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HomeMy WebLinkAboutRed Roof 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: Person Certified: FRANKIE TODESCO Pool/SPA Certification Date: May 22, 2018 Pool/SPA Certification Expires: May 22, 2023 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 10 December 31, 2018 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: BW RRI LLC for the operation of ' 1 Public [] Semi -Public ❑ Special Purpose Pool located at: 60 FORBES BLVD. Method of water treatment is AUTOMATIC CHLORINE Bathing load not to exceed, 55 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. .Amy Donovan-PaCmer, WeaCth .Agent None Date Issued 9 Town of Mansfield e Board of Health AS Swimming P®®l Appllcail®n NAME OF OWNER: BW RRI LLC ADDRESS: THE RED ROOF BUILDING 605 S. FRONT ST. CITY: COLUMBUS STATE: OH ZIP: 43215 TELEPHONE: (614) 744-2600 FAX: (614) 2255214 EMAIL:-�0274@REDROOF.COM FED ID/SS NO: 47-3368497 Certification Expires Evertr 5 Years, Permit Expires_ December 31st Yearly. PERSON CERTIFIED: rrror v,�e__-T6de,SC0 POOL/SPA Certification Date: Sl aal t H Pool/SPA Certification Expires: r,- / aA/ a 3 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification renarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE. — Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 10 FEE:$125 ❑ Public POOLOPERATION: 0 Semi -Public ❑ Special Purpose Pool POOL LOCATION: 60 FORBES BLVD. TYPEIPOOL: CONCRETE IN -GROUND LENGTH: 40' WIDTH: 20' VOLUME: 22,000 MIN/MAX DEPTH: T to 8' SWIM AREA: 800 sq. ft. DIVE AREA: NONE WATER SOURCE: TOWN WIW DISPOSAL: TOWN SEWER TYPE OF FINISH: GUNITE SCUM GUTTER: NONE DECK TYPE: NONE SKMMR WEIR LENGTH: TWO BASKETS TREATMENT SYSTEM: DIATOMACEOUS DISINFECT METHOD: AUTOMATIC CHLORINE CHEMICAL TREATMENT: MANUALLY AS REQUIRED. NUMBER OF BATHERS: 55 TOWN OF PAU- JUN 0 6 2010 DATE: 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. aP ctscr r�s -.. w Town of Mansfield - Board of Health 4FA9lS`•- Swimming Pool Application NAME OF OWNER: my P KT_ -M LLC. ADDRESS: 7-915 VVG.I IuY) P o vlkw�) CITY: N-ew A lbanj STATE: 6Y\6O ''ZIP: �°J6sq TELEPHONE: W 14 -Y7i' T- ea 6 0 FAX: G i q -. aA cG -- S 3 3 EMAIL: L t 9 Q [ A �} tU V4 WX, wm FED IDISS NO: 9-7--.3-)to 8T 97 Certification Expires Every 5 Years. Permit Expires December 31st Yearly PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: PERSON CERTIFIED: PooYSPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $125 0 Public POOLOPERATION: L7 Semi -Public ❑O Special Purposer Pool POOL LOCATION: r 66 Forbes G1vA /A sgeA f Mfg 0 o'oq8 TYPEIPOOL: LENGTH: VOLUME: MINIMAX DEPTH: SWIM AREA: WATER SOURCE: WNW DISPOSAL: TYPE OF FINISH: SCUM GUTTER: DECK TYPE: SKMMR WEIR LENGTH: TREATMENT SYSTEM: DISINFECT METHOD: CHEMICAL TREATMENT: NUMBER OF BATHERS: WIDTH: DIVE AREA: REMARKS: "N LIFEGUARD FEGUARD ON DUTY" sign is required. SIGNATURE:. - -_ __- DATE: ------_--- 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. 11l�n d�a�r ` d�Y of lndividc or Corporate Name By: Corporate Officer IManduta,l/, it Applicable) ki 47- 336 $ L197 "Social Security No. (Voluntary) or Federal Identifleation 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 Iicense suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C;\UserslsleilelDcslnopl5uolfs Docmnuniffood Ealahlislummn(s-'rempWAx CERTIFICATION PORMdoc Department of Industrial Accidents Off of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LePibly Business/Organization Name:_ R Address: 63(1 �rne� 1aC� t City/State/Zip:_ A a m,&e- I d M A Phone Are you an employer? Check the appropriate box: r5. usiness Type (required): I. d I am a employer with 19 employees (full and/ ❑ Retail orpart-time).* . ❑ Restaurant/Bar/Eating Establishment 2. ❑ I 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.] 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.Z Other � 6-L 0 e Any applicant that checks box Hl must also fill out the section below showing their workers' compensation policy information. *1f the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ,rganization should check box It1. 