HomeMy WebLinkAboutTwin Oaks - 12/3120214mo
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APR 06 ZJ21 I lf),^
IBy AN 292u�1
Check tf
Ot ,At L111C1
Town of (Aansfleld
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Tofvn of Mansfield- Board of Health e Park Row
+'>�>�•s,,>, ✓0 'ai Mansfield, MA 020,16
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Swim,miligPool Applicatian PERMIT NUMBER
FEE: $150
Re -inspection fee, $100
— PIII)lic,
NAME Or OWNER: f co r �/ Uk c.6 lnn C O, I IJOOOL OPERATION: :Tj/Semi-PUbft
it-Sscc✓Ias
_i Spp ;ial Purpose Pool
ADDRESS: LI() rolet
POOL LOCATION:=11-
CITY:N)e fleSlC-1
STATE: /VA A 21P:
TELEPHONE: LEI -j ^-) I CI LfS
IMx: 01-1 cj 0-1 30(1 C)
EMAIL:
y: I., P o
FED lo1ss NO:
Ll
Cerllficallon Expires Every 5 Years
PPs: rill Expires December 31s1 Yrarly,
PEnsON CERI'IF I ED:
Petal/,SPA Cedilicallon Dale: l q 17 1
YooJSPA GMiticafion Expires:
PERSON CERTIREG:
IZe�jL, l ),-1 e • c u
PoolISPA Cer iiication Dale: I d I z
PoolISPA Certification Expires: c I
ex t tL 2
corillicollon remorkslll nncosneryf:
REMARKS
TYPE/POOL:
LENGTH: I_Ih WIDTH:
VOLUME: l• ^�� iiOCi
M I N,tM DEPTI I: wp r 3<rr'"
SWIM AREA: ) ), y, i �' ' DIVE ARIA: L.I`'`, ; -2'
WATER SOURCE:
WIVJ DISPOSAL:
TYPE Or FINISFI, l.u,nl L,' Pln
SCUM GUTTER:
DECK TYPE: Ccn c_r c 1 C
SK.MNIR WEIR LENGTH:
TREATMENT SYSTEM: r..r
oisINFEC'f METHOD:
CH6VICAL TREA'I'tdENT: . ,)
NUMBER OF aA'rHLHS: (,__ If'
I
i
I
SIGNATURI DATE: IX)
Sign, dale an e n��ose chock payable ID Town o! rYfans/ield. Mail to: Hoard of t-loaflh, 7owr of r`vlaiU nslis, 9rr
Par/( Roar, lolaos.)�Townd, AM 02048.
CPO.'Al Certitic�
Name; Rdbart S Marcler,r, �a 1
DataCertlhod:..Junas�;;.2�`, r',a'.a••,
Fl."I I rrn,r JM.trt;r>lli
... . ...... .....
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Al Of"W09'" j- —A, A-00
Aw
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-�s —Pro—a fax copy I
At For veOcakn, coH M9.5400119
or emailservRo@iIspf.org -f--j O e
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T11;IN)ti.it Ann
or
TAX CERTIFICATION FORM
I certify under the penalises of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law,
3ovV,A0 ,$+cuc+ion CoImac,• _ge-nG�ror
Signature of Indivi ual or Corporate Name By: Corporate Officer (Man Inlor;q, i(Applicable) nsso::�W'
PLC
D L-1- 3 L-L 7 '�)sO3
"Social Security No, (Vohodary) or Federal
Idodificalion Number
"This license will not be issued unless this certification clause is signed
by the applicant,
a" 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,
r m i.... n,,,,MTa v rrPTivjr>TtnN vnuu It—
Commonwealth of Massachusetts
Town of Mansfield
r = Town of Mansfield B Park Row
y °oyr4AtAtle+od�y Mansfield, MA 02049
Board of Health
............. ....... ---1
Permit to Operate a Swimming Pool
PERMIT NUMBER: 3
PERMIT EXPIRES: December 31, 2017
Person Certified.' ROB MERCIER
Pool/SPA Certification Dole: June 09, 2017
Pool/SPA Certification Expires: June 09, 2022
Person Certified:
Pool/SPA Certification Date:
Pool/Spa Certification Expires:
In accordance with the provisions of Chapter 111, Section 127A of the Massachusetts
General Low, and Regulations established by the Massachusetts Department of Public
Health (105 CMR 435,00), permit Is hereby Issued to:
POORVU CONSTRUCTION, CO., INC. - AGENT FOR TWIM OAKS ASSOCIATES, LLC
for the operation of a rl Public 1 Seml•Public 1-1 Special Purpose Pool
located at:
149 OAKLAND STREET
Method of water treatment Is CHLORINE
Bothing load not to exceed: bathers
Number of Lifeguards required at ell flmes the pool Is open Is: None
"NO LIFEGUARD ON DUTY" sign is required,
.filmy Donovan-PaCmer, Y(eallh Agent '`; � I•y .J
,i Date Issued
What d® II do about...
