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Home My WebLink AboutHoliday Inn - 12/31/2020hr Town of Mansfield Board of Health q Ti Q�4 ,i tit Swimming Pool Application NAME OF OWNER: vlsim �dfr) JkX N"G f/vlidtf To? I' mj//P/W ADDRESS: J� CITY: STATE: /"/q ZIP: d. )d U TELEPHONE: &?i F—, -3_3I/_ FAX: EMAIL: T�tc.7_��1 FEDIDISSNO: Permit Expires December 31st Yearly. Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER FEE: $150 Public Re -inspection fee: $100 POOLOPERATION: Semi -Public 0 Special Purpose Pool POOL LOCATION: .I/i TYPEIPOOL::/ T) %IJtGh� LENGTH: (i� WIDTH: c�af VOLUME: 4:5, 54-0 6'a &7)-5 MINIMAX DEPTH: �.3% f 111kiX SWIM AREA:DIVE AREA.. WATER SOURCE: �L2rlr1 Jf Pi 17SXi</«1 WIW DISPOSAL: /LzrJ77 Ot 1lW1;5f<'/d /J / TYPE OF FINISH: PERSON CERTIFIED: lJ?C'{2 11265 llal U 4vell�' SCUM GUTTER: Pool/SPA Certification Date: '3t-, /)6 7'qdl` DECK TYPE: -T, /c °� /J° Pool/SPA Certification Expires: Ju/1+% �+ SKMMR WEIR LENGTH:/ X S PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: TREATMENT SYSTEM: DISINFECT METHOD: 0&6iy{/b� CHEMICAL TREATMENT: NUMBER OF BATHERS: p13 SIGNATURE: /��n/1-/�� Cdr 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. Town of Mansfield Town of Mansfield - Board of Midth 6 Park Row Mansfield, MA 02046 Swimming Pool Application NAME OF OWNER: V ��J i Q"I'J j' omollU) Y/ a�. Md //15A-/01 ADDRESS: CITY: ylY7Gd1ls" ee'6// STATE: rZIP: TELEPHONE: 7)Q /'"�,j f7 - FAX: EMAIL: 'J-"^-" `J Ji a JIG FED IDISS NO: J/ 7- J' Permit Expires December 31st Yearly. PERSON CERTIFIED: 11?& eL -(,� ll6'/7LT11d'-%r� /Ycz Pool/SPA Certification Date: ]&1?e_ % L 1 Pool/SPA Certification Expires.— � c.lk 1 PERSON CERTIFIED: POOL/SPA Certification Date: Pool/SPA Certification Expires." certification remarks(If necessary): REMARKS: PERMIT NUMBER FEE: $150 Public Re -inspection fee: $100 POOL OPERATION: El Semi -Public [Special Purpose Pool POOL LOCATION: J/ S �' TYPEIPOOL: LENGTH: 9 /% WIDTH: 7 - VOLUME: VOLUME: S "_3, tZ//Of).5 MIN£MAX DEPTH: f T SWIM AREA: f DIVE AREA: WATERSOURCE: lti&n al Xl7C117.ii1j`_/ cl WfW DISPOSAL: G/ /"'f'"f>le/ TYPE OF FINISH: SCUM GUTTER: ' DECK TYPE: f 11 G'1 SKMMR WEIR LENGTH: / TREATMENT SYSTEM: DISINFECT METHOD: C/6 I0rIJLp— n I CHEMICAL TREATMENT: � 610,1, attl flyp C�J�rI NUMBER OF BATHERS: 9 SIGNATURE( � , d1Y) "'�{/)/lcd/LCt' DATE: 1.2�/�zlJ Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. �QPEWar, lJ,� �V pBLC p)'� 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. 6�J Signature of Individual or Corporate Name Social Security Number (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. V4.a \ lliG vviiLVLVii.Y4µifli f til µY.lµ4iisiv4LLV dYDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wipmmass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / Please Print Legibly Business/Organization Name: V io l m �IQ/W 11,l f_) Uc LS7�' City/State/Zip: /'7 19Sh eld A9 Ud619Phone #: Ar,.e,.,yo an employer? Check the appropriate box: Business Type (required): 1. L� I am a employer with l fJ J employees (full and/ 5. ❑ Retail or part-time).* 6. 5Weestaurant/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]* 4. 4. ❑ We Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req,] 12.❑ Other Any 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 rganizathm should check box #1. ant an employer that ispraviding workers, compensad/° ins ranee for my employees. Below is the policy information.nsmanceComnanvName: f%I�LY L� /%V"71,41 ,TC_ /"/7 usurer's Address: 7�X�)'� /6a11Q/7 6 (6V JYa7�- 02 90L,2el ' 1l1 :ity/State/Zip: CAal-IA P,6. az-/,Z- olicy # or Self -ins. Lie. ,ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of rvestigations of the DIA for insurance coverage verification. o hereby cel7i�ij�jr�, under the pains andpenalties ofperjury that the information provided above is true and correct. ipnature• _ Date: Official rise 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 www.masa.gov/dia Phone Workers' Compensation and Employers Liabillty Insurance Pollcv 3APLOYERS PREFERRED INS. CO, Policy Number From °licy PeriodTo4 Stock Company EIG 2656163 01 061Z4/2019 06124/2020 naaas [leeeM1eeinaat the address of theeasetlr Transaction AMENDED DECLARATIONS Effective: 06/24/2019 NCCI Carrier # 31283 WCIRB CARRIER# PRIOR POLICY NUMBER EIG265616300 1. Named Insured and Address Agent VISION HAMPSHIRE LLC DIVERSIFIED INS INDUSTRIES INC 6465200 DBA HOLIDAY INN MANSFIELD 307 INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer # Carrier # FEIN # Risk ID # Err ity or Insured 3,1283 473112140 001033835 LIM LIABILITY CO Additional Locations: !.The Policy Period is from 06/24/2019 to 06/2412020 12:01 a.m. Standard Time at the Insured's mailing address. I. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part TWO of the policy applies to wort: in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit . Bodily Injury by Disease $ 1,000,000 each employee C, Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except HI, ND, OH, WA, WY and states listed in item 3.A. D. This policy Includes these endorsements and schedules: See attached schedule. