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Home My WebLink AboutHoliday Inn - 12/31/2021�3(o �0a 60 m �te�la Town of Mansfield Town of Mansfield - Board of Health ., s ParkRow Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER NAME OF OWNER: V�sl vn damphlri, aC, �b11Ci�a)4 on lr`.a l4zd ADDRESS: CITY: yy! + 'a f�S71Pld p STATE: / �� ZIP: TELEPHONE`50Y-a,2Od FAX: Sg-S9 -I0gL) EMAIL: �/V -kjnCCI( 0hiky�jro.CO)'Y� FED ID/SS NO: / 7_ h. / Ica /411) Permit Expires December 31st Yearly. PERSON CERTIFIED: r/C,(6i &�wo ce rtC-Ira/ Pool/SPA Certification Date:�(tne %cql)/% Pool/SPA Certification Expires: Jz/)(_ 7 aw4l PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: FEE: $150 Public Re -inspection fee: $100 POOLOPERATION: [Semi -Public Ll Special Purpose Pool POOL LOCATION:. ill_4/e�P v Cti�Llie �J� �jl f�Ct/YI�lShii� `�� TYPEIPOOL: LENGTH: WIDTH:j'M VOLUME: ��v �0 67alW �/ MIN/MAX DEPTH: Vj I!)a X C6-p SWIM AREA: '_'z--lJ- WATER SOURCE: W/W DISPOSAL: lao-,q (Jt TYPE OF FINISH: Pla skl- DIVE AREA: O A/ mans -field SCUM GUTTER: DECKTYPE: ///e, SKMMR WEIR LENGTH: of TREATMENT SYSTEM: Srdll)e� DISINFECT METHOD: /� CHEMICAL TREATMENT: /�h wv//, (, e1)i'&,f' NUMBER OF BATHERS: ?3 SIGNATURE: � U /_ I%�-_f !/✓ C/1A- DATE: � l j-----_---------- __. . t 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 Health 6 Park Row Mansfield, MA 020411 Swimming Pool Application PERMIT NUMBER FEE: $150 Re -inspection fee: $100 ' / G O Public NAME OF OWNER: V f 5iq) HaY, 5111t� JZ POOL OPERATION: ❑ Semi -Public fl�I tcicu 1 �n� l Y��r1s�e�d Special Purpose Pool ADDRESS: POOL LOCATION: `LnUIN' CITY: 1 STATE: ✓ p 1q ZIP: UJp-a TELEPHONE: d,/ - 'a%Q FAX: OW - &NVOyd . /`� EMAIL: �'W a Ai-k"/Orli. L am!% A4=J�0- FED IDISS NO: /`7. 31 .7 1/ 0 Permit Expires December 31st Yearly. PERSON CERTIFIED: Pool/SPA Certification Date:' t&1-)e. Pool/SPA Certification Expires` u 1)e- % glal/ PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: TYPEIPOOL: LENGTH: 9%/4 �/, WIDTH: rl VOLUME: g/JJ�I�CLII'� MIN/MAX DEPTH: J;j SWIM AREA: DIVE AREA: ' WATER SOURCE: 7( ,M 4 /ra ns7)elc W/W DISPOSAL: _7_aty)� 01 /ra/LS- � TYPE OF FINISH: SCUM GUTTER: DECKTYPE: -77le- SKMMR WEIR LENGTH: �a / TREATMENT SYSTEM: DISINFECT METHOD: ChkMe-, CHEMICAL TREATMENT: 00I C I I t m NUMBER OF BATHERS: L_ SIGNATUREOT ?/v 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. i CPO° Certifi Name: Tricia M. Putign Date Certified: June 7, 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. J Signature of Individual or Corporate Name Social Security Number (Voluntary) or Federal Identification Number** PauY.cln Jpiesam—1 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 for'nished 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street y` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: City/State/Zip: VOilm Hampshiw ski& �,s�, 0-/, ji9'' OA/7 Phone #: Are y�o an employer? Check theappropriatebox: 1. LT 1 am a employer with _ employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4.0 We are a non-profit organization, staffed by volunteers, with no emnlovees. [No workers' court). insurance req.] /�.L.e, Business Type (required): 5. 0 Retail 6. 0�{estaurantBar/Eating Establishment 7. 0 Office and/or Sales Grid. real estate, auto, etc.) 8. 0 Non-profit 9. DEntertainment 10.0 Manufacturing 11,QHealth Care 12.0 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 organization should check box #1. I am an employer that is providing workers,' compensation insurance for tzzy employees. Below is the policy information. Insurance Company Nan Insurer's Address: Co C, City/State/Zip: Ahl)-,L Ila / mJ isy Policy # or Self -ins. Lic. #/O�V/ J _ 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 WORIC 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 ofperjuty that the information provided above is true and correct Signature: C� � L Date: v3-o?o3-�3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permitmeense 