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HomeMy WebLinkAboutHoliday Inn - 12/31/2019 (2)7 Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: PERMIT EXPIRES: Person Certified: RUDY MARTINEZ Pool/SPA Certification Date: June 13, 2018 Pool/SPA Certification Expires: June 13, 2023 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 15 December 31, 2019 Town of Mansfield 6 Park Row Mansfield, MA 02048 In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: VISION HAMPSHIRE LLC HOLIDAY INN for the operation of a Public Semi -Public Special Purpose Pool located at: 31 HAMPSHIRE STREET (INSIDE OF THE BUILDING) Method of water treatment is CHLORINE Bathing load not to exceed: 83 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. AMY Donovan -Palmer, Health Agent Date Issued Town of Mansfield - DEC 2 8 2018 wn of Mansfield ea ltlZ _8_11gark Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $150 Ej Public Re -inspection fee: $100 NAME OF OWNER: I' %` �( POOL OPERATION: Q Semi -Public V1 SioN 414,1)ire LLG. zNU ''II�� /ll/ 0 Special Purpose Pool ADDRESS: 3j f7av p5��re SM CITY: (NIGnS.p id. STATE: M A ZIP: O Zo TELEPHONE: rsU$-333-Zzo,c) FAX: I" I ` 3TJG I *01 EMAIL: �n(�`i he �.f 1'1�t 6) /}i Ft)(bofc), C.O ✓vC FED ID/SS NO: J qI qb Certification Expires Every 5 Years, Permit Expires December 31st Yearly. 31st Yearly. PERSON CERTIFIED: v(� 'h("I;f aez, Pool/SPA Certification Date: v(0 h2lz" I Pool/SPA Certification Expires: bW 1 131Z e� 13 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): POOL LOCATION: Si r " C'I�= k, I i)iU 1 I TYPE/POOL: -rl4roun<l Too) ( LENGTH: �6 F7_ WIDTH: �1:2 FT VOLUME: (113.5(OQ 5(J(ok)- MINIMAX DEPTH: 3 F7 MAX S FT SWIM AREA: ✓Q1-'T DIVE AREA: WATER SOURCE:"ToldN a/'b'N6n5(; e /Ll. W/W DISPOSAL: j 0W I.J p� 'WlGvns iP (J TYPE OF FINISH: e lc,")- ,Y SCUM GUTTER: DECK TYPE: T 1 (e. CtRc.l_. SKMMR WEIR LENGTH: ,) i X g . JJa TREATMENT SYSTEM: S 6. (I he_ DISINFECT METHOD: L.\7 bri vlr�- CHEMICAL TREATMENT: ( NUMBER OF BATHERS: 0 x, REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: _ 2 DATE:/fY/'ZF1f_b JJ Please make appropriate hanges. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. cGu�v� Signature of Individual or Corporate Name ""Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\steite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc '\ The Commonwealth ofMassachusetts Department oflitdUS01 1Accldents a 1 Congress Street, Sltlle 100 Boston, MA 02114-201 7 mwim mass.gov/dia Workers' Cmnpensa(ion Insurance Aforlavitt Canaral Businesses, TO BC MUD WITH TIM PL;IO Ti-IING AUIIIO1n''X. APhl1Callt hiformatiola Please Print Legibly business/Organization Name: S I 0 P ���Ci`�"" f�L N Address: & Vi M P S �} I Rj:: `vl' 7L-- City/Sta.te/'Zip: _k i*S V- 1 t L Phone #:,_ 5 0 -3 3 A — 1O U Are ycu'art employer? Check the appropriate be.,(: 1, [ I aura employer with )0� employee's (roll and/ or part-time),* 2. ® I am a sole proprietor or partnership and have no employees working for me In any capacity. [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per C. 152, §1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no emuloyices. [No workers' comp_ dnsnrnnrn rrn I Business Type (required): 5. ❑ Retail 6. VRestaurant/liar/EatingEstablfshment 7. 0 Office and/or Salps (ira;L real estate, auto, etc.) 8, ❑ Non-profit 9. O'Entertairrment, 1 o. ❑ Manufacturing 11.❑ ficaah Care l2.❑ Other ".4ny applicant that oheoks box 4l most also all out the section below showing their workers' compensnlion policy information. "If the corporate officers have exempted themselves, but the corporation has other employee, a workers' compensation policy is required and such an organization should check box#L ` j ant an erttployer fliab is providing roorlrers' compensalion insurance for »:y employees. /lela(p is ore policy irifortvtation. Insurance Company Name; _/tDI?L0\1 c P-S YU, FB �_V_� 0 � r, co Insurer's Address: 19 I( (() V a ¢J - 0 E C L UEA�__ S � 1 YL t o ra City/State/Zip; C\,-\ 11 Policy tl or Self ins. Lie. It — I G -2-6 S 7r O _ Expiration Date: j % (J Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MCL.c. 152 can lead to the imposition of criminal penalties of a fine up to.$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOla ORDER and a tine ofup to 5250.00 a day against the violator. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DL4 for insurance coverage verification. 1 do hereby certil) andor the pains and penalflef of perjury tb at the information provided above is true and correct. Signaturaj[''t�C�^f`�- —" Date:.— ---- Official ase only. Do not write to this area, to be completed by city or talon official.. City or Tosvn; Issuing Authority (circle ono); I. Board of health 2. Building Department 3. CityiTtinin Cleric 4, Licensing Board 5, Selectmen's Office 6. Other Contact Person: Phone A,CORO® CERTIFICATE OF LIABILITY INSURANCE `„/ FDTe(MM/DD/YYYY) 1 11126/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must he endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Diversified Insurance Industries, Inc. 307 International Circle Suite 610 CONTACT NAME: Brlanna FOadschbeck ac°N o E,t , 410433-3000 a No): 410-433-3440 EMAIL oDREss• Brianna.Foertschbeck dil-Ins.com INSURERS AFFORDING COVERAGE NAICN Hunt Valley MD 21030 INSURERA: Employers Preferred Ins* 10346 INSURED VISI-04 Vision Hamsphire, LLC t/a Holiday Inn Mansfield INSURER B : INSURERG: INSURERD: 31 Hampshire Street INSURER E : Mansfield MA 66075 NSURERF: COVERAGES CERTIFICATE NUMBER: 1925911381 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE Arm INSO SUBS Won POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDNYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 11 OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Eaoccurence $ MED EXP (Any one person) $ GEN% PERSONAL&ACV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY JJECT LOC OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS NUTOS ON -OWNED HHIREDAUTOS AUTOS COMBINED SINGLE LIMIT Eaacuidenl $ BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ PROPERIZE MACE Peracndeni $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWE%ECDTIVE YIN OFFICERIMEMBER EXCLUDEDP (Mandatory In NH) ESCRIPTION under DESCRIPTION.n OPERATIONS below DESCRIPTION NIA EIG265616300 8/812018 6/24/2019 X PER STATUTE OC-RH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, AddIdenal Remarks Schedule, maybe aHached If more space is required) General Proof of Coverage FOR INFORMATION PURPOSES ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1 The ACORD name and logo are registered marks of ACORD All rluhts reserved. •.v�uv.v vv...Y..��nuuvu u.�v .