diarrhea in Lhe wr<,ter when chlorine si.abiiizer' is NOT. In the wate,a
A diaAval incident is a high -risk event for contantinaUon caused by Qpiospondnnn
(or, Crypto"), an extremely chiorire-tolerant parasltoThankN e, n 6 important that ,tq we staff educate
pail ons not to swrn when ih vnlh diar'I'hcalo disinfect the vrlter W,why! a d;a TRA inodent, aquatic
staff should hyperchlorinaw. or raise We he chlorine co^u:ntn!lar to a i,:Oh concr�ratco;i cr : tor„
period of wic.If necessa, before eacni ting io hyperrhlor!nale. con'atJt an agoatic prok:ern;`al tc
determine the feasibility(;he mast oNOW and ulnuical mct'nod•,, aw needed all caav'e'won<
Step I: Close the aquatic venue to cmirrin ens.
If you have multiple venues that use the same
flim-itlof', System --all of tine venues vill ^rave to
�e closed to swir inei s. Do no allo•;, a yorc to
er•ier the ven,feO until the' y erutlol ration
process is completed.
Step 2-Remove as rnudn of to TO n;.=,rtr' as
possible (forexample, using a rel or bu,:i,Qt) and
d spose oft to fecal matter in a mrival rimvml < Iean
and disinfect the ile!n used to relrovu the feed naattrr
(for example. after ire net cr bucket
a'ttmersed in the Water d: nng gwerd onn,naaor).
VACUUMING FECAL MATTER FROM THE
WATER IS NOT RECOMMENDED.
Step 3: U<,ng chlo! r,- (!,)i "Ma::; w.
sodidn) hypoch)orite), one the wMeA free
cNorine ccrcentm, on (wc lath braovil and
ma non water' at pH 11 or lest-1
Step 4: iRchleve a concenlranon umc (CI)
inactivation va UC of 11300, to mat van (Y.
drill Crypl.o.The CT i:vauv;pion valve ,t'(e s to
be carE erlratlon of Let chi'orwo v) no is pet'
million (1 , ^") 1'u1;1p6ed by t:rl I .'ita.lt^s al d
sr,ebGt; pi -I a;!o tUnpera;ur,;..
Step S. Ccv'Yn in; the, ihu m on ;;;ten-.
s Opera Ullt vA'.i
I rronalnm at we pl'opc r !ripe ; hlonnc
:oncenU'alu;rI and pl f for hyp l(rijorinatal1.
Step G. BwNash the Nor Iowan, afte!'
wKI-ing the CT inaclivauon value. It stye to
ailschm1e, drer.11y to virile ilnc acccrrcm,; Lo sta'.c
or local I P. ulauons. Do not renu n ;he belle/✓ash
tln'ou!;h :ire Gltcr.4Vhere ahI>ror.: into. rto an tlr,
61tcr media.
