HomeMy WebLinkAboutMansfield Children's Center 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: 8
PERMIT EXPIRES: December 31, 2018
Person Certified: KEVIN J. FALLON
Pool/SPA Certification Date: April 16, 2014
Pool/SPA Certification Expires: April 16, 2019
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.
MANSFIELD CHILDREN'S CENTER
for the operation of a Public [I Semi -Public Special Purpose Pool
located at.
1100 SCHOOL STREET
Method of water treatment is CHLORINE
Bathing load not to exceed: 43 bathers
Number of Lifeguards required at all times the pool is open is:
"NO LIFEGUARD ON DUTY" sign is required.
Amy Donovan-PaCmer, Weaah Agent
None
'j" .fit ,'Jl
Date Issued
Town of Mansfield
Town of Mansfield - Board:of ffealth 6,Park Row
,yg( Mansfield, MA 02048
3
Swimming Pool Application .__._.__ __ PERMIT NUMBER 8
FEE: $125
NAME OF OWNER: MANSFIELD CHILDREN'S CENTER
ADDRESS: 1100 SCHOOL STREET
CITY: MANSFIELD
STATE: MA ZIP: 02048
TELEPHONE: (508) 339-9211
FAX:
EMAIL:
FED ID/SS NO: 04-2726454
Certification Expires Every 5 Years.
Permit Expires December 31st Yearl
PERSON CERTIFIED: KEVIN J. FALLON
Pool/SPA Certification Date: 4/16/2014
Pool/SPA Certification Expires: 4/16/2019
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS: "NO LIFEGUARD ON DUTY" sign is required.
7 Public
POOL OPERATION: 1yl Semi -Public
1 Special Purpose Pool
POOL LOCATION: 1100 SCHOOL STREET
TYPE/POOL: SEMI-PUBLIC
LENGTH: 41'
VOLUME: 30,000
MIN/MAX DEPTH: 3'
SWIM AREA: 1000sf
WATER SOURCE: TOWN
WAN DISPOSAL: PRIVATE
TYPE OF FINISH: LINER
SCUM GUTTER:
DECK TYPE: 5' CEMENT
WIDTH: 25'
SKMMR WEIR LENGTH: 2 SKIMMERS
DIVE AREA: NONE
TREATMENT SYSTEM: DIATOMACIOUS EARTH
DISINFECT METHOD: CHLORINE
CHEMICAL TREATMENT:
NUMBER OF BATHERS: 43
SIGNATURE: 9 DATE: %//fL // 7
Please make appropriatech es. 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.
ignatur , f Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
D!Y;k- -- 7,9 �' - �/
*'Social Security No. (Voluntary) or Federal
Identi 'cation 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 offndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PER&UTTING AUTHORITY.
Applicant Information Please Print LedblY
� Business/Organization Name: ."A',ov t4 1,; aaL ye, —
Address: a d 0 Y",/, c� q, 5tt—
City/State/Zip: Phone #: S'D
Are yonjaa,empioyer? Check the appropriate box:
Business Type (required):
1. r I am a employer with employees (full and/
5. ❑ Retail
orpart-time).*
6. Restaurant/Bar/SatingEstablishment
2.0 1 am a sole proprietor or partnership and have no
?, Q Office and/or Sales (incl. real estate, auto, etc.)
employees workingfor me in any capacity.
