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Kernwood Country Club Pool Inspection 5-27-2016 QOCITY OF SALEM, MASSACHUSETTS BOARD OF HF-AL TH 120 WASHINGTON STREET 4"FLOOR PublicHealth Prevrnt.Promote.Protect. TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL lramdinQsalem.com L,1I212Y 1L.\14illIN,RS/REI-IS,CIIO,C[ 1,S MAYOR HEALTI I AGENT SWIMMING POOL INSPECTION REPORT NAME: DATE: TIME IN: ADDRESS: PHONE: TIME OUT: CERTIFIED POOL OPERATOR: Regulations 105 CMR 435.000 :Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V Regulation CompHance 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: TVb_ 1Y • High rate sand filter— 15 gpm/ ftz -20 gpm/ft2 (NSF filters) • DE filters—2 gpm/ftz • Cartridge filters—0.375 gpm/ft2 Automatic hypochlorinators required feed-rate capacity: • Outdoor Pools—Three pounds of chlorine per 24 hours per 10,000 gallons • Indoor Pools—One pound of chlorine per 24 hour per 15,000 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 de 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 V&CLA- &A&Lds ✓ a v :Sos�m V,/ 3aa� •�-{-.e,�, 5'r7,e -+ �� ors ����� sue, vma. �w — ►� p c �►► (q/ i��c&(z�r Gu a : '-T.06 �a SWIMMING POOL INSPECTION REPORT Regulations 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code, Chapter V NAME: DATE: Regulation ;Comliance Number 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 guardprinted in 4-inch lettering. Lifeguards shall direct their attention to area assigned 435.24 Safety Equipment—One ring Buoy for each 2000 ftz,One rescue tube and rescue hook Lifeguard staffed pools shall have readily available a backboard with straps 435.25 01 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 1 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�,_S Combined Chlorine 0.0—0.2 PPM • Bromine 2.0—6.0 PPM CCA.(C(v� I„ .dw)s __ 0 • pH7.2-7.8PPM 'Ze 0 v • 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 forspecial 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 CNIR 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 Wadi /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 H pH PH pH H 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: DATE: Remarks, Results and Actions: T pe: Type: Type: Free Free Free Chlorine Chlorine Chlorine Combined Combined Combined Chlorine Chlorine Chlorine Bromine Bromine Bromine H pH pH Alkalinity Alkalinjq Alkalini Calcium Calcium Calcium Type: Hardness Hardness Hardness Type: Type Pool Pool Pool Volume g Volume g Volume Sand Sand Sand DE Filter Type DE Filter Type DE Filter Type Cartridge Cartridge Cartridge Filter Size ftZ Filter Size ft2 Filter Size ftZ Minimum Minimum Minimum Flow Rate gpm Flow Rate gpm Flow Rate gpm Maximum Maximum Maximum Flow Rate gpm Flow Rate g m Flow Rate gpm Actual Actual Actual Flow Rate gpm Flow Rate gpm Flow Rate gpm l 1 l e C c76 o O Passed Inspection: Yes ❑No ❑ Re-Inspection Date: Inspector's Signature: Person In Charge: w 0 7 CO CD U ƒ ol O . 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TEL.(978)741-1800 FAX(9 78)745-0343 KIA-fBERI-EY DRISCOLL lramdin&salem.com LARRY RAIviDIN,RS/RF,HS,CH.O,CP-PS MAYOR HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL NAME OF APPLICANT 7V MAILING ADDRESS EMAIL ADDRESS_ _ s✓Ile" ct.' /2-L7&eV�e!0 CERTIFIED POOL OPERATOR //yy Name: D6VZ, 4117001 — Cert#: �� cSi�7sa TEL# DATES OF OPERATION(if not annual): 11k- o 20 ?/7 le? 67 -7, DAYS &HOURS OF OPERATION: TYPE OF POOL Public Semi-Public Special Purpose FEE: $21.0.00 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 I 1/20/13 poolappl l.doc Check#Date r 0/* 6 D ax Z E r0 >-1 C) o ILO O N 0 0 i 7 N o f fL]cn D 13 .N.. i 0 C O~Cl ID y I~ C 1 p c I R V; l i�. 3 C .n. O CD €; 3 C N p 7 ID I Z p 7 W =.0 tO in p 10 I O -.A G1 m i m 00 CDA C CD -+ R. I O o 0 I !;`. I Cl) a 'D 0 3 �1 3 - a � . 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Promote. Protect. Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS,CHo Mayor Iramdin@salem.com Health Agent 0 Swimming Pool Inspection Re pert Pool: C(- Date: Address _ Phone: Operator: Max Bathing Load: In accordance with I05 CMR 435.00 Minimum Standards for Swimmine Pools•State Sanitary Code ChaFter Y. �nnual Permit Posted Health and Showers signs Posted 1*�ealth:no sick employees,no sick bathers,bathers take showers,spitting prohibited,no glass. ^Life rds:Present Certification 1�ed/orange suit "Guard"printed on jersey Sun block avail. L.- Tbice Amplifier "*"'_Guard" seat V/ Emer.Communication:phone at pool i/Phone instructions _Emergency numbers f hone in unlocked area l Safety Equip: for each 2000, sq. feet )�escue tube or ring buoy(with rope) Backboard with collar and straps First Aid:Equipment area ✓(35) 1"band-aids ]0)30 gauze - __,,/(2)5x9 surgipads —(j2)antiseptic wipes v(1)8x10 Surgi 2)2"soft roller bandages ►"Scissors ✓(2)3"Soft roller bandages weezers 1) 1/2roll hypoallergenic tape U� ✓ Rescue blanket 5/�ce packs �— - - ✓Pocket mask !/terile isotonic eyewash Disinfection 1� J _Chlorine _pH 7.2-7.8 Residual free 1-3,Combined 0-0.2 2- _Bromine _pH 7.2-7.8 Residual 2-6 (ppm)(mg/0 ; Records Kept: v ? cy _Water tests _Chemicals Used _Backwashing _Attendance _Hours 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 Notes: 13el lA L.2�_ C-0 V r— 1 J i ti+., u" 0-)W" Received by- Inspected by: tA M " CITY OF SALEM, MASSACHUSETTS BO,�RD OF HEALTH 120 WASHINGTON STREET,4""FLOOR KIMBERLEY DRISCOLL TEL. (978)741-1800 MAYOR FAX(978) 745-0343 kamdin@aa—lcln.com com LARRY RAMDIN,RS/REFIS,<;I-10,(T-I�S HEALni AGENT Swimming Pool Inspection Re ort Pool: 9_16�.Ir�Ts LAI Date: 6 " 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 Health:no sick employees,no sick bathers,bathers take showers,spitting prohibited,no glass. Lifeguards: Present / /� certification ✓zd/orange suit ,/_"Guard"printed on jersey / V Sun block avail. /Voice Amplifier Elevated seat Emep.Communication:phone at pool ZEmergency Phone instructions numbers Phone in unlocked area 'Safety Equip: for each 2000,sq.feet _ rin buo with rope) _V/Backboard with collar and straps First id:Equipment area �' 5) 1"band-aids +� 10)3x3 gauze 5x9 surgipads 5412)antiseptic wipes �"(1)8xl0 Surgi ;/(2)2"soft roller bandages )7 cissors _�2)3"Soft roller bandages v, weezers �(I)'/z roll hypoallergenic tape Rescue blanket !