HomeMy WebLinkAboutWillow Crossing - 12/31/2021Town of Mansfield - Board of Health
Swimming Pool Application
NAME OF OWNER: KRE Husky Willows Crossings Operations LLC
d/b/a The Village at Willow Crossings
ADDRESS: 25 Cobb Street
CITY: Mansfield
STATE: MA ZIP: 02048
TELEPHONE:
FAX: 508-261-1333
EMAIL: ademinico@benchmarkquality.com
FED ID/SS NO: 84-1955974
Permit Expires December 31st Yearly.
PERSON CERTIFIED: Patricia M. Suydan
Pool/SPA Certification Date: 3/2812019
Pool/SPA Certification Expires: 3/28/2024
PERSON CERTIFIED: O" Cr✓f,f%
Pool/SPA Certification Date: 6 / 10 f '�t 0- o
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS:
1001
OL
Town of Ma.
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER
FEE: $150
Re -inspection fee: $100
U NUDIIC
POOL OPERATION: Q Semi -Public
Q Special Purpose Pool
POOL LOCATION: 25 Cobb Street
Clubhouse
TYPEIPOOL: Gunite concrete
LENGTH: 32'
VOLUME: 12,544
MINIMAX DEPTH: 3'6" to 3'9"
SWIM AREA: 448 s.f.
WATER SOURCE: Town
W/W DISPOSAL: Town Sewer
TYPE OF FINISH: Blue Marbleite
SCUM GUTTER: None
DECK TYPE: Concrete
SKMMR WEIR LENGTH: 8.5"
WIDTH: 14'
DIVE AREA: None
TREATMENT SYSTEM: Hayward C-600 LK Brominator
DISINFECT METHOD: Bromine
CHEMICAL TREATMENT: Bromine
NUMBER OF BATHERS: 22
//) r
SIGNATURE: �I,--`'?/ DATE: November 23, 2020
I'llare N. 4ermant, resi en an ice ecre ary
Sign, date and enclose check pa able 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 Willows Crossings Operations, LLC
Signature of Individual or Corporate Name
54-2115543
**Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate O icer (Mandatonj, if Applicable)
Karen N. Zermani, Vice President and Assitant Secretary
*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:\Users\sleite\Desktop\Scott's Documentss\Food Establishments- Temp\TAX CERTIPICATION FORM.doc
The Commonwealth of'Massaehusetts
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: KRE Husky willow Crossings Operations LLC d/b/a The village at willow Crossings
Address: 25 Cobb Street,
City/State/Zip: Mansfield, MA 02048 Phone #: 508.261-1333
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
1 am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. x❑
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
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑
We 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 corpomtion has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' compensation insni•ance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
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,,egrto, undei) the pains and penalties ofperjiny that the information provided above is true and correct.
November 23, 2020
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
Phone