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HomeMy WebLinkAboutWest Village - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 11 PERMIT EXPIRES: December 31, 2019 Person Certified: RUSSELL SMITH Pool/SPA Certification Date: March 12, 2019 Pool/SPA Certification Expires: March 12, 2024 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 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: GREYSTAR for the operation of a ❑ Public W Semi -Public ❑ Special Purpose Pool located at 792 WEST STREET Method of water treatment is CHLORINE/CHLORINATOR RAINBOW 300 Bathing load not to exceed: 93 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan -Palmer, HeaCth Agent Date Issued Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 12 PERMIT EXPIRES: December 31, 2019 Person Certified: RUSSELL SMITH Pool/SPA Certification Date: March 12, 2019 Pool/SPA Certification Expires: March 12, 2024 Person Certified. Poo)/SPA Certification Date: Pool/Spa Certification Expires: 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: for the operation of a ❑ Public Method of water treatment is Bathing load not to exceed: GREYSTAR ❑ Semi -Public located at 792 WEST STREET W Special Purpose Pool CHLORINATOR/SAND FILTER 8-10 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. .Amly Donovan -Palmer, Health .Agent None Date Issued G-� Town of Mansfield - Board offfealth ASA Swimming Pool Application NAME OF OWNER: G fj- Y5.v_(' Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Re -inspection fee: $100 O Public POOL OPERATION: 3KSemi-Public 0 Special Purpose Pool ADDRESS: 17q�_ L C__ + b4. POOL LOCATION: qcia. LoetA �{ CITY: �n-5 _.. STATE: 7rY ZIP: �.Ci =-i� TYPE/POOL'C TELEPHONE: 4oi:J LENGTH: WIDTH: VOLUME: t.{a,(�GC Ca -1 FAX:. 0 ' 6n I MINIMAX DEPTH: EMAIL: W"j;N iJTr�LGiC Mt�dllthC@.irrreilJJ`'� ix" AREA: ll -(()CJ _q, i'+` DIVE AREA: Nlfi FED IDISS NO: J J ,,,J Certi ft won Expires EVery 5 Yea's Permit Expires December 31st Yearly PERSON CERTIFIED: ZU.)�m(uJftl PoollSPA Certification Date: '�) i x j I cx Pool/SPA Certification Expires: PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: WATER SOURCE: TDA'✓\ WIW DISPOSAL: TOW & TYPE OF FINISH: i kC-� SCUM GUTTER: uJ a DECK TYPE: (2 "Ac SKMMR WEIR LENGTH: O f TREATMENT SYSTEM: r+b, i-cL k SG"%\ a (` r DISINFECT METHOD: r �'W T- n` I A � kii r i1>,li�(J a CHEMICAL TREATMENT: j21,. to<''n Q_ NUMBEROF BATHERS: C? DATE: 2 I ) SIGNATURE: Sign, date a nclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. Town of Mansfield Torun of Mansfield - Board of'Health 6 Park Row Mansfield, MA 02048 Sivinuning Pool Application PERMIT NUMBER FEE: $150 Public Re -inspection fee: $100 ❑� NAME OF OWNER: G I'C�'�4C,C- POOL OPERATION: R Semi -Public [Special Purpose Pool ADDRESS:,? (.���j- ;�i, POOL LOCATION: 1TGl� CITY: ll✓lC�/1'S"�e(d 7 STATE: MA ZIP: 0j'6ga TYPEIPOOL:6�4/ kt)A loc, TELEPHONE: 5©8 C�L 1 - 0"Sc0 LENGTH: Q/ A WIDTH: IIIA V f,,.8 , 0(i VOLUME: I5C_>0 (5AL FAX: J 0601 EMAIL:MINIMAX DEPTH: 3, S ��, I.Je01 v;t�e t'�1-r��J-��J �C¢Y`Jia�CoM FED ID/SS NO: C / SWIM AREA: �1 A DIVE AREA: IWA f�' V ),- .'5D, 144-36 WATER SOURCE: '(jLjY\ Certification Expires Every 5 Years. WM DISPOSAL: -TOWS Permit Expires December 31st Yearly. PERSON CERTIFIED: ��.5x„ 6t.a. )" Pool/SPA Certification Date:7j / I -t. I I qt Pool/SPA Certification Expires: 3/ la ICtl PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: TYPE OF FINISH: PiC;'t>AC r SCUM GUTTER: A)It DECK TYPE: 0, C CC=1�z_ SKMMR WEIR LENGTH: (g f' TREATMENT SYSTEM: C h to I- � rv_ ++ r DISINFECT METHOD: e V, to l-,v1a. to f �G../� C t -I I �c CHEMICAL TREATMENT: C K w Q'T vN_ NUMBER OF BATHERS: 8 _ 16 SIGNATURE: --� DATE: Sign, date a nclose 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. . t AA, Signiatur f Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) &I - C7� 4 "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:Wscn\sloite\Desktop\Sw1Vs DocumentsWood Fstablistnnmts-Tetnp\TAX C13RTIFICATION FORM.doc Enter your TIN In the appropriate box. The TIN provided must match the name given online Ito avoid QQ �.7 Request for Taxpayer H— m Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury Iritemol Revenue service ► Go to www.lrs.gov/FormW9 