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Home My WebLink AboutMansfield Meadows - 12/31/2019vJ MAY 06 2019 is Town ® 1i�ans veld - Board ® To�n�f Mansfield T °° iia spark Row E ° ° Mansfield, MA 02048 Swan2lning Pool Application PERMIT NUMBER FEE: $150 Re -inspection fee: $100 1� Public NAME OF OWNER: MO DtShL� Ys m�A� POOL OPERATION: X. Semi -Public �`_ El Special Purpose Pool ADDRESS: I2{�I�CJC�hUl [11y , �A-(k POOL LOCATION: 12.'jmr)" Uas)e-4-q CITY: ��(krSield l 1 STATE: MR ZIP: 0-2 d4q TELEPHONE: 502-339^'�JJ� FAX: EMAIL: 5�A.2Q I.CpOt�}i ne-rrFoSI��S . COCY� FED IDISS NO: Certification Expires Every 5 Years, Permit Expires December 31st Yea PERSON CERTIFIED: 1C.20V4--",j Pool/SPA Certification Date: 031 101 2911 Pool/SPA Certification Expires: 6 31 1 0 1 20z-?— PERSON 22PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: TYPEIPOOL: (y1Q�C-i LENGTH: 40t WIDTH: 22t VOLUME: 3(O, 30C)C) qQ1,. MINIMAX DEPTH: Si -)r1D ` SWIM AREA: N141) DIVE AREA: N 1 WATER SOURCE: kajin WIW DISPOSAL: Toon TYPE OF FINISH:t �L� CN+ SCUM GUTTER: 111 ((4 - DECK ( i - DECK TYPE: 66ff-fQ,Are SKMMR WEIR LENGTH: ` TREATMENT SYSTEM: DISINFECT METHOD: Gh10c �1`Q 1�b�` CHEMICAL TREATMENT; GL 22C) t' 28(2r NUMBER OF BATHERS: S SIGNATURE:_ T _ DATE: Sign, date and enclose check payabl o 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. (OD-� ?ods I Signature of Individual or Corporate Name 52- 20(o9 bQ o "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:\Usem\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street, Boston, MA 02111 wlvw.inass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibly Business/Organization City/State/Zip: JUV(1 Phone M & Mqg� /01) 0 Are Ids ou an employer? Check �th��e appropriate box: Business Type (required): 1.Y I am a employer with employees (full and/ S. ❑ Retail or part-time).* 6. ❑ Restauram/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We are a Corporation and its officers have exercised 9. ❑ Entertaimnent their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.11.❑ Healthre a ❑_ We are anon -profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.(4 Othrjbjfflffljnaa6j "NL \ny 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 #1. am an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. surance Company Name: 0y'��%� Im1pa e (JYl�yl surer's Address:/�I_ t yh.,,,(,,�i �_ L ,? ` � Na.MII.nnnf/IC__ 01 Jaa 00 ity/State/Zip: ✓—/bY miry # or Self -ins. Lic. #'t J(/ l tioLT Expiration Date: �U / 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 MGL c. 152 can lead to the imposition of criminal penalties of a le 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, cerlifv, under, and penalties of perjury 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 ACORD® CERTIFICATE OF LIABILITY INSURANCE ��. DAM,MMIDDM YY, 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(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 Alliant Insurance Services, Inc. 2415 East Camelback Rd Suite 420 CONTACT Cherie De erte PHONE .802-707-1934 ac e � 480-333-6973 EMAIL cdeperte@alliant.com INSURERS AFFORDING COVERAGE NAIC0 Phoenix AZ 85016-4266 INSURER A:Liberty Surplus Insurance Co 10725 100001724609 INSURED INSURERB:AXIS Surplus Insurance Company__26620 INSURERC:First Mercury Insurance Company 10657 Continental Pools, LLC INSURER D:Navi ators Insurance Company 142307 8520 Corridor Rd., #B Savage, MD 20763 -- INSURER E:Ohio Casualty Insurance Company 24074 INSURER F: Federal Insurance Company 20281 COVERAGES CERTIFIrtATP MIUvI 1596242485 REVISION NUMBER: V 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 INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDIVYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 100001724609 10/25/2018 10/25/2020 EACH OCCURRENCE $1,000,000 PREMISES Eaoccuff. $7,000,000 CLAIMS -MADE 1X OCCUR MED EXP (My one person) $Excluded PERSONAL B AOV INJURY $1,000,000 GENT. AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 PRODUCTS -COMPIOPAGG $2,000,000 POLICY ❑X PRO LOC _ Policy Aggregate $$10,000,000 OTHER: F AUTOMOBILE LIABILITY 54309825 70/25/2078 10/25/2019 Ea accitlent $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY(Per accident) $ ALLOOWNED SCHEDULED NON -OWNED X HIREDAUTOS X AUr05 DAMAGE $ Per acdtleof 8 UMBRELLALIAe X OCCUR P00100004778501 10/25/2018 10/25!2019 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 X EXCESS LIAB CLAIMS -MADE DEO I I RETENTIONS $ F WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y� 54309827 10/25/2018 10/25/2079. X STATUTE OERH E.L. EACH ACCIDENT $1,000,000 E.L. DISEABE - EA EMPLOYEd $1,000,000 OFFICERIMEMBER EXCLUDED'! (Mandatoryln NH) N/A E.L. DISEASE -POLICY LIMIT 1 $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS belan1 C D E Excess GL/EL Excess Auto Excess over D 8 E CAEXGOOOOB063501 SFI8EXC7613611V ECO1956322216 10/25/2018 10125/2018 10/25/2018 10/25/2019 1012512019 10/25/2019 Each Oce/Aggregate $10,000,000 Each Oco/Aggregate $10,000,000 Each Occ/Aggregale $10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be affached 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 GVLq R3C1 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. AUTHORIZED A ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD