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HAWTHORNE COMMONS POOL City of Salem, Massachusetts ��. iJ� q Board of Health ,• 120 Washington Street, 4th Floor, Salem, MA 01970 PubHcHeaIth Prcrm<.Promo<.Paal<C. Tel. (978) 741-1800 Fax. (978) 745-0343 Kimberley Driscoll health@salem.com Larry Ramdin, MPH, REHS,CHO Mayor Health Agent PUBLIC POOL HEALTH PERMIT Permit# PO-17-13 License For : Pool (seasonal) Date of Print 5/22/2017 Granted To: Hawthorne Commons Permit Issued 5/22/2017 Address: 205 Highland Avenue Salem MA 01970 Permit Expires 9/16/2017 Location of Establishment: 205 HIGHLAND AVENUE Permit Fee $140.00 Restrictions: Permit valid 5/26/17 to 9/16/17 Late Fee $0.00 Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 9/16/2017 , unless sooner revoked or suspended. Larry Ramdin, MPH, REHS, CHO Health Agent CITY OF SALEM, MASSACHUSETTS BOARD OE HEALTH 120 WASHINGTON STREET,4-FLOOR RECEIVED KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978) 43 MAY 2 2 2011 MAYOR lramadin saIem.c.com LARRY RAMDIN,RS/RENS,CHO,CP-FS CITY OF SALEM HEALTH AGENT BOARD OF HEALTH 2®17 ,20`t7 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL "D tt C "M1A'T15KR NAMEOF APPLICANT J4l y , 1,1�J s't ta,P I A TEL# q?D -3�— Ob MAILING ADDRESS �0 5 n q�.�o /SV e t e-1 C n a�9�o CERTIFIED POOL ERATOR r Name: 'T 1 VQ Cent#:0 1-33TgL# Q78 -273'1�7 �� DATES OF OPERATION(if not annual): (�/ LW t �� �- C `417 � DAYS &HOURS OF OPERATION: /* TYPE OF POOL Public Semi-Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City of Salem) This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 63C,Section 49a,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state ax returns and paid all state taxes required under the law. wl Sir/l7 03V-69::���� Siature Date SS#o Fred re al Identification Number Revised 5/23/11 poolappl Ldoc Check#Da[e f'J b, • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH lu 120 WASHINGTON STREET,4'"FLOOR PI1PrevebilCPromHC81�1 t. TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL lramdinnsalem.com LARRY RdMDIN,RS/REI-IS,CPIO,CP-FS MAYOR HEAL'I'I-1 AGENT SWIMMING POOL INSPECTION REPORT NAME: I [ri scarf n rnP. L/1m mn'c DATE:Z��O/� TIME IN: . X26 . ADDRESS:-2—n5 Ai Lrvt♦.AVQ1.ye PHONE: TIME Q6�$— TIME OUT:Ll S CERTIFIED POOL OPERATOR: ;��� tfv�,✓i Q vr7i Regulations 105 CMR 435.000 :Minimum Standards or Swimming Pools, State 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 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 • 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/ft' -20 gpm/ ft' (NSF filters) • DE filters—2 gpm/ft' • Cartridge filters—0.375 gpm/ft' 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 gallons 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 take a cleansing shower bath before entering the pool. No person with a communicable 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 104°F—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 si Swimming Pools, State Sanitary Code, Chapter V NAME: YG1�✓TYlnrne, nhs DATE: Regulation Compliance Number Yes No Title and Description 435.23 Lifeguards—Lifeguard certifications—Warning sign stating(if no lifeguard is required by Board of Health)"Warning—No lifeguard on Duty"and"Children under age 16 should not use swimming pool without an adult in attendance and "Adults should not swim alone"in four 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 ft2,One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 435.25 First Aid Equipment and Emergency Communication—Provide a standard Red Cross fust 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 • pH 7.2—7.8 PPM • Alkalin 50— 150 PPM 435.30 Water Testing Equipment—Provide a DPD 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 for special purpose pools 435.31 Water Clarity—Water shall be clear (black disc on bottom of pool, clearly visible from sidewalks of pool at all distance up 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 Maximum Operating Temperature for Special Purpose Pools—Water temperature not more 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 Wading/Kiddie Pool Spa 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 pHpH pH pH pH Alkalinity Alkalinity Alkalin Alkalin Alkalinity Calcium Calcium Calcium Calcium Calcium Hardness Hardness Hardness Hardness Hardness SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V NAME: HO'W 4 mrne. Lmnvos DATE: Remarks, Results and Actions: T e: T e: Type: Free Free Free Chlorine Chlorine Chlorine Combined Combined Combined Chlorine Chlorine Chlorine Bromine Bromine Bromine pH pH pH Alkalinity MOIAlkalinity Alkalinity Calcium Calcium Type Calcium Type: Hardness m Hardness Hardness Type' Pool Pool Pool Volume g Volume g Volume g Sand Sand Sand DE Filter Type DE Filter Type DE Filter Type Cartridge Cartridge Cartridge Filter Size It' Filter Size 112 Filter Size ft' Minimum Minimum Minimum Flow Rate gpm Flow Rate gpm Flow Rate gpm Maximum Maximum Maximum Flow Rate gpm Flow Rate gpm Flow Rate gpm Actual Actual Actual Flow Rate gpm Flow Rate gpm Flow Rate gpm / S r a.r' S, Passed Inspection: Yes S3No ❑ Re-Inspection Date: Inspector's Signature: Person In Charge: • CITY OF SALEM, MASSACHUSETTS lu BOARD OF HFAUH 120 WASHINGTON STREET 4"FLOOR 1'libliCHealth STREET, Prevent,Promote.Protect. TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL lramdin(a�salem.com LARRY RA bIDIN,RS/RE F[S,CI 10,Cl'-IS MAYOR HEIALTH AGENT / SWIMMING POOL INSPECTION REPORT NAME: H n W f L n e, DATE: ,Z42 _.Sly TIME IN: ADDRESS: ( I rwr�� /t�/eaty� PHONE: ME OUT:L CERTIFIED POOL OPERATOR: J©Sc e A rt a vf,-7 I Regulations 105 CMR 435.000 :Minimum Standards for Swifhming Pools, State 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 lighted, drained and ventilated- Showers with hot and cold water— Sanitary drinking water— \V/ 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 • 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/ft' - 20 gpm/ft' (NSF filters) • DE filters—2 gpm/ft' • Cartridge filters—0.375 gpm/ft' 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 gallons 435.08R( Inlets and Outlets—All special purpose and wading pools shall install an emergency shut off A 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 c9lor stripe dividing shallow and deep ends including ledges and steps 435.21 ermit 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 take a cleansing shower bath before entering the pool. No person with a communicable 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 104'F—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: 6a6c46rrLe L6 M won H S DATE: L/ Regulation Compliance Number Yes No Title and Description 435.23 Lifeguards— Lifeguard certifications—Warning sign stating(if no lifeguard is required by Board of Health)"Warning—No lifeguard on Duty"and"Children under age 16 should not use swimming pool without an adult in attendance and "Adults should not swim alone"in four 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 ft',One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 435.25 r 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 PH 7.2—7.8 PPM • Alkalinity 50— 150 PPM 435.30 / Water Testing Equipment—Provide a DPD test kit for measuring chlorine/bromine and V appropriate kit for measuring pH, alkalinity and cyanuric acid—Reagents shall not be more than one year old—Provide accurate, unbreakable thermometer for special purpose pools 435.31 Water Clarity—Water shall be clear(black disc on bottom of pool, clearly visible from sidewalks of pool at all distance up 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 Maximum Operating Temperature for Special Purpose Pools—Water temperature not more 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 Wading/Kiddie Pool Spa 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 pHpH pH pH pH Alkalinity Alkalini Alkalini Alkalin Alkalin Calcium Calcium Calcium Calcium Calcium Hardness Hardness Hardness Hardness Hardness SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V NAME: ty� kn r nrs DATE: Remarks, Results and Actions: T pe: T pe: Type: Free Free Free Chlorine Chlorine Chlorine Combined Combined Combined Chlorine Chlorine Chlorine Bromine Bromine Bromine PH PH pH Alkalinity Alkalinity Alkalinity Calcium Calcium Calcium Type: Hardness Hardness Hardness Type' Type Pool Pool Pool Volume g � Volume g Volume g an Sand Sand DE Filter Type DE Filter Type DE Filter Type Cartridge Cartridge Cartridge Filter Size ft' ` ��+ Filter Size ft= Filter Size ft' Minimum Minimum Minimum Flow Rate gpm Flow Rate gpm Flow Rate gpm Maximum Maximum Maximum Flow=gpm % Flow Rate gpm Flow Rate gpm Actual Actual Actual Flow Rate gpm Flow Rate gpm Flow Rate gpm AQ s �. Ckp vnj&r\Qj Passed Inspection: Yes MNo e-Ins ection Date: 3 t Inspector's Signature: Person In Charge: City of Salem, Massachusetts T 3j Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 PublicHealth Q9 �' ) Tel. (978) 741-1800 Fax. (978) 745-0343 Prevent.Promote Prot-L. Kimberley DriscollLarry Ramdin, MPH, REHS, CHO Mayor Iramdin@salem.com Health Agent PUBLIC POOL HEALTH PERMIT Permit# PO-16-13 License For : Pool (seasonal) Date of Print 6/21/2016 Granted To: Hawthorne Commons Permit Issued 6/21/2016 Address: 205 Highland Avenue Salem MA 01970 Permit Expires 9/30/2016 Location of Establishment: 205 HIGHLAND AVENUE Permit Fee $140.00 Restrictions: Late Fee $0.00 Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 9/30/2016 , unless sooner revoked or suspended. CITY OF SALEM, MASSACHUSETTS .BOARD OF HEALTH 120 WASHINGTON STREET,4T FLOOR. KIMBERLEY DRISCOLL TEL.(978)741-1800 FAx(978)745-0343 MAYOR Iramdin(tr)dsalem.com LARRY RAMDIN,RS/REHS,CHO,CP-FS HEALTH AGENT - - - - 20111 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL Ha Wii+k0 V-KC r�Co m m v nS - ?Z5 ! �g W a.�L Ave; J� (ens MA 01770 NAMEOFAPPLICANTil&�+(e Ir9+S�aiO TEL# q7t—g' ! &o3o p MAILING ADDRESS Gy� t1 tq h � Wil?� MA 01270 CERTIFIED POOL Name: TOSe Fes+41/� � Cert#: TEL# 7�y 79-27 3-q75DATES OF OPERATION(if not annual): .'