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Home My WebLink AboutMillhaus @ Mansfield Condos - 12/31/2019Towii ol'Alamyielcl - Board of llealth Swimming Pool Application NAME OF OWNER: h7IIf &to M46 Jrv-hW ekaff S" ADDRESS:/ g"2i}y1 CITY: 1na4d 4e-ld STATE: 414L ZIP: &'O'A f TELEPHONE: 12)0 3'3 3b?'8 FAX: EMAIL: L FED ID/SS NO: Certification Expires Every 5 Years. Permit Expires December 31st Yearly, PERSON CERTIFIED: Pool/SPA Certification Data: Pool/SPA Cedificalion Expires: PERSON CERTIFIED: Pool/SPA Certification Date: PooIISPA Cerlification Expires: certification remarks(If necessary): REMARKS: Town of Mansfield 6 Park Row Mansfield, MA 02046 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 11 Public POOL OPERATION: Semi -Public 1 -! Special Purpose Pool POOL LOCATION: / J-b �&md TYPEIPOOL:67 6i7 / �-'- LENGTH: (/ D I WIDTH: VOLUME: & (d 000 MINIMAX DEPTH: "4a -7 j SWIM AREA: / W(q -0-4- DIVE AREA: /7 WATER SOURCE: 7bwfi WIW DISPOSAL: I jC TYPE OF FINISH: SCUM GUTTER: DECK TYPE: 0410) .fie. SKMMR WEIR LENGTH: V; 6 f Cr'4a�K7' TREATMENT SYSTEM: t Wood J000 DISINFECT METHOD;,2 -b Ke C CHEMICAL TREATMENT:r.'ltuo NUMBER OF BATHERS: 76 . r IATURE c£ r°1 _.. _ _ -._._ Ul c --- DATE: date and enclose eck payable to Town of Mansfield. Mail to: Board of ldealth, Town of Mansfield, Six Row, Mansfield, M 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. By: Corporate Officer (Mandalory, if Applicable) "Social Security No. (Volunlarl)) m Federal Idenlificalim Numbor *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. CiUxlS\slvite\Ucahlopltiton's DocumenlsToud I.siabluhnrenls- Templ AN CISRn IFICA'IION FORM doc The Commonwetil/h of Massachavetts Deparhnent of Industrial Accidents O. ice o/7111'eWigations 600 64'ashinglon Street Boston, MA 02111 low 2 Intvlv.ntaSS.gav/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please PrintLegibly Business/Organization Name: W-1-11/htaN rr& kz (.v rZI0 : TZ t .mE City/State/Zip: Phone#: Db66 a3�/ 367d Areyou an employer? Check the appropriate box: Business Type (required): I . K I am a employer with _ o'. employees (full and/ 5. ❑ Retail or part -lime).* 6. ❑ Restauranl/Bar/tinting Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (ind real estate, nuns, etc.) employees working for ale in any capacity. 8• ❑ Non-profit [No workers' comp. insurance recoiled] 3. ❑ We the a corporation and its officers have exercised 9. ❑ Entertainment Ihcir right of exemption per C. I i2, § 1(4), and we have 10.❑ Manul'acluring 4. ❑ no employees. [No workers' comp. ino s•ancc rcquircd]** We by I I.❑ fleallh Care are a non-profit organization, staffed volunteers, wnh no ennployecs. (No workers' comp. insurnncc re4•i 12.0 Other °AFit applicant Owl drecks hox I most ills" lilt nut the section helum'sholeina their corkers compensation policy Information. "I I'll It: eorporme oalcc ps have exempted thwlsebes• but the corporallon lima other emptoyees, it mrnrkcrs" com p ensa Lion policy is requited and such an wt, m ial on should check box t11. ! am (tit enrphiver alma isproviding uvtrltets' cnutpenavntatr insurance for nq emple veer. 13c/ant Is fhe pu/leap htforuudlnn. Insurance Company Namc:__�•��Q7A(l --- ._-____---__-- Instncr's Aciclress: +tC_.1LfjApL (244 ---- Policy/i or Self -ills. I.ic. 4 Z -,12Gr-4 ',J6Z31a Ai/)/o Expiration Date: /A IAO 144d/ 9 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration do(e). Failure to secure coverage as required under Section 25A ol'IMGL c. 152 can lead to the imposition of criminal penalties of a Isle up to S1,500.00 and/or one-year imprisonment, its well its civil penalties in the form ol'a STOP WORK ORDL'R and it line of ton to $250.00 a day against the violato. Be advised Ihat it copy of this statement may be forwarded to the Office of Investivations of the DIA for insurance coverage verification. ! do hereb •er t i,, uJider the pains and penaRles of petytrry thud the inf'arumdon provided above is true and correct. only. Do not write in this etrea, to he campletert !