Loring Hills Condo Pool Inspection 7-6-2020 CI I'Y OF SALEM, M.ASSA.CHUSFTTS IV
BOARD OFF HEUTH
120 WASHINGTON STREET 4"FLOOR PublicHealth
P,['/P.IIt, Pf otC Now.
TEL. (978) 741-1800 FAX (978) 745-0343
KIMBERL EY DRISCOLL ltamdin(fjsalem.com
Lr1RRY R1MllIN,RS/]tL;IIS,CI10,CP-F:
NL,kYOR H r.�L r I I AG rNT
SWIMMING POOL INSPECTION REPORT
1
NAME: U( I_� � e),4'a DATE: L TIME IN:
ADDRESS: BY{ i PHONE: TIME OUT:
CERTIFIED POOL OPERATOR (h WCt( ' I G Y�5 A V Ise e V G
Regulations 105 CMR 435.000 :Minimum Standards for Swimming Pools, S Sanitary Code, Chapter V
Regulation Compliance
Number Yes No Title and Description
435.03 Bathhouse: Separate sanitary dressing facilities and water closet for each sex which are well
1 lighted, drained and ventilated- Showers with hot and cold water—Sanitary drinking water—
toilet paper, soap at sink and in showers (shatter proof containers), paper towels and waste
receptacle
435.06 Water Circulation and Filtration: Over-all recirculation and purification system designed
recirculates and filters the entire volume as follows:
• Swimming Pools Once every eight hours ou5VK rovb
• Wading Pools—Once every four hours
• Special Purpose Pools (Spas)—Once every half hour
Maximum design filtration for filters:
• High rate sand filter— 15 gpm /ftz - 20 gpm/ftz (NSF filters)
• DE filters—2 gpm/ftz
• Cartridge filters—0.375 gpm/ft2
Automatic hypochlorinators required feed-rate capacity:
• Outdoor Pools—Three pounds of chlorine per 24 hours per 10,000 gallons
• Indoor Pools—One pound of chlorine per 24 hour per 15,000 galIons_
435.08 Inlets and Outlets—All special purpose and wading pools shall install an emergency shut off
switch which is accessible, working and prominently marked
435.12 Water Depth Markings—Marked on pool deck and on vertical pool wall. Four-inch contrasting
color stripe dividing shallow and deep ends including ledges and steps
435.21 Permit Requirements and Pool Records—Permit posted in conspicuous location. Maintain
initialed records including daily attendance, amounts and types of chemicals used daily, chemical
and bacteriological tests, dates and times of emptying, cleaning, and back-washing and hours of
operation of purification equipment
435.22 Health Regulations, Signs—No employee working at swimming,wading or special purpose pool
shall have a communicable disease. Operator shall enforce the following for bathers: All bathers
shower before entering pool -Clean bathing suits—No communicable diseases (fever, cough,
cold, inflamed eyes,nasal/ear discharge)—No open sores, skin diseases or bandages—No glass
• Signage at entrance of pool enclosure or in dressing room—"All persons are required to
r take a cleansing shower bath before entering the pool. No person with a communicable
l disease is allowed to use the pool".
• Additional signage for special purpose pools—"Do not use under these conditions: Alone-
Under the influence of alcohol, anticoagulants, antihistamines,vasoconstrictors,
vasodilators, stimulants, hypnotics or tranquilizers—Consult physician if person is
elderly,pregnant, suffers from heart disease, diabetes, high/low blood pressure—Water
temperature above 1040F—Observe reasonable time limits—No oils and body lotions"
Easily readable large dial clock
SWIMMING POOL INSPECTION REPORT
Regulations 105 CMR 435.000
Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V
NAME: _ DATE:
Regulation Compliance
Number Yes No Title and Description
435.23 Lifeguards—Lifeguard certifications—Warning sign stating (if no lifeguard is required by Boar(
of Health)"Warning—No lifeguard on Duty"and "Children under age 16 should not use
nJ swimming pool without an adult in attendance and "Adults should not swim alone"in four
J " inch letters. Clothing—Lifeguards shall wear red or bright orange bathing suits, shirts or jackets
with guard printed in 4-inch lettering. Lifeguards shall direct their attention to area assigned
