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HomeMy WebLinkAboutWest Village 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: 18 PERMIT EXPIRES: December 31, 2018 Person Certified: DARKO STANKOVIC Pool/SPA Certification Date: October 20, 2017 Pool/SPA Certification Expires: October 20, 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: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a i I Public [I Semi -Public I I Special Purpose Pool located at: 792 WEST STREET Method of water treatment is CHLORINATORISAND FILTER Bathing load not to exceed. 8-10 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 l Date Issued Town of Mansfield Town ofMansfield - Board of Health 6 Park Row Mansfield, MA 02048 ,Swimming Pool Application PERMIT NUMBER 18 FEE: $125 NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIAN E.THOMPSON@MONOGRAMRES.COM FED ID/SS NO: 45-1501972 Certification Expires Evert/ 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 3/15/2017 Pool/SPA Certification Expires: 3/15/2022 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 is required. ❑ Public POOL OPERATION: ❑ Semi -Public ❑O Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL: SPA/HOTTUB LENGTH: N/A WIDTH: N/A VOLUME: 1500 GAL. MIN/MAX DEPTH: 3.5 FT. SWIM AREA: N/A DIVE AREA: N/A WATERSOURCE: 'TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINATOR/SAND FILTER CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 8-10 SIGNATURE:r_ALv%-A DATE: a � Imo, 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. Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 16 PERMIT EXPIRES: December 31, 2018 Town of Mansfield 6 Park Row Mansfield, MA 02048 Person Certified., DARKO STANKOVIC Pool/SPA Certification Date: October 20, 2017 Pool/SPA Certification Expires: October 20, 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: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a [ ] Public L7 Semi -Public [] Special Purpose Pool located at: 792 WEST STREET Method of water treatment is CHLORINE/CHLORINATOR RAINBOW 300 Bathing load not to exceed: 93 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan -Palmer, Aealth Agent D to Issued n Town of Mansfield - Board of Health SAP�}�n4�f e cl. Town of Mansfield 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 16 FEE: $125 ❑ Public NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE POOL OPERATION: S6 Semi -Public REIT ❑ Special Purpose Pool ADDRESS: 792 WEST STREET POOL LOCATION: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TYPE/POOL: GUNITE SEMI-PUBLIC TELEPHONE: (508) 261-0500 LENGTH: 56' WIDTH: 25' FAX: (508) 261-0501 VOLUME: 42,000 GALLONS EMAIL: DIANE.THOMPSON@MONOGRAMRES,COM MINIMAX DEPTH: 4 ft. FED ID/SS NO: 45-1501972 SWIM AREA: 1,400 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN Certification Expires Every 5 Years. W/W DISPOSAL: TOWN SEWER Permit Expires December 31St Yearly. TYPE OF FINISH: PLASTER PERSON CERTIFIED: HANSEL RIVERA SCUM GUTTER: N/A Pool/SPA Certification Date: 3/15/2017 DECK TYPE: CONCRETE Pool/SPA Certification Expires: 3/15/2022 SKMMR WEIR LENGTH: 8" PERSON CERTIFIED: TREATMENT SYSTEM: ':ASTRAL SAND FILTER PoolISPA Certification Date: DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 Pool/SPA Certification Expires: CHEMICAL TREATMENT: CHLORINE certification remarks(if necessary): NUMBER OF BATHERS: 93 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: DATE: _aI i 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 02045. 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. C SUil lane, W01'VOty, Signature of Individual or orporate Name By: Corporate Officer (Mandaton), if Applicable) **Social Security No. (Voluntary) 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Depar•tmerrt of Indusir•ialAccidents It) Office of Investigations600 Ifashingtorr Street Boston, MA 02111 IMMnnrss.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_HLgf1 S1erra_P-oDls,_tnc.__— ... Address:_....-.._ ----- ---..2704 Columbia Pike City/State/Zip: Phone #: 703-A20-1750 Arc you an employer? Cheek the appropriate box: Business Type (required): I. ❑ I an a employer with employees (full and/ 5. ❑ Retail or part-time).'" 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no q• E] Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3J2 Weare a corporation aid its officers have exercised 9, ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* t I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, [No workers' comp. insurance req.] 12.