B. on -profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
9, ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10, ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
l I.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information,
**If the emporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
Policy # or Self -ins. Lie. # - 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage y;4ficatign,
I do hereby certify,
6X_— v -779 -
that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town offieiaL
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
Contact Person: Phon
www.msss.govhha
Hue
EMPLOYEES
NOTICE
M
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above -mentioned chapter by
insuring with:
Utica Mutual Insurance Company
NAME OF INSURANCE COMPANY
201 Edgewater Place, Suite 295 Wakefield, MA 01880
ADDRESS OF INSURANCE COMPANY
2066058 10-07-2017 10-07-2018
POLICY NUMBER EFFECTIVE DATES
Wm. F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 781-293-6331
NAME OF INSURANCE AGENT ADDRESS PHONE #
MANSFIELD CHILDREN'S CEN 1100 SCHOOL STREET MANSFIELD MA 02048
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work"related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
WC 7506h (8-10) Wolters Kluwer Financial Services I Uniform Forms TM
C Rev. 6/09
Form ST-5 , Massachusetts
`r Sales Tax Exempt Department of
Purchaser Certificate Revenue
Part 1. Exempt taxpayer information. To be completed by exempt government or501(c)(3) organization
Name
H. Read Inc. /dba/ Mansfield Children's Center
Address
1100 School St.
City State Zi
Mansfield MA 01048
Exemption number
042-725-454
Issue date Date of expiration of certificate
7/29/16 7/28/26
Certification is hereby made that the organization named above is an exempt purchaser under Massachusetts General Laws, Chapter 64H, sections 6(d)
or 6(e). All purchases of tangible personal property or services by this organization are exempt from taxation under said chapter to the extent that such
property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or
any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation.
Signature Title Date
Willful misuse
one) In fines.
certificate may result in criminal tax evasion sanctions of up to one year In prison and $10,000 ($50,000 for
Part 2. Agent information. To be completed by agent of exempt government or 501(c)(3) organization.
Name of agent's organization
Address
city State Zip
Agent's name
Address
city Stale Zip
I certify that in making this purchase, I am acting as an agent for the exempt organization named above (select one):
❑ Government organization (local public school, city/town government, state agency, etc.).
Attach Form ST-2, if available. If Form ST-2 is not available, enter exemption number, if known:
❑ 501(c)(3) organization (parochial school, Scout troop, etc.). Form ST-2 must be attached.
Signature Title Date
Part 3. Vendor information
Vendor's name
Check applicable box:
❑ Single purchase certificate (attach detailed receipts or complete Part 4, on reverse)
❑ Blanket certificate
This form Is approved by the Commissioner of Revenue and may be reproduced.
NIASSACHUSETTS DEPARTMENT OF REVENUE
H READ INC
1100 SCHOOL ST
MANSFIELD MA 02048-2036
Certificate of Exemption
MA TaxpayerlD: 11720038
Certificate Number: 2039861248
Form ST-2
This certifies that the organization named above is an exempt purchaser under Chapter 64H, section 6(d) or (e) of the
Massachusetts General Laws. Alt purchases of tangible personal property by this organization are exempt from taxation to the
extent that such property is used in the conduct of the business of the purchaser. Misuse of this certificate by any tax-exempt
organization or unauthorized use of this certificate by any individual will lead to revocation. Willful misuse of this certificate is
subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. This certificate is non-
transferable and may be suspended or revoked for failure to comply with state laws and regulations.
Effective Date: July 29, 2016 Expiration Date: July 28, 2026
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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
or roof: uruoue utoeml-ruouc
/A^ddress of Pool:
C-0
WATER QUALITY
Water Test Results (Taylor DPD Test Kit # K-2006)
u�,pecial rurpose
Inspection Date:
u�-03,t8
kbca.vvn
Testing Times :
Initial:
Additional: Location:
Ailowable Range,
(ItA Itcable)�
. IfNecessa)
Chemical Test ',
m
).'.
swimmiu"Wank
g,g,
�(PP
swimming Pool '
WadingPoof,
Pool - .'
'Pool ,
Free Cblorme
1.0-3.0
�'
k used as a` inteetaat ...
Combined
�:Chloriue-
0.0-0.2
O •O
„pH'�
7.2-7.8
,
Alltolinity;
50-150
V �j
`GaietdmHardness,
150-1000
Recommended
Cyanuric Acid ; ;
30-100
(if asad),
Bromine
2.0-6.0
(used 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)
Testing Time(s): Tnitial: Additional:
Lneatinn:
Yisibility,Test ;
Initial Test Result
(IfA.Iicable)
Acceptable Test Result?