435.24 Safety Equipment—One ring Buoy for each 2000 ftZ, One rescue tube a d rescue hook Lifeuar
staffed ools shall have readil available a backboard with straps VLQeCfa
435.25 First Aid Equipment and Emergency Communication—Provide a standard Red Cross first aid
kit—Working, convenient, immediate, toll-free communication system with emergency medical
services, local/state police, fire department available to staff and public at all times with
instructions for use
435.29 Chemical Standards—Test for residual disinfectant and pH conducted four times a day(once
during peak load),Alkalinity and calcium test conducted weekly. Ranges are:
• Residual Chlorine 1.0—3.0 PPM Combined Chlorine 0.0—0.2 PPM
• Bromine 2.0—6.0 PPM ! ��
• pH7.2-7.8PPM �
• Alkalinity50—150 PPM ` '(�I_ 1
435.30 Water Testing Equipment—Provide a DP test kit for measuring chlorine/bromine and
appropriate kit for measuring pH, alkalinity and cyanuric acid—Reagents shall not be more than
one year old—Provide accurate, unbreakable thermometer forspecial pLiTose pools
435.31 Water Clarity—Water shall be clear(black disc on bottom of pool, clearly visible from sidewalk:
of pool at all distance a to ten yards)
435.32 Water Quality Maintenance—Special purpose pools shall be drained, cleaned and refilled a
minimum of once every 14 days
435.33 r Maximum Operating Temperature for Special Purpose Pools—Water temperature not more
1 than 104°F—Water temperature shall be tested when residual disinfectant and pH are tested
435.34 Closure of Pool—Operator shall immediately close pool until pool water conforms to 105 CMR
435.28 through 435.31 standards
435.38 General Sanitation—All pools, bathhouses and grounds shall be maintained in good repair, safe
and sanitary manner.
Remarks,Results and Action Taken:
Swimming Pool Wadin"/Kiddie Pool S a Type: Type:
Free Free Free Free Free
Chlorine Chlorine Chlorine Chlorine Chlorine
Combined Combined Combined Combined Combined
Chlorine Chlorine Chlorine Chlorine Chlorine
Bromine Bromine Bromine Bromine Bromine
H )H l}H I H PH
Alkalinity Alkalinity Alkalinity Alkalinity Alkalinity
Calcium Calcium Calcium Calcium Calcium
Hardness Hardness 1 Hardness Hardness Hardness
SWIMMING POOL INSPECTION REPORT
Regulations 105 CMR 435.000
Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V
NAME:
DATE:
Remarks,Results and Actions:
T e• T e: Ty e:
Free Free Free
Chlorine Chlorine Chlorine
Combined Combined Combined
Chlorine Chlorine Chlorine
Bromine Bromine Bromine
H H H
Alkalinity Alkalinity Alkalinity
Calcium Calcium
Type: Calcium
Type Hardness Hardness Hardness Type:
Pool Pool Pool
Volume g Volume g Volume
Sand Sand Sand DE
Filter Type DE Filter Type DE Filter Type Cartridge
Cartridge Cartridge
Filter Size ftZ Filter Size ft2 Filter Size ftz
Minimum Minimum Minimum
Flow Rate g m Flow Rate gpm Flow Rate gpm
Maximum Maximum Maximum
Flow Rate 9pul Flow Rate 9pul Flow Rate gpm
Actual Actual Actual
Flow Rate g m Flow Rate�m Flow Rate zpm
Passed Inspection: Yes Oh' Re-Ins ection Date:
Inspector's Si nature:
Person In Charge:
2
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CITY OF SALEM) RECEIVED 1P
MASSACHUSETTS
BOARD OF HEALTH J U N 2 2 2020 Public Health
' Prevent.Promote.Protect.
98 WASHINGTON STREET,3RD FLOOR
TEL.(978)741-1800 CITY OF SALEM
KIMBERLEY DRISCOLL health W al ern corn BOARD OF HEALT{�
'1JAVID GREENBAUM
MAYOR HEALTH AGENT
APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL
NAME OF APPLICANT a ` ft �L ?W-S L L C TEL# -:( 1—
MAILING ADDRESS] CA3)flU , U bbiww_ 4 a 8
EMAIL ADDRESS. �
CERTIFIED POOL OPERATOR y Q
Name:gIPeksi nJ if l`'IA AQV I L Cert#: TEL#
DATES OF OPERATION(if not annual): ZO W' .02-0
DAYS&HOURS OF OPERATION:
TYPE OF POOL
Public
Semi-Public
Special Purpose
Surface Area sf Volume gallons Bather Load
FEE: $210.00 for year-round pools q2cpaya
�eo
$40.00 Non-Profit
(Please pay total with onety of Salem)
This permit is not transferable and must be reissued upon change of ownership.
