Loading...
HomeMy WebLinkAboutWillow Crossing - 12/31/2019e Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT EXPIRES: 16 December 31, 2019 Town of Mansfield 6 Park Row Mansfield, MA 02048 Person Certified: PATRICIA SUYDAN Pool/SPA Certification Date: March 28, 2019 Pool/SPA Certification Expires: March 28, 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: KRE HUSKY WILLOW CROSSINGS DBA THE VILLAGE AT WILLOW CROSSINGS for the operation of a ❑ Public O Semi -Public ❑ Special Purpose Pool located at: Method of water treatment is Bathing load not to exceed: bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan -Palmer, Health Agent /Y 126 l 9 9k - --- Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER FEE: $150 Re -inspection fee: $100 KRE Husky Willow Crossings Licensee LLC Public NAME OF OWNER: d/b/a The Village at Willow Crossings POOL OPERATION: [t/Semi-Public V Special Purpose Pool ADDRESS: 25 Cobb Street POOL LOCATION: CITY: Mansfield, MA STATE: MA ziP: 02048-4505 TYPEIPOOL: TELEPHONE: 508-261-1333 LENGTH: FAX: 508-337-4663 VOLUME: EMAIL: ADeminico@benchmarkquality.com MINIMAX DEPTH: FED ID/SS NO: 84-1955974 SWIM AREA: WATER SOURCE: City Certification Expires Every 5 Years. WIW DISPOSAL: City Permit Expires December 31st Yearly. TYPE OF FINISH: PERSON CERTIFIED: Patricia Suydan SCUM GUTTER: POolISPA Certification Date: DECK TYPE: POo11SPA Certification Expires: SKMMR WEIR LENGTH: PERSON CERTIFIED: TREATMENT SYSTEM: Bromine Poo11SPA Certification Date: DISINFECT METHOD: POo11SPA Certification Expires: CHEMICAL TREATMENT: certification remarks(if necessary): _ NUMBER OF BATHERS: 22 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. WIDTH: DIVE AREA: SIGNATURE: a"— /�f elL __� DATE: ---- 6 z 7 / i Please make appropriate changes. Sign, date 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. KRE Husky Willow Crossings Licensee LLC Signature of Individual or Corporate Name 84-1955974 'Social Security No. (Voluntary) or Federal Identification Number Andrea M. Teichman, VP and Secretary 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:\Usen\sleite\Desktop\Scott's Documents\Food Esmblislunents- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Ulf Boston, MA 02111 wip,mmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: d/b/a The Village at Willow Crossings Address: 25 Cobb Street City/State/Zip: Mansfield, MA 02048-4505 Phone #: 508-261-1333 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 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. 8. ❑ Non-profit [No workers' comp, insurance required] 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.❑Health Care 4. F-1 Weare a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. ❑ Other *Any applicant that checks box #I must also HII 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 #l. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic, Expiration 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, der the pains and penalties ofperjuty that the information provided above is true and correct. Signature' xalx", Date: � - 0 -7` / ............_. 