<I e packs �ocket mask ✓ sterile isotonic eyewash Disinfection _Chlorine _pH 7.2—7.8 Residual free 1-3,Combined 0-0.2 C1 3,4 _Bromine —pH 7.2—7.8 Residual 2-6 (ppm)(mg/1) 0 g,0+ Reco s Kept: Water tests _✓Chemicals Used Y Backwashing 'attendance }Hours of operation Depth Markings Sidewalk and inside pool 0 da 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 rctViAce, king water fac=Lc_aL:i / ,'• Notes: co ( l U ( �3 I�I� rl� -s7 1 1�P(O r `�o O r Received by: Inspected bmcti v - J prj' `i ' W t W CD X*.C '" - - 3 - a CD Q. trtp a; Z 70 r D o m a o m in m oN r o -cr., C sNco s o, o m n_,= `0 O WiCD z; .x ° (D o o �. co tl? , r '00 CD at cc Co rn w s Fit a " - m - - CL RL CD te CD W 51 CD 3 N OCITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET 4-FLOOR PubliCHe'�lth , Prevent,Promote.Protect. TEL.(978)741-1800 FAx(978)745-0343 KIMBERLEY DRISCOLL ItamdiqC@_saletn.com salem.com Lr1RI2Y Rr1NIDIN,RS/RFI-IS,CHO,CP-FJ MAYOR HEAI:rii AGENT APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL ®� LOCATION OF POOL U)0'-4 NAME OF APPLICANT 641-n -0,29 CLt TEL# MAILING ADDRESS CERT ED POOL OPERATOR Name: 1,1vet Cert#: TEL# DATES OF OPERATION(if not annual): U G/ �h Lmx�z 6 DAYS &HOURS OF OPERATION: Q 7LD pry) , Mop p --Su o 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 523/11 poolapp]Ldoc Check#DateS-ZZ 4'� o2-Z<5?s' q ��.r.-.,�'�'� ��, � '€'�; >r v�- .,.,�.r "L.�`�,J t'��r';:At` �'�.�, f''�•'� r.: �" ' �~r�;.. '+,. All zo. � y y #'a , ¢¢ ,.,at 4,`u _. r�+k �4 ` *4"#•�,t:, gi Q ai,,r;. 4 _ �"'8'«?t,�xs. s a' �A,C p � .o� a� ��$6 +1� R� Y; � W NE .7 : ( .• ��`��7 � �, � t + �.,,+ f�.�w rY z m ,y f �`f c dam. 9 �''t ''r +,, � � _ a r .Y R.r`. m ''•c 4 ..+ r xl., "p'J °,�_."F:." y F 3« -z ' z�zzf lit ,.n" x •_.„ q ,�s f�Yr,%�y, �a - ". a s' t.t i -�� R•�#r ,��.k, r -'� a.a�4�1Er <-.,4� � s - a � �r"t��.a y,_�� _ _ 's. — � _ � � �`tr - .•�y..z., , fit - 4.y3n FTAMA as 'd"¢�' s°".6't* a : .a tom,.•' rF to mom .,.. 'lu, ��N.' ��� � r• � �laCIQi v own 'ZI �:� � � wry!-.. • � x�,,. �`c$% now _ �� � � • �,,� ate ., � � M ` & sy e1 n:wa 1a 6im 4�5'bLL i�ddSV�l auoyda�a} u MUM 10_4 ; MWI� .�;.—�..?�� .�,a„=/ �r-•�� '-�`�:..�+ - ',ts -�z' .r.� •Z,'�,J-' -'�"zs: £�' -•.�.�' ...-: s y�.:%; i."„mod'"•' -.. =, .:5:-, ice%- ..,..-'. s �) CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTO N STREET,4""FLOOR KIMBERLEY DRISCOLL TEL. (978) 741-1800 MAYOR FAX(978) 745-0343 lramdin&salem.com LARRY Rt1NMIN,RS/RGI IS,CIAO,C11-1'S HEALTIi Act Nxr Swimming Pool Inspection Report Pool:_.t C(_Xs-� Cj�' Date: 51 ar'61 Address Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards Lor SwimmiMg Pools;State Sanitary Code Cha t� er 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 COe+'e..S Red/orange suit ard"printed on jersey Sun block avail. Voice Amplifier _ levated 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 id: Equipment area V(35) 1"band-aids (l0)3x3 gauze 5x9 surgipads �2)antiseptic wipes V(1)8x10 Surgi ✓( )2"soft roller bandages V issors _ )3"Soft roller bandages � � �, CA t `�,$y H weezers 1) '/z roll hypoallergenic tape $i GI �,A 1' Ppoolescue blanket � packst ' ocket mask —sterile isotonic eyewash !3+ U 7.1 PR Disinfection _Chlorine _pH 7.2-7.8 Residual free 1-3,Combined 0-0.2 _Bromine _pH 7.2-7.8 Residual 2-6 (ppm)(mg/1) Records Kept: /Water tests ✓Chemicals Used V Backwashing h'4cd M 0Z-rq_$' V Attendance _A/Hours of operation�� ,a( 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 Notes: Ir Received by: Inspected by:F.'Sa ct.K recz(�. 1�e© i 1 c -- �, ..,e -----, T, ----'i-� -:-- �-,- -- 6- ,----- 7 - L% ,- : i.----!----�_,- �--.-4--- .- .----.-�- - ,-.----�---�--�--- . --_. - �I �--�,-- . ---,--:---,- - I �- - -- - -.- - _--- ! : -.- , ,�- I -.,.- ,- �1 1 .< I 1conim6iWealth I sac ttk - ,l 0 citO0W-SAea - 7 - Whbedioy Un ll� Board of 1I &-, mayor -l10 W*�Jgu ,er t-o0 -4Ih�nd " , SAL - ,- A,. -019 7- Swimming Pool e .t PV DATE PRINTV 05/22/2013` - I� : "-t _-- --X,- II a '-- - -, ­ �1--- 4. � -,--_- , l -I -., - - i , - .- :- . - 4,z - - 4 ,1 ESTABLISHMENT NAME. I ;, emWood CQU� PontD , Fil�4a�W- 4W 0 -000lq Kp c�4slj et !, = MA 01970 - Saio n �, LOCATED A- I ,_'— i(ERN-W0- STREET - - A E 1 A 019 0 -, w 1i . - penuit T Permit No. Perndt-Issued 'Permit ExIres Ni Restrictions/ otes AA gvv-uvlANG POOL BHP- 422 May 1 ,2 Sep 9,20� $ 4C.66� li1AJ ..-_ - — -.- ,.I ---� �- ,,�---.�- �i '. - ,I-,-- ,- . - �--- ; SEASONAL y- , -"I �- ---- Total Yee 3140.00, � ,- -< ., V - - - � .­ , , 1� � � � - ; ,. .. --,i - � � - - = , , - . - - - - - - - - -- _ �I - .., V-, ,7 ' 1_ I; �- $ -I - - - I. -� 4I1- - ,�- - t ,-- �1- I � .. - 7- � I I. -,---- - i S --- - ; - v , ;. PERMIT:EP LREg _, '6 &9�2013 BoArd . 6Ith - -v _ - - - I, . iZ ; - � " V-s1rt ;- , � - 4 Page i - - __ - - - __ - . ri° - I, ,I .. - - , I �I -- -I- � -----,-!�,--—- ------1� -�----'-.-1--—1 - - ti y CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTI I 120 WASHINGTON STREET,4T"FLOOR KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 MAYOR LRAAMDIN@S,^LEM.COM LARRY RAMDIN,RS/REHS,CHO,CP-FS HEALTH AGENT 2013 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL NAME OF APPLICANT A/I rn We o a( (o fKy Cr0-b TEL# �170 7 r MAILING ADDRESS CERTIFIED POOL OPERATOR Name: bo a`1 l aj r,7 Cert#: o!"