® OtherPool-Management-and Maintenance *Any applicant shat cheeks box tl l must also til l out are wetiou belowshowing their workars' cmnpatsation policy information. *°lithe corporate officers have exempted themselves, but the cogtoralion has other cmployces, a workers` compaisalion policy is required and such an a'g+mizatim shmuld check box 10. I mar as emphirer that A providing Ivor kers' compensation insuroneeJor mp ernplglees. !Below is the police bfororation. insurance Company Name:__-_ HMS Insurance Associates,IIIC Dnsurer's Address: City/SC.tte%zip: --- E(un��l�l1�y,�D,?19�Q_ Policy # or Self -ins. Lie. it 30WELJ4825 Expiration Date: 03/01!2019 Attach a copy of the wormers' compensation policy declaration page (showing the policy number and expiration (late). Failure to secure coverage as required under Section 25A of MGI, c. 152 can lead to the imposition of eriminal penalties ol'a fine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of to STOP WORK ORDER and a foe 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 verification_ 1 run IrereLr cern/i',auler tly pairr,> onel peuntties r f peijuq that the informadou provided above is tare and correct. Slgnattac: _pk w�L��7) Date: 03/21/2018 Phone it__ -_.___61 2514-0550 Official use mall. Do not write in this area, to he completed b,P city or toafficinI 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: Phone #: wNew.mass.@avldin MHANWARlYpoomoducts A Hayward Industries, Inc. Company CERTIFICATION OF COMPLIANCE I Hayward Industrial Drip Clemmons, NC 27012 336-712-9900 www,haywardnet,com Contains: WG1048E Description: 8" Round Suction Outlet Cover Ratings: Floor: 125 GPM Wall: 72 GPM Open Area: 8.1 s4 -in Certified to Comply with Section 1404 of the Virginia Graeme Balser Act (VGB) Pool & Spa Safety Act Test Results can be obtained fi•om:wwvv.Haywardnet.coin and/or htt ://www_nsfo ,/Certified/Pools/ Manufactured: Between October 2008 and December 2008, by Hayward Pool Products in Jiangsu Province, China and Clernmons, NC Divisions of Hayward Industries, Inc. 620 Division Street, Elizabeth, NJ 07207, Phone 908-355-7995 Date of Mfr: The Lot Number shown on the product label contains the Year & Month of manufacture. The fust number represents the year (ex 8 = 2008) and the second character the month (A=Jan, B=Feb, H=Aug, I is skipped, J=Sep, etc) Tested to ANSI/ASME 112.19.8-2007 (addendum 8a-2008) per Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act. Certified by NSF International, 789 N. Dixboro, Road, Ann Arbor, MI. 48105 1(800) -NSF -MARK. Date of Installation: - C'1 - % I 6" SPACINGBETWEEN MOUNTING HOLES 0`7 3/4" SUCTION OUTLET' COVER'W G1 048E ISWGIO48COC USED ON FOLLOWING SERIES: WG1.030AV PAK2 WG1.048AV PAK2 WG1049AVPAK2 WG1051AVPAK2 WG1052AVPAK2 WG1053AVPAK2 WG1054AV PAK2 WG1153AVPAK2 WG1154AV PAK2 SP1030AVPAK2 S P1048 AV PA K2 SP1049AVPAK2 SP 1051 AV PAK2 SP1052AVPAK2 SP 1053AV PAK2 S P 1054AV PA K2 S P 1153 AV PAK2 SP1154AVPAK2 G' ")ILDLINe HAYWARUpool Product corrrnots One source. Every poo O.�. OLS HAYWARUpool Products A Hayward Industries, Inc. Company I Hayward Industrial DrIN Clemmons, NC 27012 336-712-9900 www.bywardnecCOM Contains: WG1048E Description: 8" Round Suction Outlet Cover Ratings: Floor: 125 GPM Wall: 72 GPM Open Area: 8.1 sg-ln Certified to Comply with Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act Test Results can be obtained fiom:_vww.Hav_wardnet.com and/or littli.//N,,,-,vw.iisf.org/Cellified/Pools/ Manufactured: Between October 2008 and December 2008, by Hayward Pool Products in Jiangsu Province, China and Clemmons, NC Divisions of Hayward Industries, Inc. 620 Division Street, Elizabeth, NJ 07207, Phone 908-355-7995 Date of Mfr: The Lot Number shown on the product label contains the Year & Month of manufacture. The fust number represents the year (ex 8 = 2008) and the second character the month (A=Jan, B=Feb, H=Aug, I is skipped, J=Sep, etc) Tested to ANSI/ASME 112.19.8-2007 (addendum 8a-2008) per Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act. Certified by NSF International, 789 N. Dixboro, Road, Ann Arbor, MI. 48105 1(800) -NSF -MARK. Date of Installation: '1 - \ 3 \ 9 6" SPACING BETWEEN MOUNTING HOLES 07 3/4" SUCTION OUTLET' COVER WGI048E ISWG1048COC USED ON, FOLLOWING; SERIES: S P'I030 AV PA K2 SP1048AVPAK2 S P 1049 AV PA K2 SP10S1 AV PAK2 SP]052AVPAK2 SP1053AVPAK2 S P°1054 AV PA K2' G�)LIDLINE HAMARKNoi Product CA i"A..d.