/l2.711& �Iq�� DAYS &HOURS OF OPERATION: 9M —q 0 M_ DA j 1 TYPE OF POOL Public Semi-Public ✓ Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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. S?Sil6 Ovl-�4y�F3 Si ature Date SS#or Federal Identification Number Revised 5/23/11 poolappl Ldoc Check 0 Dat ) I rS Gin Won ff1S���fo�tf • ��� � CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH - 120 WASHINGTON STREET,4`FLOOR PlIb1lClieaIth TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL Iramdin@salem.com MAYOR LARRY RE A�4DIN,RS�RI-[S,CI CP O, -FS L-IISA CPI-I.AG FNT SWIMMING POOL INSPECTION REPORT Cg,__T NAME: �6_y Ginrete_ Cnh,moh S DATE: TIME TIME IN: ADDRESS: ,S N;gh l ry J Aveh v. . PHONE: TIME OUT: CERTIFIED POOL OPERATOR: �oSe �err1G �r_z Regulations 105 CMR 435.000 :Minimum Standards for Swimming Pools, State 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 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 • 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/ ft' - 20 gpm/ ft' (NSF filters) • DE filters—2 gpm/ft? Cartridge filters—0.375 gpm/ft' 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 gallons 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 take a cleansing shower bath before entering the pool. No person with a communicable 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 104°F—Observe reasonable time limits—No oils and body lotions" Easily readable large dial clock I. i SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V ''II /� / NAME: &kAor`nr. CDI_MM10hf DATE: Regulation Compliance Number Yes No Title and Description 435.23 Lifeguards—Lifeguard certifications—Warning sign stating(if no lifeguard is required by Board of Health)"Warning—No lifeguard on Duty"and"Children under age 16 should not use swimming pool without an adult in attendance and "Adults should not swim alone"in four 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 ft',One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 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 • pH 7.2-7.8PPM • Alkalinity 50— 150 PPM 435.30 Water Testing Equipment—Provide a DPD 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 for special purpose pools 435.31 Water Clarity—Water shall be clear(black disc on bottom of pool, clearly visible from sidewalks of pool at all distance up 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 Maximum Operating Temperature for Special Purpose Pools—Water temperature not more 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 Wading/Kiddie Pool Spa Type: Type: Free qq Free Free Free Free Chlorine Lto Chlorine Chlorine Chlorine Chlorine Combined Combined Combined Combined Combined Chlorine Chlorine Chlorine Chlorine Chlorine Bromine Bromine Bromine Bromine Bromine H pH pH pH pH Alkalinity Alkalinity -Alkalinity Alkalinity Alkalinity Calcium Calcium Calcium Calcium Calcium Hardness Hardness Hardness Hardness Hardness SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V NAME: TTa.d{horr� �n /t S DATE: 4 2 Remarks, Results and Actions: T pe: T pe: Type: Free Free Free Chlorine Chlorine Chlorine Combined Combined Combined Chlorine Chlorine Chlorine Bromine Bromine Bromine PH pH pH Alkalinity Alkalinity Alkalin Calcium Calcium Calcium Type Type' Hardness Hardness Hardness Type: Pool Pool Pool Volume g Volume g Volume g Sand Sand Sand DE Filter Type DE Filter Type DE Filter Type Cartridge C trid a Cartridge Filter Size ft= Filter Size ftz Filter Size ft' Minimum Minimum Minimum Flow Rate gpm Flow Rate gpm Flow Rate gpm Maximum Maximum Maximum Flow Rate gpm Flow Rate gpm Flow Rate gpm Actual Actual Actual /F^low Rate gpm ((�lj/lj Flow Ratte gpm�/'r� Flow /Rate gpm Soap Passed Inspection: Yes FJNo ❑ Re-Inspection Date: Inspector's Signature: Person In Charge: rm4 CITY OF SALEM, MASSACHUSETTS BOARD OF HE.AIJH 120 WASHINGTON STREET,4."FLOOR PublicHealth TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL lramduinsalem.com LARRY IiA MDIN,RS/REFtS,CHO,CP-PS Al YOR HFAI: HACP:NT SWIMMING POOL INSPECTION REPORT NAME: tfai.IAOrnP, t _r Mrrny10 DATE: OV?IZ2DT� TIME IN: r30 ADDRESS: 2Q21414 L laJ &P-P,ye. PHONE: 17942.5---0030 TIME OUT: t�T CERTIFIED POOL OPERATOR: C2 �P_Yl/'IQZLI Regulations 105 CMR 435.000 :Minimum Standards Or Swimming Pools, State Sanitary Code, Chapter V Regulation Comp 'ajice Number Yes o Title and Description 435.03 Bathhouse: Separate sanitary dressing facilities and water closet for each sex which are well 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 • 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/ft' -20 gpm/ftz (NSF filters) • DE filters—2 gpm/ft2 • Cartridge filters—0.375 gpm/ 112 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 gallons 435.08 Inlets and Outlets—All special purpose and wading pools shall install an emergency shut off Wky 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 take a cleansing shower bath before entering the pool. No person with a communicable 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 104°F—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: iP ,.nr. (nr�inrripn9 DATE:(S�✓31 � Regulation Compli ce Number Yes JVNo Title and Description 435.23 Lifeguards—Lifeguard certifications— Warning sign stating (if no lifeguard is required by Board of Health)"Warning—No lifeguard on Duty"and"Children under age 16 should not use swimming pool without an adult in attendance and "Adults should not swim alone" in four 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 ft ,One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 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 i tructions for use 435.29 hemical 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 • pH 7.2-7.8PPM • Alkalinity 50— 150 PPM 435.30 Water Testing Equipment—Provide a DPD 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 for special purpose pools 435.31 Water Clarity—Water shall be clear(black disc on bottom of pool, clearly visible from sidewalks of pool at all distance up 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 Maximum Operating Temperature for Special Purpose Pools—Water temperature not more 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 Wading/Kiddie Pool Spa Type: Type: Free Free Free Free Free Chlorine Vr p Chlorine Chlorine Chlorine Chlorine Combined Combined Combined Combined Combined Chlorine Chlorine Chlorine Chlorine Chlorine Bromine _ Bromine Bromine Bromine Bromine H 7 pH pH pH pH Alkalinity Alkalinity Alkalinity Alkalinity Alkalinity Calcium Calcium Calcium Calcium Calcium Hardness Hardness Hardness Hardness Hardness SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standard'I ! 1�s for Swimming Pools, State Sanitary Code, Chapter V NAME:��yAorne. 4 DATE:(1fi'/31/2�2� Remarks,Results and Actions: Type: Type: Type: Free Free Free Chlorine Chlorine Chlorine Combined Combined Combined Chlorine Chlorine Chlorine Bromine Bromine Bromine PH pH pH Alkalinity Alkalinity Alkalinity Calcium Calcium Calcium Type: Hardness Hardness Hardness Type: Type Pool Pool Pool Volume g 30po0 Volume g Volume g n Sand Sand DE Filter Type DE Filter Type DE Filter Type Cartridge Cartridge Cartridge Filter Size ft' 2" Filter Size ft' Filter Size ft' Minimum Minimum Minimum Flow Rate gpm Y1,4 Flow Rate gpm Flow Rate gpm Maximum Maximum Maximum Flow Rate gpm Flow Rate gpm Flow Rate gpm Actual Actual Actual Flow Rate gpm Flow Rate gpm Flow Rate gpm L �j �'` G o .� ` r ILn L C -+'n c-- JA c' ftnn i&1 e-,,- I c. Passed Inspection: Yes ONo Re-Ins ection Date: Inspector's Signature: 44"a-wz 44 Person In Charge: 1 Commonwealth of Massachusetts C E City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 05/01/2009 ESTABLISHMENT NAME: Hawthorne Commons Pool File Number:BHF-2004-000196 205 Highland Avenue Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2009-0451 May 31,2009 Sep 14,2009 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES ISeptember 14, 2009 Board of Health Page 1 S CITY OF SALEM, MASSACHUSETTS BOARD OF HEALT11 120 WASHINGTON S'1REET,4n"FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR IMANCINI SALEN1.COM JANET MANCINI, AC'L'ING HiiAIAI i AGEN'1 2009 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL ( yy v� d/ef eL_C.. NAME OF APPLICANT (tet TEL# J Zf-f a-S _0z 36 MAILING ADDRESS o� S� W !J CERTIFIED POOL OPERATOR 2 Name: tai V. . k I�`�e-tip Cert#: 0 2-2.7 '11 1 # `I�3 -7 D V C(-,110 i DATES OF OPERATION (if not annual): 1 r DAYS &HOURS OF OPERATION: D A-n^ - �S TYPE OF POOL t/ Public Semi-Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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 requ' ed under the law. l-7 S Ili Signature Date SS or Federal Identification Number Revised 8/14/07 pooaapp.wpd Check# Date 0 V5 I 7- r' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET',4''FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLl, FAX(978)745-0343 MAYOR IMANCINI(@SAI,FM.COM, JANET MANCINI ACTING HEAL'iH AGENT Salem Board of Health 120 Washington Street 4" Floor Salem,MA 01970 Pursuant to The Virginia Graeme Baker Pool&Spa Safety Act and the Commonwealth of Massachusetts Minimum Standards For Swimming Pools(State Sanitary Code: Chapter V-105 CMR 435.00),I certify that the pool and all pool drain/grate covers in the semi-public or public pool choose the e of l below ( tYP . P� swimming_L= wading special purpose_ located at Establishment Name Establishment Address r� conform to the The Virginia Graeme Baker Pool&Spa Safety Act and the American National Standard ASME A 112.19.8—2007 OR: ❑ do not conform to The Virginia Graeme Baker Pool&Spa Safety Act and the American National Standard ASME Al 12.19.8—2007 and that the pool will be shut down effective December 19,2008. ignature of pool owner Title Prii anTe ; e /' Date NOTICE of New Federal Pool Requirements The Virginia Graeme Baker Pool & Spa Safety Act INo. The provisions of the new law are designed to prevent serious injuries and fatalities associated with suction entrapment in pools and spas. By December 19, 2008, in accordance with the new federal law • ALL public, semi-public and special purpose swimming pool drain/grate covers MUST conform to the American National Standard ASME Al 12.19.8 — 2007 Suction Fittings for Use in Swimming Pools, Wading Pools, Spas, and Hot Tubs, or any successor standard, published by the American Society of Mechanical Engineers (ASME); • EVERY public, semi-public and special purpose swimming pool with a single main drain, other than an unblockable