�C�J TEL# I d=y-I-')— q`f33 DATES OF OPERATION(if not annual): rl Gty .? ,h f of o/.3 — Sz j9 f d 6/J DAYS &HOURS OF OPERATION: Han - ?1 A� 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 poolappl Ldoc Check I#Dat "Z ^ID I r w This recognizes that Emily Harney �61 has completed the requirements for CPR-AED for Lifeguards conducted by r YMCA-Lyn nfield/Peabody LV Date completed: 06/04/2011 The American Red Cross recognizes this certificate is valid from completion date for: 2 Years This recognizes that Emily Harney �t3 ® has completed the requirements for Lifeguarding/First Aid conducted by YMCA-Lynnfield/Peabody Date completed: 06/04/2011 The American Red Cross recognizes this certificate is valid from completion date for: 3 Years -.s _ This recognizes that M (/) Rebecca Wester �V 0 has completed the requirements for d CPR-AED for Lifeguards 0 conducted by YMCA-Lynnfield/Peabody Q Date completed: 06/04/2011 The American Red Cross recognizes this Certificate is valid from completion date for: 2 Years C tA This recognizes that i M y Rebecca Wester 6! has completed the requirements for Lifeg u a rding/First Aid E.� Conducted by YMCA-Lyn nfield/Peabody 49 Date completed: 06/04/2011 The American Red Cross recognizes this certificate is valid from completion date for: 3 Years ro the FOR YOLITHDEVELOPMENT° TRAINING CERTIFICATION FOR HEALTHY LIVING `ram FOR SOCIAL RESPONSIBILITY YMCA OF THE USA Rebecca Greenberg 245 Cabot St Beverly, MA 01915 Dear Rebecca, Congratulations on successfully completing a YMCA of the USA training certification. Please review the information on your attached certification card. Please use this form to correct or update your contact information or to request a duplicate card. O The information that appears on my records is incorrect. I have marked the changes above. OI have enclosed $20 for a duplicate card request for my certification. To obtain a copy of your official training transcript, please register on www.ymcaexchange.org (User ID is YMCA and Password is 9622) and create an account under the heading "My Account." Questions? Please contact us at event.registrations@ymca.net or call our Contact Center at 800-872-9622. 7E TRAINING CERTIFICATION the YMCA OF THE USA 12MAAQ711BY063 Rebecca Greenberg Lifeguard 2011 Expires 12/30/2014 YMCA OF THE USA 101 N Wacker Drive,Chicago IL 60606 ASHI-approved Certification Card Administration IIciY1c'�r t:,,. p Authorized I•structor(print Name) Ctr+�f n kje:r` } has successfully corn feted the required knowled egnd mPetently erforryTgfj- Cardholder's Signature 9 8rlcf'skilf P.ectives for k , - f J s i r.i Emerges cy 0xygefiAgministratlofi. s r Renewal cafe - - -' 1 .r 'l - r 1 CA t` Training Center Phone No. Training Center I.D. Cardholder has met the gobjectives an ASHI-authorized Inst uctoc ASHI'sl cu reculumkis cosistent with wtlely curriculum cept d satisfaction nfof W y Arnerican Safety&Health an{ASHI} g y`tea _ crAz An eme enc oxygen administration.Certification does not licensure or credentialing. guarantee fulurs peAormance,or imply state Rate Your Program Help us imp Digital Book Included With Your Certification rove the quality of instruction, To access your personal co instructional materials Student Handbook, visitpthe t�gEaebook OxYgenAdministration r and customer SerVlce. http://www.ashinstitute.org/dbdc.htm. Follow the simple instructions download center at using the password and user ID below. Your training also includes ASHI LeamingUnks'"brief web-based se Visit ashinstitute.org. that review emergency care topics covered Burin Click on the at the digital book download center. 9ments Rate Your Program link on g Your class.Learn more Page. Let us know what you think.e home Password:EGA User ID: 6A1 AMERICAN American Safety&Health Institute 1450 Westec Drive ■ SAFETY& Eugene, OR 97402 HEALTH - 800-447-3177 INSTITUTE P,member of the HSI family of brands Sunday, May 19, 2013 Rebecca Greenberg Dear Rebecca Congratulations on successfully completing your American Safety& Health Institute Basic First Aid class. In an effort to be more environmentally friendly your ASHI Approved Training Center has chosen to issue your certification card electronically. The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASHI Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Go online to access your ASHI Passport and take advantage of the additional training resources available to you: • Digital download of Student Handbook • LearningLinksTm Refresher Scenarios • Mobile Application Downloads • E-mail Renewal Notification • Rate Your Program Survey Register now at www.hsi.com/passport/. Use the registration code 3477 to register. YMCA of the North Shore Inc-Association Office 245 Cabot St Beverly, MA 01915 -------------------------------------------------------------------------------------------------------- _ ASHI-Approved Certification Card � M Dorothy Calandra CertificationCard f' Authorized Instructor(Print Name) 118058 Registry No. _Rebecca Greenberg 01/26/2013 01126/2015 has successfully completed and competently performed Class Completion Date Expiration Date the required knowledge and skill objectives for this program. 