'ran art employer that is providing workers' compensation insurance for my employees. Below is the policy inrformadonr. nsurance Company Nan usurer's Address:_ :ity/State/Zip: elic # or Self -ins Lie. Expiration y lttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cr urinal penalties of a me 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 ,f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestiaations of the DIA for insurance coverage verification. do hereby certify, under rile pains Official use only. Do not write in this City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building 6.Other Contact that tire information provided above is true and correct. to be completed by city or town: official Permit/License 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office www.mass.gavidia Phone AcoRH CERTIFICATE OF LIABILITY INSURANCE `i 9/6/201 s DATE(MMIDD/YYYY) 1 6/1 /2018 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 this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lockton Companies, LLC 601 108th Avenue NE, Suite 1969 Bellevue WA 99004 CO TACT PHONE I FA% ExU: IA/C. No): Et A ADDRESS: INSURERS AFFORDING COVERAGE NAICs INSURER A: The First Liberty Insurance Corporation 33588 INSURED Red Roof Inns, Inc. 1447203 The Red Roof Building INSURER B : _ INSURERC: INSURER D : 605 South Front St. Columbus OH 43215 INSURER E : NSURERF: COVERAGES REDR001 CERTIFICATE NUMBER: 15421326 REVISION NUMBER: XXXXXXX 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 TYPE OFINSURANCE SLSUBR IWvo POLICY NUMBER POLICY MDNYY IITR MMMr LIMITS COMMERCIAL GENERAL LIABILITY CLAIM&MADE OCCUR NOT APPLICABLE EACH OCCURRENCE $ XX. CX)CX' RENTED PREMISESDAMAGETO Ea accuRencut $ XXXXXXX MED EXP (Anyone emon) $ XXXXXXX PERSONAL&ADV INJURY S XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PEA LOC OTHER: GENERALAGGREGATE S XXXXXXX PRODUCTS-COMPIOPAGG $ XXXXXXX $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY NOTAPPLICABLE COMBINED SINGLE LIMIT Ea accident $ X70CXXXX _ BODILY INJURY (Pat person) $ XXXX7iXX BODILY INJURY (Par accident) $ XXXXXXX PROPERTY DAMAGE Per accident $ri s XXXXXXX UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS�MADE NOTAPPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XYXXXXX DEC) RETENTION$ I $ XXXXX7C{ A WORKERS COMPENSATIONER AND EMPLOYERS' LIABILITY OFFICERIMEMBER EXCLUDEDCUTrve Y/❑NN (Mandatory In NH) Ues, describe under SCRIPTIONOF OPERATIONSbelow NIA N WC6-641-4377G0-017 9/6/2017 9/6/2018. X STATUTE ER E.L EACH ACCIDENT S l 000000 E.L. DISEASE -EA EMPLOYE $ 1000000 E.L. DISEASE -POLICY LIMIT IS 1,000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may bealtached ifmore space is required) RE: Red Roof Inns 810274 it 60 Forbes Road; Mansfield, MA. 15421326 Department of Industrial Accidents Office of hivestigations 600 Washington Street Boston MA 02111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ACORD 25 (2016/03) ©1 The ACORD name and logo are registered marks of ACORD All riahte reserved. Bank # PkVI DeBOARn OF HEALTH Date: 6 6-18 Schedule: From Whom Account Number Amount _ BW RRI LLC 01512A45006 $ 125.00 125.0 125.00 The above is a detailed list of moneys collected by me, amounting in the aggregate to: $125 00 for the oenod endino �s a-1R PAM JUN 0 6 2018 CLrFi;KA r.�c --i 2 8 n •; POOL OPERATION MANAGEMENT® May 22, 2018 Frankie Todesco 60 Forbes Boulevard Mansfield, MA 02048 Dear Frankie Congratulations upon your successful completion of the CERTIFIED POOL/SPA OPERATOR course! I hope that your experience was a positive one. You will be receiving your certification from the National Swimming Pool Foundation within 6-8 weeks. You can use this letter as proof of certification until your certificate arrives. The networking through your classmates can be a valuable resource to you. You are also invited to enhance your knowledge by participating in future CERTIFIED POOL/SPA OPERATOR courses and visiting www.pooloi)erationmana.gement.com. To help you at your facility, you can hire one of our CPO instructors aid you in making your job easier and your facility safer. Callus to schedule an inspection of your facility. Also, be sure to visit our website to find all the CPO products and services you need to run a safe facility. Thank you for your participation. If you should have need of our services in the future, please contact us. Sincerely, J Trevor Sherwood Vice President 68 EDWARDS ROAD • BRICK, NJ 08723 • PHONE (732) 451-1D40 • FAX (7321 451-1630 www.pooloperationmanagement.com Contains: WG1048E or Ratings: Floor:_ 12 Certified to Comply with Set Test Results can be obtained Manufactured: After Dect Clemmons, NC Divisions 355-7995 Date of Mfr: The Lot Number first number represents the yet skipped, J=Sep, etc) Tested to ANSFASME 112.1 Act (VGB) Pool & Spa Safety 48105 1(800)-NSF-MARK, Date of 07 3/4" SUCTION OUTLET COVER WG1048E G 1-0LINE COMI'riOLS 20, � •I 1I®N OF COMPLIANCE I HaWuard Industrial Drive ClemmOnS, NC 27012 336-712-99oo MWIlaymrdnet.com ;W Description: 8" Round Suction Outlet Cover Wall: 72 GPM Open Area: 8.1— -- sue.