drain (interpreted by the Consumer Product Safety Commission to have minimum dimensions of 18 inches by 23 inches or have a diagonal measurement of 29 inches or more), MUST be equipped with one or more additional systems or devices designed to prevent suction entrapment. As outlined in the law these additional systems or devices may include a safety vacuum release system (SVRS), suction limiting vent system, gravity drainage system, automatic pump shut-off, or any other system determined by the CPSC to be equally effective in preventing suction entrapment; • If a public, semi-public or special purpose pool can not comply by December 19, 2008, the CPSC requires that the pool or special purpose pool shut down until the proper covers are installed and, when applicable, an additional suction entrapment prevention device or system is installed as outlined in the law; and • Non-compliance with these federal provisions may result in the imposition of civil or criminal penalties under sections 20 or 21 of the Consumer Product Safety Act. By December 19, 2008, in accordance with regulation 105 CMR 435.00 • Anti-vortex drain covers must be replaced if they do not meet ASME Al 12.19.8 — 2007; • Gravity drainage systems are NOT exempt from the drain/grate cover provisions; • Drain disablement is NOT an acceptable suction entrapment prevention option, pursuant to 105 CMR 435.00 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V; • An operating permit, pursuant to 105 CMR 435.21, should NOT be issued to any public, semi- public or special purpose pool that does not comply with the requirements; • Variances pursuant to 105 CMR 435.46 shall NOT be granted since the federal law implies preemption of state requirements; • Public, semi-public and special purpose swimming pools that are not open on December 19, 2008 are not required to be in compliance until the day that they re-open; and • It is the pool operators' RESPONSIBILITY to provide written confirmation that pool drain/grate covers conform to the American National Standard ASME Al 12.19.8 —2007. For more information please visit the MDPH —Community Sanitation Program website www.mass.gov/dph/dcs or contact the Massachusetts Department of Public Health, Bureau of Environmental Health at 617-624-5757. i Aquaknot Pools Inc. 55 Woodrock Rd. Weymouth, MA. 02189 Hawthorne Commons November 6, 2008 205 Highland Ave. Salem,Ma. 01970 To whom it may concern, Aquaknot Pools Inc.has installed 2 DS-360 Main Drain covers in the swimming pool. This will bring the pool into compliance with the Virginia Graeme Baker Act of 2007. For AquaknotPools Inc., Y ;atnck O'Connor City of Salem, Massachusetts Board of Health l 120 Washington Street, 4th Floor, Salem, MA 01970 PublicHeaIth Tel. (978) 741-1800 Fax. (978) 745-0343 Kimberley Driscoll Iramdin@salem.com Larry Ramdin, MPH, REHS, CHO Mayor Health Agent PUBLIC POOL HEALTH PERMIT Permit# PO-15-11 License For : Pool (seasonal) Date of Print 6/3/2015 Granted To: Hawthorne Commons Permit Issued 5/22/2015 Address: 205 Highland Avenue Salem MA 01970 Permit Expires 9/7/2015 Location of Establishment: 205 HIGHLAND AVENUE Permit Fee $140.00 Restrictions: Late Fee $0.00 Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 9/7/2015 , unless sooner revoked or suspended. 1 Y p V CITY OF SALEM MASSACHUSETTS BOARD or HEAIM-i 120 WASHINGTON SrRF7F:r,4'°'FI.,oOR KIMBERLEY DRISCOLL TFL.(978)741-1800 FAx(978)745-0343 MAYOR LRAMDINQSALEM.COM LARRY RANMIN,RS/REHS,CHO,CP-FS HEALTH AGENT 2015 APPLICATION��F��OR PERMIT TO OPERATE A SWIMMING POOL -r1� LOCATION OF POOL ; } G.LL� 0✓"X-- CCneil Wt on NAME OF APPLICANT 1 �?NVKy(I TEL# C1?8 -g-4- 10030 MAILING ADDRESS db �tb I41➢e Srr �n c rw/l O1a70 CERTIFIED POOL OPERATOR cy Name: W itSpin Rj ,,ey a, Cert#:01'3��� 01TEL DATES OF OPERATION(if not annual): lM a� �a ,9015 6peo 5-e�ey4o-r b , a015 C1 SQ DAYS &HOURS OF OPERATION: �'! 601 q;" I-Vt �nrlar� a Su11 Aay TYPE OF POOL AWO Public Semi-Public r� Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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 1,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. i 9 115 015­�S`I930 Signature Date SS#or Federal Identification Number Revised 5/23/11 poolappI Ldoc Check 4 Date l5� /} /y ` CITY Or SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON 'TREET,47 FLOOR ICM13ERLEY DRISCOLL TEL. (978) 741-1800 MAYOR FAX (978) 745-0343 tramdjn@saicin.com salcin.com LNtRI'RA%1DIN,RS/RN IS,CI10,CP-FS HFjuxi-i Aa:NT Swimming Pool Inspection Report Pool: Y P Wl b Date: Address 0 Phone: $ _ 30 Operator: d Max Bathing Load: In accordance with 105 CMR 435.60 Minimum Standards for Swimming Pools:State Sanitary Code Chap/ter V. �/ Annual Permit Posted k Iv Ace Health and Showers signs Posted Health: no sick employees, no sick bathers, bathers take showers, spitting prohibited,no glass. Lifeguards: Present _Certification _Red/orange suit _"Guard"printed on jersey E_Sun block avail. _Voice Amplifier _Elevated seat mer.Communication:phone at pool _Phone instructions _Emergency numbers Phone in unlocked area Savetyip: for each 2000,sq.feet ue tube,00r ring buoy(with rope) boardKvith collar and straps First Aid Equipment area ��(,✓(,�5 I"band-aids 0)3x3 gauze 6 nror2 y 5x9 surgipads )antiseptic wipes Yxiseezers x10 Surgi soft roller bandages ors �3"Soft roller bandages 1 '/z roll hypoallergenic tape scue blanket f9d packs 9pocket mask V sterile isotonic eyewash Disin etion 7, Chlorine /pH 7.2—7.8 Residual free I-3, Combined 0-0.2 _Bromine _pH 7.2—7.8 Residual 2-6 (ppm)(mg/1) _Records Kept: Water tests hemicals Used Backwashing /a Attendance ours of operation V Depth Markings Sidewalk and inside pool j�l�Diving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c cracks,non slip surface, not over 10' above water level and at least 13' unobstructed headroom Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted, drained,ventilated, impervious construction, one shower and one toilet per 40 bathers,hot and cold water,soap provided,no common cups,towels,combs, pool adequately enclosed, approved �{{Inking water facilities Notes: Yj� Iexs �a rx ' S1,nCs�a�v�� e�Yhc�, t7� If c����r G t.yiT �onc,IZlr,ociy-- Received byw_,- � Inspected by: a 04R; yq'�e'i & _44 ^'" f':ra„'Z"'�yw3,t C ,.'a••r x 117'«@.•""AY:Y«`n •4„ .' 'pL°F ..- `'3 'tr.:." '06ME ..� ( b ,�p d:F. :; Sr $ rcr3r;C, 4i "+C 'd{ v t " ` "4' m. "'f,- •r+fi ;hptS.R+.Fy yi„r `"^«5d?e=d ;.eae ,H n.M r i R„q fi�h'k t ^y,�1,. .E€5 ,[i)s,� Z.: .E � Y 5°mC yj�a$. i! •.., 4 ra + l:mR) Z'ru. q�.` >s /'� Y �j• tiQQ, �t �'' rte+ r {.� 5 'v",n;x y�'•�xA��,ai.Fit w °:``� �./'� ��4�G7IG�`� M SSu%A-Jhusetts f ' rG v,�r•',: }5.# 's ti + }k. tk5s'krf wq t"d�,r�, P. ':d 4 lir`.P u)a" -T" .dhf*ka•1' a+ F"' :*'- ''j" r )wY' k u"a* s✓ n'" k -�f kr 5 Ry n R rz r �r :\ ' `: ' a "�••x � `"a``7's r�^.,, za :�: >ay �, r a,. $ •,� y � n ,l�v .. � w,,,,3�� c m � ,u§, G � fi ��, ,.��, � A r 1 � Board�of' ,ealthx i• `R ..y, „t e�, �, '^a EY @ x_,�� r "v,$��,. 5 �' bi. R, rvy^ a r ' " "' * * e � '130 Washington Street4th FlogrSa"IemMA +,44 i su% 4+n f n oe nroE b d ' �^' „t �• - t3 . .� 77.41;11 Y800 ax (978)s7,45 0343;��;x �.a�a�i-, hry� �,� 'c" �*.,€.A,,;: "�;r � .:`,;�� � °�•�"�� , .a�� „`,.: Kimberley Onscoll :"IrafTldlrt(Q�S' 12�T1 COrll t r terry R6 AWRSIREHS,'CHO CP FS•M "f MayOrxs .` kS S "i yf at, y a'k,'r xz. >r e m-...v y T `r£ .:. r ,.. t sit T q;F"�,tu; Yg .ert r ,k •rxt r S,�y., �r Heaith eM 's,t , c e kqm "Yvr'�'.�2 e a '^:.{ y r>t✓''pu #_, rv,,..a a, �t.4r�' S'k'"miz'Su�. n d x uk2 �-.'raft 1? rr �>:. m rc`1Y r•'b7., $' P d t kb ma r@i ,r :r@@ 11119. "Al "� ' & FPUBLIC POOLfI E�ALTHPERMIT` .£�d,� hx<�:. � f 5 S u S ica. J A 8 �,•1YY)4 f\ ]a Y t Permit#y ':ti. ap kk+'k"xr. H'°'f �1,� "'yL:}t +v,: ,..a n F .c ,hi' ex zr, \., 'Rat.".,rt b�k ` ::'lye x p, °t .,,a.3�i+ `?'•<u.. , , Baa k - z '"`-✓r,u''£a�.: " j tv ,fa y:c vf„rsY + xa„t ,.:,. 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This permit or license is granted m conformity:vnth the'statuesand o finances relating thereto, antl expires,ort 4/30/2045 , unlesasooner 's,� , +' ,, ai.revoluid Or snS ended ,j a ' rn r. ,^; ..g "M„s °` w a., s;. •,. a . a` p t „ps�"°r a ° ` to Y*, l rc �"4 " �'`tY ta+Kv'r�. + - ,z >m g ss Itiq ia £ v t ge �,g {t v nv tir a x 'r f lvI A A . has CITY OF SALEM, MASSACHUSETTS BOARD OF HEAL 11 120 WASHINGTON STREET,4111 FLOOR KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 MAYOR LRAMDIN(CI�SALEM COM LARRY RAMIDIN,RS/REI-IS,CHO,CP-FS HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL j" a W' '-/I"��orI1L turn al Oyl S NAME OF APPLICANT 149,1 v7l 0ryLP (/0)71VYI M TEL# 1 p _7 /� - E2 - 0030 MAILING ADDRESS �2 0 � Aah la rt M CERTIFIED004OPERAT c Name: I IS� 1✓,Q ra- Cert#: TEL# q - 0 a� �ll�j o DATES OF OPERATION (if not annual): brI24I( I-/ — 9/.5/]V DAYS & HOURS OF OPERATION: 9611 OLM TYPE OF POOL Public Semi-Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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. 36 67 3 K Slgnature Date S#or Federal Identification Number Revised 5/23/11 poolappl l.doc Check#Date <�1 CITY OF SALEM, MASSACHUSETTS - BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBLRLLY DRISCOLL F,1\(978) 745-0343 MAYOR lratndin@salein.com LARRY RIDIDIN,RS/Riq IS,C1 10,CP-FS H1:AL-ni A(;FNT Swimming Pool Inspection Report Pool:_ 0I1 ri Date: 5'W ?, Address Phone�� Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards for Swimming Pools:State Sanitary Code Chapter V. Annual Permit Posted Health and Showers signs Posted cc!l�Health: no sick employees,no sick bathers, bathers take showers,spitting prohibited,no glass. Lifeguards: Present 4 _Certification _Red/orange suit _"Guard"printed on jersey 1/ _Sun block avail. _Voice Amplifier _Elevated seat Enver.Communication: phone at pool I _Phone instructions _Emergency numbers Phone in unlocked area Safet Equip: for each 2000,sq. feet Rescue tube or ring buoy(with rope) Backboard with collar and straps V First Aid: Equipmentarea �35) 1"band-aids 10)3x3 gauze )5x9 surgipads12)antiseptic wipes (1)8x10 Surgi :Z(2)2"soft roller bandages lssors (2)3"Soft roller bandages— _1/ Tweezers ) '/,roll hypoallergenic tape Rescue blanket a packs J _Pocket mask sterile isotonic eyewash isi ection Chlorine 4,� _pH 7.2—7.8 Residual free 1-3, Combined 0-0.2 / -Bromine �,t� _pH 7.2—7.8 Residual 2-6 (ppm)(mg/1) V Records Kept: _Water tests _Chemicals Used _Backwashing / _Attendance _Hours of operation V Depth Markings Sidewalk and inside pool rAL Diving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c cracks,non-slip surface,not over 10' above water level and at least 13'unobstructed headroom Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted, drained, ventilated, impervious construction,one shower and one toilet per 40 bathers,hot and cold water,soap provided,no common cups,towels,combs, pool adequately enclosed, approved drip mg water facilities I Notes: V 3 QQ _ dck nz l �s Received by: Inspected by: . %bgy8yz IV�,®{n�'IT.. •.