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HomeMy WebLinkAboutMiscellaneous - 305 MIDDLETON ROAD 4/30/2018 �io5 M,a�l� KoaL Y The Commonwealth of Massachusetts /C,Executive Office of Health and Human Services Department of Public Health Bureau of Environmental Health Community Sanitation Program 5 Randolph Street 3 GOVERNOR O DEVPATRICK GOVEE Canton,. , MA 02021 JOHN W.POLANOWICZ Telephone: (781) 828-7910 SECRETARY Facsimile: (781) 828-7703 CHERYL BARTLETT,RN COMMISSIONER Marian.Robertson@state.ma.us August 14,2014 Samantha Overton,Deputy De u Director MassParks Department of Conservation and Recreation 251 Causeway Street, Suite 600 Boston,MA 02114 (electronic copy) Re: Facility Inspection—Harold Parker State Forest,North Andover Dear]Vis. Overton: In accordance with M.G.L. c. 111, §§ 3 and 127A as well as Massachusetts:Department of Public Health(Department) Regulations 105 CMR 440.000: Minimum Standards for Developed Family Type Camp Grounds(State Sanitary Code, Chapter VI),and 105 CMR 445.000: Minimum Standards for Bathing Beaches(State Sanitary Code,Chapter VII); I conducted an inspection of Harold Parker State Forest on August 8,2014 at 10:30 a.m. accompanied by Jonathan Brown, Community Sanitation Program.Violations noted during the inspection are listed below: HEALTH AND SAFETY VIOLATIONS (*indicates conditions documented on previous inspection reports) Contact Station I'I Bathroom No Violations Noted Lorraine Park Campground Dumping Station No Violations Noted Camp Sites 105 CMR 440.07(4) Water Supply: Missing backflow preventer on water spigot at camp site# 222 Frye Pond—Beach Area 105 CMR 445.020(A) Operation: Missing proper signage Dumpsters Front Dumpster No Violations Noted 440-14-DCR-North Andover-Harold Parker State Forest-Report 8-14-14 Page 1 of Dumpster Near Camp Site#17 No Violations Noted Dumpster Near Camp Site #59 No Violations Noted Dumpster Near Camp Site #113 No Violations Noted Comfort Station # 1 2 Compartment Sink No Violations Noted Men's Bathroom No Violations Noted Women's Bathroom No Violations Noted Comfort Station#2 2 Compartment Sink No Violations Noted Men's Bathroom 105 CMR 440.09(5)* Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, wall damaged behind toilet in toilet stall #3 105 CMR 440.09(5) Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, wall damaged behind toilet in toilet stall # 2 105 CMR 440.09(5)* Lavatories and Showers: Shower not maintained in a clean and sanitary condition, possible mold growth in shower#3 105 CMR 440.09(5) Lavatories and Showers: Hot water faucet loose on sink# 1 and 2 105 CMR 440.09(5) Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, door frame damaged Women's Bathroom 105 CMR 440.08(2)* Toilet Facilities: Outer door riot weather tight 105 CMR.440.09(5)* Lavatories and Showers: Wash basins not-maintained-in-a clean-and sanitary- - condition,all sinks rusted 105 CMR 440.09(5)* Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, shower wall tiles damaged in all showers 105 CMR 440.08(2)* Toilet Facilities: Screens not tight fitting 105 CMR 440.09(5) Lavatories and Showers: Handicapped shower head leaking 105 CMR 440.09(5) Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, door frame damaged Comfort Station#3 2 Compartment Sink No Violations Noted Men's Bathroom 105 CMR 440.09(5) Lavatories and Showers: Shower not maintained in a clean and sanitary condition, wall tiles damaged in handicapped shower 440-14-DCR-North Andover-Harold Parker State Forest-Report 8-14-14 Page 2 of 4 j Women's Bathroom No Violations Noted Play2round No Violations Noted Comfort Station#4 2 Compartment Sink No Violations Noted Men's Bathroom 105 CMR 440.08(2)* Toilet Facilities: Screen door damaged 105 CMR 440.09(5)* Lavatories and Showers: Wash basins not maintained in a clean and sanitary condition, all sinks rusted 105 CMR 440.09(5)* Lavatories and Showers: Shower not maintained in a clean and sanitary condition, grout missing in shower#2 and 3 105 CMR 440:09(5) Lavatories and Showers: Lavatory not maintained in a clean and sanitary condition, wall damaged behind toilet#2 105 CMR 440.09(5) Lavatories and Showers: Debris on floor throughout bathroom Women's Bathroom 105 CMR 440.07(4)* Water Supply: Missing backflow preventer on water spigot under sinks 105 CMR 440.09(5) Lavatories and Showers: Wash basins not maintained in a clean and sanitary condition, sink#2 and 3 rusted 105 CMR 440.09(5) Lavatories and Showers: Shower wall tiles damaged in all showers 105 CMR 440.09(5) Lavatories and Showers:Light shield over toilets not secured properly 105 CMR 440.08(2) Toilet Facilities: Screen not secure in window Observations and Recommendations 1. Hot water temperature measured 1040F in handwash sinks at Comfort Station# 3 in the men's bathroom. Hot water temperature range for handwash sinks is 110°F to 130°F. This facility does not comply with the Department's Regulations cited above. To review the specific regulatory requirements or download a copy of 105 CMR 440.000, please visit our website at www.mass.gov/dph/dcs and click on "Family-Type Campgrounds"(available in both PDF and RTF formats). To review the Beach Regulations or download a copy,please visit the Beaches website at www.mass.gov/dph/beaches. and click on"Minimum Standards for Bathing Beaches, State Sanitary Code"(available in both PDF and RTF formats). 440-14-DCR-North Andover-Harold Parker State Forest-Report 8-14-.14 Page 3 of This inspection report is signed and certified under the pains and penalties of perjury. • Sincerely, W M0 U4 arian Robertson Environmental Health Inspector, CSP,BEH cc: Suzanne K. Condon,Associate Commissioner, Director, BEH Steven Hughes,Director, CSP,BEH Susan Sawyer,RS/RENS,Health Director,North Andover Health Department J Priscilla Geigis,Director,MassParks,DCR (electronic copy) Gary Briere, Assistant Director for Recreation, MassParks, DCR (electronic copy) Anita Wysocki, Camping Program Coordinator, MassParks,DCR (electronic copy) Ruth Teixeira,Director of Park Improvement,DCR (electronic copy) Susan F. Hamilton, Regional Director, DCR (electronic copy) Thomas M.Walsh, District Manager, DCR (electronic copy) Steve David, Supervisor, DCR (electronic copy) 440-14-DCR-North Andover-Harold Parker State Forest-Report 8-14-14 Page 4 of 4 Date ...t�...�...................... i �p10RTly, 1 ° "`° ti° TOWN OF NORTH ANDOVER * , PERMIT FOR WIRING sSACHUs� This certifies has permission to perform ..c .e:r(� ......................................................................................... wiring in the building of.... .. P.a.u:...... at .... ........................ALECTR Nh Andover,Mas . tt �� ` Fee....l� .....Lic.No. .? .. .k?........ © NSPECTOR Check•# O Commonwealth of Massachusetts Official Use only T Permit No. 1 �� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: '77 City or Town of: X);N /-n Dae t To the inspector of Wires: By this application the undersigned gives notice of his//or her intention to pe o ktheectrical ork describ ' below. Location(Street&Number) 305 �� cr'jP f L-9 3 Owner or Tenant A, Cryo ev+-t,-� Telephone No. `. Owner's Address S/ c4".k, -k4 I.s this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) , Purpose of Building Utility Authorization No. k;xisting Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / VoltsO erhead El Undgrd ❑ No.of Meters � Number of Feeders and Ampacity VLv� e zw2� 7 a"' AP Location and Nature of Proposed Electrical Work: Com ledon of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.Sus Paddle No.of Total , P• ) Fans( Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA •` No.of Lighting Fixtures Swimming Pool Above ❑ °- ❑ a o Units Lighting g °g g rnd. grind Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection an No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Connnnc tion [J Other No.of Dryers Heating Appliances Sec No of Devices or Equivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivaient j OTHER: Attack additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify.) (Expiration