978.356-9622 Y2861 AMERMAN Training Center Phone No, Training Center I.D. ISAFETY& This card certifies the holder has demonstrated the required knowledge and skill objectives to a cur- HEALTHA rently authorized ASHI Instructor Certification does not guarantee future performance,or Imply licen- sure or credentialing.Course content covers all age groups and conforms to the 2010 AHA Guidelines INSTITUTE for CPR and ECC,and other evidence-based treatmentrecommendations.Certification period may not exceed 24 months from class completion date.More frequent reinforcement of skills is recommended. CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH NN 120 WASHINGTON STREET,4 f(1 FLOOR TEL. (978) 741-1800 KIMBEERLEY DRISCOLL FAX(978) 745-0343 MAYOR ltam 'n G salem.com LARRY RINIDIN,RS/RIiIIS,CL 10,CP-11S HE;ILTFI AGIN'r Swimming Pool Inspection Report Pool: L- Date: Address Phone: -� Operator: Max Bathing Load: In accordance with 105 CMR 435.00 Minimum Standards Lor Swimming Pools.State Sanita Code Chanter 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 ✓ Emer.Communication:phone at pool ✓Phone instructions —Emergency numbers _✓Phone in unlocked area Safety Equip: for each 2000,sq.feet V';f1escue tube or ring buoy(with rope) 1-- Backboard with collar and straps v"First Aid: Equipment area ✓(35) 1"band-aids 10)3x3 gauze ,/(2)5x9 surgipads12)antiseptic wipes ei(1)8x10 Surgi _✓(2)2"soft roller bandages _scissors _I(2)3"Soft roller bandages Tweezers �1)'h roll hypoallergenic tape L.-Rescue blanket ice packs _ Pocket mask ✓sterile isotonic eyewash Z Z 7 Disinfection �I'l �� v Chlorine _ 17.2—7.8 Residual free 1-3, Combined 0-0.2 _,,-Bromine -- pH 7.2—7.8 Residual 2-6 (ppm)(mg/ 0 :l Records Kept: f3a' V"Water tests ✓ Chemicals Used Backwashing _✓Attendance _Hours of operation {��' r�� �, . —�Depth Markings Sidewalk and inside pool l Ali 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 v" 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: 34,1w�� Received by: Inspected by: v n w CITY OF SALL'M, AIASS.ACHUSET'I'S BOARD OF HEALTH 120 WASHINGTON STREET 4`'FLOOR PublicHealth f'--L i'romotc.Protect. TEL. (978) 741-1800 FAX(978) 745-0343 K1Ml3L?RIJ','Y DRISCOLL lratndinosa let n.cona LiM10"R.kMDIN,RS/RFU IS,CIK),CP-FS AXYOIt Swimming Pool Inspection Report Pool: fermi C t`4i C.W Date: Address - Phone: Operator: Max Bathing Load: In accordance with 105 CMR 435.&Minimum Standards for Swimmin Pools•State Sanitary Code Chanter V Annual Permit Posted %ol'—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 Emer. Communication:phone at pool Phone instructions _Emergency numbers _Phone in unlocked area S2Rescue Equip: for each 2000,sq.feet tube or ring buoy(with rope) _Backboard with collar and straps First Aid:Equipment area (35) 1"band-aids —(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) '/2 roll hypoallergenic tape _Rescue blanket _ice packs Pocket mask —sterile isotonic eyewash C� py Disinfection - ��C�,e ��� �J•CJ� ��(] _Chlorine5.4 `],�' pH 7.2—7.8 Residual free 1-3,Combined 0-0.2 P ,/ _Bromine _pH 7.2—7.8 Residual 2-6 (ppm)(mg/1) V Records Kept: Water tests _Chemicals Used _Backwashing _Attendance _Hours 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 Notes: Received by. Inspected by: R Commonwealth of Massachusetts a City of Salem b Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 05/24/2011 ESTABLISHMENT NAME: Kernwood Country Club Pool File Number:BHF-2004-000193 1 Kernwood Street Salem MA 01970 LOCATED AT: 0001 KERNWOOD STREET SALEM, MA 01970 Permit Tye Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2011-0443 May 28,2011 Sep 6,2011 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES September 6, 2011 w Board of Health Page 1 I CITY OF SALEM, MASSACHUSETTS BOARD OP H.EAL'1Z-1 ' 120 WASHINGTON S nzr,.]3T,411'FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 RECEIVED ncxrrNriAuivl sAl.r;n�.CO�i MAYOR MAY 172011 DA-vID GREENBAum,RS CITY OF SALEM AcrrNG HFAMU AGENT BOARD OF HEALTH 2011 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL e_C fl U ( `tJ NAME OF APPLICANT_h C nl W 6 0 � CG ���1-"( ��O TEL# -l L� a MAILING ADDRESS i�e� o M O CERTIFIED POOL OPERATOR O/ /9•5� Name: a � Cert#: TEL# a] -9a7 DATES OF OPERATION (ifnotannual): MOW *emb2r Jrl oZ0 11 DAYS &HOURS OF OPERATION: o - i �1 Aon --� _I 'm 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. T-• •a tzte c y ► fo r ene-v:-io � Sni r^ve.rnentts� or Eq * went changes are matte all plans f^r .,.accordance e..,h the 5�.. �a:ii.arI Code,before»^y , p , -. p- b-� r 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 eral Identification Number Revised 10/6/10 poolappl Ldoc Check# Date d a �t Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Swimming Pool Seasonal Permit DATE PRINTED: 06/30/2011 ESTABLISHMENT NAME: Kernwood Country Club Pool File Number:BHF-2004-000193 1 Kernwood Street Salem MA 01970 LOCATED AT: 0001 KERNWOOD STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2009-0445 Apr 23,2009 Sep 30,2009 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES September 30, 2009 Board of Health Page 1 e +i s l• ti ,j CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4T"FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR DGRII;[sNBAUM(�!SALI-Ibf.COINI DAVID CTRFFNBAIJM, AM ING HEAi:rH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL 1 s+- -5a Le M H �- NAME OF APPLICANT Q I'I1WOOJ Ca C(Ub TEL# Z d'-7��- 1 X(U MAILING ADDRESS [ (✓> �} _ -F 5a,LP I'v1 M 1 C1-70 CERTIFIED POOL OPERATOR Name: 'boLA `j I CLS A-1 b Y I n Cert#:a/4195� TEL# DATES OF OPERATION (if not annual): 5-ea 50.,,cd- ! emoria P 'Da.4 wu k-PiJ -k� LZL, y),r bay DAYS &HOURS OF OPERATION: 11 A-M - 2 PM fat l 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. I_r 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 63 C,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 8/14/07 poolappmpd Check# Date CITY OF SALEM BOARD OF HEALTH — 120 WASHINGTON STREET 4TH FLOOR, SALMI, MA 01970 n i SYMMY LNG POOL INSPECTION REPORT Pool: Ltmu-0ca Ccz)untrlc(. i- Date: siaj� t Address: Phone: _ Operator: Max_ bathing load:` In accordance with 105 CMR 435.000 Minimum Standards for Swimming Pools, State Sanitary Code: Chapter V. V- ANNUAL PERMIT POSTED to� (c� vt tl �5�"�� I► - HEALTH and SHOWER SIGNS POSTED C.'a ower door -HEALTH: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. ,�- LIFEGUARDS: Present Or- 'r v/ -certification redl_q•range suit ✓- "guard" printed on jersey sunblock avail_ � A e�a`mplifierOJV- elevated seat 1�-EMER COMMUNICATION: phone at pool -phone instructions - emergency numbers -phone in unlocked area ✓- SAFETY"UIP-: for each 2000 sq. feet v - rescue tube or ring buoy (with rope) �- backboard with collar and straps - FIRST AiD : equipment area ; e/-(35) Vbandaids ,, fi -(10) 3x3 gauze -(2) 5"x 9" surgipads 5 A -t -(1) 8x10 surgi -(2) 2" soft roller bandages 1 V/- scissors -(2) 3" soft roller bandages V- tweezers ✓-(1) 1/2" roll of hyperallerger is tape V/- rescue blanket ice packs V-02) antiseptic wipes I - pocket mask 1) sterile isotonic eye washrctle , ✓- DISINFECTION Q., i. - 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 - - ,p --- -- ---- -- ---- ---- -water tests V - chemicals used ✓- backwashing CO- f ✓- attendance - hours of operation IV1J C.�7oh} V - DEPTH MARKINGS: sidewalk and inside pool DIv1NG BOARDS: rigidly constructed, properly anchored, braced for heaviest load, no splinters or cracks, non-slip surface, not over 10' above water level and atleasi 13' unobstructed headroom. V/- BATI-HOUSE: seperatc dressing and sanitary facilities for each scx-adjacent to pool, well-hghtcd,drained, ventilated, impervious construction,one shower and one toilet pc[40 bathers,hot and cold water.soap provided no common cups, towels, combs Pool adequately enclosed approved drinking water facilitics received by: _-- — inspected by: Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor lQmbedey Driscoll SALEM,MA 01970 Mayor Swimming Pool Seasonal Permit DATE PRINTED: 05/26/2010 ESTABLISHMENT NAME: Kernwood Country Club Pool File Number.BHF-2004-000193 1 Kernwood Street Salem MA 01970 LOCATED AT: 0001 KERNWOOD STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWUMMING POOL- BHP-2010-0432 May 26,2010 Sep 12,2010 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES September 12,2010 Board of Health Page 1 Inspection of Date Time Name Address Owner Tel. No. Type of Inspection_ Inspector ( " ) Remarks and Violations are listed below: Report Received by:. - - fir- `• ' �` ,,.�, I - ,;ward bell rif i mimk"owaft wl m t•� ri L J -t I I-Iti T I _ _ I I r y1� � �.1 I �y _ J I_L f !: L L-1 �� J+• L� ... , _�J I'�L 1 -C-� ■���1 ll 1_~ �i I1 - L v ! I I -1 �c CJ �I� ` �ISti II -fir -��-+ S11 _ l} .1 J 1 ' ii_ - - -_- - �. - ... -_ - - I e I �L�.j !�11—f �-t Ir....� 6 i - 1 ' t f T !:-A J 4-_ i _�1- ! 1 r I I �I @PR1 ` -A - I I I_d L-_iJ I I low Inspection of Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( " ) Remarks and Violations are listed below- Report Received by: i I I I i This recognizes that C 0 y i �LL has comp e`t d t*'e equirements for ! Ct ' ° i ifegirarding/first Aid j s' conducted by I I'M CA-:L'yiuilield/Peabody comp i b, Date completed o ~ The American Red Cross r-ecogmzes this certificate as valid for, , year(s)from completion date. Thus recognizes that W W 8 Deirdre Foley .22 � has completed the requirements for 1.0 o Lifeguarding/Waterfront/First Aid t conducted by u Holy Cross College w U P__ Date completed 4/29/2008 d The American Red Cross recogiuzes this certificate as valid fora year(s)from completion date. J j N E p q 4 U o 0 o O O t U c � P 21 y v5 v , ti c -o � b .G, o _ _..---- -- -. .P a u o -I U �. recognizes that � t This Lmily Harney z °1 requirements for U ? ° 'M!� o has completed the N c " Lifeguarding/First Aid { Bft, a N i ) conducted by I� all n army un)apt aa,,JagD YMCA-Salem '6 completed 5/19/2009 Date The American Red Cross recog nizes tcertificate completion date. 4. as valid f.....or 3 year(s)from comp -- — I = to This recognizes that V tn Max Dornbush has completed the requirements for .O Lifeguarding/Rirst Aid a conducted by JCC North Shore Date Completed 4/23/2010 The American Red Cross recognizes this certificate as valid for 3 year(s)from completion date. This recognizes that = H H Max Dornbush v i has completed the requirements for V CPR/AED for Lifeguards E� d a conducted by JCC North Shore Date Completed 4/23/2010 The American Red Cross recognizes this certificate as valid for 1 year(s)from completion date. This recognizes that N Max Dornbush V has completed the requirements for •1 V Bloodborne-Pathoaens Training:PDT �W Q conducted by JCC North Shore _ Date Completed 4/23/2010 The American Red Cross recognizes this certificate as valid for 1' year(s)from completion date. CITY OF SALEM, MASSACHUSETTS BAARD DF-MEALTH 120 WASHMGTDN-STREET,,-4TH FLOOR-._ SALEM, mtA OTM TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTr, IIIIPK,RS;'CHO - HEALTH AGENT Swimming Pool Inspection Report Pool: VPMt.t C60117IN CJy Date:--c�� � �rl - — Address 1 k:�.rn u ec,4 5f Phone: 9119 1,145-(a(() A 5 Operator: ,-&M A, k' Max.Bathing.Loadr..