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HomeMy WebLinkAboutWillow Crossing - 12/31/2019 (2)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: 7 PERMIT EXPIRES: December 31, 2019 Person Certified: PAUL J. MILLER Pool/SPA Certification Date: May 15, 2015 Pool/SPA Certification Expires: May 15, 2020 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: B -X MANSFIELD, LLC dbaTHE VILLAGE AT WILLOW CROSSINGS for the operation of a Public Semi -Public VeSpecial Purpose Pool located at 25 COBB STREET Method of water treatment is BROMINE Bathing load not to exceed: 22 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. .Amy Donovan-PaCmer, Health .Agent Date Issued Town of Mansfield - Board of Swimming Pool Town of Mansfield Park Row ansffiel'i MA 02048 JAN 14 2919 PERMIT NUMBER Re -inspection fee: $100 Public NAME OF OWNER: 13•X, "O ks)N'ald . tom' otlb/4 POOL OPERATION: D Serpi-Public the V,'Ita5f dl Lclrltpry GYaS t,2pS n_ [ Special Purpose Pool ADDRESS: . &lob SjYeaf POOL LOCATION: Z.Jr 006(9 Skeet - CITY: ManS�e-ld STATE: 1-0- ZIP: OZ q� TYPEIPOOL: 6Ui't'1'f'G c0/Lc-of-f-C. TELEPHONE: 5% - Ztpl- 1373 LENGTH: 3.2, WIDTH: I� I FAX. 5—by. 337-(1(0I 3 VOLUME: EMAIL: pctCyTay,i`vj@(�fy.t-l��vt ezll�rj 7 ,Co.yr MIN/MAXDEPTH: '3,0 'Iv FED ID/SS NO: �%-yySZ�yV % SWIMAREA: IM sr- DIVEAREA: Kjotje WATER SOURCE: 1 014, r Certification Exoires Every 5 Years. WtW DISPOSAL: 'foNyt Se.Wev Permit Expires December 31st Yearly. TYPE OF FINISH: kfV2. t'%I(,tr!,%.}.(_ PERSON CERTIFIED: jQaU( J, I(,ll IIeY SCUM GUTTER: N6rk Pool/SPA Certification Date: 5 ( IS/201,5 DECK TYPE: L-Mtlee'f-C Pool/SPA Certification Expires: 5 15 (Zoe 0 SKMMR WEIR LENGTH: '� ,s" PERSON CERTIFIED: TREATMENT SYSTEM: POVW40 GZSDOLK FjypYyl��pf�� Pool/SPA Certification Date vDISINFECT METHOD: $mf✓tt; Poo//SPA Certification Expires: CHEMICAL TREATMENT: (3 fOyl�tt/lC certification remarks(if necessary): NUMBER OF BATHERS: ZZ REMARKS: SIGNATURE:��`� lY� DATE: 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. JI; "`V�% J Signature of Individual or Corporate Name e)-7-ws 2yyo "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:\Dsers\sleite\Desktop\Scotts DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc Ae Conuntinivealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wrviv. rnass.gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/OrganizationnN/a�ine: 5—x "`205 )'60 LLCci�/j�Q%ytQV/��Q9C}�1���'d�CPCSSI(l�5 Address: �Z Nbb (5/eet V City/State/Zip: UQOS�RP(d1 PA 62 I g Phone #: 033 Are on an employer? Check the appropriate box: Business Type (required): INI am a employer with —43- 0 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 10.0 Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We I I.❑ Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.IXOther s'e/1lby lAm M/Yl%'Y(-u/lr 6/ *Any applicant that checks box #1 must also 611 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 non an employer that is providingAportcers' compensation insuraanee for my employees. Belot, is the policy information. Insurance Company Name: ' ' I ch -i-r1S(.IYGt✓ a- c olnoan q Insurer's City/State/Zip: 30 Sf . haat tilN 3. (6 Policy # or Self -ins. Lic. # N l UJ6(y9g,7qo 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 nnprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, made tt� , pai s mud penglti ofperjury tbat the information provided above is true and correct. Sienature: /�/ �!`� `�z\I nate- /2_/2,7//51 Phone#• 5`0$'201-1333 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License It Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person Phone 21 k �'�'1'T-uc?go!,1.'. �!eu�a �o 6U6'ObS'6LL le ddSN auoyda!a;'uoge�yuan ion N •t Ah ! J M \ v N �= .� W 0 k �'�'1'T-uc?go!,1.'. �!eu�a �o 6U6'ObS'6LL le ddSN auoyda!a;'uoge�yuan ion •t Ah ! J M \ v x .� W 0 0 d 0 y k �'�'1'T-uc?go!,1.'. �!eu�a �o 6U6'ObS'6LL le ddSN auoyda!a;'uoge�yuan ion v x .� W 0 d t ~ V k �'�'1'T-uc?go!,1.'. �!eu�a �o 6U6'ObS'6LL le ddSN auoyda!a;'uoge�yuan ion Page 1 of 1 ACORO" CERTI ICATE & LIABILITY INSURANCE � GATE �.� 23/ 2018Y) 04/23/2018 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 have ADDITIONAL INSURED provisions or 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 Willie of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONE 1-877-945-7378 FAX 1-888-467-2378 Ext: A/C No: EMAIL certificates@willis.