� *�� :4+'�m�i� "w v x t y� .}} � p,�ry~t kkrt 'u w - ,r," � 3 f ! .1*'t �'� �. � � ' �Y �f'�_ - ^ �' y �u s.. 3 Y"^ @ I '� � d, "I4 ✓ S, $ L:Sc"'v+' •«T j ro$ al L W n ° � all r `+'L 4 v qg "3yR Y Yx p' '4 do 1 Ralk 'Ya" �' `O '6 kn �� °d rra�� ° ""'�'�k y„r usY�n Y 7 'r +'r � i` �' ` �r -;�k. �... SL ' r• ^"ti a^r s'i•' 4; +� :�E'm' `, vx nm a a` d .i s 'tea 'UyS.; 'cs �• x .... b . 3aAr ; 4it X0.1."'' .9 .r! _ a•P�+ Y r ! % r �,.y, +r lyy �, '' •M ® p � r Tr'� a ra . W Ox Og 'S b$ 9' " �! �^ s � _ .A _. wfCrO" y+�tig y: O � ..x`'' ,� ^ Riot d"$' ^� % w` '..QI y�,�', .rs, q, Om.m " 1�,r�ae C 4 S" ,r s •"` +.i E_,fis54 4CAW^'h„P` �..� � �fl-,k��'" mn:y a 5*�' ' . r m' w,.,. �, N ' tk 5 r }ksx ♦ ura n +^' a_y,a 0 �. a nri { . a x . N e� a d,, � '�a: � g � TM , !%Gs � a LL, 14 .� `'ra Al ' r,n�n Ny ,gw^ 3&' sb, n as 0 O.,y_• J�..k ,"+, xdQx'74 W + hb 'idY"t�'"` "' #,04 �� ' ° •' sr �" " Cl 'b re CL �,� m ,rwm ¢, .$ ".'�• 'm 'sGd� 'mo'T� °t..�.,.. �prx' L�o4"u � ;ZO a' ,�¢,"w � ., ,L " M m W E >r r� CITY OF SALEM, MASSACHUSETTS Bonxn OF HrnLXy 120 WASHINGTON STREET,4'11'FLOOR KIMBERLEY DRISCOLL TEL.(978)741-1800 Fnx(978)745-0343 MAYOR LRAMDIN0qSAI.I:iM.(;OM LARRY RAMDIN,RS/RBHS,CHO,CP-RS HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL-205 Highland Avenue Salem MA 01970 NAME OF APPLICANT Hawthorne Commons TEL# 978-825-0030 MAILING ADDRESS Same CERTIFIED POOL OPERATOR Name: High Sierra Pools Cert#: TEL#- 781)605-8337 DATES OF OPERATION(if not annual): May 25,2013-September 2, 2013 DAYS &HOURS OF OPERATION: Monday through Sunday 9am to 9pm_ TYPE OF POOL Public Semi-Public Special Purpose X FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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. Signature Date SS#or Federal Identification Number Revised 5/23/11 poolappl Ldoc Check#Date CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4°'FLOOR KIMBERLEY DRISCOLL TF-L. (978)741-1800 MAYOR Fax(978) 745-0343 lmmdin@saletn.com LARRY RANIDIN,RS/RF[IS,CIR1,CP-K, HEAI;fH Auwr Swimming Pool Inspection Report Pool:- O Date: SW�l Address O Phone:_ Operator: Max Bathing Load: /n accordance with 105 CMR 435.00 Minimum Standards for Swimmi_e Pools,State Sanitary Code Chapter V Annual Permit Posted Health and Showers signs Posted Health: no sick employees,no sick bathers,bathers take showers, spitting prohibited,no glass. Lifeguards: Present _Certification _Red/orange suit _"Guard"printed on jersey / _Sun block avail. _Voice Amplifier _Elevated seat I Emer.Communication:phone at pool _Phone instructions _Emergency numbers Pya,�on, _Phone in unlocked area NN_ Safety Equip: for each 2000,sq. feet Rescue tube or ring buoy(with rope) _Backboard with collar and straps First Aid: Equipment ar' e'a �35) 1"band-aids 10)3x3 gauze )5x9 surgipads 12)antiseptic wipes 1)8x10 Surgi :/(2)2"soft roller bandages issors — (2)3"Soft roller bandages.- Tweezers ZYI)%:roll hypoallergenic tape V1 � Rescue blanket e packs / Pocket mask sterile isotonic eyewash V Disi ection Chlorine L _pH 7.2—7.8 Residual free 1-3.Combined 0-0.2 _Bromine r 4i ',I' _pH 7.2—7.8 Residual 2-6 (ppm)(mg/1) V Records Kept: r„ _Water tests _Chemicals Used _Backwashing Attendance _Hours of operation V Depth Markings Sidewalk and inside pool N3�L:Diving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c cracks,non-slip surface,not over 10' above water level and at least 13'unobstructed headroom Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted, drained,ventilated,impervious construction,one shower and one toilet per 40 bathers,hot and cold water, soap provided,no common cups,towels,combs, pool adequately enclosed,approved drinking water f cilities Notes: V S 2 aCc{4, es Received by: Inspected by: Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 05/16/2012 ESTABLISHMENT NAME: Hawthorne Commons Pool Fite Number:BHP-2004-000196 205 Highland Avenue Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes SWIMMING POOL- BHP-2012-0440 May 18,2012 Sep 23,2012 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES ISeptember23, 2012 Board of Health Page 1 97Pi1,j25-0097 02:01:15 p.m, 05-08-2012 111 CITY OF SALEM, MASSACHUSETTS BOARD OF HrALTH 120 WASHINGTON S'rREcr,0'FLOOR HIIvIEERLEY DRISCOLL TEL(978)741-1800 FAx(978)745-0343 MAYOR taAntntN(alsal.rnt.cnnr LARRY R\MDIN,RS/RENS,CFIO,CP-FS 1 HEA1.rH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL Hawthorne Commons 205 Highland Ave Salem,MA 01970 NAME OF APPLICANT Meghan NewberryTEL#_978-825-0030_ MAILING ADDRESS-205 Highland Avenue Salem,MA 01970 CERTIFIED POOL OPERATOR Name:_Martin Pekarek Cert#:_22-101481 TEL#_(781)605-8337 DATES OF OPERATION(if not annual)May 27,2012-September 4,2012 DAYS&HOURS OF OPERATION: Monday through Sunday 9am-9pm TYPE OF POOL Public Semi-Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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 pequry that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. �AQ/S a/ O S gna re Date SS#or Federal Identification Number Revised 523111 poolappl IAoc Check#pate �� �n Wlce us IMP05TANT MESSAGE FOR A.M. DATE p TI P.M. M 4Mk`-,*- � n Q pmffhnS OF RHONE AREA CODE NUMBER EXTENSION ❑FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED �!' PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESS GE c 6N - i S& SIGNED p t�NIVERSAL_ 48005 MADE IN U.S.A. NOTES Inspection of ba Ayau- 1.35{'yLm ' t l �7E l Date � +Z 11 Time Name Address Owner Tel, No. Type of Inspection Pa�\ cD'��la� Inspector ( � 1 Remarks and Violations are listed below: ...p.� CZYWV1n;K4 WAS l'�cPiv� ��kL Djp i'� ' rt1�11S U+ l 16-` Poiln owyyt2 m*d CI—Ckitj Qfjk -n,�l I6, ?AC ertfm erg axe ' �)Q- rArak g)(or'- pal �s Vicec��vftiec ± bu hQd d A iy 6 — obl my.)" CbSeA 5sJM UM 06+0 *000- X00 ' oreX00 �n hc�Eeeh 1 rovl m <�j. CPO w((( �P� c�n�t r;, in cr'lC6n Wq UeJ- cel i'� w�l e I CICA iTmel co Report Received bi Inspection of Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( ' ) Remarks and Violations are listed below: e c n � �. 1��1 3 Cc-f eco/ ( o nri+CAJam s - Report Received by: Inspection of �`�- d- l�tJ� Date Time Name Address Owner Tel. No. Type of Inspection \ Inspector ( � I Remarks and Violations are listed below: CZ2v Vo -tom 0M tS. Report Received by \� f CITY OF SALEM, MASSACHUSETTS \ 130ARD OF HEALTH 120 WASHINGTON STREET,4O'FLOOR TEL. (978) 741-1800 KIM]31312LLY DRISCOI I FAX(978) 745-0343 14AYOR Iramdin@salem.com LARRY RAMDIN,RS/REHS,0 K),(T-FS HEAI::fIlt1GEN11, Swimming Pool Inspection Report Pool: Ylm" l �YYtWI S Date: J Address WCC i�r Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards for Swimming Pools:State Sanitary Code Cha t V. nnual Permit Posted _ Health and Showers signs Posted Health: no sick employees,no sick bathers, bathers take showers, spitting prohibited,no glass. If(Lifeguards: Present _Af _Certification _Red/orange suit _"Guard"printed on jersey _Sun block avail. _Voice Amplifier _Elevated seat mer.Communication: phone at pool Phone instructions _Emergency numbers S_Phone in unlocked area afety Equip: for each 2000, sq. feet _Rescue tube or ring buoy(with rope) ` _Backboard with collar and straps V First id: Equipment area 35) 1"band-aids =j10)3x3 gauze MCWf_ 5x9 surgipadsl ( )antiseptic wipes V 8x10 Surgi 1 �2"soft roller bandages ssors 1 — (2)3" Soft roller bandages ?escue eezers /z roll hypoallergenic tape blanket ' epacks c qtket mask �ferile isoteb cteyeew h �d _ Disinfection 1 '(• An� Chlorine pH 7.2–7.8 Residual free 1-3,Combined 0-0.2 romine pH 7.2–7.8 Residual 2-6 (ppm)(mg/0_ReKept:ater tests \/ hemicals Used V Backwashing Attendance VHours of operation Depth Markings Sidewalk and inside pool Diving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c cracks, non-slip surface, not over 10' above water level and at least 13' unobstructed headroom Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted, drained, ventilated, impervious construction,one shower and one toilet per 40 bathers,hot and cold water,soap provided,no common cups,towels,combs, pool adequately enclosed,approved drinking water facilities tl Notes: 3x3 c, f_ 3 C �'Pr:SIyP rc i L rt Received by: Inspected by: 6.3 Ct 1 CLVIJj'L CX_ Commonwealth of Massachusetts • r City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 0610212011 ESTABLISHMENT NAME: Hawthorne Commons Pool File Nmnba:BHF-2004-000196 205 Highland Avenue Salem. MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes SWIMMING POOL- OHP-2011-0460 Jun 2,2011 Dec 31,2011 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES December 31, 2011 Board of Health Page 1 I — CITY OF SALEM MASSACHUSETTS BOARD of HEALTH 120 WASHINGTON STREET,4"'FLOOR KIMBERLEY DRISCOLL TFL.(978)741-1800 FAX(978)745-0343 MAYOR LRAMDIN@SALiiM COM LARRY RAIN,RS/REHS,CHO,CP-FS HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL Z05 14jQtJ Wd A✓PMUe $Aleve MA 0197() NAME OF APPLICANT JA Jjn 2,e CpMnyvJ& TEL#_9 71-8Z5-0030 MAILING ADDRESS SAME CERTIFIED POOL OPERATOR Name: R(1GJ jm i R�W'f A Cert#: ?