- _ In accordance w 105 CM 435.00 Minimum Standards Lor Swimming Pools,•StateiSanitaryCode Chanter V. Annuat Permit-P-Qsted 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 _;7 _ ._` oice nlifier, b/Elevated seat Emer,Communication:phone at pool 1 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 f First Aid: Equipment area _,/j35) 1"band-aids /(10)30 gauze LI(2)5x9 surgipads _/(12)antiseptic wipes (1)8x10 Surgi "(2)2"soft roller bandages Scissors —(2)3"Soft roller bandages Tweezers jt�j1) `/z roll hypoallergenic tape Rescue blanket - ice packs /Pocket mask ✓sterile isotonic eyewash Disinfection (✓Chlorine- i —pH 7.2-7.8 Residual free 1-3,Combined 0-0.2 _Bromine-tea _pH 7.2-7.8 Residual 2-5 (ppm)(mg/1) Records Kept: ✓Water tests Chemicals Used _Backwashing Attendance 1i Hours of operation I�KDepth 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, �,Or drained,ventilated,impervious construction,one shower and one toilet per 40 bathers,hot and ;M v(5 vw-h) j,,O cold water,soap provided,no common cups,towels,combs,pool adequately enclosed,approved- drinking wall ex-tl�Icil it'ies Notes: W E �, t fc. 4 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: 04/23/2009 ESTABLISHMENT NAME: Kernwood Country Club Pool File Number:BHF-2004-000193 1 Kernwood Street Salem MA 01970 LOCATED AT: 0001 KERNWOOD STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2009-0445 Apr 23,2009 Sep 30,2009 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES September 30,2009 Board of Health A Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HL.ALTH 120 WASHINGTON STRIZE'r,4TM,FLOOR TFI,.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR 1MANCIN1@SALrM.COM JANET MANCINI, ACTING HE AI:11-I AGENT 481p p 6200.4 2009 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL LOCATION OF POOL f'1'i1UJ00 �t. �� (96g N! - NAME OF APPLICANT p Lr ti W Op a Lt rtfr±l Gil V-b TEL# �74 Y- U MAILING ADDRESS I }j j Cn LOM A 5 f, Ja( P vyi HA- o l G -7 y CERTIFIED POOL OPERATOR Name:."N)u t f[CIS 4 9✓i A k Cert#: 4/95 JL TEL# DATES OF OPERATION (if not annual): SR GJ6,19 - r1'1 PiWO ram.o-( b Ott r W is Pr Id +zj L,6or ,bd t� DAYS &HOURS OF OPERATION: TYPE OF POOL Public Semi-Public X 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 ofperjury that I,to my best knowledge and belief,have filed all state tax retums and paid all state taxes required under the law. Signature Date SS#or Federal Identification Number Revised 8/14/07 poolappmpd Check# Date 51 i 4, + r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOL.L FAx(978)745-0343 MAYOR IMANCINI&ALEM.COM JANLT MANCINI ACTING HEALTH AGENT Salem Board of Health 120 Washington Street 4 h 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 type of pool below) swimming wading special purpose located at T V 1-e Establishment Name Establishment Address ❑ conform to the The Virginia Graeme Baker Pool&Spa Safety Act and the American National Standard ASME A112.19.8—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. mt.41"X. �APL V�5 Signature of pool er/Co rat' n President Title ,0(Ckote En 3/30 /07 Print name Date Q �52 o 8 7 Qa z o z W w y F ° N wui x � 5 �. G �z z s o 0 o W 4 v !tLU ul , . Lu O WW a I y: 1 ua Q w Z. C w m � � � � � � � Z w o Q ° l w - ° p C a n O LL lil=� llrrnbnoob �ountrp (�iu� LINDA RAWSON 1 KERNWOOD STREET COMPTROLLER SALEM,MA 01970 (978)745-1210 x201 . Email:linda@kernwoodcc.org. FAX(978)745-0157 ' 8" Low Profile Anti-Entrapment Suction Outlet Cover and Frame The AquaStar line of suction outlet covers compliant with the new VG B Series Product Specification Sheet Virginia Graeme-Baker Pool and Spa Safety Act(ASME/ANSI A112.19.8-2007) 1 Features I .WNW I ( For Single or Multiple Drain Use ��� i�� IASME• (See Installation Instructions) Single: �• *1 ar� irf Floor:100 GPM at 4.2 fps/Wall:70 GPM at 2.9 fps Dual: �`�"'l�I�� i i Floor:100 GPM at 2.1 fps/Wall:70 GPM at 15 fps Triple System: Floor:200 GPM at 2.8 fps/Wall:140 GPM at 1.9 fps i iFloor/Wall:108 GPM at 1.5 fps 7.7 sq.in.Opening #316 Stainless Steel Screws Super Strong UV Resistant ABS/ASA Material Easily and Safely Retro-Fits to Most Brand's Existing Frames and Sumps That Model# RLP8AVxxx Does Not Already Fit* i (See Cross-Reference Chart and Installation Instructions for Details) Patent Pending Flow-Max*Technology Super Low-Profile Eliminates Cleaner Hang-Ups Meets or Exceeds ASME/ANSI Al12.19.8-2007 i National Standards and ASTM G154 UVTesting � � + Listed with IAPMO R&T E o 50 Per Case *Fits:AquaStar(All Pre-VGB 8"Models),American,Pentair,Color Match,Waterway,and most Custom Molded(CMP) Part Numbers/Colors I � LP8AWGB101 White LP8AVVGB102 Black i _ LP8AWGB103 Lt.Gray rr: (2� j ® LP8AWGB104 Blue j LP8AWGB105 Dk.Gray { LP8AVVGB106 Bone A R [� LP8AWGB107Taupe 1.8"Anti-Entrapment Cover LP8AWGB708Tan - _ - - - - - - 2.8"Anti-Entrapment Frame 3.#316 Flat Head Phillips Strew, Stainless Steel,qty 2 I P 877-768-2717 F 877-276-POOL info@aquastarpoolproducts.com www.aquastarpoolproducts.com 7 { A A 8" Anti-Entrapment Suction Outlet Cover and Frame VGB Series The AquaStar line of suction outlet covers compliant with the new Product Specification Sheet Virginia Graeme-Baker Pool and Spa Safety Act(ASME/ANSI A112.19.8-2007) Features For Single or Multiple Drain Use 41 ASME (See Installation Instructions) �ae�xia-e f Single: 2.07 Floor:88 GPM at 3.2 fps - ►- Wall:70 GPM at 2.6 fps Dual: Floor:88 GPM at 1.6 fps Wall:70 GPM at 1.3 fps 1 Triple System: I Floor:176 GPM at 2.1 fps Wall:140 GPM at 1.7 fps Floor/Wall:123 GPM at 1.5 fps 8.8 sq.in.Opening #316 Stainless Steel Screws Manufactured from Super Strong UV Resistant ABS/ASA Material I Meets or Exceeds ASME/ANSI Al 12.19.8-2007 glow 1111111 ' I National Standards and ASTM G154 UVTesting Exposure f Listed with IAPMO R&T fII I 50 Per Case i Part Numbers/Colors __.._ ❑ 8AV101 White ;:,� ::•� 8AV102 Black i 8AV703 Lt.Gray ! T 13'3' i-rnf S 8AV104 Blue 8AV105 Dk.Gray i'az 8AV106 Bone A 8AV107Taupe - 8AV108Tan � "F. ' _ - -� � - 1,8"Anti-Entrapment Cover 4: 2.8"Anti-Entrapment Frame / 3.