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HomeMy WebLinkAboutStation Pointe Apts. 1 - 12/31/2019t Town of Msfield Town of Mansfield - Board of Hey Ali 6 Park Ro — "---------Mansfield,-MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $150 Public ,(JRe-inspection fee: $100 ,��� a� NAME OF OWNER: CA�LCfJf> �rn �tll e'� POOL OPERATION: `�f Semi -Public ADDRESS: ((`` x-N(A.+7. 0v -Ie )Jc 1 �'/r CITY: l(-i�(' e_ `& STATE: f"i\ ZIP: ©2 -CIA? TELEPHONE:50 - 93"t -"IT? Q, Special Purpose Pool POOL LOCATION: � L C4 -f, A'�ks 1 TYPE/POOL: '(ti1au-N LENGTH: q q Vt r C 0 VJ (_y 1 WIDTH: 5q -JP[ FAX: VOLUME: 3ti, Oj�� 9(1,k (' EMAIL: (/'C"C'la�(,�%�i1-�.� �L.iT1 i`S,C.i:'i� MINIMAXDEPTH: �3 ---}U � j4 FED ID/SS NO: jZ_ � joq C)- - SWIM AREA: 15S21Gt DIVE AREA: �( WATER SOURCE: l ()Lcn Certification Expires Every 5 Years. Permit Expires December 31st Yearl PERSON CERTIFIED: C.N��51(.2V &_Z4 kCv Pool/SPA Certification Date: b31(C) `2V n Pool/SPA Certification Expires: U3' (0 I Z�ZZ PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. W/W DISPOSAL: TYPE OF FINISH: SCUM GUTTER: rY) DECKTYPE: SKMMR WEIR LENGTH: r i TREATMENT SYSTEM: iN DISINFECT METHOD: i11C4 �y( L CHEMICAL TREATMENT:T(�\j�e.' NUMBER OF BATHERS: —I' SIGNATURE: �1�CL�1,ly�.,_ DATE: _ CiJ' C7OI� Please make appropriate changes. Sign, to 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 I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ( �o_ �- cxI;, L) -C. - Signature of Individual or Corporate Name By: Corporate Officer (Mandator, if Applicable) )2- 2011,01010 *"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:\Uscn\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Comtnonwealth of Massachusetts Department oflndustrial Accidents " Office of Investigations 600 Washington Street'. Boston, MA 02111 wit minass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address City/State/Zip: JAVOQ, Mh X)�Q�_ Phone M ,0)1' �9 � 100 b Are ou an employer? Check the appropriate box: Business Type (required): 1.M I am a employer with _ employees (full and/ 5. []Retail or part-time) * 6. ❑ Restaurant/Bar/Eating Establishment Z. ❑ I am a sole proprietor or partnership and have no ❑Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We, are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑. We are a non-profit organization, staffed by volunteers, ILEI Health are with no employees. [No workers' comp. insurance req.] 12.�f Other j 1 any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information. 'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ganization should check box M. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. surance Company Name:A/%Afff W //?lfj',]/ f f YAM11W C) Intl . surer's ity/State/Zip: flicy # or Self -ins. Lic. #._SJAM0214 Expiration ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a to up 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to.the Office of vestigations of the DIA for insurance coverage verification. to hereby certify, under t �i s and penalties ofperjury that the information provided above is true and correct use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone Ac"R,O® CERTIFICATE OF LIABILITY INSURANCE � IMMIDD Oq E018"YYY 10!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 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 Alliant Insurance Services, Inc. 2415 East Camelback Rd Suite 420 CONTACT Cherie De erte NAME: PHONEC No.6O2-707-1934 AICFAX No,, 480-333-6973 E-MAIL a .cdeperte@alliant.com SAFFOROINGCOVERAGE NAIC# Phoenix AZ 85016-4266 INSURERA:[us Insurance Co 100001724609 INSURED INSURER 13s Insurance Com an ZSurIus INSURER C:r InsuranceCom an 126 E Continental Pools, LLC 8520 Corridor Rd., #B Savage, MD 20763INSURER INSURERDInsurance Com an Elt Insurance Com an INSURER F: Federal Insurance Com an 0281 COVERAGES rFRTIFICATF NI IMRFR- 1598242485 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 INS MD POLICY NUMBER POLICYEFF MMIDDIYYYY POLICYEXP MMIDDIYYYV LIMITS A X COMMERCIALGENERALLIABILITY 100001724609 10/25/2018 10/25/2020 ACH OCCURRENCE $1,000,000 EAGE TO RENTED PREM SEE(Ea occurrence) $1,000,000 CLAIMS -MAGE 1X OCCUR MED EXP (My one person) $Excluded PERSONAL &AOV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG $2,000,000 POLICY [X] fEOT []X] LOC Policy Aggregate $$70,000,000 OTHER: F AUTOMOBILE LIABILITY 54309825 10/25/2018 10/25/2019 Ea accident) $1,000,000 BODILY INJURY (Par person) $ AUTO ALTOS NED SCHEDULED BODILY INJURY (Per accident) $ PROPER DAMAGE $ Per eddentli IANY HIRED AUTOS X NON�AUTOOWMED AUTOS B UMBRELLA LIAR X OCCUR POGI00004778501 