�.TEL# (o1"1-Rtk0- 2_)0 (= DATES OF OPERATION(if not annual): Skimle k .2 jj ber, -31, 2611 DAYS &HOURS OF OPERATION: 9LMAIYS — 9 C46el TYPE OF POOL -� Public Semi-Public Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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. Signature Date SS#or Federal Identification Number Revised 5/23/11 poolappll.doc Check#Date J4 Village Construetion 23 Congress Street Salem, MA 01970 978-745-9777 December 15, 2004 Custom Pools, Inc. 123 River Road Newington,NH 03801 Atm: Lisa Augusta Dear Lisa, Enclosed you will find a complete copy of the documentation (i.e. Mass. State sanitation codes, point by point responses from Robert Freligh,Nationwide Aquatic Consulting, as well as information from our project manager regarding the specifications required to open the hotel pool. i The last communication is a fax sent to you requesting input about specific items. We have not received any information from you therefore we are now unable to accommodate our guests with a pool over the holiday season as the board of health is refusing to accept it. i At this time, we will need you to review the entire package including all specifications required by the board of health as well as the responses, inquiries and any other information required to complete the installation of the pool. Please forward a letter stating that all items are within the mandated criteria and any questions you may have can be directed to either,Robert Freligh of NAC, Inc. or Russell Tanzer, Project Mgr.,Village Construction(all names and numbers are contained in enclosed documents). Sincerely, Michael ockett Village Construction 111 cc: T VI LGE FACSIMILE TRANSMITTAL SHCET _ TO: "ROH: Z15A COHCANY:C. V W 4ATG J��3L� FAX NUMOCR(fj^/: /©3. TOTAL NO.OF PAGES INCLUDMG COVER R@ YOUR REFERENCE NUMBER.: /V. A , C , Co&fig--)v 35.E vRf.ENT Cl FOR RGVICW O PLEASE COMMENT ❑ PLEASC REPLY 0 PLEASE RECYCLC NOTCSICOMMCNTS: SA . j�Le��s �'/�t ,� ZvoK VIA ?5�11 TYx , a . -Nationwide Aquatic Consulting, Inc. NAC, Inc. BOX 193 PO Box 695 NAHANT MA 01908 Chestertown, NY 12817 1-888-833-5770 TEL 1-781-581-3594 FAX Russell Tanzer, Asst. Project Mgr. 9/29/04 Village Construction 23 Congress St. Salem, MA 01970 Russell; In review of the fax sent by you to NAC on 9/29/04 1 have the following comments and observations. Most of the comments by Custom Pools are acceptable and clear up some missing or erroneous information Your company should have looked into the first sections (453.02-435.05) and made and changes necessary- little should have to have been done here, but catching some oversight at this stage is much easier to correct than when the building is in punchlist. 435.06 1-a. Custom Pools is now saying there will be a 4.16 hour turnover- this is much more desirable than the information stated on the plans. Changes must have been made that were not noted on the documents I reviewed. At start-up I will be looking for gauges on pump suction and pump discharge to verify the flow rate- the flow meter can be adjusted from these readings. 2-d. The feeder is still an issue. The explanation from Custom Pools is not adequate. I have looked at the brochure and called the manufacturer. The feeder will be a problem and should be changed. 4. See above. Still an open issue. I could not make out the comment next to 435.24, is there any way to get the list of safety equipment to be supplied by the pool operator? The same issue is taken with 435.35. The Health Code calls out specific requirements for the first aid kit, without specifics on the contents of the kit to be supplies I can not tell if this will be a problem with the Health Dept. The note next to 435.30 does not give enough information either. Could Custom Pools provide cut sheets on the safety equipment, first aid kit and test kit to be supplied with the project? 1 'Nationwide Aquatic Consulting, Inc. NAC, Inc. BOX 193 PO Box 695 NAHANT MA 01908 Chestertown, NY 12817 1-888-833-5770 TEL 1-781-581-3594 FAX It is a pleasure working with you and your facilities, and NAC looks forward to serving you and your facility in the future. If there are any questions please do not hesitate to call. Regards: Robert R. Freligh, NAC, Inc. CC: file, Salem BOH 2 09/28104 09::2f1." FAX 8034315109 CUSTOM POOLS INC X1001 123 River Rd. Newington, NH.03601 custorn Pools PHONE; 603-431-7800 _ FAX; 603-431-5109 ©a ftx '0 �� SS ape To: Alaplft 5ffi�c.uon From: Lisa Augusta I Fame: 978-7455654 Pages: 4 Pho„m We% September 28,2004 ( Re: CC: ❑Urgent 0 For Review ❑Please Comment CD Please Reply ❑ Please Recycle •Comments; AM:Russell Tanzer, Please see the following response to your fax an September 16,2004. l Sincerely, Lisa iI I I 09f28104 09:28 FAX 6094515109 CUSTOM POOLS INC 0002 09/24/2004 12:36 . . ,-9797456654 VILLAGE CONSTRUCTION PAGE 02 Nationwide Aquatic Consulting, Inc. NAC, Inc. PO Box 193 PO Box 695 Nahant, MA 01906 Chestertown, NY 12817 M-833-5770 781-581-3594 FAX 9116104 Russell Tanzer, Asst, Project Mgr. Village Construction 23 Congress St. Salem, MA 01970 Dear Russell, I have reviewed the project to the extent of the information that is available. I will point up the things that are a problem, things we stili need to go over and things that are OK- I will send the form that I work from and a copy of the MA Health Code by a-mail; if they do not come through I will hard copy ASAP_ 435.02 Was the design approved? They usually are not, but if so we should find the person that did the initial approval and work with him/her. 435.03 1. This section looks good, the 'dressing rooms' criteria are usually waved in the case of hotel/motels-the Health Dept. figures everyone has a dressing room. 2-4. Facilities are fine for the bathers. 5. The hose bib we discussed should be installed in the filter room or the toilet area. 6. This is usually waived in the case of hotel/motels-the Health Dept. figures sick or injured bathers would go back to their room, or stay on the deck if the injury is serious. 7. Hopefully there will be storage space in the filter room. 8. lighting was not inspected, but in hotel/motel settings this is usually never an issue, o�t�.wyy, e4� 9. This will be adequate (we hope) as the pool builder will install the heater as to ll"`"��5 specs. 10. The ventilation of these areas should be adequate;._the_HVAC-_designer.._._ — -_-- - _- stibuld-back tors gip: 11- This design should not have any problems in this area. 12- Not applicable. 13- There should be a drinking fountain in the pool area, but the project is a little too for along for the addition of this feature, and the health Dept. rarely asks for this, except in the case of large pools (Schools, YMCA's, etc.) 1 `/iN 14. Hopefully this area is covered. t" 435.04 The sewage disposal system for the building should have been acceptable per Health Dept. CUSTOM FOOLS I C 0008 09/28/01-- 09;28 FAX 6034315'109 VILLAGE RUCTION PAGE 03 Nationwide Aquatic Consulting, Inc. NAC, Inc. PO Box 193 PO Box 695 Nahant, MA 01908 Chestertown, NY 12817 888-833-5770 781-581-3594 FAX 435.05 2. Hopefully all the rest of the trades have worked to the codes. 3 &4.To be inspected when pool is nearer completion. 435.06 SE c 1-a. The prints showed a flow rate of 27 gpm and an eight hour turnover. There is �(p8 no note as to pool volume. A call to Lisa at Custom Pools indicated the pool volume was about 13,000 gallons, which would make the flow rate calculations Sa exact- some leeway should be allowed for dirt building up on the filter. The 27 gpm flowrate would give an eight hourtumover, that is compliant with the Health Code, but a six hour turnover is doable with the existing filter and is �) recommended. 2-a. The filter is OK- -b. The model of the pump is not specified- only that it is a 1 HP. The exact a- pump should give the 27 GPM at the maximum efficiency. -d. The feeder called out is NSF listed for Trichlor, this is guaranteed to be a problem with the Health Dept. and will be a definite problem with the new t, roperator. `3-b. Filtration rate is only 8.6 gpm/sgft., the literature calls out 15 gpm/sgft., but � fr this low rate is OK as per a call to PacFab on 9116/04.,�jj 4. The chlorinator should be changed. A ezll to Sani King indicated that the only chemical that is approved for use in this device is Tnchloro-s-triazinetrione. This sanitizes is for use in outdoor pools. The build up of Cyanuric Acid (a component c, of Trichloro-s-triazinetrione) to a level exceeding 100 ppm will trigger closure by Tthe Health Dept. Liquid chlorine or Calcium Hypochlorlte is recommended. W _ 435,08 2. There is an automatic fill system in the material supplied to NAC, but nothing on the prints. Is the make-up water to be fed into the pool, or into the piping in the j}i�-„d'1, filter r ? 3. The inlets can be inspected when the pool is nearer completion There-is-no.. -- �_ information-on-this-piese of the-equipment-Th"e"location of the returns looks OK on the print. ,n SZrre The main drains should be reviewed before the pool is to be put into S �rrN • - �, operation. Is there any information that could be provided on the main drains? x}35.09 `�O�There should be no cross connection of the pool water piping and the potable y5i z./ water system. The backwesh should go out through an air gap. 435.10 1. The 50150 split should be set at the time of start-up. 0 CIISIYOM POOLS INC la 004 0%/ /8ia/[ed4 91?$JPAI bh 9787456654 VIlLAGE CONSTRUCTION PAGE 04 Nationwide Aquatic Consulting, Inc_ NAC, Inc. PO Box 193 PO Box 695 Nahant, MAGI 908 Chestertown, NY 12817 888-833-5770 — 781-561-3594 FAX 3. The skimmer location and number of skimmers is fine, but will be inspected when project is closer to completion. 435.12 1. The depth markings on the pool wall looked Ok (I could only see one) and will be inspected when the pool is uncovered. There must be markings on the pool deck also. 2. There must be 4' stripes on the steps, there are presently 2x2 tiles (making w� pk this a 2"stripe).Another line of tiles must be added before the plaster is applied. 435.13. The walkway was not measured, the dimensions looked OK, but the pool was covered, so accurate measurements could not be taken. This will be checked when the pool is nearer completion, �4( 435.22 Proper signage must be installed (See 435.22). Only 'taking a shower' e and 'no one with a disease' must be on the wall by code, but the listing in 435.22- 2. plus any regulations of the host facility, should be on signs. 435.24 Safety equipment should be in the pool equipment package. is there any way to get information on these pieces of equipment? 435.25U a 7 s{ �1 } { .i !C,y ir- a��^ 1_A first aid kit should be in the pool equipment package. is there any way to get information on these pieces of equipment? 