#316 Flat Head Phillips Screw, Stainless Steel,city 2 A% a P 877-768-2717 F 877-276-POOL info@aquastarpoolproducts.com www.aquastarpoolproducts.com = HAYWARUPooiProducts PN: ISVR1000 Rev: M One source. Every ,coal. STRATUM TM Model VR1000 NOT xr&t OWNERS MANUAL OPERATION,&PARTS us C(STE�? us �rnncic IVA, THIS MANUAL CONTAINS IMPORTANT INFORMATION ON THE OPERATION, AND SAFE USE OF THIS EQUIPMENT. THIS MANUAL IS INTENDED FOR THE END USER OF THIS PRODUCT. Basic safety precautions should always be followed,including the following:Failure to follow instructions can cause severe injury and/or death. AThis is the safety-alert symbol.When you see this symbol on your equipment or in this manual,look for one of the following signal words and be alert to the potential for personal iniury. AWARNING warns about hazards that could cause serious personal injury,death or major property damage and if ignored presents a potential hazard. ACAUTION warns about hazards that will or can cause minor or moderate personal injury and/or property damage and if ignored presents a potential hazard. It can also make consumers aware of actions that are unpredictable and unsafe. The NOTICE label indicates special instructions that are important but not related to hazards. USE ONL Y HAYRARD GEM)ME REPLACE-HEA,T PARTS WHAYWARDPooiProducts A Hayward Jnnlos-re i.Ir.,C9•n.Osf y ��;�� l/ \.�- `� -��_. * ` f� fir'_` 1 \_ i:ti '_�� �• _ — �:ti . ♦ Fh• ..'� r• F•"JZ':�`+;i i R.;'it•+G$••PC ti'4••�'N'•?•' r•.••, ti•,•:. �.. -� ?Y�+;•�•��.� ��'4L �' 15t9 � , ► ,�� � ,i15t +► t ,ri ,hl� ,► .�� . 1'.'r�: 'tir..• .��•:� �•� ' �'? am.i .} s' �I► uu aH 111 ►D . i.��44}/i li it i 1 /�-Y►If 14}t!f!■JH► }} }!+� �� t r °Ly `'4�•'.�w�• �Ii.��'Yf -:—�u► *�� r+il � r14 .. 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RA.D.'� KNt � _ Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 05/22/2008 ESTABLISHMENT NAME: Kernwood Country Club Pool File Number:BHF-2004-000193 1 Kernwood Street Salem MA 01970 LOCATED AT: 0001 KERNWOOD STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes SWIMMING POOL- BHP-2008-0464 May 22,2008 Dec 30,2008 $140.00 SEASONAL Total Fees: $140.00 PERMIT EXPIRES December 30,2008 J Board of Health rJ This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 r Mai 21 08 ili25a Joanne Scott Salem BOH 878 745 0343 P. 1 JA Qrf Of Ih s31 i s I�5�4 ,a�*� Bpx�i"tT)C?rF36ALTt-i 1-70 I3G'A�1-Il'1VGTON S11tk.ET,41n'FLUC7Ii T)3L.(978}741.18G3 YT iBF-RUY DRISC' ?I.I_ FAX(978)745-0343 Iti 'i lYar5AL5T�.CX�lti1 NLAC)OR JOAN,E SOD—T, 2008 APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL Loy:ATIONT OU00L I �<.e Y-n c .d©j- 56L iti-Aiver OF APPLICANT LtL ?tiT_ e r✓1(.t�00r� �v1 r allb TEL # C7?t ` �5- MAiLINC ADDRESS l�r�c,�cio & CER.T FIED 13CJOL OPERATOR Name_bvcscitas Ni b r,y\k DATES OF f�.FFFt,41'11JN j:i[Yoe artn;atj,. SPR'SQ+rY�IQyl'lU ri�c OtAk Pr cL4 �Q bor b y A _— \ _. . .--- DAYS&HOLJRS OF OPERATION TYI,'iE O F PQOL Riblic 8en;i-Fublic FM S210.0 6:or year,round pools `b 140.00 forfse:a uua1$40.O0 N ik-Proflt (Encase pay total with ow:elieelt pay 1v to thrl t:js u!Saicnt) This pOC;ltit is not iraatsferab?c snd attusC Ike r 'sStaee ion change of ownership. In accordance with tirc State Sataita"Y('s)da?,before uny riitovatioars,improvements,or Equips lent charges are mace,all plans for such inust be subr:titied to and approved by the Salew Board off€ealth. t1f5L??llf tQ M£iC Lii:11 ttr fr l.-,`j C.ti�;,sY 4ticl.i CC4l'i1'}'ut7�C•r tlte.¢taint:,aiv�pe.italti�s o!'perjury[i;is 1,to My best knst4v udg and.bciit:f.havc filed 3ii statz tux r2tunis awl j aid all staxG2 unLii-r tilt.1:1W. X,,� /&. - ...— f-,.2-/ , 0 ? Sig:saturw 1af; — 5 i or i d,v!al IdcYttificBlsOn Narllb4.r Roy scdJi 4?(?7 pu�l:tpp:w xl CIr•.;_k 1 3alc Ja 6� xz CITY OF SALEM BOARD OF HEALTH — 120 WASHINGTON STREET 4TH FLOOR, SALEM, MA 01970 Swrn,rMXNCP00L MSPE rION REPOT Pool: �.fY� v —Date: aJ Address: 0 Phone: Operator: Max. bathing load:_ _ In accordance with 105 CMR .435.000 Minimum Standards for Swimming Pools,- Slate Sanitary Code: Chapter V. _ - ANNUAL PERMIT POSTED i ALTH and SHOWE'll SIGNS POSTED cm ZALTH: no sick employees, no sick bathers, bathers take showers, spitting prohibited, no glass. -LIFEGUA� Present _ certification Xred/orange suit X-11 guard" printed on Jersey _- sunblock avail. voice amplifier elevated seat _-EMER COMMUNICATION: phone at pool _/-phone instructions - emergency numbers �S15n jt,'� 1h phone in unlocked area V 5.l -�� of I _SAFETY EQ .: for each 2000 sq. feet escue tube or ring buoy (with rope) V- backboard with collar and straps (� (� (1Z fRS 1 AJ 1J C: uIpment al ca V _ 5) 1' bandaids 1�- 10) 3x3 gauze i/-(2) 5"x 9" surgipads 5 ld � � r 8x 10 surgi -(2) 2" soft roller bandages CLK*" --efAlf"f cissors i/ �') 3" soft roller bandages tweezers l/(1) 1/2" roll of hyp�-(12) rgenic tape rescue blanket packs antiseptic w1pes pocket mask -(I) sterile isotonic eye wash _ DISINFECTION �/ � - ctilorine pH� 2 7.8 Residual. fre31-3, combined 04'2 - bromine pH 7.2 - 7.8 Residual: 2-6 (PPtn) (M9/1) t�t 1ZT ORDS: 1. pt I� _ water tests chemicals used - backwashing V - attendance hours of operation to r �" e, File-�' Xl-'PTH MARKINGS: sidewalk and inside pool DIVING BOAIZDS: ngidly constructed, properly anchored, braced !of heaviest load, no s inters of cracks, non slip �mlhc,e:, not ov(.l 10' 'ibovc v"ater level and atica,l 1 //Unobstn)ctcd headroom BA 1 I IIIOUSE: scpcatc dressing and sanitary (aciliUcs lot cash sca - ad)accnt to pool, well hphicd.diaincd. ventilated, impervious construction,one shower and one toilet pcf 40 badhas,hot and cold watu soap provided no caninon cups, towels_comps txiol ad(cluatcly enclosed approved dnnktne water aeilitics 1 received b tnslxxted by: Inspection of _ ___ Date Time Name_ _ __ ._ — — __ _ Address Owner . __ _. Tel. No. Type of Inspection _ _ _ Inspector Remarks and Violations are listed below: _ Report Received by: ' m II aj _UIL _ 11 ti I ! 