Additional Test Results
fNa6essaty)
Swimming Pool
�u
Secchi Disk
Wading Pool
-Aaaatonat resting was conauctea to evaluate me eaeetiveness or corrective actions taken to acmeve compliance wun me water Clarity standards requtrea.
435-Inspector Field Notes Page 1
435-Inspector Field Notes Page 3
`?= 03 , i " zl ✓ Bathhouse and sanitary facilities adequate lighting; ventilation; sanitary condition I
(` 03", - _ j LAdequate enclosure around pool; Gate self -latching w/ latch 4 ft above ground I
Water circulation & filtration systems: Filter Effluent flow meter
Suitable automatic equipment for pH control adequate; CO2 cylinders anchored. Inaccessible to
public, adequate ventilation provided
Inlets and outlets: Inlets located to produce uniform circulation; Over rim fill spout 6" above
08 ; maximum water level; Properly shielded and located
Main drain suction outlets covered with suitable protective covers and grates. Cannot be removed
08 without the use of tools; Open area does not provide entrapment of fingers, toes etc; At least one
antivortex drain provided. 4,L Yo\oe
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 ..
to Iq
tools. Close pool immediately if outlet covers missing, broken, loose or can be removed
without tools until repair can be made.
08
AA
Special purposepools a d wading pool equipped with emergency shut off pump switch; Accessible
Q9 :'
Cross connections: Potable water supplied through air gap
10; ,
Skimming facilities: 50% of recirculation drawn from surface of pooh
Line with floats separates non -swimmer area from deeper water; Water depth markings on deck
12
and walls; Properly spaced; Boundary line on pool floor and walls; Step edges marked with
contrasting color
I Walkways and decks 4 ft wide, safe condition I
75 ft; Not less than 2 ladders
X H S Diving equipment in safe condition
17 ool supervision: Pool supervision provided
Effective Jan. 1' 1999: Pool Supervision Certified as Operator from YMCA or NSPF
,Permit Requirements: Permit Issued; Adequate maintenance and testing records
Records initialed by person making tests
Health Regulations: Signsposted; Health warning s
Lifeguard required: es ❑ No If lifeguard
garment worn: Whistle and bullhorn Drovided
proper suits, and
24 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
25 device in unlocked area and available at all times to staff and the public; Operating instructions and
- emergencv numbers posted co lab �s$
26 rite and backwash water disposal properly discharged; No direct connection to sewer system;
Separation tank provided for diatomaceous earth filter backwash water
29 ✓ heroical Standards
29 ..-. Pool water tested with appropriate frequency
an. Water testing equipment; DPD kit provided for chlorine and bromine; Unbreakable thermometer
I 31/32, ±: , - I ./I Water Clarity; Water Clarity Maintenance: Filtration system operating continuously 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
5. Backwash the filter thoroughly. Be sure the effluent is discharged directly to waste and
in accordance with state or local regulations. Do not return the backwash through the filter.
Where appropriate, replace the filter media.
6. Swimmers may be allowed into the pool after 8 hours and when the free
available chlorine level has been returned to the normal operating range, (1.0-3.0 ppm). Maintain
the free available chlorine concentration and pH (7.2-7.8) at standard operating levels. If
necessary, consult state or local regulatory authorities for recommendations on bringing the free
available chlorine levels back to an acceptable operating range.
7. See A5.
M. Vomit and Blood Incident Procedures in Swimming Pools
A. Vomit
Vomiting while swimming is frequently due to swallowing too much water and is
probably not infectious. It is possible for Noroviruses, also known as Norwalk -like viruses, to be
spread by vomit; therefore if the entire stomach contents are vomited, respond to the vomit
incident as you would the "Formed Stool" procedure above. The procedure is:
1. Direct everyone to leave all pools into which water containing the vomit is circulated.
Do not allow anyone to enter the contaminated pool(s) until all decontamination procedures are
completed.