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC4 Nashville, TN 372305191 USA INSURERA: Arch Insurance Company 11150 INSUREDLlo Benchmark senior Living LLC Lloyd's INSURER B: Y B7874 INSURER C: 201 Jones Road, Suite 300 West Waltham, MA 02451 INSURER D: INSURER E: INSURER F: CLAIMS -MADE OCCUR 1vcr%rA QQ CERT IriCA1E INUMDEK: WS�513iz RF\/ISIrIiJ XIIIMDCD- 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. ILTR TYPE OF INSURANCE ADSL INSD BUBR POLICY NUMBER POLICY EFF Miamprr1'YY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMARENTED PREMISES Ea occurrence 5 MED EXP (Any one person) $ PERSONAL B ADV INJURY $ AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ GEN'L PRO - POLICY JECT LOC PRODUCTS - COMP/OP AGG $ g OTHER: I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlenfl S 110001000 X ANYAUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED y BODILY INJURY (Per accitlenl) 8 AUTOS ONLY AUTOS 41 CAB4987 ]05 04/01/2018 04/01/2019 HIRED NONAWED ccotgqONLY Hx PROPERTY DAMAGE Perryci e $ omp/l: 1000 X B UMBRELLA LIAB OCCUR EACHOCCURRENCE $ 20,000,000 X EXCESS LIAB X CLAIMS -MAGE SB -LT CA% -01986-18 04/01/2018 04/01/2019 AGGREGATE $ 20,000,000 DED RETENTION$ $ WORKERS COMPENSATION _ X AND EMPLOYERS'LIABILITY YIN STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 A ANYPROPRIETOR/PARTNERrEXECUTIVE OFFICER/MEMBEREXCLUDED] II NIA 41WCI4987905 04/01/2018 04/01/2019 (Mandatory In NH) If yes, describe under E.L. DISEASE -EA EMPLOYEE $ 11000,000 E.L. DISEASE -POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS below A Business Auto 41CAE4987805 04/01/2018 04/01/2019 Any Auto/CSL 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Included as an additional Named Insured: B -X Mansfield LLC Re: The Village at Willow Crossings - 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ss ID: 16000676 PATCH: 681249 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield - Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 ^� IV ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ss ID: 16000676 PATCH: 681249 Page 1 of I ^GCERTIFI CERTIFICATE OF LIABILITY INSURANCE C V °ATE(MM/ �� 04/23/22018018"' 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 have ADDITIONAL INSURED provisions or 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 Willie of Illinois, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT PHONE Ex[: 1-877-945-7378 FAX No: 1-888-467-2378 E-MAIL ADDRESS; certificates@willia.com Nashville, TN 372305191 USA INSURERS AFFORDINGCOVERAGE NAIDN INSURERA: Lloyd's 87874 INSURED A Benchmark Senior Living LLC INSURER B: INSURER C: 201 Jones Road, Suite 300 West Waltham, MA 02451 INSURER O: PREMISES Ea occurrence INSURER E: M ED EXP (Any one person) $ 10,000 INSURER F O ERAGES CERTIFICATE NUMRFR• W5931308 -'LV lU4 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, IN SR LTR TYPE OF ADDL I O SUBR D POLICY NUMBER MMIDI��Y MMIDDfYYYY LIMITS ALGNERAL LIE X COMMERCIAL GENERAL LIABILITY 6 Park Row Mansfield, MA 02048 A %t CLAIMS -MADE ❑ OCCUR X $100,000 Retention EACH OCCURRENCE $ 11000,000 PREMISES Ea occurrence $ 100,000 M ED EXP (Any one person) $ 10,000 SB-LTCA-01673-18 04/01/2018 04/01/2019 X Professional Included PERSONAL BADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY [—] PRO- JECT LOC GENERAL AGGREGATE S 31000,000 PRODUCTS - COMP/OP AGO $ 1,000,000 OTHER Policy Aggregate 5 15,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOSO AUTOS ONLY AUTOS ONLYLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accitlenl $ S A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MAGE SB -LT CAX-01986-18 04/01/2018 04/01/2019 EOCCURRENCE -AGGREGATE $ 20,000,000 $ 20,000,000 DED RETENTION$ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITV VIN ANYPROPRIETOR FARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ NIA PER OTH- STATUTE ER $ E.L. EACH ACCIDENT $ (Mandatoryfyes, In NH) R yes, Idescribe under E.L. DISEASE -EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASEPOLICYLIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attached It more space Is required) Evidence of Bost Liquor Liability CCRTICICATC Uni 110 Gl 7BBn-2875 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16000676 BATcB: 681249 s.ca.cn r rvry SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Town of Mansfield AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 Gl 7BBn-2875 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16000676 BATcB: 681249 Mansfield Board of Health 6 Park Row Mansfield MA 02048 Tel.