1 1 I I - ! } ! S � - � ��ddi1F�tto�R ■ - - I Inspection of Date Time Name Address Owner _. Tel. No. Type of Inspection Inspector ( ' ) Remarks and Violations are listed below: Report Received by: Inspection of Date Time Name Address Owner _ Tel. No. Type of Inspection Inspector ( "' ) Remarks and Violations are listed below: no Report Received by: _ I X►��1 — — — — — Aoils�g1111#i�� Pl bM JOT ;wWW,berOtm aa*MUW bm**Was#i , 1 tT t�1 I }' � I I� � }� I� � • i � 9 '�i I ��� Jj - r I � . _ -U ..d,: _ I1 � I 1 I rc .�+E1A'I I 1 I ,;'y _I I _11 _ L� �I•�__` ,� _ ," J ��• s-l_'_L_ kj� '�1 �� I t' ' ,'• - �� ��� .� III 1I1f s 10 _ r Erb t (:�) 1 la' I Lei. 1 1 i t er� � �h- L _ � �I.._ I�-' �_� 'tLv L•. iJ j/ F' I I IV ? IIti. - � 1. I� t �~ J GI-� - r• � + ' - � ,-' I I I •� l L' 3 I L Inspection of _ Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( ' ) Remarks and Violations are listed below: Report Received by: This recognizes that This recognizes that _ EMILY SOLOMON EMILY SOLOMON y � � N v` e has completed)the requirements for v O �., has completed the requirements for dV LIFEGUARDING/FIRST AID �L.V CPR/AED FOR THE �� PROFESSIONAL RESCUER E'aay o Q $ Q conducted by conducted by Kevin Salisbury Kevin Salisbury d, Date completed 04/21/2007 a, Date completed 04/21/2007 The American,Red Cross recognizes this certificate F` The:1anericat1Red Cross recognizes this certificate as valid for .3 year(s)from completion date. as valid for year(s)from completion Bate. S7118 )Universal Cert. 653998 (Rev. Oct. 20 Chairman, Amcr&Red Cross Chairman, .Americ n Red Cross In st ctor's ure Instnut r' tture Chapter Chapter RI-iODE ISLAND RHODdE ISLAND Holder's 'igi ture Hot er's Sign tore v Cert.653998(Rev.Oct.200I) r/ Cert.653998(Rev.Oct.2001) versa) Cert. 653998 (Rev. Oct. 2001 ) E� American American �d ■ed Cr s Red Cross Together,we can save alf Together,me meal k \ e e§ / P. ƒ} § /. 7 } n , n q n _ ° \ rD \ \ / n \ \ . CD « ) $ ) 0- g ; a § \@ _ § ƒ \ § \M ° \ § g a ~ y § E ` B � \ x - � �� ® R R \ e p@mpdw m agmm; Ulrgle ¥,ems mTU200aJmJm#IMO mpg .a mozz6zz# pQjojdTuo3 a(I t �' JJ_JZ)S! a ,kq p;;opnpu, �■ k �§ 44m���ku, J m»p�2 ] n� Joi s oca Amap9 AJmm«R 0 AIo pO 7 $ ; T his recognizes that C wJ li Rgobbins. C apetedthe requnremeints for L y V rd Training and First Aid 0 e Q conducted by f Northeast 1Vlassaehusetts i pleted 2��20p6 rt x an Red Cross recognizes this certificate year(s)from completion date. This recognizes that C N +� 3uli a Robbins C rn "' has complete�c the requirements for Ij d� 0 CPR for the professional Rescuer Q� � conducted by 3 ARC of Northeast I%Iassaehusetts Date completed { Ai The Am rican Red Cross/eCo1Puzes this certificate as valid for year(,)from completion date. This recognizes that C�► �' v p a has com�j#tt&&t ftuements for Ww N AEB Essentials(Adult) a� v conducted by AR 1� e Date CC6mpleot Massachusetts !.4 The American Red CrosAMP995 this certificate as valid for year(s)from completion date. This recognizes that This recognizes that Elizabeth Wester IC Elizabeth Wester v c has completed the requirements for t)4. tr has completed the requirements for '�V CPR/AED for the Professional Rescuer V N Lffeguardiug/First Aid conducted by cohdueted.by o�,� YMCA-Lynnfield/Peabody YMCA--Lynrifleld/Peabody a, Date completed 6/6/2007 Date.completed ~ The American Red Cross recognizes this certificate i 6/6/2007 t The American Red Cross recognizes:tWs certificate as valid fori year(s)from completion date. as valid fora year(s)from completion date. l This recognizes that — -- N Elizabeth Wester This recognizes that a has completed therequirements for tj 50 : C N V Elizabeth Wester L. h Lifegiiarding First Aid t) p a has completed the requirements for La CPR/AED for the Professional Rescuer �. conducted by o Q fY " � '<YIVICA.-]f,ynnfieid/Peabody 3 Conducted by c Date:completed 6/6/2007 Sm eYMCA-Lynnfleld/Peabody F' The American Red cross recognizes this certificateNow asvalldfor3 year(s)from completion date. o Date completed 6/6/2007 The American Red Cross recognizes this certificate as valid fora year(s)from completion date. a N . 0 n _J 3 a u N r 73 U N F O V � m a co H b N E OV qq cna e6 Q 2a� 'mm m+• y oo� N 1,6 � l7 � b O x.C's tl d c= Cc y 'E \� afij m arms um�am'aaypgol m t1� E y ssoj:)Pon UBDIAOLUV + czAl O y L NO ct m o R c,j U N U \ r � ! � \ k . � k ` # � } � M - � cyC fins g L2 e � e J \ � C� J c m \ (D 7 \ / ° . / � � \ . J / J SCE cc \ • . \ , ® d d J I To: Lifeguard Training Graduate: Certifications to be received; 1UnP American Red Cross From: Peabody-Lynnfield YMCA Lifeguard Training First Aid ?_59 Lynnfield Street Peabody MA 01960 CPR/AED for Pro. Rescuer Subject: Congratulations! Congratulations to you upon completion of Lifeguard Training through the Peabody-Lynnfield YMCA. Your certifications will follow soon in the mail. Courses in waterfront lifeguarding, water safety, and other trainings are offered by qualifies Red Cross and YMCA Instructors. We hope that the skills you have learned will be helpful to you and your family and that you remind your friends that your local Red Cross/YMCA's are always in need of volunteers and support for vital services to your community. Now we would like to take this time to personally thank you for the opportunity of teaching and working with you. I feel that we have all gained much from these experiences. In the future, if I may be of any help to you please feel free to contact me. REMEMBER to keep your training updated and always keep your standards HIGH. Thanks again and have a safe and happy season. Your ifeguar�,I st rs. ti