~ One sou rce. Every poo nxawA.nxaou?auYt April 3, 2018 Dear Pool Operator, Town of Mansfield 6 Park Roo y, Man#ield, Alauachuseus 02048 Health Department Ani, Donoran-Palmer, tVTPH, RS Health Agent The pool season is quickly approaching. During inspections last year, several code requirements were often found absent. Before scheduling a pool inspection with the Health Department, please be sure that the following requirements are met. If an additional inspection is needed, it may take up to a week to reschedule. ❑ DPD test kit should be no more than one year old (435.30) ❑ A ring buoy and a rescue hook meeting standards are available (435.24) ❑ Emergency communication is in working order and is available to both the staff and the public at all times (435.25) ❑ Records of residual disinfectant four times a day are available for several days before the inspection, along with the alkalinity and calcium hardness results (435.29) ❑ Proper signage is on display (435.22) ❑ First aid kits are sufficiently packed (435.25) ❑ Water depth shall be plainly marked on the pool deck at the edge of the pool and on the vertical walls, at or above the water surface (435.11) ❑ Ledges and step edges shall be marked with a 4 inch stripe of contrasting color. The boundary line between the shallow and deep areas should be marked with a 4 inch stripe of contrasting color on the floor and walls of the pool. (435.11) This is only an abbreviated list of requirements which I have included to make the pool inspections move more smoothly. ALL Pool operators are required to meet ALL regulations as set forth in MA 105 CMR 435. Additionally, please submit a written policy on how the facility deals with fecal, vomit and blood incidents in swimming pools. If you have not sent documentation to the Health Dept proving that existing drain covers fulfill VGB Act requirements, please do so before scheduling an appointment. Please do not hesitate to contact me if I can be of any other assistance. Sincerely, J Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 fax- (508)269-7425 E'nzailadpalniei@lilanracldma.coni V ",W&L Laboratories $ Water Analysis + Iood/Scatood Analysis 8- Metals/Chemical Analysis + bllcrobiological Testing 246 Arlington Sttect, Quincy, MA 02170 Tel: (61 7) 328-3663 1 am (617) 172-0706 REPORT Lab. ID #: 84783 Report Date: 5/9/18 Total Pages: 2 Attn: Mr. Martin Pekarek High Sierra Pools Management 2704 Columbia Pike Arlington, VA 22204 Sample Received Date/Tune: 4/27/18, 10:50 AM Sample Received Temperature: N/A Sample Collected Date/Time: 4/27/18, 8:50 AM Sample Collected By: O.J. (Client) Sample Analyzed By: M -MA -1100 Sample Analyzed Date/Time: 4127/18,3:25 PM Sample Identification: Two (2) pool water samples labeled: 1) Pool 2) Spa Sampling Location: West Village, Mansfield, MA TEST RESULTS: Test Heterotrophic Plate Count Pseudomonas Aeruginosa MCL.: Masinmm Contaminant I..evel Mod: Modified Method ": Exceed MCL i': Analyzed by Sub. Partner 1;: Not in a scope or M -MA -I 100 Mass. Cert. No.: M -MA -1100 cc: Mansfield 13011 Unit #1 #2 CFU/mL < 1 < 1 CPU/IOOmL < 1 < I MCL Metbod Reference 200 SM 921513, 21" Ed, 2005 < 1 SM 9213E', 21" Ed, 2005 Report reviewed�. �9 and approved by: 1 �S' ti �F~ y:�� Lab. Director Signed Date Page I or I W a z C: — _ ___ _ — ____ Q O N ❑ Q ��CO 0 o O N } m w \�` z Zio z 'Ti "- N \ O u E o m d� \._\ �\ O m =0 ID 0 co z �D ®ErG (DW �°QCcL �N N C \ m LU a aC) wPro - -- — — T aNv�¢ w a 1 w wwLW w ui a (D awi � wLU m y Z Cr �"__ —~, s co WW a U U \W wU Q s w ` h y 41. w Lou �/� ,", o /'�•J anni - � '�; d h n� C1l \rt t `. .. z < o o 0 o T? LLIEL1 z \} m r 1 zo L o m ¢ w w ia- w z r=z1 d o O O- w w z w 2 0 a ❑ O w w 2 Laboratories i° Water Analysis + Food/Seafood Analysis 4- Metals/Chemical Analysis t Microbiological Testing 246 Arlington Street, Quincy, MA 02170 I'd: (61.7) 328-3663 Fax: (617) 472-0706 Lab. ID #: 84817 Attn: Mr. Martin Pekarek high Sierra Pools Management 2704 Columbia Pike Arlington, VA 22204 Sample Received Date/Time: 5/l/18, 10:40 AM Sample Received Temperature: N/A Sample Collected Date/Time: 5/1/18, 9:00 AM Sample