Step 7'I:1llo'a w;lmmers bacr. 1( ') :hr --..tor o,
after the ro w� err C 1" rnact.vallon voluc has bean
achieved and the 600 BUM UmCiNVOIon anc
pl-I are r,wthrr ;he operat ny, range a looted 'ny the
state cr loc.), rcgulatory:tuitte"S;:
Con<en trntion r-rec chlorhul
c on<en U';ttiun i'Inx!
>< time (CT) (harts par (in minutes)
inar.tivncion voluc I aril lion sump i
6S
15,300 20' (cr 12 75 ho.vs)
—15,300 IO = 1330 j
(or 25.i aours)
Chlorine Slob i nc' I w rl,de compnwtd:!cc^.ai ;.vav c,:oa d O'lor nrn; tr':chlcr
J.. rlelly the attar;cu uti,eture sho,ld Lc iJ`F (JS"i:) or t:r;w: o jr, .!; IhC ltypce'hlnnnelam Ig ores:.
1 !a'eT.11ivP Of)I o... co..Id m<I:.>fe In " lot AK a x ouf t ivww d S wwn i swin Us o .at (: + 0 ": C on
e nsom o(0y,m gn a.B own c' c:.ct•11. Mo, r,,cso IVI0'It ,t.lulrcl (I^-Cod:•�ya .-C, r,Cu C, ,. �tll k'dr, 1,31:'1
;cvrren'.<C von pate t-W (C is wmle7le a'.,_ d: nets,ilIL�°"S 'u�Pl.nr!,., ra.:,ll er •J:v:nmp, or_ a ,vddc.u!uv;!)
LCDC doe;rgtrecomn•and{4strgis! ,.,In" io: C,ynto.dier "lie. Chilli •uo :iu:c:I -I_r vga",I,!'U. tdand,.r rm'I.l .1.
5. SLrelds If'i. hllll Wt Ans,.good YII omAh hIl. Inacb.ouun of [i}yvospnnrl.!,m pm van under ecreaonat v:.Mq, condamre.i v`llno Fleald•.
?COO:Gpp513-20.
' I'dny <oMCn;i0nel lest YiL c.tme:.-q,t•, �e free d9pnn: cc •tc _ndiLn^s tn�s I•.p,rr. Cfe <hlnr;.e Ie:: S;rp•. rant ;an n:a::ru E:!e ch!cn;r ,� �. rar,r,e :h,t .ral.::1c! 29..i:'i
{::vn (S ch as thou usrd in nce me:f mcurry) o: n!Al d lu uat m a ;tar:::n,d DPi7 IC..t >.n ut nc chlonn�. free r.;rter.
What do � do abOUt...
diarrhea in the water when chlorine stabilizer" is in the water?
A diarrheal incident is a high risk event for contamination caused by Cryplosporldiuna (or"Crypto'•).
an exti ernely chlorine -tolerant parasite. �'nererere, At important that aquatic staff educate paucns no-.
to swim when M with d,ard,ea.Tc, rlisin in the water folkming a diarrhea) modcn'•, a,aA war) ON ad
hyperchlorinate, or race the 6'ce chlorine concentration to z high concentration for along perieci of
time, If necessary, before attempting to Lypei chef irate, consul( an aquatic el ofessi onal to determine the
feasibility, the most optirnal and practical metbach, and needed safety, consldei ndons.
Step I: Close the aquatic venue to sa%;mmers K
you have multiple venues that use :he same. filt ation
system —all of Te venues will have to be closed In
s rumens. Do aot allav anyone to erne; Me venue(s)
until the hyper Chlot nation pl'ecess a cr naplem,
Step I Remax as much of the Ica; matter as
posaii,le (for example, mog a net or &Qe;l
and dispose of the local -natter it• a sa&,,a,y
m annen. Lean and d sin;ka the item used to
remove the fecal matter (for example, after
leaning, lezve the net or bucket immersed In
Me water during 'nyper<Florina.ionj.