{p city or amen gflivial. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. City/Town Clerk 4. Licensing Board 5• Selectmen's Office 6. Other Contact Person: Phone mwvmc.mmss.aov/thin a �® CERTIFICATE OF LIABILITY INSURANCE -BATE o5/1412/14/2o1s 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 INSURERS), 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 C & S INSURANCE AGENCY INC CONTACT NAME: Lisa Fonseca PNC NNo Ext: (508) 339-2951 AIC No: E-MAIL isa candsins.com ADDRESS: sa@candsins.com INSURERS AFFORDING COVERAGE NAIC # O BOX 406 INSURERA: AIM MUTUAL INS CO 33758 MANSFIELD MA 02048 INSURED INSURER B : INSURER C: MILLHAUS AT MANSFIELD CONDOMINIUM TRUST INSURER D : INSURER E 137 SCHOOL ST INSURER F: FRANKLIN MA 02038 CfTVFRAOFR CFRTIFICATE NUMBER: 402343 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. CTR TYPE OF INSURANCE name Me BURR POLICYNUMBER POLICY SEE EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCU RRENCE $ CLAIMS -MADE ❑ OCCUR ❑ MAGETO PREMISES E. oxurrenco $ MED EXP(Any one person) $ — PERSONAL &ADV INJURY $ N/A GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ POLICY ❑ jE' LOG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) It ANY AUTO BODILY INJURY IF., accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ Id AGGREGATE $ EXCESS LIAR CIAIMS-MADE N/A DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEMEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) NIA NIA VWC10060205362018A 12/20/2018 12/20/2019 - �/ X StATUTE EORH EL EACH ACCIDENT $ 100,000 E.L. DISEASE- EA EMPLOYEE $ 100,000 EL.DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DE SCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in farce on the date that this certificate was issued (unless the expiration date On the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE C' Mansfield MA 02048 Daniel M. CIO,W„fey, CPCU, Vice President— Residual Market— WCRIBMA n 1RRR.201d ACORn CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD A.I.M. Mutual INSURANCE COMPANIES C & S Insurance Agency Inc PO Box 406 Mansfield, MA 02048 A.I.M Mutual Insurance Cornpany Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company Associated Employers Insurance Company 11 /05/2018 Insured: Millhaus At Mansfield Condominium Trust Re: Workers Compensation Insurance Policy V W C-100-6020536-2018 Enclosed is workers compensation policy # VWC-100-6020536-2018A for Millhaus At Mansfield Condominium Trust, effective 12/20/2018. Please note that this policy is also available online at www,aimmutual.com via our ServicesOnline Web Portal. As always we appreciate your business and please do not hesitate to contact your customer service representative It you have any questions. Sincerely, Daniel A. Landers Director of Field Operations 54 Third Avenue - P.O, Box 4070 - Burlington, MA 01803-0970 - Tel: 781.221.1600 / 800.876.2765 - Fax: 781.270.5690 BURLINGTON - HOOKSETT, NH - HOLYOKE - MARLBOROUGH sponsored by Associated Industries of Massachusetts 0 BMW IL c am am n o t t