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HomeMy WebLinkAboutMansfield Meadows 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: 7 PERMIT EXPIRES: December 31, 2018 Person Certified: SVETOSLAV A. KAZAKOV Pool/SPA Certification Date: March 10, 2017 Pool/SPA Certification Expires: March 10, 2022 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 MEADOWS (BEACON PROPERTIES) for the operation of a El Public V Semi -Public f I Special Purpose Pool located at. 12 BONNEY LANE #9 Method of water treatment is CHLORINE TABLETS Bathing load not to exceed: 51 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan-PaCmer, HeaCth Agent Date Issued X�j•1GJr- r'��g1FC/ 5 Town of Mansfield - Board of Health N o �prF�AS A Swimming Pool Application NAME OF OWNER: MansF1'f.AMmdvL s (3e(v0r i'PWkPL+I�9) ADDRESS: I'l gDi111ty f. Nl) 2 if q CITY: ML��I�1d J STATE:MA ZIP: (y2fi b TELEPHONE:�5O�)3 �i_n55I FAX: I EMAIL: svuattwuv(P FED IDISS NO: 52 _ 2.01-pq Cn- u Certification Expires Every 5 Years, Permit Expires December 31st Yearly. PERSON CERTIFIED: BVOIDS 1f,v i:a.7.. kov Pool/SPA Certification Date: MCI r Ch I o 12U 1`( Pool/SPA Certification Expires: Marro 10).202-'1 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER "i FEE: $125 ❑�� /Public POOLOPERATION: ❑V Semi -Public Special Purpose Pool POOL LOCATION: 19 -Bonne 1 min, 10 TYPEIPOOL: IvA l n LENGTH: I{(1' VOLUME: 254 000001 MINIMAX DEPTH: -'-8/ SWIM AREA: 4If0 WATER SOURCE: -IoVYN WIW DISPOSAL: iOW(V TYPE OF FINISH: PAINI SCUM GUTTER: N/A DECKTYPE: C'pNeWde) SKMMR WEIR LENGTH: P) t I TREATMENT SYSTEM: Is WIDTH: �2 DIVE AREA: N/A DISINFECT METHOD: Ch i0i211716 70tb1Q1S CHEMICAL TREATMENT: I" 1.220 Feede v - NUMBER OF BATHERS: 6 ( f� '^ SIGNATURE. f ; (,Ar(P ? COAMOC'AJ710001-S DATE: Please make propriate 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. 04/30/2018 MON 11:59 FAX 1 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. Mo signature or mciviouei or Corporate Name (Mandatory) By; Corporate Officer (Mandatory, If applicable) 62- 2,0000 ** Social Security Number (Voluntary) or Federal identification Number * This license will not be issued unless the cerfillcation alsuse is signed by the applicant. ** Your Soclal Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax tiling or tax payment obligations. Licensees who fall to correct their non -filing or delinquency will be suWeot to license suspension or rovooatlon. This request Is made under the authority of Mass, General Laws, Chapter 62C, Section 40A. 0002/002 ' The Contmonipealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 wiminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibly Business/Organization Name: , i 8711)(J)MMy� S Address: M5 -/-)V �-ity/State/Zip: 0 Phone #: NO WP- % 0 d 0 re yo an employer? Check he appropriate box: Business Type (required): I am a employer with �v 1 employees (full and/ 5. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment F] I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $- ❑ Non-profit ❑ We are a corporation and its officers have exercised 4. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑Health Care El We are a non-profit organization, staffed by volunteers, p with no employees. [No workers' comp. insurance req.] 12.0 Other N ()V{%71 fd y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. the corporate officers have exempted themselves, but the corporation bas other employees, a workers' compensation policy is requimd and such an rization should check box #1. r an entployer that ispro^iding workers' compensation insurance for my employees. Below is the policy inforinadon. ranee Company rer's /State/Zip: ;y # or Self -ins. Lie. # l/' lt%/ �11 � Expiration Date- ch a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ire to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ;ligations of the DIA for insurance coverage verification. &ereby certify, underpains and penalties ofperjuty that the information provided above is true and correct ficial use only. Do not write in this area, to be completed by city or town official ty or Town: Permit/License # wing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Other mart Person: Phone acoRO® CERTIFICATE OF LIABILITY INSURANCE `,.,i DA E(MMIDD YYYY) 1/12/2018 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(tes) must 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 Alliant Insurance Services, Inc. 2415 East Camelback Rd Suite 420 CONTACT NAME: PHONESao. 