HomeMy WebLinkAboutCanoe River CG - 12/31/2021f [ I €
MAY 2 7 Z 'i fU Cv\_QC_k
Town of Mansfield
Town qj rffanTielrl - Board o, f Health 6 Park Row
Mansfield, MA 02048
Swimming inn Pool Application PERMITNUMBER
FEE: $150
Re -inspection fee: $100
NAME OF OWNER: 6y,00- i
cc;". '`J' j�
ADDRESS: ()� Lzt�f� +,reek,
CITY: IvLArt§-�-.ao y
STATE: MA ZIP: DP L( '
TELEPHONE: 9-Off.33 (_16W
FAX: //��
EMAIL: (} . c e,6/�nJc''���/�,-`'�O�"')
FED ID/SS NO:
Permit Expires December 31st Yearly.
PERSON CERTIFIED:
CCvM61 1
Pool/SPA Certification Date:
1 irl WI y$
Poo)/SPA Certification Expires.
k1jH/)3
PERSON CERTIFIED: riG
t�
J CAfrb �I
Pool!SPA Certification Date
1t h N I f V
Pool/SPA Certification Expires.
i tit qja�
certification remarks(if necessary):
REMARKS:
Public
POOL OPERATION: Semi -Public
Special Purpose Pool
POOL LOCATION:
O A j -ir_c
TYPE/POOL:
LENGTH: WIDTH:
VOLUME: 3jcoo (IJ td�OW
MINIMAX DEPTH: 3/S CI AA „(/
SWIM AREA: / DIVE/ EA:
WATERSOURCE: Y.gn'5T---AA -QW ,\ (•Jgt�r'
W/W DISPOSAL:
TYPE OF FINISH: LPp xrf
SCUM GUTTER:
DECK TYPE: covie rA-(,
SKMMR WEIR LENGTH:
TREATMENT SYSTEM: Chto(`�A('
DISINFECT METHOD:
CHEMICAL TREATMENT:
NUMBER OF BATHERS:
a9 e,NA q,Iq
SIGNATURE: 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.
The Commonwealth of Massachusetts
Department of'Industrial Accidents
ow
Office of Investigations
600 Washington Street
Boston, MA 02111
wiiminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: 132 Nk �1-
City/State/Zip: Nn i > 1 1. OabLIS Phone #: 5309' JJq, W,
Are y9u an employer. Check the appropriate box: Business Type (required):
L I am a employer with �C) employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establisluuent
2. ❑ I am a sole proprietor or partnership and have no T ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees wonting for me in any capacity.
[No workers' camp. insurance required] 8. ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertahunent
their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing
no employees. [No workers' comp, insurance required]* 11. ❑ ylealth Care
4. ❑ We are a non-profit organization, staffed by volunteers, I.�1
with no employees. [No workers' comp. insurance rep.] 12. Other
*Amy 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 Dui
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: / tMuicAn �tnSvC4^ce 6(-OQ
Insurer's Address: Ro, qw q
City/State/Zip:
qb-
Pokey # r Self -ins. Lic. # �� Z Z li �i �t Expiration Dale: 3
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late).
Failure to secure coverage as required under Section 25A of MGL a 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, under the pains and penalties ofperjury that the information provided above is true and correct.
Phone# Cell M4`-tii`Q,30) ofTice 5Z08'aT V19a t
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License
3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
Contact Person: Phone
www.mass.gov/dla
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.
�i
Signature Individual or Corporate Name
*4Social 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.
CAUsers\s1eite\Desktop\Scot1's Doeoments\Eood Establislunents-Temp\TAX CERTIFICATION FORM.doc