for Instructions and the latest information. send to the IRS. I Name (as shown on your Income tax return). Name Is required an this line; do not leave this ling blank. or _...... -.. _ _.. GS West Village Project Owner LLC 2 Business namo/dismgarded entity name, if different from above O1 mP 3 Check appropriate box for federal tax classification of the person whose name Is entered on line is Check only one of the Y 4 Exemptions codes apply only to P ( PPY Y � following seven boxes, certain entitles, not Individuals; see a o ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate Instructions on page 3): N ii single -member LLC Exempt payee code (if any). '� ❑✓ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► P `e Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting t lir LLC if the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC Is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code Of any) - t1 Is disregarded from the owner should check the appropriate box for the tax classification of Its owner, ' 8 ❑ Other (see Instructions) ► (Mpr•s io ettounlsm•mienreaomvee ln_e LL_sv to 5 Address (number, street, and apt. or suite he.) See instructions. Requester's name and address (optlonall 465 Meetiri Street - Suite 500 5 City, state, and ZIP code Charleston,$C 29403 _ 7 List account nUmber(s) here (optional). - - Enter your TIN In the appropriate box. The TIN provided must match the name given online Ito avoid I Sodal security number - backup withholding. For individuals, this is generally your social security number (Bait). However, fora alien, sole proprietor, or disregarded entity, see the instructions for Pan I, later. For otherFM H— m entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, TIN, later. or _...... -.. _ _.. Note: If the account is In more than one name, see the instructions for line 1. Also see What Name andi Employer Identification number Number To Give the Requester for guidelines on whose number to enter. �1 F—T--F—F—r- Certification Under penalties of perjury, I certify that: - --- - ---- 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not requivd to sign the certification, but you must provide your correct TIN. See the Instructions for Part II, later. Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An Individual or entity (Form W-9 requester) who Is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social Security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns Include, but are not limited to, the following. • Form 1099 -INT (Interest earned or paid) Date 0- //bl tt • Form 1099 -DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN. It you do not return Fornf W:9 to the requester with a TIN, you might be subject to backup Withholding. See What Is backup withholding, tater. Cat. No. 10231x Form W-9 (Rev. 10-2018) The Commonwealth of Massachusetts Department of Industrial Accidents' Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 791,)- Ua + � {- -4 City/State/Zip: n; .e hone #: ;�09- o2C, l Are ou an employer? Check the appropriate box: Business Type (required): 1. I am a employer with �5 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑re Health Ca 4. ❑ We are a non-profit organization, staffed by volunteers , an with no employees. [No workers' comp. insurance req.] 12.0 Other /ySiYh¢ ni CC?MMU t1c 1� *Any applicant that checks box #t 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 organization should check box #1. I am an employer t/rat isproviding workers' coatpensation insurance for my etuployees. Below is the policy information. Insurance Company Name: M L L 6 fw, '�- ' Insurer's Address: H �b t k&y r1 _t — City/State/Zip: QA 09 [0 C Policy # or Self -ins. Lic. # C. !4 S ti Y 6 r5 Expiration Date: 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 MGL 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 WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties o er'ury that the information provided above is true and correct. Official 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 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: ACE American Insurance Company NAME OF INSURANCE COMPANY 436 Walnut Street, Philadelphia PA 19106 ADDRESS OF INSURANCE COMPANY