VACUUMING FECAL MATTER FROM THE
WATER IS NOT RECOMMENDED,
Step 3: Using unstabilized chlorine (for example.
sodium hypochlorito), Fate to wanA free
Who concenlrawn (see bulicas below) and
maintain water at phi 75 or less.:
Step I Hyperchlonnaw) Chloru,e stabilizer doves
Me rate at which free chlorine Inactivates or Uls
Crypto, and the more stabilizer thete is in the
wate- the longer it takes to !:il! Crypto.
If the cyanuric acid CMICCUIU'Ati011 is I--I5 parts
per million (ppm)'' ,
Raise the r-fic chioruae cowtrntianon to
2C ppm) ano Ma main it for )fl Y,ours or
• Raise the free chlorine concentration to
30 ppm' and maintain it for 18 hours of
• Raise the free chlorine coocentraton to
V the cyanuric acid concent"don is more
than IS ppm, lower the concena'adon co
1—I5 pprn by draining partially and adding
fresh water wichouc chlorine stabilizer before
attempting to hyper chlorinate.
Step S. Confdrn twat to ' hvion Sysw-n
h cpssating wh, q 0C v:'a:,_r nacres an o
melinained w ll,c n'oper face chlormm
concenb'ation ant. pH for'
Step G: Badovash the filer thoroughly Wier
hyperchlorirKen has been completed. Be sure to
ofshafle dh eCOy to ,'paste and amending to state
a local regulations. Do not return the bad;:^:ash
through the f1ter'Where appropriate, replace the
filter media.
Step 71:A11ow s;vimmer; back rnto tho water
only after hyperchlonnatlon has been completed
and the CJ'ee chorine ror.Ceniration and p1.1 -1-e
widen the opow ng rargc :+,Mowed by the state or
local regulatory authorg
90 ppm' and maintain it for 35 haws —_
L Cabrine ;lubdiyers Inaude con grounds such as gnr.vra aod. tlichin[ arU I'ahler.
i, ldo.illy.lis vote:' Icr npCl'atvrt::!tovlU he 77"F (?S'C) cr teel,Cr dur,nP 1� h'/Perci,lUr,�m:,cn I:rocct�.
;. FIte,an,e opucAs could aidude c,tula LSQ I!tC n'dtcr lhtJvLlt 2 S:.GnOtr'/ CR." ieCiion 5):,C.rJ {rCr' CxJrp 9..aVSno'c: b� Y. O' C),Urq;) lO Ihoo'_UGAI, .^(JY,C L^2
min ttrer cfCr/pl000cyts in d-.caq.:auc.cnue(s)be'ca one rnl..a anLned r+Ito M<A^IPGwl.; P'tahn Code (PL\i-1CY ranGvf. V.I j24(n.mev
,!,Q,n of :he hL\PIG a -vital)( at v_,wriwpr,.�/mar:rr,...c^•cr'.; vr,M1n•'r;.hm�l) (700,300 acvaac'¢r:. Q)
a. Murphy jL.Arro..ocu 111, Lu. k, hll.wsa IL, Ilc.tch hll and Hdl Vri Ucc; of q'anunc acd on the ma<ty ,Lon of Cr ypar.;;n,r.;unn Pnn,:nl cr.:cr r;) p<r:hloc,:Ibon
Uxulibons, unvur,:I 5ei ; i::ednu! 2CI S:d9:7bt8 55.
j. Kul cOnvCnl.'.n.tl lot nits crwl "'e0,e irCC toll r.ru CcnCcnP...
mdudef 2b^lo Pprn )still as i!rotc vsCA ,n Pm roc<I Wwc D D t
G CDC dots not reimwooui Its Ln!; the "' L,r for Cr/puo A,-, m:aun dcflrol5 Cr); 1is nf,l ..r, : la !'.
nnl e,K,M,,AY tleow y the slr"Cl ure of tie pa, astr.