2. Remove as much of the vomit material as possible using a net or scoop and dispose of
it in a sanitary manner. Clean and disinfect the net or scoop (e.g., after cleaning, leave the net or
scoop immersed in the pool during disinfection). Vacuuming stool from the pool is not
recommended*.
3, Raise the free available chlorine concentration to 2 ppm (mg!(,), pH 7.2-7.5, if it is
<2.0 ppm (mg/L). Ensure this concentration is found throughout all co•eirculating pools by
sampling at least three widely spaced locations away from return water outlets. This free
available chlorine concentration was selected to keep the pool closure time to approximately 30
minutes..,
4Maintain the free available chlorine concentration at 2.0 ppm (mg/L), pH 7.2-7.5, for
at least 25niinutes before reopening the pool. In the presence of chlorine stabilizers such as
chlorinated isocyanurates, a level of 3.0 ppm (mg/L) of fiee available chlorine must be achieved.
Ensure that the filtration system is operating while the pool reaches and maintains the proper free
available chlorine concentration during the disinfection process.
5. Establish a vomit accident log. Document each vomit accident by recording date and
time of the event, free available chlorine concentration at the time or observation of the event
and before opening the pool, the pH, the procedures followed to respond to the vomit accident
(including the process used to increase free chlorine residual if necessary), and the contact time.
B. Blood
Disease -causing organisms found in blood (e.g., Hepatitis B virus or HIV) are spread
only through activities that involve the exchange of infected bodily fluids, such as, in sexual
contact and sharing needles with an infected individual. According to the CDC, that agency is
not aware of any of these organisms being transmitted to swimmers from a blood spill in a pool;
therefore, there is no recommended procedure to be followed after a blood spill in a swimming
pool. As a matter of comfort, the pool operator may choose to close the pool temporarily to
satisfy patrons.
* No uniform recommendations for disinfection of vacuum systems are available. However, if a
vacuum system is accidentally used, the waste should be discharged directly to a sewer or other
approved waste disposal system and not through the filtration system. The dilution effect of the
pool water going through the hose may reduce the risk for high-level contamination of the
vacuum system.
¶ Many conventional.test kits cannot measure free available chlorine levels this high. Use
chlorine test strips that can measure free available chlorine in a range that includes 20mg1L (such.
as those used in the food industry) or make dilutions for use in a standard DPD (N, N-diethyl- p-
phenylenediamine) test'kit using chlorine -free water.
June30,2003
1
The Commonwealth of Massachusetts
Executive Office, of Health .and Human Services .
Department of Public Health
Division_of Community Sanitation
305 South Street, Jamaica Plain, -MA 02130-3597
MITT ROMNEY
GOVERNOR
(617) 983-6761--(617) 983-6770 - Fax
KERRY HEAIEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
CHRISTINE C. FERGUSON
-
COMMISSIONER
.
�Fecal;.Vomit and Blood Irtcidents in Swimming Pools
l.` FECAI Y vCIDENT PREVENTION IN SWMMMG POOLS
Although the actual health and safety risks associated with fecal accidents are considered to be
minimal, provided that proper pool chemical levels are maintained, fecal incidents do pose a
significant interruption in pool operations. As such, prevention of fecal incidents should be
stressed. The following preventative measures shall be implemented at all pools:
A. Patrons must be directed to take a cleansing shower before entering the pool.
B. Do not permit diaper changing at poolside.. Do not allow young children to be
"dipped" or rinsed off in the pool as part of the diaper -changing process.
C. Patrons who are ill or have suffered from diarrhea within the previous two (2)
weeks should be denied admittance into the water. It has been shown that persons
with cryptosporidiosis continue to shed crypto oocysts (the infectious form of the
organism) in their stool for 2 weeks after their diarrhea has ended and can
therefore infect others.
D. All persons wearing diapers, or who would be of diaper -wearing age (e.g. infants
and toddlers), should wear swimsuit diapers or tight -fitting rubber or plastic pants
which will contain fecal matter and prevent it from entering the pool.