602-707-1900 FAc No, 480-333-6973 E-MAIL INSURERS AFFORDING COVERAGE NAIC# Phoenix AZ 85016-4266 wsURERA,Liberty Mutual Fire Ins. Co. 23035 100001724608 INSURED INSURER B :Liberty Surplus Insurance Corp10725 INSURER C:AXIS Surplus Insurance Company 26620 Continental Pools, LLC 8520 Corridor Rd., #B Savage, MD 20763 INSURERD:First Mercury Insurance Company 10657 INSURER E:Navigators Insurance Company 42307 INSURERF:Oh10 Casualty Insurance Company 24074 COVERAGES CERTIFICATE NUMBER: 1671569023 REVISION NUMBER: 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 LTR rypE OFWDDQSM INSD WD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/OD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY 100001724608 10/25/2017 10/25/2018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 POLICY a JF"f1XI LOC PRODUCTS - COMP/OP AGG $2,000,000 Policy Aggregate $$10,000,000 OTHER: A AUTOMOBILE LIABILITY AS2661066678027 10/25/2017 70/25/2018 CO BINEDt SINGLE LIMIT $1000,OOD BODILY I NJURY(Par person) $ X ANY AUTO ALL OWNED SSUIHEEDULED OS BODILY INJURY (Per accident) $ NON -OWNED X HIRED AUTOS X AUTOS OPERT M GE $ Per accident) C UMBRELLq LIAB X OCCUR ELU790250012017 10/25/2017 10/25/2018 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 X EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y� WA766DO66678017 10/25/2017 10/25/2018--' SPER TATUTE ORH X 1 E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED9 (Mandatory In NH) N/A E.L. DISEASE - EA EMPLOYEE]$1,000,000 E.L. DISEASE -POLICY LIMIT 1 $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D E F Excess GUEL Excess Auto Excess over D & E NJEXDDDDD5872903 SF17EXC7048301V ECO1856322216 10/25/2017 10/25/2017 10/25/2017 10/25/2018 10/25/2018 10/25/2018 Each OcdAggregate $10,000,000 Each Occ/Aggregate $10,000,000 Each Occ/Aggregete $10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space is required) EXCESS LIABILITY OVER "F" Indian Harbor Insurance Co NAIC#36940 Policy#SXS0050794 10/25/17-10/25/18 Each Occ/Aggregate $15,000,000 CERTIFICATE HOLDER CANCELLATION © 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Continental Pools ACCORDANCE WITH THE POLICY PROVISIONS. 8520 Corridor Rd. Suite B Savage MD 20763 AUTHORIZED RE © 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 a 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 NAME OF POOL �(\\��5 �AwS SWIMMING POOL INSPECTION REPORT c coves \ =u N a.s TVPF C)P PO OTr PT TRT TC r1 SFMT-PTIRTTC IIA SPFCTAT. PT TRPn FPn(1T. (1 NAME OF POOL �(\\��5 �AwS ADDRESS OWNER c coves \ =u N a.s ADDRESS DATE OF INSPECTION POOL CAPACITYINSPECTED # OF GALS �jCo�C�O BY T r� �\ METHOD OF WATER TREATMENT _ BATHER LOAD C7� \pv # OF LIFEGUARDS WATER SOURCE: 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. REGULATION X/✓ VIOLATIONS/COMMENTS ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching w/ latch 4 It above ground. .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter Effluent Flow meter reading: 11 I gpm. # of turnovers j If 3�,� .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 i .08 Special purpose pool and wading pools equipped with 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 purpo a pools. .23 Lifeguards required: Yes �y No E]If lifeguards required. Propedcr`edentials, proper 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 l -\'CA ✓I �e5� V/ N, V\vv\2--i Bromine 1.72:0-6.0 onm*i 1 I Total Chlorine I , .. . .. ,,wsJ Cyanuric Acid(30 100 ppm) Comb. (0 0 `0 Chlorine. Water Temp. 1(iA°F .e ,. , ., . ,I I pH level IA .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 w✓ 34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNEDSIGN 1� 1 Y�-ii : " ,rir✓�.� 0 r Board of H Ith/Health Department