Collected By: A.N. (Client) Sample Analyzed By: M -MA -1100 Sample Analyzed Date/Time: 5/1/18, 12:35 PM Sample Identification: Two (2) pool water samples labeled: 1) Pool 2) Spa Sampling Location: West Village, Mansfield, MA TEST RESULTS: Test Total Coliform MCL: Maximum Contaminant Level Mod: Modified Mcliod M: Exceed MCL t: Analyzed by Sub. Partnor 1:: Not in a scope oPM-MA-1100 Mass. Cert. No.: %I-bIA-1100 cc: Mansfield Bort Report Date: 5/9/18 Total Pages: 2 Unit 91 #2 MCL Metbotl Reference CFU/100mL Absent Absent Absent SM 922213, 21" Ed, 2005 Report reviewed and approved by: Lab. Director Signed Date Peoaa I or l r�- Q) r J z �,rI,1,11, m m 1 m w W � �L, wFN Ozac�> N N *\ a 5 U a (7 > a a z w O v d= w UJ o F R'QOJ=Naw H o W rSt. Q�}NNOt-oF Z + k J �- � U �,rI,1,11, m m 1 m w W � w W cn ao N N *\ a 5 a w z aaz z w -- — d= u a o F o H o a m k J W � U m m 3 Q u > �.,1..._ Q > 0 O w` W G� ¢ w �� uj I o Q N h U ¢ �,rI,1,11, m m 1 m w W � w W w W ao e 5 a w z aaz z w -- — o F o H o a m k J W � U m m 3 Q u > �.,1..._ Q > 0 O w` W uj w w ZP ui — -a O � Z O U z -Wi a a 'y v oa �,rI,1,11, m m 1 m w W � w W w W 5 z aaz z w � o F o H o m m m m 3 Q u > �.,1..._ Q > 0 O w` W w w �,rI,1,11, m m 1 m w W � w W w W 5 z aaz z w � z W 2 _d LL O a O X F- LU Identify yourself as a (e.g., unconscious child pulled from the water). • Explain the purpose of the call (e.g. need an ambulance or police). • Give the address of your location. • Answer questions addressed to you. • Do not hang up until EMS call -taker tells you to do so. 91TIMITITOTPUTMETFIF 911 should only be used when a true emergency exist: MEDICAL, POLICE, FIRE. DO NOT CALL 911 FOR NON -EMERGENCY situations. Using 911 line for private matters is inappropriate and strictly prohibited. • Activate the EAP: lifeguard blows three strong short whistle blasts and points to location of incident. He follows with one long blast and verbally yells to clear the pool immediately. • Lifeguard will direct nearest adult to call 911; and report back to guard when it is done. Same adult should be told to enter the management office and inform office to meet ambulance, unlock gates, etc., for access. • Lifeguard directs additional adult to clear the pool. Other adults may be directed to assist as needed to retrieve first aid kits, AED etc. • Provide the rescue — as per your training, follow best practices for in -water rescue. Remember: for a non -breathing victim, breathing is the priority. • Provide emergency care as needed until EMS arrives and releases guard. • Report, advice, release — lifeguard fills out an incident report immediately after the incident. Immediately notify your supervisor when 911 is summoned. LlHIGH SIERRA POOLS c'o 0 The Leader In Swimming Pool Mon age ment © 0 4 Contents Y 2. GENERAL FACILITY DATA AND POLICY STATEMENT .......... 3 A. Emergency numbers ................... . .. . . . . . ..... . .. 3 B. 911 Policies .......................................... 3 3. EMERGENCY PROCEDURES FOR CRITICAL INCIDENTS , .......4 A. Drowning emergency ...................... . . . . ..... . .. 4 B. Minor pull out of distressed or struggling swimmer .............. 5 C. Spinal management....................................5 D. Missing person ....................................... 6 E. Chemical emergency ................... . .. . . . . . ........ 7 F. Fire...............................................7 G. Weather emergency .......... . ........... . . . . . ..... . .. 8 4, EMERGENCY PROCEDURES FOR NON-CRITICAL INCIDENTS .... 8 A. Disorderly behavior .................................... 8 B. Minor slips and falls .................................... 8 C. Lack of water clarity ................................... 9 D. Dealing with blood, vomit, and feces ........................ 9 5. ADDITIONAL INFORMATION FOR ONE GUARD FACILITIES ..... 