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HomeMy WebLinkAboutHoliday Inn - 12/31/20191b Town of Mansfield e �.. ..� vn of Mansfield -Board- a�Health.....:..................s ParlrRow....................._.................._..........I Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $150 Re -inspection fee: $100 NAMEOPOWNER:. Vj5im, ddnpsh/L a6 �/d�CdCuJ ;inn ADDRESS: �I l'l.175�j-P/ri CITY: STATE: /P0 ZIP.: doI)7 f TELEPHONE: JqF -331 - d l?a FAX: V ,? -339 - 11)yd EMAIL: Y(( &gand @/�l4-1kD. (07) FEDID/SS 0: j ertificatlon Expires I rermr tjunres vacee��moer mal Tearl PERSON CERTIFIED: Nub marAl)CZ Pool/SPA Certification Date., 61I3J dOI Sr Pool/SPA Certification Expires: 611,4 �da.Z3 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: carfleoafion remarks(lf necessary): REMARKS: ® Public POOLOPERATION: © S I-PUbilo Special Purpose Pocl POOL LOCATION: TYPEIPOOL: Sy LEN4TF,¢ A./ Li WIDTH: ti),+ /0 1`^�f%ND 1OLUME:• IQpO 4C MINIMAX DEPTH: �/ f SWIM AREA: /(l,& 'l DIVEAREA: WATER SOURCE: -ro V/U, WdTef WNW DISPOSAL: 5071 C TYPE OF FINISH: P`�gsy erL- SCUM GUTTER: - '-" - AM DECK TYPE; 'rt L SKMMR WEIR LENGTH: IA TREATMENT SYSTEM: 0qUi0rA,4rQ21> DISINFECT METHOD: S AVr 1 v A),4 Z+AT (d'0 CHEMICAL TREATMENT: 50T) I U W\ R d PdC N l.d ti• 1-rC NUMBER OF BATHERS: U SIGNATURE: f f DATE: '`//5 // Sign, date and enclose check payable to.Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048, '\ The Commonwealth ofMassachusetis Departnidnt oflndilstrialAccidents I Congress Street, Nalle 100 Boston, MA 01114-2017 ivotinlass.gov/din Wtirkers' Componsnfion TnsuranceAffidavit: General Businesses, TO BE MUD wral TTM VI) l2MIXITNG A(JTfl0IUWY. A.>ltilicatlt IntarmatioTz \ I Please Print Lt, iblV Business/Orgatdzation Name;_ v S 0 Aditreas: City/State/Zip _Ik V'iNS V-I C-L " 'OZ () Phone #: � Z-- Are you an employer? Check the Appropriate box: 1. I aura employer With _bmpidyees'(full, and/ orpart-time),* 10 1 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 employees. [No workers' comp. Insurance req,] }Any, applicant that checks box ql must also fill out the section _below shoving them Business Type (required): 5. ❑ Retail 6, VResfaurant/Bar/EatingEstablishment 7. Q 0fico and/or Sales (incl. real. estate, auto, etc:) 8, ❑ Non-profit 9. ❑ Emertainment, 111.❑ Manufacturing I t.❑ Health Caro 12.❑ Other Willie Corporate Cff cers have Mmpted themselves, but the Corporation has other employees, a workers' compensation policy is required and such sp organization should chock lax NI. I am an employer flrat is providing workers' compensatiodt irtsaratice for niy employees. 8eloiv is the policy btformadon. Insurance Company Name; Insurer's Address:_ 1 �y i) Ll _f) P.7 9 t.1 E �Q��D R (TE City/State/zip; C\/ Policyft or Self -ins, Up. �(0 0 13xpiration Date: 1 ?— � U_I Attach a copy of the workers' compensation policy declaratiou page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMOL.c. 152 can lead to the imposition of criminal penalties of a fineup to.$1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o f Investigations of the DIA. for insurance coverage verification. I do hereby-certtounder Ilia painsand penal ies ofperjury dial the information provided above is true and correct. tn Siaturo rrn,6Date: Z 6_____ Official use only. Do not write In this area, lobe completed by city or town off iclat. City or Town: Permit/License issuing Authority (ciXnle on(,): 1. Board of health 2.13uilding flepartment 3, City/'Town Clerk 4, Licensing Board 5, Selectmen's Office 6.Other__�_.,�__` Contact Parson: Phone TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) '�- Jll-2f qD **Social Security No. (Voluntary) or Federal Identification Number *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\sleite\Dmktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc AC Rom® CERTIFICATE OF LIABILITY INSURANCE GATE (MMI00 YYYY) 11/26f2018 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 - NAMEACT Brlanna Foertschbock PHONE..Exl: 410-433-3000 uc No:410-433-3440 