Date) Estimated Value of Electrical Work: 560"' (When required by municipal policy.) Work to Start: 7 $ i Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certljy, under the ins and penalties of perrjury, that the informatio o this a • anon is true and completes FIRM NAME: LIC.NO:: Licensee: �lJ,t2f /Z lC Signa LIC.NO.: /70�' �} (Japplicable,e4w "exempt"in a license number line) Bus.Tell.No., ;70'-9a�q=Fo 7? Address: AV- We Alt.Tel.No.:&/7 X1 gfdq OWNER'S SURAN E WAIVER: Tam aware that the icedo of have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ 05— Signature _ Telephone No. f _ _ 19 vo -z , I D. INSURER'S AFFIDAVIT AS TO WORKER'S COMPENSATION INSURANCE I I, Alliant Insurance, 131 Oliver St., Boston, MA 02110 [Name,Address] am: an authorized representative of Insurance Company [Company Name] (a producer" in the voluntary market)t an authorized agent of Travelers , Insurance Company(an agent in the voluntary [Company Name] market, authorized to sign on behalf of a producer)t an authorized signatory of the ,the Prime Contractor(an insured [Company Name] of a producer in the involuntary market pool)$ an authorized signatory of ,the Sub-Contractor(an insured of [Company Name] a producer in the involuntary market pool, group,or otherwise insured)$ and do hereby aver that effective July 15, 2013 [Date], Power Line Contractors,Inc._,the Prime or Sub-Contractor,is insured for Workers' Compensation insurance with Travelers Casualty and Surety Insurance Company under Policy No[s]. DTAUB7820N07413 ,pursuant to the attached Certificate of Insurance, and in accordance with Massachusetts General Laws, Chapter 152 and Subsection 7.05A of the Standard Specifications for Highways and Bridges of the Highway Division of the Massachusetts Department of Transportation. 4 gn e Assis nt Account Representative Title COMMONWEALTH OF MASSACHUSETTS On this 19th day of July ,20 i 3before me,the undersigned notary public,personally appeared j Stephen Turner [document signer],proved to me through satisfactory evidence of identification,which was/were ,to be the person who signed the preceding or attached document in my presence,and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of their knowledge and belief, J ,Notary j [Printed Name] NICOLE ROY * Notary Public COMNiaNW,,EALTH OF MASSACHUSETTS nny.Commission Expires `July 20,2019 A producer is an insurance company that provides insurance policies directly,not an insurance agent. t For Prime or Sub-Contractor companies insured through the voluntary market,this Affidavit must be completed by the insurer or an authorized agent of the insurer. t If the Prime or Sub-Contractor is insured through the involuntary insurance market,a pool,such as the Worker's Compensation j Inspection and Rating Bureau,or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may be signed j by an authorized signatory(company officer)of the Prime or the Sub-Contractor. 15 it r r I I i Fold,Then Detach Along All Perforations >R COMMONWEALTH OF MASSACHUSETTS.< BOARD`OF EL<:ECTR ICIANS . ISSUES TNE.JOLLOWING LICENSE AS A MASTER::.ELECTRICIAN :Q Z ,TOWER LINE CONTRACTORS -INC. >JAMES R OAGLE W` Z PO Box 2059 ±� WOBURN 11A 018$8 00.59 170$7 A 0j%3)/ nil }6 70005 . 1 r P ' Dat A TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . / .Y . . . has permission for gaAin allation . .L✓ . , , ,in the buildings of. G� C �(. , � WJ1e r V' at . . .� • +� . A . . . . . . . . . . , North Andover, Mass. Fee . Lic. No. . .i ,."l�U . . . . . . . . . . . . . . . . . . . . . i GASINSPECTOR Check# { 8551 w, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: N ANDOVER MA. DATE: 01/17/2013 PERMIT# JOBSITE ADDRESS: 305 MIDDLETON RD OWNER'S NAME: HAROLD PARKER STATE FOREST GOWNER ADDRESS: TEL: 617-780-4524 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT V\ CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO ❑ APPLIANCES FL401 Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES D NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [�] OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the t of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance �-e inent vis' of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: LICENSE# L P9 33 /SI/ATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE:MA ZIP:01844 FAX:978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO. OSTERMANGAS.COM �\"A\) MASTER❑JOURNEYMAN [__1 LP INSTALLER ECORPORATION E]# PARTNERSHIP ❑# LLC 2] #45-326-3311 "45U\'z"C 0 vh- Q'­�,_ �' ; 1211 e(,p s4c-5, w . C'-f 1p ov> a I f I r � a I i i 44. I t i 01/15/2013 17:17 9787380118 ENERGYUSA PROPANE PAGE 02/02 I I "C( NfMOi�WEALTH OR M SSA'CHUSETTS 6?1_WABERS AND G SFIITERS LICENSED AS AN LP + AS INSTALLER ISSUES Tl•IE ABOVE 1.11 BLASE TO: 4 M].CHAEL A BRYSON SR ;f B kRBCR CT I LYNNM, 01902 ,1 — .10 .93$ or./oI .14. 1,6008� r. � �GIVI•N bMWEAL.TH OF AgSACH;IFSET'1'S• :' • p,.t'I I.BERS ANQ a ASFITTERS, LICEI�w D JOURDIF.' MAN GA•SFI i•`TE ISSUES THE ABOVE LIOENSE T0; MICHAEL •3RYS.0N 11 ARBOR CT 1�YNN kA 01902-1,1111 . �tio01 05 .;,• :., I i I Date . . "t. .I . . . TOWN OF NORTH ANDOVER r. PERMIT FOR GAS INSTALLATION This certifies that . . .1J! �' . . e6p . . . . . L tx'J has permission for gas installation . . . . ,ir? Z `S in the buildings . . . at . . . . . . !�''� . . , 4� R `. �.•. . ,North Andover, Mass. Fee .�l..'. . Lic. No. .q n . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# �ZfA 8550 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: N ANDOVER MA. DATE: 01/1712013 PERMIT# JOBSITE ADDRESS: 305 MIDDLETON RD OWNER'S NAME: HAROLD PARKER ST.FOREST GOWNER ADDRESS: TEL: 617-727-7659 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO ❑ APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10' 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE ihave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES 0 NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance wit II Perti prov' ' n of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. LL acv PLUMBER/GASFITTERNRME: y�C a� LICENSE# 01M 133IGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY:Methuen STATE:MA ZIP:01844 FAX:978-738-0118 r TEL: 800-368-9956 CELL: EMAIL:INFOcDOSTERMANGAS.COM MASTER 0 JOURNEYMAN 0 LP INSTALLER OCORPORATION ❑# PARTNERSHIP ❑# LLC [2] k45-326-3311 ,� I � � I � � I _� I f I - - .�` �. f, . I r II i �/ ��/l �� U � � �� E � f i GENERATOR APPLICATION DATE: � I �q LOCATION: OWNERS NAME:— &-O�s� �A2I�er— � GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: V�t��✓� ���-- PHONE NUMBER: ELECTRICAL GAS -- �) �X ��� �/Z�L-- RESIDENTIAL MMERCIAL TEMPOR,4RY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL 01/15/2013 17:17 9787380118 ENERGYUSA PROPANE I PAGE 02/02 • I 11 I IUI SSACHUSETTS } Cl�)JjIAONWEALTM OF • PLU:JI.BERS AND G SFITTERS ' LCE SED AS AN LP i�AS INSTALLER ISSUES TI-JE AGAVE 1.11 ENSE TO: I MICHAEL A BRYSON SR =i 8 ! RBICIR CT LYNN M, 0190 -1110 ; 933 0 /01 .,1.4 1'b0�i89 F :Clfill*MONWEALTH OF A5SACH;USE P..t'lII,BERS AND FITTERS "50JOURNEMN GASPI fE LICEI` ISSUES THE ABOVE LICENSE TO; ! MICHAEL .3RYSON 8 ARBOR GT 1�YNN �A 01902-1111) co01 05/01/14 ,lti��i4i'rr AM I I I _ I I 7RECEIVED � Commonwealth of Massachusetts 03 City/Town of �a, o��,� � System Pumping Record NORTH ANDOVE - � Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: _ t` forms on the muter,use .4A t- 2(Cc12 l l4lZ �Q/L��T ` � !fi✓ only the tab key Address to move your /)dam, A/ut)(�UL cursor-do not City/Town State Zip Code use the return key.. 2. System Owner: Name Address(if different from location) --- - ----- City/Town - State Zip Code Telephone Number B. Pumping Record i 3 1. Date of Pumping Date/l! 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- ......— --"- _ 4. Effluent Tee Filter present? ❑ Yes RrINo If yes, was it cleaned? ❑ Yes Q�lo 5. Condition of System: ! oo —._.. 6. �Name, s Pumped By: vehicle License Number )i vii vc�2 l=�Vt/i2�✓.Cl Company 7. Location where contents were disposed: Noah Andover MA Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 r �,