11 IHIGH SIERRA POOLS The Lender in Swimming Poo! Management • Equipment and facility check/corrective action — the deck area and locker rooms should be cleared and the access to the pool locked. The lifeguard will not reopen the pool without direction from High Sierra management. The lifeguard will remain on site until released by High Sierra Management. • Return to duty. • Activate EAP: lifeguard blows three strong short whistle blasts and points to location of incident. He follows with one long blast and verbally yells to clear the pool immediately. • Lifeguard directs additional adult to clear the pool. Other adults may be directed to assist as needed to retrieve backboard, first aid kits, AED or call 911 if needed, etc. • Provide the rescue — as per your training, follow best practices for in -water rescue. The guard should make the rescue with appropriate equipment. • Provide emergency care, if needed. • Report, advice, release — lifeguard fills out an incident report immediately after the incident. Immediately notify your supervisor when 911 is summoned. • Complete the forms thoroughly including signature, date, witness names and contact information. Do not make any statement of opinion to anyone other than High Sierra management. • Equipment and facility check/corrective action. • Return to duty. • Activate the EAP: lifeguard blows three strong short whistle blasts and points to location of incident. He follows with one long blast and verbally yells to clear the pool immediately. • Lifeguard will direct nearest adult to call 911; and report back to guard when it is done. Same adult should be told to enter the management office and inform office to meet ambulance, unlock gates, etc., for access. • Lifeguard directs additional adult to clear the pool. Other adults may be directed to assist as needed to retrieve first aid kits, AED etc. • Safely enter the water, using the slide -in entry. LIHIGH SIERRA POOLS o 5 The Leader in Swimming Pool Management G e EVACUATE THE POOL, POOL AREA and POOL HOUSE to a safe area. • Take the Safety Data Sheet with him/her to the evacuation safe area. • Call 911 and tell the call taker the nature of the emergency. • Administer First Aid to anyone showing signs or symptoms as described in the Material Safety Data Sheets. • Meet with Emergency Responders and Explain the Nature of the Emergency. • Notify supervisor and High Sierra Pools office AS SOON AS POSSIBLE. � • Large quantities of water should be applied to the burning combustibles to remove heat and fire intensity control. • Do not use dry chemical or halon -type fire extinguishers where chlorine gas may be involved. These agents can result in explosive reactions with chlorine. • When extinguishing a fire, only large volumes of water should be applied and the only by person trained in chemical fire response. • Once started, the reaction of wetted or mixed chlorinated pool chemicals may continue generating heat, unless the material is cooled below its reaction temperature or until all chlorine is used. F. Fire • Alarm sounds and lifeguard is alert (911 system is automatically activated) or lifeguard activates EAP. • EVACUATE THE POOL, POOL AREA and POOL HOUSE to a nearest emergency exit. • Take a copy of the Safety Data Sheet to the evacuation safe area. • Once at the assembly point, lifeguard will check all areas and patrons without putting himself in risk. • Administer First Aid to anyone in need. • Notify supervisor and High Sierra Pools office AS SOON AS POSSIBLE. • Call 911. HIGH SIERRA POOLS G � 0 0 o �7 The Leader In Swimming Pool Management Q Health Department requires that pool staff can clearly see the bottom of the pool. At all times a 4 inch puck should be clearly visible from all areas. Follow these procedures for questionable clarity: • The entire pool must be closed if the bottom drain cannot be seen. Notify supervisor and High Sierra office. Patrons may be allowed to remain on the deck depending on the facility protocol. A water test will be undertaken and pool equipment will be checked for correct functioning. Appropriate remedial action will be undertaken by trained staff only. In the event that blood, vomit or feces are discovered in the pool or on deck the following procedure is indicated. • All bathers must leave the pool immediately. • Disposable gloves must be worn. • Remove as much of the material as possible using scoop or net and dispose of the material using sanitary facilities. • For any time of Accidental Fecal Release (AFR), MANUALLY remove as much or the material as possible. If the AFR is formed, remove it from the pool without breaking it a part. It is less likely that Recreational Water Illnesses will spread if this action is taken in promptly. Use a scoop or net and dispose of the material using the sanitary facility. Vacuuming is not recommended, however