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSU RANCE POLICY WC 00 00 01 A INFORMATION PAGE Insurer: POLICY NO. 91WCI4987906 ARCB INSURANCE COMPANY 2345 Grand Blvd Suite 900, Kansas City, MO 64108 NCCI Code # 28355 The Insured: BENCHMARK SENIOR LIVING LLC Mailing address: (SEE NAMED INSURED ENDT) 201 JONES ROAD SUITE 300 WEST WALTHAM MA 02451 Individual Partnership Corporation or Other workplaces not shown above: See Workers Compensation Classification Schedule 2. The policy period is from. 04-01-2019 to 04-01-2020 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: CT MA ME NH RI VT B, Employers Liability Insurance: Part Two of the polioyapplies to work in each state listed in Item 3.A. The limits of our liability under Part Two are; Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury byDisease $ 1,000,000 policylimit Bodily Injury byDisease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AL AK AZ AR CA CO DE DC FL GA HI ID IL IN IA KS KY LA MD MI MN MS MO MT NE NV NJ NM NC OK OR SC SD TN TX UT VA WV WI D. This policy includes these endorsements and schedules: See Schedule of Forms and Endorsements 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. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium See Workers Compensation Classification Schedule Total Estimated Annual Premium $ 1,136,764 Minimum Premium S 750 Expense Constant $ 338 Countersigned by 0 1987 Na0anal Cnmell,m Campemmpm Inrumnce Policy Number 41WCI4987906 SCHEDULE OF FORMS AND ENDORSEMENTS ARCH INSURANCE COMPANY Named Insured BENCHMARK SENIOR LIVING LLC Effective Date: 04-01-2019 12:01 A.M., Standard Time Agent Name WILLIS OF ILLINOIS, INC. Agent No. 208 WORKERS COMPENSATION FORMS AND ENDORSEMENTS 00 ML0065 00 06-07 US TREASURY DEPT'S OFAC ADVISORY NOTICE 05 ML0043 20 05-08 PH NOTICE - ME ACC PREVENT/LOSS CONTROL 05 ML0002 22 06-13 MASSACHUSETTS SIGNATURE PAGE WC 00 00 01 A 07-97 WC INFORMATION PAGE LOCATION2 11-99 SCHEDULE OF NAMES & LOCATIONS WC 89 06 01 01-98 SCHEDULE OF NAMED INSUREDS) WC 89 04 15 07-97 WC CLASSIFICATION SCHEDULE WC 00 00 00 C 01-15 INSURANCE POLICY 00 WC0001 00 12-02 WORKERS COMP & EMP LIAB INS POL DED ENDT 00 WC0001 30 04-03 WORKERS COMP & EMP LIAB INS POL DED ENDT 00 WC0031 00 08-11 LARGE RISK ALTERNATIVE RATING OPTION 00 WC0031 46 01-12 VT L RISK ALT RTG OPT DEDUC PREM COM END 00 WC004 00 11-03 EARLIER NOTICE OF CANCELLATION BY US WC 00 03 01 A 02-89 ALTERNATE EMPLOYER ENDT WC 00 03 03 C 10-04 EMPLOYERS LIABILITY COVERAGE ENDT WC 00 03 10 04-84 SOLE PROP, PARTNERS, OFFICERS, OTHER COV WC 00 03 11 A 08-91 VOLUNTARY COMP AND EMPLOYERS LIAB COVG WC 00 03 13 04-84 WAIVER OF OUR RIGHT TO RECOVER WC 00 04 14 07-90 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 14 A 01-19 90DAY REPORT-NOTIF CHANGE IN OWNERSHIP WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT WC 00 04 21 D 01-15 CATASTROPHE (OTHER THAN CERT ACTS) ENDT WC 00 04 22 B 01-15 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 00 04 25 05-17 EXPERIENCE RATING MODIFICATION FCTR REV WC 06 03 01 04-84 CT APPLICATION OF WORKERS COMPENSATION WC 06 03 03 C 07-11 CT WC FUNDS COVERAGE ENDT WC 06 06 01 A 10-17 CT NONRENEWAL & RENEWAL ENDT WC 18 06 01 04-84 ME INSPECTION IMMUNITY ENDT WC 18 06 03 A 06-95 ME CANCELATION AND NONRENEWAL ENDT WC 18 06 04 05-88 ME FINAL PREM AUDIT ENDT WC 18 06 06 08-99 ME NOTICE WC 18 06 07 A 07-11 MAINE SUPPLEMENTAL BENEFITS FUND ENDT WC 20 03 01 04-84 MA LIMITS OF LIABILITY ENDT WC 20 03 02 A 09-08 MA ASSESSMENT CHARGE WC 20 03 03 D 08-10 MA NOTICE TO POLICYHOLDER ENDT WC 20 04 05 06-01 MA PREMIUM DUE DATE ENDT WC 20 06 01 A 07-08 MA CANCELLATION ENDT WC 28 04 04 01-08 NH PENDING RATE CHANGE ENDT WC 28 06 01 04-84 NH SOLE REPRESENTATIVE ENDT WC 28 06 04 04-92 NH AMENDATORY ENDT WC 34 03 01 C 03-10 OH EMPLOYERS LIABILITY COVERAGE ENDT WC 38 04 01 B 01-15 RI SHORT RATE CANCELLATION ENDORSEMENT WC 89 0614 Policy Number 41WCI4987906 SCHEDULE OF FORMS AND ENDORSEMENTS ARCH INSURANCE COMPANY Named Insured BENCHMARK SENIOR LIVING LLC Effective Date: 04-01-2019 