�...N�v�v.v �.uv .iu� Insurance Policy EMPLOYERS PREFERRED INS. CO. t Po — P i ocA y.,, A Stock Company ONy ea z' From tz EIG 2656163 00 08/08/s2018 06/24/2019 Ins: eda'sleieg?,e(elnme of theaddress oflhe POLICY DECLARATIONS NCCI Carrier # 31283 WCIRB CARRIER# PRIOR POLICY NUMBER NEW DIVERSIFIED INS INDUSTRIES INC 6465200 VISION HAMPSHIRE LLC DBA HOLIDAY INN MANSFIELD 307INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer # Carrier # FEIN # Risk ID # Entity of Insured 1 31283 473112140 001033835 LIM LIABILITY CO Additional Locations: 2. The Policy Period is from 08/08/2018 to 06/24/2019 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1000,000 policy limit Bodily Injury by Disease $ 1:000,000 each employee C. Other States insurance: Part THREE of the policy applies to the states, if any, listed here: All states except AK, DE, HI, ND, OH, RI, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ Assessments and Taxes $ SEE EXTENSION OF INFORMATION PAGE 231 Expense Constant $ 338 Premium Discount $ -1,163 Total Estimated AnnualPremium $ 23,580 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly Countersigned this Day of Issued Date: 08/09/2018 Authorized Representative Issuing Office EMPLOYERS PREFERRED INS. CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NO 28277-2685 Issued Date 08/09/2018 WC990630 (5198 Ed.) INSURED COPY Page 1 of 4 ACORO® 1...� CERTIFICATE OF LIABILITY INSURANCE BATDI 11/26//26/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of, the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Diversified Insurance Industries, Inc, 307 International Circle Suite 610 NAME CT Brianna Foertschbeck acoNNo E t 410-433-3000 p�% No :410-433-3440 E-MAIL Aoo Ess: bnanna.foertschbeck dii-ins.com INSURERS AFFORDING COVERAGE NAIL# Hunt Valley MD 21030 INsuRERA: CINCINNATI INSURANCE CO. 10677 INSURED GLOB-01 Vision Hampshire, LLC t/a Holiday Inn Mansfield, MA c/o Hospitality Cover Plus, LLC INSURER B: Continental Insurance CO." 35289 INSURERC: Ohio Casualty Ins Co" 24074 INSURER D: INSURERE: P.O. Box 1572 Cockeysville MD 21030 INSURER F: COVERAGES CFRTIFICATF NIIMRFR'71740711q REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OFINSURANCE ADDL N D SUBR D POLICYNUMeEft POLICY EFF MM/OD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERALLIABILITY CLAIMS -MADE OCCUR Empl Beneflis INN0003005 11/1/2018 11/1/2019 EACHOCCURRENCE $1,000,000 PREMISES Eeoaurrenca $1,000,000 X MED EXP(Any one person) $1.000 X Hquorl.labilily PERSONAL &AOV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jECT � LOC OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG $2.000.000 Empl Behr/Liquor $1,000.000 A AUTOMOBILELIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY X $600 comp X $1.000 Call CAA5250328 1111/2018 11/1/2019 COMBINED SINGLE IT Ea acrAdent $1,000,000 BODILY INJURY (Per person) $ DODILY INJURY(Peracoident) $ PROPERTY DAMAGE $ $ e X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE 5094764769 11I1/2016 11/1/2019 EACH OCCURRENCE $26,000,000 AGGREGATE 1125,000,000 BED I X I RETENTION$ J a BID $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE YIN OFFICERIMEMBEREXCLUDEDT (Mandatory in NH) if yes descdbeunder BESGIRIPTION OF OPERATIONS below NIA STATUTE I I PITH E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ O A Excess U.1,iliy Excess Auto Llabilily ECO1966977639 EXS0610142 11/1/2018 1111/2018 11/112019 11/1/2019 LImIVAggregale CSL Limit 25,000,000 4,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES JACOPO 101, Additional Remarks Schedule, maybe attached if more space is required) Re: Holiday Inn Mansfield - 31 Hampshire Street, Mansfield, MA 02048 General Proof of Coverage reo"crl"Te HOLDER CANCEI I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Town of Mansfield 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE 91988.2015 ACORD CORPORA ItUN. All rights resemea. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 12/28/2018 _ IMG_0921.jpg https://mail.google.com/mail/u/0/#inbox?projector=l 1/1