WLR 065438653 1/1/2019 to 1/1/2020" POLICY NUMBER 8110 E. Union Ave., Suite 700 EFFECTIVE DATES Lockton Companies Denver, CO 80237 303-414-6000 NAME OF INSURANCE AGENT ADDRESS PHONE # 600 E. Las Colinas Blvd., Suite 2100 Greystar Real Estate Partners, LLC Irving, TX 75039 EMPLOYER ADDRESS February 13 2019 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Fecal, Vomit & blood Incidents in Swimm The pool must remain closed until all of the following been completed: For any type of accidental fecal release, direct al the pool. Manually remove as much of the mate the AFR is formed, remove it from the pool with apart. Use a scoop or net and dispose of the mal sanitary facilities. Clean and disinfect the scoop/ For formed stool raise the free available chlori and ensure the pH is 7.5 or less and the temperz or higher. Maintain the chlorine concentration fi minutes before opening the pool. Return the chlo normal levels. For Diarrheal Dischargraise the free available chi ppm. Maintain the pH of 7.5 or less and a temperz degrees or higher. Maintain the pH and chlorine IE hours. The filtration system should be operating tl disinfection time. Backwash the filter after the full time. The filter effluent should be directed to was to the pool. Return the chlorine level to normal level Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $150 Public Re -inspection fee: $100 NAME OF OWNER: /: POOL OPERATION: R(`Seml-Public �J O Special Purpose Pool ADDRESS:-C(��{ �.�, - POOL LOCATION:We: CITY: 4n 5 <-, STATE: qA ZIP; 60L } L) TYPE/POOL: e �J TELEPHONE: -a�l-p 500 LENGTH: t)(" WIDTH: �tJ VOLUME: qca oLSC C7 r,-1 FAX: �(3$ -a'C 1 - t7 �XJi /'� MINIMAX DEPTH: EMAIL: �,, �� ilii✓-tr�iC(�'t�i.SL""_,��7pI\'U SWIM AREA: l DIVE AREA: r FED ID/SS NO: J J �(�U �'�= WATER SOURCE: TOL )v\ PERSON CERTIFI T SYSTEM: %it cc t 4 POOI/SPA C2rtlfl ' � w �.. METHOD: f� �1,W i _,.�✓,,moi_ „_»s a.:�*. .:1" ' ,-, l� Pool/SPA certification REMARKS: TREATMENT: 01,to v-,r\Q_ BATHERS: C( SIGNATURE: DATE: Sign, date a nclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. TM OF MAWIFIELD PAID 1 11 Bank #: Packet #: 0�'�e TOWN OF mmspIrMLO P,AII7 APR 2 0 2010 �M"CM *,MT Mansfield Conservation Commission Site Review Please attach site/plot plan showing approximate location of activity. Conservation Department may require that the project be flagged or staked out on the property where work is proposed. *Owner's/Contractor's Name: — Gn V) r vw xaCV-c *Location of project: IL66- g"'4- &+- Map: Lot: *Contact Info: Phone: A 7j '$S 1 •- 8S29 Email: (: "Nj *Proposed project: CD� include Y7).N ***AS PART OF THE BUILIDNG PERMIT PROCESS, THE CONSERVATION COMMISSION MAY CONDUCT A SITE INSPECTION IN ORDER TO DETERMINE JURISDICTION*** 1(1PPLICANT'S SIGNATURE: - - Conservation Department provides below information and fill ouf - Please do not write below this line. Does the project fall within: • Wetland or 100 -foot buffer zone to wetland or waterbody: yes no • 100 -year Flood Zone: yes no • 200 -foot Riverfront Area to perennial stream: yes no • Area of Critical Environmental Concern(ACEC): yes no • 100 foot buffer zone to an isolated vegetated wetland and/or vernal pool*: yes no *as defined by state wetland In regulations and/or Town of Mansfield bylaw • Natural Heritage & Endangered Species Program Estimated or Priority Habitat: yes no (Ifyes, and not within Mansfield Conservation Commission jurisdiction, it is up to the applicant to communicate with Mass Wildlife's Natural Heritage staff directly to file the appropriate paperwork under the Massachusetts Endangered Species Act (MESA).) Is a further filing with the Mansfield Conservation Commission or Department required? NO Proposed work is not subject to Conservation Commission jurisdiction. No filing needed. YES, Administrative Review (AR) Request for Determination of Applicability (RDA) Notice of Intent (NOI) NO AR / NOI / RDA has been filed and/or approved by Commission/Agent on (date): Comments: Reviewing Agent/Commissioner/Staff: Date: Question? Please call the Mansfield Conservation Department (508)261-6454 or email kconver(&mansfieldma.com (Revised 5/20/2019) 'Fence to be Automa[tn wool Cover lawsGnw4 no 11 ., r �Y �v F viag N 4 .-I x£°S