, '4oclF7j�
p(1!!CI r�l
anseo",a.�1�
gy.�l_�t
Man& 5.2019
Dcar Pool open.!,
:1 omm of ' A/1" ws leld
Pal'h. Rol. r! 'm."fir/d
Attached is the public and scnu-public: pool npplicll,on for tl'tis year.
(-(eallb Dep ailaawl
Ivry Dnnamm Paluttll ;1dPFl, !?
1 1 rulth , 'I ravV
Please nibrinit the aunched documents and payment ut the Health Depm unent uo I mer 16"1 Sin) L 2019
Plense note that ALL of these documents must be submiunl each year It the tiling to be complete.
Incomplete filings will be rc:nrnd and no permit will be issued.
r S',vimiuing Pool Application
�./ccnil'icd fool operetor rlocnmcnlntion
r./ /fits cmtificauoc Pont
Workers' Compensation Insurance Arfdavil: General Business svilh it copy ofille policy
declaration pngc
Written policy on Ilow, the facility deals wilh kcal, vomit a:;d blood mukTams in stcmunl g pools
Moving 12xtvard, the took Dymnment will commammme with permit holders through email. rather than
reguhr mail.
New uermil fees, ndopted by the Board of Health in ScImern er 2018, will npply to Tese mnewak The
netr fee p.r pool iss S 150. A re -inspection fee of S I0o will In i.s.suml if violations nre found during tellIm•c
i aspect o cs.'-�
Please cio not V;esivac :e co::'.nct in,, if I call be oiar•y cthur assis;nac:c.
Sincerely,
r.�
Amy Donovan-Palmct', N•111H, RS
health Agent
Pham 10, 26F7J66 10%(50AY26/-742 L'tarl s!ll:rdiurr(%nrruuftGbtm.rout
The Cont»uutwealtli gf'Alassachusetts
Department of Industrial Accidents
Gjfrce of Investigations
600 Washington Street
Boston, MA 02111
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
13tlsiness/OrganizationName:r CbO,ryv^ C0A5AruGk10n C,w,0;>,
tA
Address: -Ho rave rt t tide 3] 5
City/State/Zip: Q 49 2 2Phone #: U (� 52`1 1p�
Are you an employer? Check the a ropriate box: Business Type (required):
1. a I am a employer with -)—o employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Rcstau ani/Bar/bating establishment
2. ❑ 1 am it sole proprietor or partnership and have no 7, aOffice and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 4. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp, insurance required]**1 1.❑ Health Care
4. El We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
`Any xpplicam chat checks box kl must also all out the section (below showing their workers' compensation policy information.
•*Itthe corporate officers have excinpled themselves, fiat the corporation has other employees, a workers' compensation policy is required and such an
organization should check box NI
tau an earplayer that is pronidirtg workers' cantperrsatina iusuraare for my eaq�loyecs. Belo iv is the policy inforntaion.
Insurance Company
Insurer's Address: t-S q 3¢ d Ave tcx,r l t n a k MA bi'6C)-?�.
City/State/Zip; t,jQ, V i (N51cn L A- r) \'603
Policy ff or Self -ins. Lic. tt_ VQC C. 5W7 6� S 9 Expiration Date: I& 12o2,z
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 c. 152 can lead to the imposition of criminal penalties of a
foe 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 clay 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.
t do herek ), 5ortifr, under the pains and penalties of perjury that the information provident above is true and correct.
b
Official use only. Do not'iw*e in this area, to be ewupteted by eipr or town official.
City or Town:
Pernift/License
Issuing Authority (circle one):
1, Board or Health 2. Building Department 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass-gov/dia
Phone
ACOR& CERTIFICATE OF LIABILITY INSURANCE
DATEIMM12I
04/30/20021
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 pollcy(les) must have ADDITIONAL INSURED provisions or he 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
CONTACT Arlene Marsh
NAME:
(781) 444-3050 FAX.3051
ANc:
Aronson Insurance
AONNeo s_(_11)444.
kTC
Ones.AMarsh®aronsoninsurancecom
950 Highland Ave
INSURERISIAFFORDINO COVERAGE
NAICY
_
INSURERA: AEIC
Needham MA 02494
INSURED
INSURER B:
INSURER C:
POowu Construction Company Inc
_
INSURER 0:
40 Grove Street, Suite 315
_
INSURER E:
INSURERF:
Wellesley MA 02482
COVERAGES CERTIFICATE NUMBER: 2021-2022 REVISION 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.