-_ the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act iavwardnet com and/or http://wwX nsf or Certified/Ponh/ by Hayward Pool Products in Jiangsu Province, China and ustries, Inc. 620 Division Street, Elizabeth, NJ 07207, Phone 908- uown on he product label contains the Year & Month of manufacture. (ex 8 = 2 08) and the second character the month The (A=Jan, B=Feb, H=Aug, I is tdum 8a-2008) per Section 1404 of the Virginia Graeme Baker by NSF International, 789 N. Dixboro, Road, Ann Arbor, MI. 6, SPACING ETWEEN MOUNTIN HOLES ISWG1048COC Rev B USED ON FOLLOWING SERIES. WG1030AVPAK2 WG1048AVPAK2 WG1049AVPAK2 WG➢051AVPAK2 WOI 1152AV PAK2 WG➢053AVPAK2 WG➢054AVPAK2 WG1153AVPAK2 WGI154AVPAK2 SP1030AVVPAK2 SP1048AVPAK2 SP1049AVPAK2 SP1051AVPAK2 SP1052AVPAK2 SP1053AVPAK2 SP1054AVPAK2 SP1153AVPAK2 SP1154AVPAK2 Pool Products One source. Every pool. Jane Doucette From: Amy Donovan -Palmer Sent: Thursday, June 21, 2018 1:32 PM To: Jane Doucette Subject: Red Roof Inn Hi Jane, Could you please email Frankie the Red Roof Inn pool license? He's still working on a couple things so I'm going to keep the inspection form here until everything has been corrected. Here's his email: 10274@REDROOF.COM As I'm typing, I'm vaguely remembering that maybe you need a quick tutorial on how to email permits directly without printing them out. Let me know if you do. Thanks, Amy Amy Donovan -Palmer, MPH, RS Health Agent Town of Mansfield 6 Park Row Mansfield, MA 02048 508-261-7366 1 Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL: PT TBLIC ❑ SEMI-PUBLTC M SPECIAL PURPOSE POOL ❑ NAME OF POOL l '1 _ ADDRESS — OWNER ADDRESS DATE OF �� POOL CAPACITY 0 INSPECTED BY INSPECTION # OF GALS METHOD OF WATER L 4 .r a BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT c, c�, z LOAD 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 "✓' are satisfactory. I REGULATION X/✓ VIOLATIONS/COMMENTS I ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching w/ latch 4 ft above ground. .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter E uent flow meter reading: 'IO gpm. # of turnovers L. r .06 Suitable automatic equipment for disinfection of pool water. .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 the use of 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, 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 v\cay.v�A ,08 Special purpose pool and wading pools equipped emergency shut off pump switch. Accessible and prominently marked. .09 Cross connections. Portable water supplied through air gap. .10 Skimming facilities. 50% of recirculation 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 pool floor and walls. Step edges marked with contrasting color. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. .15 Diving equipment in safe condition. 17 Pool supervision - Pool supervision provided. Effective Jan. 1, 1999, pool supervisor certified as pool operator 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 purpose pools. .23 Lifeguards required: Yes ❑ No Ek If lifeguards required. Proper credentials, roper suits and garments worn. Whistle and bullhorn provided .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. .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 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 - k V\A 'P1 c 8-Q 1�, W. 5 o-p- Vv C'i _ c2.5cs-e '<. • w"'« v.s'\1j It C� a<<e2'C \Vwt \�\ V,JL POOLSIDE READINGS Bromine Total Chlorine 51=¢5 Free Chlorine `',r a. C> Cyanuric Acid (30-100 ppzn) Comb. �x . Chlorine Water Temp. pH level = QPV' 8LM ; 1 • a * parts per million Other .29 Pool water tested with appropriate frequency. .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools. .31 Water clarity .32 Water clarity maintenance. Filtration system operating continuously. .32 Special purpose pool drained, cleaned and every 14 days. 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 .38 General sanitation REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE GCS V a e w✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED SIGNE • Operator Board of Health/Health Department