(508) 261-7366 Fax (508) 261-7343 STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORTS TYPE OF POOL: PUBLIC H SEMI-PUBLIC 9 SPECIAL PURPOSE POOL Lj NAME OF POOL: Village at willow Crossing ADDRESS: 25 Cobb st. ADDRESS: 25 Cobb st. DATE OF INSPECTION: 05/23/2019 POOL CAPACITY # OF CALS: 27000 INSPECTED BY: J. Lee RE -INSPECTION DATE: Call Office METHOD OF WATER TREATMENT: Bromine BATHER LOAD: 0 NUMBER OF LIFEGUARDS: 0 WATER SOURCE: Town Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435,000. Items marked with IV, are satisfactory. REGULATION X/4 VIOLATIONS/COMMENTS .03 Bathhouse and sanitary facilities adequate lighting; ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching w/latch 4 ft above ground. Flow meter reading: 43 gpm; water turn over rate: 4.86 hours .04 Sewage Disposal. .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter Effluent flow meter reading gpm. # of turnovers .06 Suitable automatic equipment for disinfection of pool water. .06 Carbon dioxode (CO2) equipment for PH control adequate, n/a Carbon dioxode (CO2) cylinders anchored. Inaccessible to public, adquate ventilation provided. .08 Inlets and outlets - Inlets located produce uniform circulation. Over rim fill spout 6" above maximum water level. Properly shield and located. .08 main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without the use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain provided. .08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump. Properly located and plumbed. .08 Suction outlet cover in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools until repairs can be made. .08 Special purpose pool and wading pools equipped with n/a emergency shut off pump switch. Accessible and prominently marked Prepared by: PIC: U G1\+V Page 1 of 2 Pages .09 Cross connections. Portable water supplied through air gap. J .10 Skimming facilities. 50% of circulation drawn from surface 11 of pool. .12 Line with floats separates non -swimmer area from deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. Patricia Suydan's CPO certificate is in the mail. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. .15 Diving equipment in safe condition. n/a .17 Pool supervision - Pool supervision provided. Effective Jan n/o 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. .21 Permit requirements- Permit issued. Adequate maintenance and testing records maintained. Records initialed by person making test. Recommend, add a No Diving pictoryya] sign for children who .22 Health regulations: Signs posted. Health warning signs posted for special purpose pools. might not read - S �Y a)c! e_cJ .23 Lifeguards required Yes No if lifeguards required, Proper credentials, proper suits and garments worn. Whistle and bullhorn provided. .24 Safety Equipment. Rin q buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. .25 Emergency Communication System at pool and in working order. Emergency communication device in unlocked area and available at all times to staff and the public. Operating instruction and emergency number provided. .26 Waste and back wash water disposal properly discharged. No direct connection to sewer system. Separation tank provided for diaatomaceous earth filter backwash water. Bromine concentration > 11 ppm, PH > 8ppm Regulation .29 Chemical statdards. Bromine(2.0-6.Oppm), X Alkalinty(50-150ppm), Cyanuric Acid(30-100ppm), Water standard: Bromine 2.0-6.Oppm PH 7.2 - 7.8ppm temp.(104F), Total Chlorine Free Chlorine(1.0 - 3.0 d fGmw.� -` N a.Cj ��WYh ppm), Comb. Chlorine(0.0 - 0.2ppm), PH level(7.2 - 7.8) .29 Pool water tested with appropriate frequency. .30 Water test equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools Water visually clear, drain cover grid viewable from pool .31 Water clarity .32 Water clarity maitenance. Filtration system operating J continuously. side. .32 Special purpose pool drained, cleaned and every 14 days. Maximum operating temperatures for special purpose Pools. .33 Thermostatic control provided, and only accessible to the n/a pool operator, for each SPP. Pool was voluntarily closed by Patricia, CPO. due to water .38 General sanitation. .34 Closure of the pool. Pool must be closed until it meets the X standards of 105 CMR 435.29 through 435.31. chemical incorrectly mixed(435.29), call office when repaired. Page 2