2. There must be an emergency phone on the pool deck. I forgot to ask if there was one planned, is there? r 435.26 2&3, is the backwash disposal system approved by the BOH? 435.30 4p t 1__A test kit shoUld_be_In.-the pool-equipment package.-Is there any way to get information on these pieces of equipment? It is a pleasure working with .you and your facilities, and NAC looks forward to serving you and your facility in the future- it there are any questions please do not hesitate to call. Regards: Robert R. Freligh, NAC, Inc. a J VILLAGE _ FACSIMILE TRANSMITTAL SHEET TO: � FROM: �Js —s coNPnNr: / Q f� DATE.- FAX mumurtt: nrcFA%NUMOER: i_ TOTAL NO.OF PAGES INCLUDING COVER: G� RE YOUR REFERENCE NUMRER: �DoI� co/vs oz- ❑URGENT *FOR REVIEW ❑ PLEASE COMMENT ❑ PLEASE REPLY Q PLEASE RECYCLE NorE.7coMNENrs: � If z L/iSRj f�tl� ,'4 Gook _715.1)7]7 FAX 978-745.6654 . , Nationwide Aquatic Consulting, Inc. NAC, Inc. PO Box 193 PO Box 695 Nahant, MA 01908 Chestertown, NY 12817 888-833-5770 781-581-3594 FAX 9116104 Russell Tanzer, Asst. Project Mgr. Village Construction 23 Congress St. Salem, MA 01970 Dear Russell, I have reviewed the project to the extent of the information that is available. I will point up the things that are a problem, things we still need to go over and things that are OK. I will send the form that I work from and a copy of the MA Health Code by e-mail; if they do not come through I will hard copy ASAP. I 435.02 Was the design approved? They usually are not, but if so we should find the person that did the initial approval and work with him/her. 435.03 1. This section looks good, the `dressing rooms' criteria are usually waved in the case of hotel/motels-the Health Dept. figures everyone has a dressing room. 2-4. Facilities are fine for the bathers. 5. The hose bib we discussed should be installed in the filter room or the toilet area. 6. This is usually waived in the case of hotel/motels-the Health Dept. figures sick or injured bathers would go back to their room, or stay on the deck if the injury is serious. 7. Hopefully there will be storage space in the filter room. 8. Lighting was not inspected, but in hotel/motel settings this is usually never an issue. 9. This will be adequate (we hope) as the pool builder will install the heater as to specs. 10. The ventilation of these areas should be adequate; the HVAC designer should back this up. 11. This design should not have any problems in this area. 12. Not applicable. 13. There should be a drinking fountain in the pool area, but the project is a little too far along for the addition of this feature, and the health Dept. rarely asks for this, except in the case of large pools (Schools, YMCA's, etc.) 14. Hopefully this area is covered. 435.04 The sewage disposal system for the building should have been acceptable per Health Dept. Nationwide Aquatic Consulting, Inc. NAC, Inc. PO Box 193 PO Box 695 Nahant, MA 01908 Chestertown, NY 12817 888-833-5770 781-581-3594 FAX 435.05 2. Hopefully all the rest of the trades have worked to the codes. 3 & 4. To be inspected when pool is nearer completion. 435.06 1-a. The prints showed a flow rate of 27 gpm and an eight hour turnover. There is no note as to pool volume. A call to Lisa at Custom Pools indicated the pool volume was about 13,000 gallons, which would make the flow rate calculations exact- some leeway should be allowed for dirt building up on the filter. The 27 gpm flowrate would give an eight hour turnover, that is compliant with the Health Code, but a six hour turnover is doable with the existing filter and is recommended. 2-a. The filter is OK. -b. The model of the pump is not specified- only that it is a 1 HP. The exact pump should give the 27 GPM at the maximum efficiency. -d. The feeder called out is NSF listed for Trichlor, this is guaranteed to be a problem with the Health, Dept. and will be a definite problem with the new operator. 3-b. Filtration rate is only 8.6 gpm/sqft., the literature calls out 15 gpm/sqft., but this low rate is OK as per a call to PacFab on 9/16/04. 4. The chlorinator should be changed. A call to Sani King indicated that the only chemical that is approved for use in this device is Trichloro-s-triazinetrione. This sanitizer is for use in outdoor pools. The build up of Cyanuric Acid (a component of Trichloro-s-triazinetrione) to a level exceeding 100 ppm will trigger closure by the Health Dept. Liquid chlorine or Calcium Hypochlorite is recommended. 435.08 2. There is an automatic fill system in the material supplied to NAC, but nothing on the prints. Is the make-up water to be fed into the pool, or into the piping in the filter room? 3. The inlets can be inspected when the pool is nearer completion. There is no information on this piece of the equipment. The location of the returns looks OK on the print. The main drains should be reviewed before the pool is to be put into operation. Is there any information that could be provided on the main drains? 435.09 There should be no cross connection of the pool water piping and the potable water system. The backwash should go out through an air gap. 435.10 1. The 50/50 split should be set at the time of start-up. Nationwide Aquatic Consulting, Inc. NAC, Inc. PO Box 193 PO Box 895 Nahant, MA 01908 Chestertown, NY 12817 888-833-5770 781-581-3594 FAX 3. The skimmer location and number of skimmers is fine, but will be inspected when project is closer to completion. 435.12 1. The depth markings on the pool wall looked Ok (I could only see one) and will be inspected when the pool is uncovered. There must be markings on the pool deck also. 2. There must be 4" stripes on the steps, there are presently 2x2 tiles (making this a 2" stripe). Another line of tiles must be added before the plaster is applied. 435.13. The walkway was not measured, the dimensions looked OK, but the pool was covered, so accurate measurements could not be taken. This will be checked when the pool is nearer completion. 435.22 Proper signage must be installed (See 435.22). Only 'taking a shower and 'no one with a disease' must be on the wall by code, but the listing in 435.22- 2, plus any regulations of the host facility, should be on signs. 435.24 Safety equipment should be in the pool equipment package. Is there any way to get information on these pieces of equipment? 435.25 1. A first aid kit should be in the pool equipment package. Is there any way to get information on these pieces of equipment? 2. There must be an emergency phone on the pool deck. I forgot to ask if there was one planned, is there? 435.28 2&3. Is the backwash disposal system approved by the BOH? 435.30 1. A test kit should be in the pool equipment package. Is there any way to get information on these pieces of equipment? It is a pleasure working with you and your facilities, and NAC looks forward to serving you and your facility in the future. If there are any questions please do not hesitate to call. Regards: Robert R. Freligh, NAC, Inc. Design Checklist- MA Health Code Compliance Section: 435.02 Design approval- Has plans, approved by MA Registered Professional Engineer or Registered Architect, been submitted to Local Board of Health?Y/N Date Has design been approved?Y/N By whom Date: Have changes been submitted?Y/N Date Approved?Y/N By whom Date: Has Board of Health been notified one week prior to pool opening?Y/N Date Scheduled Health Dept. inspection date: 435.03 1).Adequate dressing rooms? Cross trafficking?_Hotel N/A 2). Showers- 1/40 Bathers Y/N OK 3). Toilets- Females 1/40 Y/N OK Males 1/40 (1/3 urinals)Y/N OK 4).Washbasin- 1/60 bathers (in vicinity of toilets)Y/N _OK 5). Hose connections for flushing dressing rooms. Y/N OK 6). Room for sick/injured Y/N (blanket Y/N) OK 7). Storage space-janitorial supplies/instruction equipment-Y/N_OK_ 8). Lighting- Pool OK Deck OK Bathhouse/toilet areas OK 9). Heating units clear Y/N OK 10). Ventilation of showers/toilet areas OK 11). Acoustical properties (for lifeguards)__OK 12). b-fence-up to five feet-board or stockade NOT APPLICABLE Six feet or over- chain link Self latching gate-four feet above ground No openings wider than three inches c- barrier for indoor pools 4' high gate not wider than 3", self latching gate 13). Drinking water (bubbler)_NONE 14). a- toilet paper holders OK b-waste receptacles (covered in women's area) OK d- soap dispensers (no glass) OK e- mirrors unbreakable/safety glass OK 435.04 Sewage disposal acceptable Y/N By whom?_OK- HEALTH DEPT._ 435.05 1). Location acceptable OK 2). Conform to national, state and local building codes OK 3). No projections on wall of pool_NOT FINISHED-TO BE INSPECTED N _ 4). Walls acceptable NOT FINISHED-TO BE INSPECTED 1 Design.Checklist- MA Health Code Compliance 435.06 1). Turnover rates: a-pool (eight hours)_OK- 13,000 gallons(per Custom Pools)/8 hrs/60min= 27gpm b-Wading pool (four hours) c- Special purpose pools (1/2 hr) d-Slide flumes (1 hr) 2). Equipment: a-filtration system OK-TR-60 8.6 GPM/SQFT-OK PER PACFAB 9/16/04 b-pump(s) DURAGLASS 1_1 MODEL NOT CALLED OUT c-hair& lint strainer_OK_DURAGLASS d-feeder for sanitizer_PREFORMAX- NSF LISTED FOR TRICHLOR ONLY f-flowmeter(effluent)_NONE SPECIFIED g-balance tank/float tank/above rim fill spout_NA h-test kit NONE SPECIFIED I-complete system_MAIN COMPONENTS OK- 3). Filtration rates: Rapid rates ( 3 gpm/sgft) High rates ( 15 gpm/sqft-unless otherwise approved by NSF)_8.6 GPM/SQFT-LOW GPM/SQFT NOT A PROBLEM AS PER CALL TO PACFAB DE (1.5 gpm/sqft or 2 gpm/sgft with continuous body feed) Cartridge (0.375 gpm/sqft) Extra set of cartridges Variance necessary? 4). Chlorinators finely adjustable?_NSF FOR TRICHLOR ONLY COULD BE A PROBLEM Delivery rate 3 Ib chlorine/10,000 gals/24 hrs for outdoor pools_ Delivery rate 1 Ib chlorie/15,000 gals/24 hrs for indoor pools 5).Brominator? NA 6). Equipment labeled? accessible? TO BE INSPECTED 7). CO2: NOT APLICABLE a- injection point in recerc pipe with 5 second contact time? b- cylinders secured/protected? c- 60 sqft floor space mechanical ventilation 3 minute air change? vent suction from floor opposite air intake? discharge 1 ''/z' pipe minimum, does not contaminate outdoor area? 435.07 1). All materials non-toxic? OK resistant to corrosion and stress? OK 2). Drainage of all piping and equipment?TO BE INSPECTED 2 u . Design Checklist- MA Health Code Compliance 435.08 1). Inlets placed for uniform recirculation? OK submerged/adjustable? OK 2). Fill spout: under board/next to ladder?