ILTR
TYPEOFINSURANCE
D
MSR D
POUCYNUMSER
MMIUOJYYYY
MMIODIYWY
LIMITS
A
COMMERCIALGENEMLUABILITY
CUMNIS.MADE OCCUR
VVCCSODSO18958
OW30/2020
05/30/2021
EACH OCCURRENCE
3
PRE ISO E omunenca
3
MED EXP An ore Parann)
3
X
Workers' Compensation
PERSONAL& AOV INJURY
S
GEN'LAGGREGATE LIMITAPPLIES PER:
POLICY ElJSC LOG
OTHER
GENERALAGGREGATE
$
PRODUCTS - COMPIOP AGG
3
Employers Uab
$ 1,000,000
AUTOMOBILE UABILITY
ANYAUTO
OWNED TUONLY AUTOS
HIRED NON-ONMED
AUTOSONLY AUTOS ONLY
COMBINED SINGLE LIMIT
eactld.nl
S
BODILY INJURY (Par Mraon)
3
BODILY INJURY(P.,emdon
S
'PROPERTY
PftOPEflTY DAMAGE
Par actltlanl
S
S
UMBRELLA LIAO
EXCESSLIAB
OCCUR
CLAIM&MAOE
EACH OCCURRENCE
3
AGGREGATE
3
OED RETENTION 3
3
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORMARTNERIEXECUTIVE Y�
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
R ym, aeembe ur,tlar
DESCRIPTION OF OPERATIONS bal"
NIA
WCC5005010958
O6/3012020
05/30/2021
X STATUTE ORH
E.L. EACH ACCIDENT
3 1.000,000
E.L DISEASE - EA EMPLOYEE
3 1,000,000
E.L. DIBEA$E PDLIDY LIMIT
3 1.000,000
DESCRIPTION OF OPERAfiONSJ LOCATIONS I VEHICLES IAGDRD f01, AtltllLlanal RamerSe Sahatlula, may ba aaeohotl II moro epec0le maulratll
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS.
SPark Row r.................a...I.........—
Mansfield MA 02048
(D1988.20'IB ACORD
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
reserved.
ACORO® CERTIFICATE OF LIABILITY INSURANCE
`,/'
DATEIMMMD/YYYYI
04/30/2021
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 pollcy(les) 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 endoreemenl(a).
PRODUCER
NAME: Arlene Marsh
Aronson Insurance
PHONE (781)444.3050 FAX Ne: (781)444-3051
IAX. Ka. Ran: IJUC,950
AOURESS: AMarshigilaronsonlnsurance.nom
Highland Ave
iNSURER(SI AFFORDING COVERAGE
NAICN
INSURERA: AEIC '
Needham MA 02494
INSURED
INSURER 8:
INSURER C:
POomu Construction Company Inc
INSURERo:
40 Grove Street, Suite 315
NSURER E:
INSURERP:
Wellesley MA 02482
COVERAGES CERTIFICATE NUMBER: 2021-2022 REVISION 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 REOUIREMENT 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.
LTA
TYPEOFINSURANCE
RED
me
POLICYNUMSEfl
IMMfli
MM0)UIYVYY
LIMITS
A
COMMERCIAL GENERAL LIABILITY
CIAIMSMAOE DOCCUR
WCCSOOSO18958
05/30/2020
05/30/2021
EACHOCCURRENCE
S
PREMISES EB wma e
S
MEDIEXP(Amrormixinam
S
x
Workers'Compensation
PERSONAL SAOV INJURY
S
GEN'LAGGREGATE LIMIT APPLIES PER
POLICY JECT LCC
OTHER.