12:01 A,M., Standard Time Agent Name WILLIS OF ILLINOIS, WC 38 06 01 09-89 WC 36 06 02 06-93 WC 44 06 0 WC 89 0614 �`C. m. RI DIRECT LIABILITY STATUTE ENDT RI SAFETY INSPECTION ENDT VT LAW ENDORSEMENT VT CANCELLATION AND NONRENEWAL ENDT WC 6 EMP LIAB INS FOREIGN COV ENDT FOREIGN COVERAGE ENDT-MASSACHUSETTS FOREIGN COVERAGE ENDORSEMENT -VERMONT 1 04-89 WC 99 06 02 B 07-14 WC 99 06 03 05-04 WC 99 06 03 MA 05-04 WC 99 06 03 VT 05-04 WC 89 0614 �`C. m. RI DIRECT LIABILITY STATUTE ENDT RI SAFETY INSPECTION ENDT VT LAW ENDORSEMENT VT CANCELLATION AND NONRENEWAL ENDT WC 6 EMP LIAB INS FOREIGN COV ENDT FOREIGN COVERAGE ENDT-MASSACHUSETTS FOREIGN COVERAGE ENDORSEMENT -VERMONT NCCI Carrier Code 28955 ARCH INSURANCE COMPANY NAME AND LOCATION SCHEDULE Named Insured BENCHMARK SENIOR LIVING LLC Agent Name WILLIS OF ILLINOIS, INC. State MASSACHUSETTS B -XII HAVERHILL LLC 254 AMESBURY ROAD HAVERHILL MA 01830 Legal Entity: LLC FEIN: 47-2560198 SIC Code: 8059 NAIL Code: 623311 # EMP : 86 H -XII LEOMINSTER LLC 1160 MAIN STREET LEOMINSTER MA 01453 Legal Entity: LLC FEIN: 47-2570446 SIC Code: 8059 NAIL Code: 623311 If EMP : 73 B -X MANSFIELD LLC 25 COBB STREET MANSFIELD MA 02048 Legal Entity: LLC FEIN: 27-4452440 SIC Code: 8059 NAIC Code: 623311 # EMP : 136 H -X NORTH CHELMSFORD LLC 2 TECHNOLOGY DRIVE NORTH CHELMSFORD MA 01863 Legal Entity; LLC FEIN: 27-4396657 SIC Code: 8059 NAIC Code: 623311 # EMP ; 80 F Effective Date: 04-01-2019 12:01 A.M., Standard Time Agent No. 208 Page 8 Jane Doucette From: Jody Hanson <JodyH@nathansongroup.com> Sent: Wednesday, July 10, 2019 3:11 PM To: Jane Doucette Cc: Shanda London Subject: RE: Willows Crossings - Mansfield Pool and Food Permit Issues Attachments: Wentworth Certifications.pdf; P. Suydan - Pool Operator Certificate.pdf Dear Jane, The Allergen Certificate and Pool/Spa Operator certificates are attached. The dining area serves 128. Please let me know what the appropriate fee is. T 1 )0 Lastly, I confirmed the licensee/operator does not hold employees, and so I have asked for Benchmark Senior Living (the management company) to send their worker's comp certificate. I will send it ASAP. Thanks. Jody Hanson I Associate The Nathanson Group PLLC 600 University Street, Suite 2000 Seattle, WA 98101 p 206.623.6239 1 efax 206.299.3958 iodvh P nathansonRrou p.com www. natha nsongroup.com From: Jane Doucette <Jdoucette@mansfieldma.com> Sent: Wednesday, July 3, 2019 9:27 AM To: Jody Hanson <1odvH@nathansongroup.com> Subject: Mansfield Pool and Food Permit Issues Hi Jody, just wanted to let you know I have received the pool and food permit applications but I will need the certified pool/spa operator certificate and no Allergen Certificates were sent with the food application. Also, a check (#20660) for $360.00 was sent with the food application; could you tell me how many people you serve meals to. Thanks Jane Disclaimer 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. CONFIDENTIALITY NOTICE: This message and all subsequent messages contained in this email chain are confidential and may be privileged. If you believe that this email or any subsequent email has been sent to you in error, please reply to the sender that you received the message in error; then please delete this e-mail. Thank you. DISCLAIMER OF ELECTRONIC TRANSACTION: This communication does not reflect an intention by ,. i . the sender or the sender's client to conduct a transaction or make any agreement by electronic means. Nothing contained herein shall constitute an electronic signature or a contract under any law, rule