105-9723 USA 1-800-NSF-MARK / 734-769-9010 www.nsforg - -- - Q p_ HIGH FLOW SAFETY oH$at�N� yp --HIGH-FLa SCONFORMITY �.+'EpTIFICATE Y.,) %�9[ illF{'�`j�R0.i�! 1 `�f SDX HIGH FLOW TY Submerged Suction Outlet For Single or Multiple Drain Use For Use on Wall and Floor No Surnp Required nc€uctras t-tfro I-ii0 k plate and Safety verath f s affIt Qecdiameter ra fr �rvle a tau 4 1 read at enrexlstlr7c} drain bulkhead style tamY�.€rSi>Y� a replace$ most existing drain covers up ha 1 O" In dialzn3ter. FLOW RATING riOOR WAU. One SE: X or SDX Retrrx 200 G--FM 102 GPM Sgti are Inches of 0pen€n9 ` 43 201 sq Inches vetocity @ 200 GPM -. 1 485 fps pLACE OF MANUFAicTURM Parammint Pool & Spa Systems, 295 F. e-orporato Place chandler, AZ 86'.25 USA I480j 093-7607 MAME OF Tk111`tD r- ,AFSi'Y LAI`FJORATt RYS lAr-Imo R&T LAD -rr=' RECO$gD CA65cum3 SN-rA'i@t'l't 4: BAPM`.i R8 7. 5001 E PhiladslPhia Street Ontario. CA 91761 (909) 472.41D4 Test Repol't—March 17, 201 1 Virginia Caracme Baker Pool and Spa, Safety Act < ASMEA112.113-8-2007 • A(VS1fAPSP - 7 • IAPMC, Listed SL1X Mandel Nur'tbor0k Concrete XXX,-182-22B2-XX vroyf XXX»9 7`2•�:s1 "1.•XX Ftbelgl,7SS X)XX-182-2212-XX Petro XXX-1917-2212•>(X Retro Vinyl xXX-159.22'I 2•XX Retry EqP.'?Ilzer X X B 57-221 2-XX I...IFC SF'Afd. 5 eEARS FROMDATF-0 IhJ5TA1_LATI0N Install Date - - ntss{ s pC 7 Roplac,ament 5 years from Instailsr-i elate tAn2rOp py;5j F_: SucUr:n SafatS' :ifanrfartlg requim lh&t tiratn tlraics uscid 4a C.bva�r swrp5 +'rn rvt have= II'�e suction nip^ GUY at least 1.5 times the Ore Fd r+n sudl behind tile esE.rAIP Icov, ir, Ttl nm f (INOle LJJMPi o ui se to the b c ent for .r fatt,e cover,iit may ad desiJ 'y` rr',sirlci water flow ;o thl) pu+np, Potentielly 1'9C€uCin{i hyCirnUliC GtIIC19nCy, but this dac?y nest Pos'i a SuotfalI yOr,tY h1..'?I tl. ThtF is r-onfirrti�.d by Ihr; €APMr) Tact ReporP. Thin E'rnt;uct rrausi be Installed In >2cer>rclarace with€:Id gippllc�bW� F'eadsral,&a4q and Local 4;ndas. HEALTH AND SAFF,TY VIOLATIONS/ GENERAL Notes: SANITATION VIOLATIONS (* indicates conditions documented on previous inspection reports) i \ " ty \l l_ 43S-Inspector Field Notes Page 3 Commonwealth 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: 14 PERMIT EXPIRES: December 31, 2018 Person Certified: STEVEN M. PASCALE Pool/SPA Certification Date: November 09, 2016 Pool/SPA Certification Expires: November 09, 2021 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: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a f ! Public Semi -Public yi Special Purpose Pool located at 31 HAMPSHIRE STREET Method of water treatment is SALINE Bathing load not to exceed: bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan -Palmer, Heaah Agent Date Issued QPVA _ a /� t- nsfield Town of Mansfield - Board of Ho,..... _ Mansfield, MA 02048 i Swimming Pool Application _ PERMIT NUMBER 14 FEE: $125 NAME OF OWNER: VISION HAMPSHIRE LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: (508) 339-1040 EMAIL: FED ID/SS NO: 47-3112140 Certification Expires Every 5 Years. Permit Expires December 31st Yearl PERSON CERTIFIED: STEVEN M. PASCALE Pool/SPA Certification Date: 11/9/2016 Pool/SPA Certification Expires: 11/9/2021 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. "No Lifeguard on Duty" sign I I Public POOL OPERATION: Semi -Public v, Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SPECIAL PURPOSE LENGTH: 7 WIDTH: 7 VOLUME: 863 MIN/MAX DEPTH: 3' SWIM AREA: 154: sq ft WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: BRICK RAISED SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: SALINE DISINFECT METHOD: SALINE DIVE AREA: N/A CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: SIGNATURE: o- -� (jr w DATE: t (/3 d �7 Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. Department of Public Health — Community Sanitation Program STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.00 Name of City/Town of Pool: ❑Public ❑Special Pt Inspection Date: LtV�c \ Accompanied By: Telephone #: Owner/Operator: Water Source: Pogl.Capactty# of 4allon8:= j > I Bather>Load .i `s I ,# of Lifeguards; � '! 