In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 63C,Section 49a,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,
have filed all state tax returns and paid all state taxes required under the law.
d,dol J;� 61j6Uo2y 5-2-&63aSO
Signatur at SS#or Federal Identification Number
This section for office use only
Check#-- '- `t3—Date 12 h Amount
. Tito Critrtritil'tisiiaulth o uretts
Departmetit-q f Industrial Aecidems
OPie,ipyinvestagtatioas
ddlt.WashirraM i Streit
Howo l;,leers. 02111.
) ,w1o..' l''AS.ti.r'arOl�lrliaa
Workers"Compensation Insurance Af#itia 'it: Builders/Contractors/Electiieians/Plumbers
- .. )leant Infoitiinfl6n: I7J. Pleas PHht�e iblA+
.1dtEletF3t�ci,ie,sri)s :tnizti7aii+[ridi�ii[nalj: w nQ4 , T WW Lu
Address --,J,.�...�-
Ciil' -lSfait:t'Zi Amu. 0(00e Phon'd:
Are you an employer':Cheek the npprupriate,box: T.pe of project.(r-egidred):
1. :. I mn an rmpioycr with =t_ 1 am a general contractor and.1 6. New construction
employees(lull tins):+orp:ut title,).* have hired the 8 th-contractors7. kttriodt[ing
1:.. 1 ant a sole proprietor or pariner- listed on thr attached;he&
ship and have no employees These,stabweantractors have T3cnioli6on
Working for Inc.in an,,,capacity. employees and,have work-urs g gni3diltg adi;it an
[No workers'co5.np.insurance_ romp.insurance..t
nquiredj 5: s We-are a-corporitiun and its i 10. Electrical:tpaita or additiolls
. ;. I am a homeowner doing ah,stork otiicc.rs have exereised their l l:_:1'fnrnoine rcp:tirs or additions
myself [No workers'vornp. right p1 rxcipption-ptrm MOL
insurance rcgttircdj= c;1513.k l(4),.and we.have no ! 12:- Root'repsirs
Ltt9piuVc' s: i3o ct°ctrkers' , i
1_T. Cliher S(�71 tY1rt9 i ryVi
rump tnstirtncc requircil.j
"Any applicant that checks 131sx oil mast also fill out the"Minn heiew shoa►•ing their workers'coaipensation policy Wrarruatiun.
tlloin oslacrs aYINI snhtult this afridaeit ladicatinn tl►er ere doing all work and then hire outside-contractors lnust mit)ruit S new artidavii:indicatinx Ands.
rCntttttchars that check this.hox ntuil tatlielt an additional sheet rhan ing the name aY the sub-contractors;lend state whether or nott those entities have etnplpyces. if
the sah4onI rat tars_have. their.sttlrlc7aT'cynt
aril are elnptojyroluf.6 prolddixg Imilllfers'eoaaapensratiiur irlsurasie foe env emj layeet.•chic hr the poke.)=andfi►h sire
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Job Site:\ddtti .r_ O asp ( m &�cl� K� . /k+ ty st tc Zip:-_ /`2i.C"K.i��/1 92 Qd6,C/
Attach a copy of the workers' compensation policy declardtioii page(shoving d*.p6Hi%y number.and expiration(date).
Failure to.secure coverage as required.ander.Section.2Sa.oftl OL 152 can lead to the-,imposition oI'crittiinal Penalties-ot:a fine
tip to 51.500.00 anA or one year imprisonment:as wall as ciN41 penalties in the#form of a STOP AVORK ORIDEk and a fine of
5.?9.0 a doy against viohiior:Bey advised-that a copy of this statenidnt,maybe for%varded to the Ofi ice of Investigations of[be
DJA tor.eovera a verification.
!do heMx eery, under the-pains rani)&rrrrlties ofpeijury Heart tell b1forhidtinri pravided riboue is hire•and-carreer.