E. Do not allow pets in the pool area. See 304 CMR 12.08.
F. Maintain the chemical feed equipment and chemicals at optimal levels. This
includes maintaining the disinfectant levels (residual'chlorine levels between 2.0
and 3.0 ppm); optimal pH (7.4-7.6); alkalinity (80-120 ppm); and calcium
hardness (200-400 ppm). Note: Lack ofproper pH can greatly affect disinfection
effectiveness in chlorinated pools.
H. FECAL INCIDENT PROCEDURE IN SwBoMG PooLs
There is a concern regarding the potential transmission of cryptosporidium parvum (a parasite
excreted in the feces of infected humans and other mammals) and escherichia coli 0137:H7 (a
harmful strain of coliform bacteria living in the digestive tracts of humans and other animals).
Most organisms found in properly chlorinated pool water, including E.coli 0157:H7, are killed
very quickly. In fact, usually only a few seconds of disinfection are needed to kill 99.9% of
these organisms. Those organisms that are more resistant to disinfection, such as cryptosporidia,
are typically introduced into pool water via very watery diarrhea. This is seldom noticed or
reported. Thus, solid stool is unlikely to contain cryptosporidia. This knowledge thus requires a
two -pronged approach to managing a fecal incident.
(The following information was adapted from "Responding to Fecal Accidents in Disinfected
Swimming Venues. " Morbidity and Mortality Weekly Report, May 25, 2001,Centers for Disease
Control and Prevention bgp://www.cdc.goy/mmwr/ydVwk/mm502O.pdp
A. Formed stool (solid, nonliquid)
1. Direct everyone to leave all pools into which water containing the feces is circulated.
Do not allow anyone to enter the contaminated pool(s) until all decontamination procedures are
completed. Z
2. Remove as much of the fecal material as possible using a net or scoop and dispose of it
in a sanitary manner. Clean and disinfect the net or scoop (e.g., after cleaning, leave the net or
scoop immersed in the pool during disinfection). Vacuuming stool from the pool is not
recommended*.
3. Raise the free available chlorine concentration to 2 ppm (mg/L), pH 7.2 7.5, if it is
f2.0 ppm. (mg/L).. Ensure this concentration is found throughout all co -circulating pools by
sampling at least three widely spaced locations away from return water outlets. This free
available chlorine concentration was selected to keep the pool closure time to approximately 30
minutes.
4. Maintain the free available chlorine concentration at 2.0 ppm (mg/L), pH 7.2-7.5, for
at least 25 minutes before reopening the pool. In the presence of chlorine stabilizers such as
chlorinated isocyanurates, a level of 3.0 ppm (mg/L): of free -available chlorine must.be achieved.
Ensure that the filtration system is operating • while the pool reaches and maintains the proper free
available chlorine concentration during the.disinfection process.
5: Establish a fecal accident log. Document each fecal:accident byrecording :date and
time
-ofthe event; formed stool-or=diarrhea; free -available chlorine -concentration -at-the. time or
observation of the event and before opening the pool, the pH, the procedures followed to respond
to the fecal accident (including the process used to increase free chlorine residual if necessary),
and the contact time.
B. Diarrhea (liquid stool)
1. See Al.
2. See A2.
3. Raise the free available chlorine concentration to 20 ppm (mg/L) I and maintain the pH
between 7.2 and 7.5. Ensure this concentration is found throughout all co -circulating pools by
sampling at least three widely spaced locations away from return water outlets. This chlorine and
pH level should be sufficient to inactivate Cryptosporidium and should be maintained for at least
8 hours (one turnover for a standard pool). If necessary, consult an aquatics professional to
determine and identify the feasibility, practical methods, and safety considerations before
attempting the hyperchlorination of any pool.
4. Ensure that the filtration system is operating while the pool reaches and maintains the
proper free available chlorine concentration during disinfection,