EWe.MAIL ADDRESS: brianna.foertschbeck dii-ins.com INSURERS AFFORDING COVERAGE NAIC0 Hunt Valley MD 21030 INSURERA: CINCINNATI INSURANCE CO. 10677 INSURED GLOB-01 Vision Hampshire, LLC I/a Holiday Inn Mansfield, MA c/o Hospitality Cover Plus, LLC INSURERS Continental Insurance CO.' 35289 INSURER c: Ohio Casualty Ins Co" 24074 INSURERD: INSURER E: P.O. BOX 1572 Cockeysville MD 21030 INSURER F: COVERAGES CERTIFICATE NUMBER' 717407119 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. MISS LTR TYPEOFINSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICYEFF MM/DDNYYY POLICYEXP MM/DDIYYYY LIMITS A X COMMERCIALGENERAL LIABILITY INN0003005 11/1/2018 11/1/2019 EACH OCCURRENCE $11000,000 CLAIMS -MADE E OCCUR DAMAGETORENTED PREMISES Ea occurrence $1,000,000 X MED EXP(Anyone person) $1,000 EMM Sense, X UquarLiability PERSONAL& ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2.000,000 PRODUCTS-COMP/OP AGO $2,000,000 A POLICY ❑ i'mw IFx1I LOG OTHER: AUTOMOBILE LIABILITY CAA5260328 11/1/2018 11/l/2019 Empl eenf/LI vor COMBINED SINGLE LIMIT Ea accident $1,000,000 $1,000,00U BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY, (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED )( NON.OWNED AUTOSONLY AUTOS ONLY X $500 Comp X $1.000Co11 pe°ac RTYDAMAGE $ $ B X UMBRELLALIAB X OCCUR 5094764769 11/1/2018 11/1/2019 EACH OCCURRENCE 525,000,000 AGGREGATE $25,000,000 EXCESS LIAR CLAIMS -MADE DED I X I RETENTION$ WORKERS COMPENSATION STATUTE ERH $ E.L, EACH ACCIDENT $ AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVEEREXCLUDEDY ELDISEASE - EA EMPLOYEE $ OFFICERIMEMB❑ (Mandatory In NH) NIA E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS belov! C A Excess Uabir Excess AutoLability ECO1966977539 EXS0510142 11/1/2018 11/1/2U18 11/1/201.9 11/1/2019 Licari' Vregale CSL Limit 25,000,000 4,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is funereal Re: Holiday Inn Mansfield - 31 Hampshire Street, Mansfield, MA 02048 General Proof of Coverage r`A nICEL AT!ON VCt(iIrWHI C DVLUCK""��--"""' 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 AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048 V IeDD'LU ID HVVRU 4VRfVR1111V r'1. I-�n,�yu a,vuv.... u. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 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(les) must 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 CONTACT NAME: Brlanna FOertschback PAHONE t, 410 433-3o00 a No):410-433.3440 E-MAIL ADDRESS: Brianna.Faertschbeck dii-ins.com INSURERS AFFORDING COVERAGE NAIC 9 Hunt Valley MD 21030 INSURER A: Employers Preferred Ins" 10346 INSURED VISI-04 Vision Hamsphire, LLC Us Holiday Inn Mansfield INSURER B : INSURER C: 3.1 Hampshire Street INSURER D: INSURER E: Mansfield MA 55075 INSURER F: 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 LTft TYPE OF INSURANCE ADDLB N D RR Me POLICY NUMBER POLICY OFF MMIDDIYYYY POLICYEXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE n OCCUR I EACH OCCURRENCE $ DAMAGETORE T D PREMISES E.oc=.Lea $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑ JECT PRO- ❑ LOC OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO ALLOYING) SCHEDULED AUTOS AUTOS NON'OWNED HIRED AUTOS AUTOS(Per H COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE ... Kenn $ $ _H UMBRELLALIAB EXCESS LIAR OCCUR CLAIMS -MADE — EACH OCCURRENCE $ AGGREGATE $ DED RETENTION§ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORPARTNER/EXECUCVE YN/A OFFICERIMEMOER EXCLUDED? (Mandatory In NH) If yes, describe under OE SCRIPTION OF OPERATIONS below EIG265516300 818/2018 6/24/2010 ;ti X STATUTE �RH- EL, EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYE $1,000,DOU E.L. DISEASE -POLICY LIMIT I $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACOR0101, Additional Remark.Schedule, may be attached if more space larequlred) General Proof of Coverage CEOTIFICATE HOLDER CANCFI I ATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATION PURPOSES ONLY AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rlgnts reservea. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD is llilFLUMV1111 .ns..nuranvnce Polro.P-o'I, ...�uwue.. w..w ..ngr.eyew �mvwy Iicy EMPLOYERS PREFERRED INS. CO. Polic mb PoIIcySPerod°- A Stock Company EIG 2656163 00 08/08//5220AAa18 06/24/2019 Ins 0ed a 'slated ,,.relnme of (headdress ofthe .v+��f+,^'o�tfianSOCtIOn�'i rsr,,,,.„�3..,.."J�,-,.,-w='.�.;.i.�.n� ,. �..Z�..,.. POLICY DECLARATIONS NCCI Carrier # 31283 WCIRB CARRIER# PRIOR POLICY NUMBER NEW 1 NM�me ljisuredsantl Address - Agent _. 4 .. s �� VISION HAMPSHIRE LLC DIVERSIFIED INS INDUSTRIES INC 6465200 DBA HOLIDAY INN MANSFIELD 307 INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer # Carrier# FEIN # Risk to 9 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 $ 11000000 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 �(7,& Issued Date: 08/09/2018 Authorized Representative Issuing Office EMPLOYERS PREFERRED INS. CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 Issued Date 08/09/2018 WC990630 (5198 Ed.) INSURED COPY Page 1 of 4 . `Gloot . t Town of Mansfield - Board of Health N P 91ff0 AN Swimming Pool Application NAME OF OWNER: t7�)'Yli)..7i11i7J' jj_(� Wichi Jn/-t ADDRESS: CITY., r,(ls�G°rC,Y /11"' STATE: ZIP: o'Vlp TELEPHONE: V�,;�L-.j /1} FAX: !. �IZ%h�" <_�. I1." 1 1 EMAIL: FED IDISS NO: 7J % I j2'! Certification Expires Every 5 Years. Permit Expires December 31at Yearly - PERSON CERTIFIED: jj�Ld(yG/ Pool/SPA Certification Date:fr3�svt PoolISPA Certification Expires: PERSON CERTIFIED: PoolISPA Certification pate: PoolISPA Certification Expires: certification remarks(if necessary): REMARKS:, ❑I Public Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 POOL OPERATION: 0 Semi -Public [Special Purpose Pool POOL LOCATION: ✓!7 ��jl&l 151t'_("-I TYPEIPOOL: ,, / LENGTH: r WIDTH: 1 I n VOLUME: kj l'ii..9 MINIMAX DEPTH: SWIM AREA: ! DIVE AREA: WATER SOURCE: Tam W/W DISPOSAL: �O ,':s TYPE OF FINISH: /'i �� SCUM GUTTER: TY 1fJ DECK TYPE: //jI SKMMR WEIR LENGTH: TREATMENT SYSTEM: (2LG,Ti�/) DISINFECT METHOD: CHEMICAL TREATMENT: NUMBER OF BATHERS: p SIGNATURE:/ � _ (� C/ 17 DATE: c "Vo Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. Jane Doucette From: Tricia Putignano <tputignano@hifoxboro.com> Sent: Thursday, March 28, 2019 2:55 PM To: Jane Doucette Subject: Re: FW: Pool licensing Attachments: 2019 Special Purpose Pool Permit.pdf Hi Jane, Yes Rudy is still employed with us. On Mon, Mar 25, 2019 at 9:13 AM Jane Doucette QdoucetteCa mansfieldma com> wrote: Hi Tricia, Is Rudy Martinez still the pool certified person? I was told he is no longer there. From: Tricia Putignano[mailto:tputignanoCd)hifoxboro.com] Sent: Friday, March 22, 2019 11:58 AM To: Jane Doucette Subject: Re: FW: Pool licensing Hi Jane, Please see attached pool permit. I'm sorry for the delay. Have a great weekend. Best, Tricia On Wed, Mar 13, 2019 at 3:445 PM Jane Doucette <Jdoucettegmansfieldma.com> wrote: Hi Tricia, still have not heard back about the special purpose pool at the Holiday Inn. I am sending the paperwork for the pool. Please fill out and return immediately; you do not have a permit to be operating that pool. From: Amy Donovan -Palmer Sent: Tuesday, March 5, 2019 8:43 AM To: Jane Doucette Subject: Pool licensing Later than I originally told you but not forgotten... Please email this out to the pools who usually get licensed in May. Thank you, Amy Amy Donovan -Palmer, MPH, RS Health Agent 6 Park Row Mansfield, MA 02048 Phone:508-261-7366 The information contained it) this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. Tricia Putignano°-Fei'meira General Manager 31 Hampshire Street I Mansfield, MA 02048 T: 508-339.2200 E: tputignano(a hifoxboro.com b AN 114W HOTEL. The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive It. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing In; Security, archiving and compliance. To find out more Click Here. Tricia Putignano-Ferreira General Manager 31 Hampshire Street I Mansfield, MA 02048 T:508-339.2200 E: tputignano(a�hifoxboro.com Holiday 1w AN 114WHOTEL