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 EMPUIVER 0 Workers' Compensation and Employers Liability Insurance Polley EMPLOYERS ASSURANCE CO. Policy Period Policy Number From To A Stock Company EIG 2656163 02 06/241g2020 06/24/2021 InsweJ a'�s'sleletl%erein aellhe adtlress oflhe Transaction RENEWAL DECLARATIONS NCCI Carrier # 36870 WCIRB CARRIER# PRIOR POLICY NUMBER EIG265616301 1. Nartaed Insures) and Address, Qgegt 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 # Rlsk ID # Entity of Insured 36870 473112140 001033835 LIM LIABILITY CO " Additional Locations: 2. The Policy Period is from 06/24/2020 to 06/24/2021 12:01 a.m. Standard Time 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: MA B. Employers Liability Insurance: Part TWO of the policy applies to work 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 ND, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 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. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 231 Assessments and Taxes $ ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; Expense Constant $ 338 Premium Discount $ Total Estimated AnnualPremium $ 8,966 ❑ Semiannual; ❑ Quarterly; ❑ Monthly Countersigned this Day of Issued Date: 06/19/2020 Authorized Representative Issuing Office EMPLOYERS ASSURANCE CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 Issued Date 06/19/2020 AGENT COPY WC990630 (5/98 Ed.) Page 1 of 4 EMPLOYERS EMPLOYERS ASSURANCE CO. A Stock Company 14120 SALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Code No. Classification Description Premium Basis Total Est. Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium Massachusetts Rating Period: 06/24/2020 through 06/24/2021 Site 00001 8810 CLERICAL OFFICE EMPLOYEES NOC 0 0.070000 0.00 9052 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, 350,000 1.490000 5,215.00 DRIVERS 9058 HOTEL: RESTAURANT EMPLOYEES 150,000 1.380000 2,070.00 Site 00001 Total $ 7,285.00 Total of Sites for Rating Period $ 7,285.00 Rating Period Total $ 7,285.00 Rating Period: 06/24/2020 through 06/24/2021 9037 RATE DEVIATION ADJUSTMENT - 7,285 0.080000 -583.00 9812 INCREASED COVERAGE II 6,702 0.020000 134.00 9898 EXPERIENCE MODIFICATION 6,836 1.100000 684.00 0277 ALL RISK ADJUSTMENT PROGRAM 7,520 0.090000 677.00 0900 EXPENSE CONSTANT 338.00 9740 TERRORISM PREMIUM 500,000 0.030000 150.00 0986 DEPARTMENT OF INDUSTRIAL ACCIDENTS ASSESSMENT 8,014 0.035100 281.00 Rating Period Total $ 1,681.00 State Total $ 8,966.00 Policy Total $ 8,966.00 Issued Date 06/19/2020 AGENT COPY WC990630 (5198 Ed.) Page 2 of 4 Y i.MPLOYERIT EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 State MA VISION HAMPSHIRE LLC 31 HAMPSHIRE ST MANSFIELD MA 02048-1113 WORKERS'COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 SITE LOCATION SCHEDULE Issued Date: 06119/2020 AGENT COPY WC990410 (7106 Ed.) Page 3 of 4 i:MPLOYERS" EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NO 28277-2685 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 ENDORSEMENT SCHEDULE State Form Nbr. Ed. Date Description MA WC000000C (1/15) WC/EL INS. POLICY FORM BOOKLET MA WC000115 (1/20) ENDT OF PEND LAW CHG TO TRIPRA NIA WC000403 (4/84) EXPERIENCE RATING MOD FCTR MA WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT NIA - WC000414 (7/90) NOTIFICATION OF CHG OWNERSHIP NIA WC000422B (1/15) TERRORISM RISK INSURANCE PROD MA WC000424 (1/17) AUDIT NONCOMPLIANCE CHARGE END MA WC000425 (1/17) EXP RATING MOD FACTOR REV ENDT MA WC200301 (4/84) MA LIMITS OF LIABILITY ENDT MA WC200302A (9/08) MA ASSESSMENT CHARGE MA WC200303D (8/10) NIA NOTICE TO POLICYHOLDER ENDT MA WC200405 (6101) MA PREMIUM DUE DATE ENDT MA WC200601A (7/08) MA CANCELLATION ENDORSEMENT NIA WC200604 (11/02) MA POLICY DEFINITION ENDT MA WC99040SA (3/07) INSTALLMENT PAYMENT ENDT Issued Date: 06/19/2020 AGENT COPY WC990633 (6198 Ed.) Page 4 of 4