10/25/2018 10/25/2019 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 X EXCESS LIAB CLAIMS -MADE 1 DED I I RETENTION$ $ F WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y-E.L. 54309827 10/25/2018 10125/2019" X STATUTE OERH EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYE $1,000,000 OFFICER/MEMBER EXCLUDED'! (Mandatory in NH) NIA E.L. DIBEASE- POLICY LIMIT $7,000,000 If yes, describe on,., DESCRIPTION OF OPERATIONS below C D E Excess GL/EL Excess Auto Excess over D & E CAEXOOOOOB063501 SF18EXC7613611V ECO1956322216 10/25/2018 10/25/2018 10/25/2018 10/25/2019 10/25/2019 10/25/2019 Each Occ/Aggregate $10,000,000 Each Occ/Aggregate $10,000,000 Each Occ/Aggregate $10,000,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) EXCESS LIABILITY OVER "F" Indian Harbor Insurance Co NAIC#36940 Policy# 10/25/18-10/25/19 Each Occ/Aggregate $15,000,000 Proof Of Insurance Continental Pools, LLC 8520 Corridor Road, Ste B Savage MD 20763 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD CORPORATION. All riahts reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I International Lifeguard Training Program Certification Issued to: Anthony Gordon Certification Number: 1081-3537 Completed on: Certification Expires on: 04/14/2019 04/14/2020 Training Level: Pool Includes Health Care Provider BLS, First Aid, and Oxygen Administration Training Depth: 8 ft 12.4 In Instructor Name: M&M &Oymerm Training Center: James L. McKeown Boys & Girls Club of Woburn O o The bearer of this codification has demonstrated the knowledge and the skills required to successfully complete this ❑IIs Education Services course, provided by an authorized Training Center and Instructor. Complete curriculum information and validation of this codification may be confirmed by scanning the QR code above or by entering Y the codification number into the validation tool located at: jelis,rom. e ,' Questions or comments? Email us at: 2aocalinnrgjellis.c,s n pt H ® 2019 Blis & Associates, Inc. 15979 Vineland Rd. Suite 105, Orlando, FL 328191 Phone: (407) 401-7136 International Lifeguard Training Program Codification Issued as Anthony Gordan Course Completed: Certification Expires: 04114/2019 04/14/2020 Training Center: James L. McKeown Boys & Girls Club of Woburn Instructor: William Alsamemi Training Level: Pool(IWws Hca etc, Flnt AA&oa Aamm) Depth:8 it 12Aon a I The bearer of this fetesonificationis has demonstratedScrelc the knowledge and ed the skills required to successfully complete this EIAs Complete Services course, provided by an tion of this Training Center and confirmetord Cocanni gthecurriulum QRcodeabo Information validation the certification maybe Into tmetl by do scanning located OR t: j0le above by entering the Question number Into the Email us at: tool locatetlab j,ornrrl. Questions or wmmenl5?Email us at: eduwtimrC'ellis cora ! International Lifeguard Training Program Certification Issued to: Mile Angeleski Certification Number: 1026-2046 Completed on: 04/14/2019 Certification Expires on: l Training Level: Pool Includes Health Care Provider BLS, First Aid, and Oxygen Administration Training Depth: 8 ft 12.4 m Instructor Name: MAawi Nsamwaw Training Center: James L. McKeown Boys & Girls Club of Woburn 04/14/2020 The bearer of this certification has demonstrated the knowledge and the skills required to successfully complete this Ellis Education Services course, provided by an _ authorized Training Center and Instructor. Complete curriculum information and validation of this certification may be confirmed by scanning the OR code above or by entering � the codification number into the validation (ort located at: hhsxm. Questions or comments? Email us at educatkm@jolliscom ® 2019 Ef is & Associates, Inc 15979 Vineland Rd. Suite 105, Defense, FL 328191 Phone: (407) 401-7136 International Lifeguard Training Program Certification Issued to: Mile Angeleski Course Completed: Certification Expires: 0411412019 04/14/2020 Training Center: James L. McKeown nays & Girls Club o1 Woburn Instructor: William Alsamemi Training Level:Pool pnromes Ncl'BLS.. Fio(AA802 Afton) Depth: 8 It 12.4 re I The hearer of this certification has demonstrated the knowledge and the skills required to successfully complete this Ellis Education Services course, provided by an authorized Training Center and Instructor. Complete curriculum information and validation of this codification may be confirmed by scanning the QR code above or by entering the codification number into the validation fool located at: jellis crm. Questions or comments? Email us at: en matim@pjalls.cmn