GENERALAGGREGATE
s
PRODUCTS -COMPIOPAGG
3
Employers Uab
s 1.000.000
AUTOMOBILE
LIABILITY
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON-OlAa1E0
AUTOS ONLY PAUTOS ONLY
COMBINED SINGLE LIMIT
Ea ecddsnl
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BODILY INJURY (Per penPnl
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BODILY INJURY IN, aWd.1)
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3
A
WORHERSCOMPENSATIO
AND EMPLOYERS' LIABILITY
ANY PROPRIETORNARTNEWEXECUIVE YQ
OFFICEMMEMSER EXCLUDED?
(Mandataryin NR)
Ilya., deamLeunaar
DESCRIPTION OF OPERATIONS blow
NIA
WCC500501895B
05/30/2C21
05130/2022
OTH•
%� SN PERTATUTE ER
EL FACHACCIOENT
S 1,000,000
E.L. DISEASE• EA EMPLOYEE
S 1,000,000
E.L. DISEASE - aOLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACOR )101, Addltlanal Remorks SEMdule, may w aaaahed ll maro epees is n4ulrotlt
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE 09SCRIBRO POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Mansfield
ACCORDANCE WITH THE POLICY PROVISIONS.
S Park Row
—
AUTHORIZED REPRESENTATIVE
Mansfield MA 02045
T�
01988.2015 ACORD CORPORATION, All rights reserved.
ACORD 25 i2018103) The ACORD name and logo are registered marks of ACORD
Ali o® CERTIFICATE OF LIABILITY INSURANCE
DaTE/3012021
oal3m2oz1
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 pollcy(les) 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 endoreament(s).
PRODUCER
NAONTACT ME: Arlene Marsh
Aronson Insurance
PHONE (781)444-3050 F (781)444-3051
C No I • A/C• Not:_,
950 Highland Ave
Aooaess: AMarsh@aronsoninsuranw.com
INSURER(S) AFFORDING COVERAGE_
NAICp
Needham MA 02494
INSURERA: AEIC
INSURED
INSURER B:
Poorvu Construction Company Inc
INSURER C:
40 Grove Street, Suite 315
INSURER D:
INSURER E :
Wellesley MA 02482
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2021-2022 REVISION 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 W)TH 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.
Wall
Tp
TYPE OF INSURANCE
INSO
WVO
POLICY NUMBER
MMIODIYYVY
MMIDON"Y
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S
PREMISES Ea occu0ane,o
S
CtAIMS•MAOE DOCCUR
MED EXP (Aft one person)
S
X
Workers'COmpensalion
PERSONAL SAOV INJURY
S
A
WCC5005018958
0513012020
05/30/2021
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY PRO-
JECT LOG
GENERALAGGREGATE
S
PRODUCTS - COMPIOPAGG
S
Employers Liab
S 1.000,000
OTHER
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea.wannl
S
BODILY INJURY (For person)
S
ANVAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Porecutlene
S
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
P PERTY_DAMAGE
I'mawaonl
S
a
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
S
EXCESS LIAR
CLIMSMADE
DEB I I RETENTION S
S
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY VIM
ANY PROPRIETORIPARTNERIEXECUTIVE N
OFFICERIMEMBER EXCLUDED?
NIA
WCC5005018g58
05/30/2021
05/3012022
PER H.
X STATUTE R
E.L. EACH ACCIDENT
S 1,000.000
El DISEASE - EA EMPLOYEE
S 1000,000
(Mandatory In NH)
If yes, deamao ulMat
OE SCRIPTIONOFOPERATIONSaol"
E L DISEASE• POLICY LIMIT
s 1.000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Addalanal R-11ft Setlodula, may to anachad it mom space is mqulmd)
CERTIFICATE HOLDER r.nurE1 I ATlnu
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (201610311 The ACORD name and logo are registered marks of ACORD