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required' Isei'ow is subject to veriftcatiott andchange by audit. . Minimum Premium $ Assessments and Taxes $ SEE B(TENSION OF INFORMATION PAGE 231 Expense Constant $ 338 Premium Discount $ -1,440 Total Estimated AnnualPremlum $ 26,439 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; CI Semiannual; ❑ Quarterly; ❑ Monthly ountersigned this Day of sued Date: 06/28/2019 Authorized Representative suing Office EMPLOYERS PREFERRED INS. CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 :ued Date 06/28/2019 990630 (5/98 Ed.) INSURED COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY INFORMATION PAGE ENDORSEMENT The following items) C I Insured's Name (WC 89 06 01) [ ] [ ] Policy Number (WC 89 06 02) [ ] [ ] Effective Date (WC 89 06 03) [ ] [ ] Expiration Date (WC 89 06 04) C I [ ] Insured's Mailing Address (WC 89 06 05) [X] [ ] Experience Modification (WC 89 04 06) [ I [ ] Producer's Name (WC 89 06 07) . C I [ ] Change in Workplace of Insured (WC 89 06 08) [ ] [ ] Insured's Legal Status (WC 89 06 10) [ ] WC 89 06 00 A (Ed. 07-87) Item 3.A. States (WC 89 06 11) Item 3.B. Limits (WC 89 06 12) Item 3.C. States (WC 89 06 13) Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC. 89 04 15) Interim Adjustment of Premium (WC 89 04 16) Carrier Servicing Office (WC 89 06 17) Interstate/Intrastate Risk ID Number (WC 89 06 18) Carrier Number (WC 89 06 19) is changed to read: EFFECTIVE 06/24/19 AMEND TO INCREASE PAYROLL FOR CLASS CODE 9052 FROM 11045,440 TO 1,057,000; CLASS CODE 9058 FROM 828,026 TO 1,010,000 AND CLASS CODE 8810 FROM 118,800 TO 310,000 PER THE AGENT'S REQUEST. *Item 4. Chance To: Total Estimated Annual Premium $ 26,439 Minimum Premium $ 231 Deposit Premium $ 2,413.30 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which It Is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) This endorsement, effective 06/24/2019 Policy No, EIG 2656163 01 Issued to VISION HAMPSHIRE LLC Premium $26,439 Countersigned at at 12:01 AM standard time, forms a part of Of the EMPLOYERS PREFERRED INS. CO. Carrier Code 31283 Endorsement No. 001 on By: Authorized Representative WC 89 06 00 A (Ed. 07-871 01987 National Council on Comoensatlon Insurance. Inc. s i Premium Basis Rate Per $100 Classifications Code Total Estimated of Estimated No. Annual Remuneration Annual Premium Remuneration Total Estimated Annual Premium $ 26,439 Minimum Premium $ 231 Deposit Premium $ 2,413.30 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which It Is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) This endorsement, effective 06/24/2019 Policy No, EIG 2656163 01 Issued to VISION HAMPSHIRE LLC Premium $26,439 Countersigned at at 12:01 AM standard time, forms a part of Of the EMPLOYERS PREFERRED INS. CO. Carrier Code 31283 Endorsement No. 001 on By: Authorized Representative WC 89 06 00 A (Ed. 07-871 01987 National Council on Comoensatlon Insurance. Inc. s i GLOBALVISION HOTELS Standard Operating Procedure Name: Fecal, Vomit and Blood Incidents Discipline: Brands: Holiday Inn Foxboro -Mansfield Date Issued: 1/1/2019 Fecal Response: • For any type of AFR, Direct all users to leave the pool • The pool Must remain closed until all of the following procedures have been completed • manually remove as much of the material as possible with a scoop or net • clean and disinfect the net or vacuum if used after use For Formed Stool • Raise the free available chlorine level to 2ppm (mg/L) and ensure the PH is 7.5 or less and that the temperature is 77 degrees Fahrenheit or higher • Must maintain the chlorine concentration for at least 25 minutes before opening the pool Diarrhea Discharge • Raise the free available chlorine level to 20 ppm (mg/L) Maintain the PH of 7.5 or less and temperate is 77 degrees Fahrenheit or higher • The filtration system must be operating during the entire disinfection time • Backwash the filter and make sure it is directed to waste and not back in the pool • Return the chlorine level to normal levels as required • Open the pool after the concentration has been maintained as follows 1. if the cyanuric acid concentration us 1-15 ppm raise the free chlorine concentration to 20ppm and maintain it for 28 hour or you can raise it to 30ppm and maintain it for 18 hours as well as 40ppm and maintain it for 8.5 hours 2. if the cyanuric acid concentration is more than 15 ppm lower the concentration to 1-15ppm by draining partially and adding fresh water • All Fecal Release should have an AFR incident Log Reported Vomit and Blood Contamination • For any Vomit or Blood contamination have all users leave the pool • Remove as much vomit as possible with a net or vacuum • Clean and Disinfect the net that was used and or hose for vacuum • Clean and watch PH and chlorine levels for 8-12 hours and make sure it maintains the levels needed • Oen the pool after all procedures have been completed and levels are back to normal