S,tvnfaarlre. /I Date* O
Offciatl arse rear))? Do malt.write M this.a exit to be cn»pleteil:by city or toiP11 rif�ckll �
Cite or Town: ['erntil/IiCctt+e.It:
Issuing Atithutit�(CiFcle tlete):
!.Board of Hi-at.h .2. I3uitding Deportattent .3.:_1t}/TttYvn:Clerk_ a.Electrical b6piOor 5.Plinnbing.frispr ,ctor
b.Other
I
} Contact person: Phone 9:
q`oRo® CERTIFICATE OF LIABILITY
CERTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYANDCO INSURANCE DATE(MM/DD/YYY7
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE C 10/24/2019
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
UPON THE CERTIFICATE HOLDER. THIf
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, OVERAGE AFFORDED BY THE AUTHORIZE[
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIpTHE ISSUING INSURER 5,
If SUBROGATION IS WAIVED, subject to the terms and conditions of the ollc ( ) AUTHORIZE[
this certificate does not confer rights to the certificate holder in Ilea of such endorsement{s}. NAL INSURED provisions or be endorsed
PRODUCER y, certain policies may require an endorsement. A statement on
Phoenix-Alliant Insurance Services, Inc. coNTacr
2415 E Camelback Rd Ste 950 AME: Jackie Hanauer
Phoenix AZ 85016 PHONE
602-707-1898 FAx
EMAIL A/ o•480-333-6973
At]!7 s : hxcs carts alliant.com
�— �—INSURED INSURER S AFFORDING COVERAGE
- INSURER A:LibertySur lus Insurance Cor NAIL#
Continental POOL,LLC INSURERS:Federal Insurance Corn an Can
8520 Corridor Rd.,#B 10725
Savage, MD 20763 INSURERC:AXIS Su Plus Insurance Com an 20281
INSURER D:Crum&Forster S ecialt Insurance Com an 26620
INSURER E: NaVI ators Insurance Cc an 44520
COVERAGES INS RERF. Ohio Cas I Insurance Com an 42307
THIS IS TO CERTIFY THAT THE POL C ES ()IF NSURANCE BSTED361.59090 BELOW HAVE BEEN ISSUED TO THE I
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT
NUMBER: 24074
CERTIFICATE MAY O ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED gY NSURED NAMED ABOVE FOR THE POLICY PERIOD
UMENT WITH RESPECT TO WHICH THIS
ILTR ~ SUBJECT TO ALL THE TERMS,
TYPE OF INSURANCE ADD SU8 PAID CLAIMS.
A X COMMERCIAL GENERAL LIABILITY POLIC NUMBER PO/LIICY.EFF POLICY EXP
100001724608 �'�' MMro yyyY --
CLAIMS-MADE a 10/25/2018 10/25/2020 LIMITS
OCCUR EACH OCCURRENCE $1,000,000
A T REN E
PRE is Ea urr n a $1.000,000
GEN'L AGGREGATE LIMIT APPLIES PER: MED EXP An one parson] $
POLICY[�] PERSONAL&ADV INJURY $1,000 000
JET ❑X LOG GENERAL AGGREGATE
OTHER: $2 000,000
8 AUTOMOBILE LIABILITY PRODUCTS-COMP/0P AGG $2,000,000
X ANY AUTO 54309826 10/25/2019 CO BINED SINGLE LIMIT $
10/25/2020 $1,000,000
OWNED SCHEDULED as n
AUTOS ONLY HIRED AUTOS BODILY INJURY(Per person) $AUTOS ONLY NON-OWNED
ONLY BODILY INJURY(Per accident) $
PRO,,RB DAMAGE $
C UMBRELLALIAB X
X EXCESS LIAR OCCUR P-001-000047785-02 $
CLAIMS-MADE 10/25/2019 10/25/2020
EACH OCCURRENCE $1,000,000
DED RETENTION$ f AGGREGATE a WORKERS COMPENSATION $1,000,000
AND EMPLOYERS'LIABILITY 54309827 Excess CGL oni
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 10/26/2019 10/25/2020 X PER TH• $
OFFICE(Mandatory iq EREXCLUDEDI N/.A STATUTE R
(Mandatory In NH)
If yes,describe under E.L.EACH ACCIDENT $1.000,000
DESCRIPTION OF OPERATIONS below E.L. EASE-
D Excess CGUEL EA EMPLOYEE $1,000 000
E Excess Auto SEO-105967 E.L.DISEASE-POLICY LIMIT $1.000,000
F Excess of Excess CGUEL&Auto SF19EXC7613611V 10/25/2019
101251211, 10/25/2020 10/25/2020 Each Accident
ident egetes 10 000,000
ECO(20)56322216 10/25/2019 10/25/2020 Each Accid 99s&Acc 10,000,000
Each Occ/A 10,000,000
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
above and EXCESS LIABILITY follow form of underlying COMMERCIAL GENERAL LIABILITY,AUTOMOBILE LIABILITY and EMPLOYER'S LIABILITY
shown above:led tin Harbore Insurance Company,NAICExcess
#36940 PolicyLiability
P provides Each Ove rrence/A10/25/2019gregates-10125 limits of$15,0001000 Quell sill shownPolicies
# active 10/25/201 g_1 p�25/2020
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Proof Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Continental Pools, LLC ACCORDANCE WITH THE POLICY PROVISIONS,
8520 Corridor Road, Ste B
Savage MD 20763 AUTHORIZED REPRESENTATIVE
CORD 25(2016103) The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. All rights reserved.
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