if performed, vacuum the immediate area to waste. Clean the scoop and net and place them in the pool while disinfection procedure is completed. p9pleoren 09r, "M • Raise the free available chlorine to 3ppm (mg1L) and ensure the pH is between 7.2-7.5. • Maintain the free chlorine concentration for at least 60 minutes after the cleaning procedures conducted. • The filtration system must operate the entire disinfection time. Backwash the filter after the full disinfection time. The filter effluent should be directed to waste. HIGH SIERRA POOLS O The leader in Swimming Pool Management O ci 9 1 A11111 I 11Vr;AL—tnF11AtT1A]• ONE a •+ Call First or Care First? Also Call First for: • An unconscious adult or adolescent (12 years or older). • A child or infant who you see collapse suddenly. • An unconscious infant or child known to be at high risk for heart problems. • An unconscious person younger than 12 years old. • Any victim of drowning. Y HIGH SIERRA POOLS �Q o The leader in Swimming Pool Management Q �7 Bank H PktO a Town of Mansfield - Board of Health 'yU AtA Swimming Pool Application NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 'TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM FED IDISS NO: 45-1501972 Certification Expires Evert/ 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 3/15/2017 Pool/SPA Certification Expires: 3/15/2022 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 PERMIYNUMBER 16 FEE: $125 ❑ Public POOLOPERATION: W Semi -Public ❑ Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPEIPOOL: GUNITE SEMI-PUBLIC LENGTH: 56' WIDTH: 25' VOLUME: 42,000 GALLONS MINIMAX DEPTH: 4ft. SWIM AREA: 1,400 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER 'SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: ASTRAL SAND FILTER DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 93 SIGNATURE:,b to l �:�'t>.�^. k DATE: r I q 1 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. Town of Mansfield x 6 Park Row, Mansfield, Massachusetts 02048 R 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 L� SWIMMING POOL INSPECTION REPORT TVPF nF Pn V)1.- PrrRr TC rT RRMT-PT rRT.TC n CPF.CrAT. Pr rRP01CF Prinr. NAME OF POOL \ ` , ADDRESS \ `_ OWNER ADDRESS DATE OF o a r v POOL CAPACITY _ ��j 0 0 INSPECTED BY rip Q INSPECTION # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT ���� LOAD - -\ U -VQ N 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" V" are satisfactory. REGULATION X/✓ VIOLATIONS/COMMENTS .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: !&L_gpm. # of turnovers .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 V11without 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 .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 purpose pools. —/ .23 Lifeguards required: Yes El No Lid If lifeguards required. Proper credentials, 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 Cyanuric Acid *parts per million 1 .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 Total Chlorine Free Chlorine Comb. Chlorine pH level Other REGULATION NO. .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. r-� SIGNED ', �•' SIGNER Operator Board of Heallh/Health Department Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 Health Department Amy Donovan -Palmer, Health Agent CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL, PT TBLIC, ❑ SF.MT-PTTBT.TC SPECIAL PURPOSE POOL ❑ NAME OF POOL � ADDRESS OWNER ADDRESS DATE OF 4 POOL CAPACITY, ` L �a(300 INSPECTED BY � INSPECTION # OF GALS METHOD OF WATER,�� BATHER # OF LIFEGUARDS WATER SOURCE: TREATMENT LOAD �3 p y1 Regulation 105 CNIR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000. Items marked with a "✓" are satisfactory. 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 f tration systems. Filter Effluent flow meter reading: gpm. # of turnovers tV .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 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 If lifeguards required. Proper credentials,Trroper 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 nk Y�I4 -'V , w e C ' Total Chlorine Cyanuric Acid Q0 T00 ppm) ,,. = Comb. (0 0 0 2 pptp) Chlorine 6 Water million .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 hj Other 1093 .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. c` 1�SIGNED � SIGN t \i"il Operator Board of Health/Health Department