_NOT ON PRINT no sharp edges? NOT ON PRINT not greater than 2"out? NOT ON PRINT at least 6"above water level? NOT ON PRINT - 3). Inlets: not a hazard? NOT INSPECTED push surface debris toward skimmers?_OK ON PRINT- NOT INSPECTED (c) not greater than 20' apart?_OK ON PRINT- NOT INSPECTED_ not less than two (600 sift or less)?_OK one per 600 sift or fraction thereof?_OK velocity through inlets (15 feet/sec max.)_OK main drains: lowest point of pool? OK pools over 30'-at least two? OK spacing not greater than 20'apart?_OK spacing not more than 15'from walls? OK grating secured? NOT INSPECTED grating approved by NOT INSPECTED water velocity through grating?_NOT INSPECTED open area non-entrapment? NOT INSPECTED grates anti-vortex? NOT INSPECTED grates non-tripping hazard? NOT INSPECTED two suction openings for each pump separated by 3' or two planes? OK ON PRINT- NOT INSPECTED 5). Special purpose/wading pools cut-off switch? NA 435.09 1). Cross connection(s)? NOT INSPECTED 435.10 1). Water drawn 50% 50 % split from surface and bottom of pool? NOTINSPECTED 2). Gutter capable of 50% of flow rate from pool?_NA provide effective skimming? prevent flooding of deck? provide inspection and cleaning? not hazardous (sharp edges/openings)? opening for grating at least 2x area of piping? provides handhold for bathers? 3). Skimmers: a- one per 500 sqft. (or major fraction thereof)of surface area? _ OK special purpose pools- one per 100 sgft. Of surface areas? b- weirs at least 3"? OK c- 20 gallons/min/foot each weir? OK d- cleanable basket or screen? OK e- slide plate for balancing?NOT INSPECTED 3 Design Checklist- MA Health Code Compliance f-skimmers 30 gpm, min.-total 50%of flow rate? OK g-material acceptable? �OK freeboard not greater than 6"(unless handhold provided)?_OK— 435.11 1). Swimming pool depth min. 3' OK slope 1'to 12'max. (depth For less)_OK exception needed from Board of Health?NO _ 2). Special purpose pools depth 5' max. depth of bench 2'max. 3).Walls: slope 1'to 5' max. OK competitive pools-walls vertical to 3.5'_OK a- coves-depth 34' 12" radius max.`OK b- coves-depth 4' &up radius=depth of pool minus 2.5'—OK— ledges acceptable? NA 4). Ledge not more than 4" and about 45? NA ledges sloped slightly toward main drain?—NA 435.12 1). Depth markings on deck?_NOT INSPECTED vertical wall visible from inside pool?,OK-THE ONE I COULD SEE markings 4" high minimum/dark colors? OK-THE ONE I COULD SEE_ one foot depth intervals to a depth of 5'?_NOT INSPECTED appropriate places not greater than 25'around deep area_NOT INSPECTED polyethylene line/floats at break?_NOT NECESSARYIN THIS POOL 2). 4"stripe at break?_NOT NECESSARYIN THIS POOL steps and ledges?_OMLY 2"STRIPE ON STEPS 435.13 1). 4'walkways around pool?—NOT INSPECTED 3"around diving board? NA %" per foot slope to deck drain?—NOT INSPECTED 435.14 1). One ladder per 75'of perimeter(min. 2)_OK handrails? OK 2). Spa handrails? (min. 1) NA 435.15 3). Diving board height 1 m max.? NA 13' overhead room (8' behind, left&right and 16'ahead)? 4). Competitive board(s)- FINA or NCAA standards? 5). Handrails 1 m-30"over board and to edge of pool? Over 1 m- 36"over board and to edge of pool? 435.16 1), Water source approved by BOH?Y/N Date? _ 435.17 2). Operator certified?_AS PER GC 435.18 1). Permit? Y/N? Posted? 4 Design Checklist-MA Health Code Compliance 435.22 3). Signage? NONE CALLED OUT 4). Spa signage? NA 5). Spa clock? NA 435.24 Safety equipment? (one unit for 2000 sqft of surface area) ring buoys & rope?`NONE CALLED OUT rescue tubes with lifeguard ( one per station)? backboard with lifeguards? rescue pool (outdoor pools only)? 435.25 1). First aid kit compliant?YIN_NONE CALLED OUT 2). Emergency communication system? NONE SEEN 435.26 2&3). Disposal approved by BOH?_NONE SEEN 4). Separation system for DE? Y/N 435.27 2). Bather load? 4). Special purpose bather load? 435.30 1). Test Kit DPD?Y/N _NO Model 435.33 2). Special purpose pool(s)thermostat for high limit?Y/N_NA I I 5 ,may � Inspection of V(.W V, u�fif W- CC`-'�r X17 I n rml Date Time Name Address Owner Tel. No. Type of Inspection Inspector Remaar�kss and Violations are listed below: o box ' QP �301 ,��k Ice, Oct (0- 2lil h1:3� Q� 0 ���rn M I'm u6 116 C kIn ivw=e o �h�(C)w. Ci DAI d ill be, e .l tkg- noOI meeT_ 5 UJI-MMIoG . Report Received by Oate :1�. Time �.W �., Neme - "�AddFess'- ,own¢a Tel No._ Type,of Inspection =• �'n.� aInspctor ` ( ' Remarks and'Yiolatwns are listed below toy .b { ti �2 S$ 61JQ e T 71 111 +ti.>w TOO all ( Yt F� E d f Jt zV ii i� e i t I v ' ! 5 i ASK p Y k! v r il4a el ' s �f - " tA+ . , 1 f1 >} r t "fa 7t i iP,., -,}, df list 11 $ r�YX u >! 4 r'. Fj. t s{t` (a �*,.JC ti fi ,Y a. ' i,y�s i " tr. / ^- i f } a` f i S'4>•" yy '1 `3: a C v f Y �4� f �, k � � i Fr 1' � '4�f ��F k i '� / Jyq� �R. Id Ax •{•S �t {�'-;' R .i Y Y• � 5 n P r y roei a,t'�e j',.3 w z r v r� ; s �j s `), •. +sSif" � � ! ° it r'}4 �, _. i x f a r T3' yt ; f1hZ:i ax h4 ,u3`c* t� i � � t��"' JI �iS� §��� ..• :'^+.Ve� � if i- Ff� -�fS a- � p x '"15*�tY L+ ' t tk' A 3. ^} 1 -Zc �k� J� � »y� r iNY Z !J Rx r i L a s ✓� br n s J t i u E x'➢ 7.e .r r ,'R'e iv " $ 4, � b<s, 'y t^ f x ' M � e { 4�. }-,{moi +'s}` d t i 11qq { 1 .rtry fi 't s 1J T Alf t 5H 4tY i F Wi {{aah OVA } 2 yy r t s �' ed t&, ✓� 1 .. r S a Y1.4 Y J u Y�jt' Y f J q yq f +' xg[ti_ $ ,y � a a A o fi Elio, fv Y a QA Frr i t � � f i P� '{W P•[K�f tt f 5 'S N EGA 2 Rk L Y e Atai t"i ' l5! F (M % l F$, f t Y "f t{ '% f F' y , ei ° x } 1rP �0 ,..I", mt+>; rr"h. .><>_, ,L zx.•,... u_ .. .r._�.,.. �.9« , �_„ . ,. .w'... .vbr . r:� , ��A:*d,+fi`,�.�1'kv+.+�?ti'^.Gf�.��"�s"i n'� Y.niPFI�"' _ . w Wli�:, .,. k.�`kLn,3�a Inspection of i 1��- l4i�k c "7YbbY nrr, k�l Date t.J l) /�� Time Name Address Owner Tel. No. i Type of Inspection Inspector j ( ' { Remarks and Violations are listed below: ! \ I -)/,) E/7, 7 � � , �� � �xc� --H1 -i .�l-f� �. `il :?rt ��1� ens { l c1 - 1 r { ti( ru " - ( t t t �.. f .��.•°-�� <;:,"�� CV' { � . ^ li1 � 1 �;<' >�1 -s�-�,�' '.c..,.i11`•-ltt-, i��' !.<�: �'1 �',Yr,�'� � ["K1`- 0 t 4�� 1 � 6 -A —)n t: .1� rtl�f ' �nC � � tC� i`- Report Received by2a,..,, �—=:► = Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor Kimberley Driscoll SALEM,MA 01970 Mayor Swimming Pool Seasonal Permit DATE PRINTED: 05/05/2010 ESTABLISHMENT NAME: Hawthorne Commons Pool File Number:BHF-2004-000196 205 Highland Avenue Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2010-0418 May 28,2010 Sep 19,2010 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES ISeptember 19,2010 Board of Health Page 1 i .'may CITY OF SALEM, MASSACHUSETTS t2 r p l r i BOARD Oh HIiALTH 120 WASH1NCTON SrREET,4111 FLOOR T E1..(978)741-1800 I IMBERLEY DRISCOLL FAX(978)745-0343 MAYOR DGRE.G:NBAUNI&SALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION �FOR PERMIT TO OPERATE A SWIMMING POOL Ink, n LOCATION OF POOL ��� �irn/I� >}/ 1�5 J� t S d wot C( tr( r 0 I R 0 ��^ ,- ^ T v NAME OF APPLICANT 1,f(y1 TEL MAILING ADDRESS CERTIFIED POOL OPERATOR p (, Name: T— O it V l� Cert#00-2'7 TEL 2— DATES DATES OF OPERATION (if not annual): 0 t1- "TI O DAYS &HOURS OF OPERATION: ) d.Ile /gym - rl • el 0 ? m TYPE OF POOL Public Semi-Public Special Purpose FEE: $210.00 for year round pool $140.00 seasonal$40.00 Non-Profit (Please pay total with one check p ble to the City 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 1,to my best knowledge and belief,have d d all s to tax returns and paid all state taxes required under the law. J� Ib Signature Date SS#or Federal Identification Number Revised 8/14/07 poolapp.wpd Check Date o h0 S S�e/S-S no Inspection of {Tr1t A ,� �(Wl Date .�U /�� Time Name Address �� �fic4 ) 1�✓I � �. Owner Tel. No. Type of Inspection Inspector ��Ck�GVi��Da -t' O,wtffi� • ..h ( ' ) Remarks and Violations are listed below: ! u/\ r' rN-�✓11.' r- . •, iY OP,r- c11PoitC-u (S so �cz�' )(qt, 5��� • n� rl �rrc o�1t soft r:AQr ��rl �✓�o �I, nicl Kfa � I I \ )(IQ,k4A0Sk NrnC � 'a" AW " it• (�ra�nf 14GC 4,�Irf-n n ri n D r Report Received by: Inspection of -A� t, h iDate - -� '�.i-II C Time Name `y Address + 7 b k i / +6 ,Owner Tel. No. Type of Inspection . r InspectorL. r ( � 1 Remarks and Violations are listed below: r- ... •,x .YI �' +. •�I .c r• :I ,C1._i !"� 1-, t' �'�� , : , 1 ' 1i a i i f P F � . A �, I'k� n�'e , (' ��� xC� � �< 1p� , , Ar-� C�� t^r• � cX� - � � Y '�'��C ( �ltlt�t ('�v1� �Ir "ter -Fit -)t ;d K-tf� K-1 C n rl '1 1,-)- + c Report Received by: - -T CITY OF SALEM BOARD OF HEALTH - 120 WASHINGTON STREET 4TH FLOOR, SALEM, MA 01970 SM iMING POOL INSPECTION REPORT Pool: or rn✓Yl Date: Address: Ce R�ln I ct "A0e­. Phone q7-S &S-pU*O Operator: Max. bathing load: 1n accordance with 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code: Chapter V ✓- ANNUAL PERMIT POSTED ✓ - HEALTH and SHOWER SIGNS POSTED -HEALTH: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. LIFEGUARDS: Present _- certification - red/orange suit _- "guard" printed on jersey _-sunblock avail. -voice amplifier - elevated seat -EMER COMMUNICATION: phone at pool _-phone instructions - emergency numbers -phone in unlocked area SAFETY EQUIP.: for each 2000 sq. feet - rescue tube or ring buoy (with rope) backboard with collar and straps - FIRST 'AID : equipmem area -(35) 1" bandaids */-(10) 3x3 gauze / -(2) 5"x 9" surgipads -(I) 8xI0 surgi 1 -(2) 2" soft roller bandages - scissors -(2) 3" soft roller bandages tweezers -(1) 1/2" roll of hyperallergenic tape rescue blanket - ice packs AZ -(12) antiseptic wipes - pocket mask ✓-(I) sterile isotonic eye wash DISINFECTION 1.6 ✓ - chlorine pH 7.2 - 7.8 Residual: free 1-3, combined 0-0.2 - bromine pH 7.2 - 7-8 Residual: 2-6 (PPm) (mg/1) RECORDS: kept 7-D , I // - water tests �/ - chemicals used — - backwashing ROO I/ - attendance - hours of operation - DEPTH MARKINGS: sidewalk and inside pool DIVING BOARDS: rigidly constructed, properly anchored, braced for heaviest load, no splinters or cracks, non-slip surface, not over 10' above water level and atleast 13' unobstructed headroom - BATHHOUSE: scperatc dresnng and sanitary facilitics for tach scx -adjacent to pool, wcll-hghtcd.dramcd, ventilated, impervious construction,one shower and one toilet pu 40 bathers,hot and cold water. soap provided. no common cups, towels, combs 0001 adeQuzlcly enclosed approved drinking water facilitics received by:_ inspected by Aquaknot Pools Inc. 55 Woodrock Rd. Weymouth, MA. 02189 Hawthorne Commons November 6, 2008 205 Highland Ave. Salem,Ma. 01970 To whom it may concern, AqualmotPools;Inc.has installed 2 DS-360 Main Drain covers in the swimming pool. This will bring the pool into compliance with the Virginia Graeme Baker Act of 2007. For Aquaknot Pools Inc. . . d atrick O'Connor Stingl Products-DS360 Drain Cover Page 1 of I fin 9L T Your J� Peace •••/ �urlraeuvi of Mind i Maln Page Just In! Our Products � Regulatory Info Bullding/Heath Inspectors -Tech Info Contact Us PRODUCTS-DS360 DRAIN COVER . DS 360 will retrofit 5 1/2"-8"dia.sumps (Actual Cover 11"dia.) . Universal.fastener kit and security tool 01, Included in both models . I� t'xsg4�• . Both DS 360 &DS 360 M are pool - MR cleaner friendly . Either model works on dual drain as well ,`-..z as single suction outlets - - FL . Certified Safe flow of 123 G.P.M. . ASME/ANSI A312.19.8 2007 Standard - Compliant . Able to be installed on a Vertical or Horizontal plane . 