or regulation applicable to electronic transmissions. Replies Filtered: Any incoming reply to this e-mail communication or other e-mail communication to us will be electronically filtered for "spam" and/or "viruses." That filtering process may result in such reply or other e-mail communications to us being quarantined (i.e., potentially not received at our site at all) and/or delayed in reaching us. For that reason, we cannot guarantee that we will receive your reply or other e-mail communications to us and/or that we will receive the same in a timely manner. Accordingly, you should consider sending communications to us which are particularly important or time -sensitive by means other than e-mail. 'S i THE i( NATHANSON _ GROUP ;'gua 9 VZ. - JUN JUN 2 8 2919 G: June 27, 2019 Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 Re: Swimming Pool Application Enclosed is a Swimming Pool Application for the facility located at.:25-Cobb Street, Mansfield, MA 02048. This application is being filed due to a change of ownership of this facility. If you require additional information, please contact me at 206-623-6239 or shandal(@nathansongroup.com. Sincerely, Shanda London Senior Regulatory Compliance Coordinator One Union Square 600 University Street, Suite 2000 Seattle, WA 98101-1192 206.623.6239 www.NathausouGroupxom Jane Doucette From: Shanda London <shandal@nathansongroup.com> Sent: Wednesday, July 10, 2019 2:58 PM To: Jane Doucette Subject: RE: THE VILLAGE AT WILLOW CROSSINGS MANSFIELD This is for a semi-public pool. We received very little information in order to complete the application but this is a change of ownership only, the operations of the pool will remain the same. Once I receive the pool certification, I will send it to you. Thanks Shanda From: Jane Doucette <Jdoucette(c)mansfieldma.com> Sent: Tuesday, July 9, 2019 12:49 PM To: Shanda London <shandal@nathansoneroup.com> Subject: THE VILLAGE AT WILLOW CROSSINGS MANSFIELD Hi Shandal, In addition to the pool certification, is the pool a semi-public or special purpose pool (the previous application was for a semi-public pool). Also, most of the application was not filled out. Disclaimer 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. CONFIDENTIALITY NOTICE: This message and all subsequent messages contained in this email chain are confidential and may be privileged. If you believe that this email or any subsequent email has been sent to you in error, please reply to the sender that you received the message in error; then please delete this e-mail. Thank you. DISCLAIMER OF ELECTRONIC TRANSACTION: This communication does not reflect an intention by the sender or the sender's client to conduct a transaction or make any agreement by electronic means. Nothing contained herein shall constitute an electronic signature or a contract under any law, rule or regulation applicable to electronic transmissions. Replies Filtered: Any incoming reply to this e-mail communication or other e-mail communication to us will be electronically filtered for "spam" and/or "viruses." That filtering process may result in such reply or other e-mail communications to us being quarantined (i.e., potentially not received at our site at all) and/or delayed in reaching us. For that reason, we cannot guarantee that we will receive your reply or other e-mail communications to us and/or that we will receive the same in a timely manner. Accordingly, you should consider sending communications to us which are particularly important or time -sensitive by means other than e-mail.