'i WATER QUALITY Water Test Results (Taylor DPD Test Kit # K-2006) Testing Times : Initial: Additional: Location: Chemical Test Allowable,Range ; ".� i£A heable�- ` (ffNecessa . term) .- .. ` _ swimmF ing ool+gPop1 Swimming �: Wading , "' Poor,Pool ' Treelilorine (used as adistnfeatant) 1.0-3.0 i Combined 'C6l6rine " 0.0 0.2 t 7.2-7.8 _1. C p `) , b Alkalinity ; 50-150 Calctuut )3a'dness 150-1000 (Recommended" prJ CyanucicAcid,," 30-100 Mused).. 2.0-6.0 as a disinfectant) 'Additional testing was conducted to evaluate the effectiveness of corrective actions taken to achieve compliance with the chemical standards required Water Clarity Results (Secchi Disk) Testinn Time(s): Initial: Additinnal: Lneatinn. Visibility Test 11?tial Test Result. ' � Acceptable.Test Result? .� � �ddltiorial Test Results. ' ' � Swirn gPOni .: Secchi Disk Wading Pool Adamonm testing was concocted to evaluate the efectveness or corrective actions taken to acnieve compliance wild the water clarity standards required. 435-Inspector Field Notes Page 1 Bathhouse Water circulation & filtration systems: meter Q6 Suitable automatic equipment for pH control adequate; COZ cylinders anchored. Inaccessible to public, adequate ventilation provided C 08 Inlets and outlets: Inlets located to produce uniform circulation; Over rim fill s out 6" above maximum water level: Pronerlv shielded and located Main drain suction outlets covered with suitable protective covers and grates. Cannot be removed 08 ithout the use of tools; Open area does not provide entrapment of fingers, toes, etc; At least one antivortex drain provided. V Each system outlet provided against user entrapment by antivortex cover or other means.; Minimum of 2 suction outlets provided for each pump, properly located and plumbed. Suction outlet covers in place, unbroken and secure and cannot be removed except with the use of 08 tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools until repair can be made. 08 Special purpose pools and wading pool equipped with emergency shut off pump switch; Accessible .-_ and prominently marked. ✓ Cross connections: Potable water supplied through air gap Skimming facilities: 50% of recirculation drawn from surface of pool Line with floats separates non -swimmer area from deeper water; Water depth markings on deck 2 s and walls; Properly spaced; Boundary line on pool floor and walls; Step edges marked with contrasting color - Walkways and decks 4 It wide, safe condition • w�hc eUr` 5b\�� Ladders, steps —one per 75 ft; Not less than 2 ladders 6. Diving equipment in safe condition X7 , Pool supervision: Pool supervision provided Effective Jan. ls` 1999: Pool Supervision Certified as Operator from YMCA or NSPF 2i ✓ Permit Requirements: Permit Issued; Adequate maintenance and testing records maintained; Records initialed by person making tests 22 -. Health Regulations: Signsposted; Health warning signs posted for special purpose pools 23 ��° Lifeguard required: ❑ Yes EXNo If lifeguard required: Proper credentials, proper suits, and garment worn; Whistle and bullhorn provided 24pools Safety Equipment: Ring buoy and rescue hook provided; Rescue tube and backboard with straps at 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 posted Waste and backwash water disposal properly discharged; No direct connection to sewer system* Se oration tank provided for diatomaceous earth filter backwash water hemical Standards V Pool water tested with eippropriate frequency a 30 Water testing equipment; DPD kit provided for chlorine and bromine; Unbreakable thermometer forspecial purpose pools Water Clarity; Water Clarity Maintenance: Filtration system operating continuously Special purpose pools drained. cleaned, every 14 days 33 �i� ✓ a. Thermostatic control provided for each SPP b. Thermostatic control only accessible to the pool operator General Sanitation 435-Inspector Field Notes Page 2