27 sq. in.open surface area minimizes potential"Differential Hold Down Forces" of dual drain systems . DS 360 M works on 5 1/2"-B"dia.sumps as well as retrofit smaller 5"sumps utilizing additional knockouts(Actual Cover 10 3/8" dia.) Made by Drain Safe Ittp//www dreinsacoMDS360Ids360.hbnl Copydom 0 2005.2008 Sdngl Products All rights reserved.. http://stinglproducts.com/products/productsg/`2Ods360draincover.htm 10/17/2008 Shaw's 7.493 (978) 741 - 8660 STORE DIRECTOR - MARK BEBBER i 9/27/09 13;98 749381 0156 304 I MISCELLANEOUS MR MONEY ORDER 140.00 . . MR MO FEE .85 SUBTOTAL MISCELLANEOUS 140.85 ** SUBTOTAL 140.85 r** TAX .00 - **» TOTAL' _:x_4..0.85. __ ....._ -- — - --- **+ CASH 200.00 - - I s** CHANGE 59.15 ar+t*�+trararr�E�raarrritatu�wtwaa��et�a�Ex Total Number of Items Purchased 0 MONEYGRAM PAYMENT SYSTEMS,INC.DRAWER P.O.BOX U76 N vtFasE IE4o aFYLaSF sloE MINNEAPOLIS,MN SWO wwZ9m tmQAT114MOUNT..,,r fF 5 8.214 5 4 3 9 370 706,7IIJ E 7Da;A000 W -- • •DETACH HERE♦ • M 9U71-P ----------------- i Certificate of Conformity Page I of 1 Print this document for compliance with: VG$ 2008 Certificate of Conformity Identifying Product Name: DS 360 Citation: Section 14 (g)of the Consumer Product Safety Act, 15 U.S.C. § 2063 (g). ASMElANSI A112.19.8 2007 and VGB 2008 Manufacturer. New Water Solutions,Inc, Contact: Ron Schroader P.O. Box 360 Topton,NC 28781-USA Phone: 800-513-4372 Date of Manufacture: 2008 Sanford, Fl.32771- USA March 26, 2008 IAPMO R&T Lab: 5001East Philadelphia Street, Ontario CA. 91761-28I6-USA Phone: 909-472-4100,Fax: 909-472-4243 www.iapmo.org file:!/C:\Documents and Settings\dtenaglia\Local SettingsUemporary Internet Files10LK3... 12!1!2048 I 7 CommonwealthofMassachusetts ° City of Salem 'txT y/ Board of Health KlmbefleypDnsC011 120 Washington Street,4th Floor Mayor SALEM,MA 01970 DATE PRINTED: 05/13/2008 r '_ ESTABLISHMENT NAME: Hawthorne Commons Pool a « . - File Number:BHF-2004-000196 205 Highland Avenue ,,• ' +fid ga ' 6 '. xr x n•sp gV-�`F --.rL Salem._.:_ - MA-'-019_700,* �dS LOCATED AT: SALEM, MA 01970 1 ,= sw #x� 1 y i Permit Type Permit No. Permit Issued Permit Expires Fee It %Notes " �e � SWIMMING POOL- BHP-2008-0456 May 13,2008 Dec 30,2008 $140.00 ; a> SEASONAL -Total Fees: $140.00- a � f S j 3 4 . r v $' F M _ �w�s�����.. .,3avy`^ a ' - }' ar`£ctx wfp �•dw�uT�wi13�-� '4 PERMIT EXPIRES IDecember3O, 2008 . _ 3 Board of Health 1 I" t s � 7 r.'>rt���� a��..- � s L R CITY OF SALEM, NLAsSACIIUSETTS BOARD OF HEALTH 120 WASHINGTON S'rREF r,4"'FLOOR, TEL. (978)741-1800 KIMBBRLEY DRISCOLL F,ix(978) 745-0343 MAYOR alnrcl vi(dsni. �. :oro JANE"I'MANCINI Ac"FING HI'.AI:11i AGENT Swimming Pool Inspection Report Pool: 4aU5C-torla R .t M Ovv 5 Date: S la t tool Address d VP,. _—Phone:_ Cciis eZS� Operator: Max Bathing Load: In accordance with 705 C 435.00 Minimum Standards for Swimming Poets:State Sanitary Code Chanter R Annual Permit Posted Health and Showers signs Posted Health:no sick employees,no sick bathers,bathers take showers,spitting pprohibited,no glass. Lifeguards: Present _Certification Red/orange suit _"Guard"printed on jersey _Sun block avail. _Voice Amplifier _Elevated seat _V Enter,Communication:phone at pool _Phone instructions _Emergency numbers _Phone in unlocked area %/ Safety Equip:for each 2000,sq.feet ,/Rescue tube or ring buoy(with rope) __V Backboard with collar and straps ✓ First Aid:Equipment area (3 5) 1"band-aids ,G(10)3x3 gauze _(2)5x9 surgipads (12)antiseptic wipes -�(1)8x10 Surgi (2)2"soft roller bandages Scissors (2)3"Soft roller bandages Tweezers (1) %roll hypoallergenic tape Rescue blanket �[ice packs V Pocket mask sterile isotonic eyewash Disinfection _Chlorine _pH 7.2-7.8 Residual free 1-3,Combined 0-0.2 Bromine pH 7.2-7.8 Residual 2-6 (ppm)(mg/1) Records Kept: Water tests ✓Chemicals Used Backwashing Attendance -:�j Hours of operation Depth Markings Sidewalk and inside pool t Diving Boards rigidly constructed,properly anchored,braced for heaviest load,no splinters or c cracks,non-slip surface,not over 10'above water level and at least 13'unobstructed headroom Bathhouse: Separate dressing and sanitary facilities for each sex,adjacent to pool,well lighted, drained,ventilated, impervious construction,one shower and one toilet per 40 bathers,hot and cold water,soap provided,no common cups,towels,combs,pool adequately enclosed,approved drinking water facilities Notes: cdo k�3 'S �lhc� itwP S' r 'ttl i - a 0.f Ict'f Received by: Inspected by: Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 DATE PRINTED: 05/13/2008 ESTABLISHMENT NAME: Hawthorne Commons Pool File Number:BHF-2004-000196 205 Highland Avenue Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2008-0456 May 13,2008 Dec 30,2008 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES IDecember3O, 2008 Board of Health Page 1 L r r ` CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4-FLOOR TEL(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR )SCOIT2SALEM.COM JOANNE Sccrr, HF.ALTHAGENT 2008 APPLICATION 1ATION FOR PERMIT IT TO OPERATE A SWIMMING POOL LOCATIONOFPOOL QQS \\K�� �p.�, O)a1kM (nA -7 C) tI NAME OF APPLICANT NWVVIOCYl -(`OMejoAC, TEL# 97B- I -z6 30 MAILINGADDRESS ab5 �tt3 IGMh (1�1Q SO,I, AVI (1 6191.-70 CERTIFIf p POOL OP TOR 0 I—1'qt 9q? Name: p1 U, 1�_ AQ.,UJnO\As Cerra#:—TEL# OR —,9S v3 11" 1 DATES OF OPERATION (if not annual): M cx' G4 1 SQD\pp " 0 �S DAYS&HOURS OF OPERATION: 9 Ayre 6 CN p k TYPE OF POOL Public Semi-Public �- Special Purpose FEE: $210.00 for year round pools $140.00 for seasonal$40.00 Non-Profit (Please pay total with one check payable to the City 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 C er 3C,Section 49a,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have le allstPtZ lay ons an paid all state taxes required under the law. 1 / 1-7 66 q '2®— Si afore Date SS#or Federal Identification Number Revised 8/14/07 poolapp.wpd Check# Date .•R 0 I, �� c .�- •.+ ,.r ar.. ✓ < so y y..!Jrr .: •.+y •:: s a`'♦ v 's ..d' �✓. ♦i�,,.;y _ z�, y.;•• �`:�0�•. r ;r $ .. 'a ' d,•vt '. ♦ :r''�ti C+♦ivy 'r '' %♦f♦. J;ti' ' �, , •1� f f + wrVp i � L 5wj pts' ♦.•♦r'� Certified Pool / Spa Operator. - as an Operator of Aquatic Facilities CPO® Registration. No. 01 -181999 , is hereby Certified and Registered by the NATIONAL SWIMMING POOL FOUNDATION •y. onw, 10/28105. DATE CERTIFIED CG . O RIPNCTOr � C.E.O. tS�p�•�4' �: { f J 1 Ifl�f 'f ,.. �Jd f f i N J J♦} i �f �J hN� i'S' JrJ+ •�rbr •.•.. ...o.!a. ..a✓..b..,r•,, .:�- ,.a6.y-rti�'r. .•✓,.h. .:$�-� 03�. ' •'r'rW .._+Y'<, i tE♦,a e �e9a'♦,•, ti3y 9 `,.• i+ -'�' <p„y�. � �r ,y..-.,.v � m >.i 4v_+1e.:. .L'✓✓ �✓_-.^.Esv }�,�s..�� �t X�'.��✓ .vvfrSe'.`��.<'��r-•s.`f-_�..d, °k9 __ _..;., ga'�v'✓ y� •.1�� /��' /��✓�,\�.e"�---'''v'✓'sE �Sy,i CITY OF SALEM BOARD OF HEALTH - 120 WASHINGTON STREET 4TH FLOOR, SALEM, MA 01970 WE SWDD ING FOOL INSPECTION REPORT Pool: Date: Jr/aa Address: p Phone: Operator: Max. bathing load: 1n accordance with 105 MR 435.000 Minimum Standards for Swimming Pools; Smrz Sanitary Code Chapter V -,kNNUAL PERMIT POSTED V,IM-ALTH and SHOWER SIGNS POSTED HEALTH: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. ok- LIFEGUARDS: Present certification - red/orange suit _ - "guard" printed on jersey sunblock avail. - voice amplifier _ - elevated seat - EMER- COv�iTNICATION: phone at pool /hone instructions �mergency numbers (/- phone in unlocked area L/ SAFETYE for each 2000 sq. feet rescue tube or ring buoy (with rope) / OFA - backboard with collar and straps V - FIRS i : uipment area � Al�5) 1" bandaids � 0) 3x3 gauze (/-(2) 5"x 9" surgipads XA��roE 1) 8x10 surgi V-) 2" soft roller bandages (J�k tC ) issors :Z(2) 3" soft roller bandages tweezers ) 112" roll of hyperal genic tape �( rescue blanket �e packs -(12) antiseptic t�pocket wipes mask (1) sterile isotopic eye wash DISINFECTION ] rd chlorme pH 7.2 - 7.8 Residual. free 1-3, combined 0-0-2 bromine pH 7.2 - 7.8 Residual: 2-6 (PPM) (Mg/1) _ RECORDS. I t )water tests v/Chemicals used _/backwashing attendance hours of operation _V- DEPTH MARKINGS: sidewalk and inside pool tJ - ( DIVING BOARDS: rigidly constructed, properly anr h anchored, braced foeaviest load, no A splinters or cracks, non-shi) ,urface, not over 10' above water levcl and ztleast 13' - � unobstructed headroom i1A fHHOUSL-: scpcmtc dresLn¢ and sanitary facilities for wch scx-adjaocnt to pool. ..vcll hFhrcc,diamcd, veniilaled, imtx;rvious constnioion, one shower and one toilet per 40 bathers,hot and cold watcr. soap ptovidcd no common cups, Iowelc,conchs Ix,ol adconalcly C11clO$V1 approvCd drinking water racilitics received b _ y _ Inspected by. cati ce*4nz I Paul C.Agersea Service Supervisor I LfMHORNE m COMMONS 205 Highland Avenue•Salem,Massachusetts 01970 '*, tel:978.825.0030•fax:978.825.0097 ^N I.hawthornecomrnons@meEncpropertes.com•w vvvrnetricproperties.eom Paul C. Agersea Se COMMONS I 205 Highland Avenue•Salem,Massachusetts 01970 tel:978.825.0030•fax:978.825.0097 hawthornecommons@metricproperties.com•www.metncproperues.com