HomeMy WebLinkAboutMansfield Apartments - 12/31/2021�215�
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Torun of Mansfield - Board of Health
Srvinnning Pool Application
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NAME OF OWNER:
Moos6eL,,l -Afauow-its A ac
ADDRESS: Aocbmocs AV6
CITY: "am kld )
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Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER
FEE: $150
Public Re -inspection fee: $100
POOL OPERATION: Semi -Public
Special Purpose
1 PPool
/V
POOL LOCATION: A o Gwo S 7"� oUQ.
STATE: VIA 21P: 07-N8 TYPE/POOL: 61,101k( I eokf-
y 1
TELEPHO�.pNE: r_ yy LENGTH: t4L''p14 V WIDTH: IT
-OCULD VOLUME: 2't SIO godtfns
FAX: Y) 33 - c { 2yj
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EMAII • `l7fis ,[�j IYI MIN/MAX DEPTH:�✓�I J
FED IDlaa NO: SWIM AREA: �Q,�� DIVE AREA: ht
Ad b to- vWATER SOURCE: I DWI`)
Certification Expires Every 5 Years. W/W DISPOSAL: ' I p'()
Permit Expires December31 st Yearly. TYPE OF FINISH: sk
K-6 PERSON CERTIFIED: �0"Aav eadt ')O%/ SCUM GUTTER:
`_,��N�o��oQep,n
Pool/SPA Certification Date: '1yote.�Y bek 2(n
(WLO DECK TYPE: �-Dm 11
Pool/SPA Certification Expires:
PERSON CERTIFIED:
Pool/SPA Certification Date:
Pool/SPA Certification Expires:
certification remarks(if necessary):
REMARKS:
SKMMR WEIR LENGTH:, I�8pt,.(L
TREATMENT SYSTEM:,�,v`Y O(1 nv'
DISINFECT METHOD: 60A,)( �N 'L
CHEMICAL TREATMENT:4y0ow-
NUMBER OF BATHERS: `t' t
SIGNATURE: �(�eCtLsIeLI c_ 0hv1,(,l6( 6 �l/1 Z/2 Z'
Sign, date and ent'lose check payable 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.
kpW6eeoI A(w4mek,4SaC 7 ff /;
Signature of Individualor Corporate Name By: qy rpgr to Officer (Mandntory, if Applicable)
38F 430%
**Social Security No. Wolwrtary) or Federal
Iderrlification Number
*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.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street, Suite 100
c Boston, MA 02114-20117
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information
Please Print LeLriblv
Name (Business/OrgauizatioiVIndividual): Coo k; uu i L Yt ots Z-
Address: -A VC
'
City/State/Zip: 5(-Wng l-p 4 Q$ 3 Phone#: _�Dl—llr�l
�41 00
Are you an employer? Check the appropriate box:
Type of project (required):
l.❑ I am a employer with employees (full and/or part-time),'
7. ❑ New construction
2.❑ I am a sole proprietor or partnership and have no employees working for me in
$, ❑ Remodeling
any capacity. tNo workers' comp, insurance required.]
9. ❑ Demolition
3.❑ [ mn a homeowner doing all work myself. [No workers' comp. insurance required,] r
4. ❑ 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 ❑ Building addition
ensure that all contractors either have workers' compensation insurance or are sole
11. ❑ Electrical repairs or additions
proprietors with no employees.
12. ❑Plumbing repairs or additions
S. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These have
13. ❑ ROOF repairs
sub -contractors employees and have workers' comp. insurance.t
6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
14. Other 'mm
152, §l(4), and we have no employees. [No workers' comp, insurance required.]
*Any applicant that checks box ill must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ��,�
Insurance Company Name: `ta.X.i.A.t 0+, 1 iW pLl(-tAme, e ry ( p Ly[,C
Policy # or Self -ins. Lie. #: �tJ It 30 � 9 X4 Expiration Date: ,� 0 l a_11 O?DQ-
Job Site Address: a 4 is- C. cks-b am2Q�bacC , C/ t milt IjZ uZOCity/State/Zip: �(tenenjkla 8 1-6 —
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form (if a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
I do hereby certify, ! n#dyer-the pains and penalties ofperjury that the information provided above is true and correct.
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. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
a`vK " CERTIFICATE OF LIABILITY INSURANCE
DATEIMMIDD(YYYY)
10/26/2020
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 policy(ies) mugt have ADDITIONAL INSURED provisions or b -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
Phoenix-Alliant insurance Services, Inc.
2415 E Camelback RdSte950
Phoenix AZ 85016
NAMEAcT Stephnie Logan
PHONE PAX— ----
c Ea • 602-707-1898 Arc N6:480.333-6973
goliliess: Dhxcsgcerts(5alliant.com
INSURERS) AFFORDING COVERAGE
NAIC4
INSURER A: Federal Insurance Company
INSURERS: Navigators Insurance Company
---R y
20281
42307
INSURED
Continental Pools, LLC
wsuRER c: Old Republic Insurance Company
24147
8520 Corridor. Rd B
Savage, MD 20763
INSURER D: Lexington Insurance Company_
19437
INSURER E: Westchester Surplus Lines Insu
10172
INSURER F: Allied World Assurance COm p an
19489
- -I
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,
INSR I
LTR
TYPEOFINSURANCE
ADDL
SUBR
POLICYNUMBER
POLICYEFF
MIODA'YYY
POLIGY'EXP
MM/DO
LIMITS
C
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE E OCCUR
MWZY 315873
10/26/2020
10/25/2022
EACH OCCURRENCE
$4,500,000
PREMISES a occurrence)
MED EXP (Any oneperson)
$ 1,000,000
$ 10,000
PERSONAL a ADV INJURY
$4,500,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
POLICY � JET M LOC
OTHER:
GENERALAGGREGATE
$5,000.000
PRODUCTS - COMP/OP AGG
$5,000,000
$.
A
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
54309825
10/25I2020
10/25/2021
Ee BINEDaccidenSINGLE LIMIT
$1-,000,000
X
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident)
—
$
Anyqutc Includes
$Hired, Non -Owned
e
UMBRELLA LIAB
EXCESS CIAO
X
OCCUR
CLAIMS -MADE
NIA
SF20EXC7613611V
54309827
10/25/2020
10/25r2020
10/25/2021
10/25/2021
EACH OCCURRENCE
$
X
ATE
$DED
RETENTION$q WORKERS COMPENSATION
EMPLOYERS'LIAaILITY YIN
FICER/MEMSEREXCLUDEO?
lm NH)
yes, describe underDESCRIPTION OF OPERATIONS below
o Event
TUTE ERHANYPROPRIETORIPARTNEWEXECUTIVE
$5,000,000AND
H ACCIDENTOF
$1,000,000andatary
EASE -EA EMPLOYEE
M
$1,000,000If
EASE -POLICY LIMIT
$ 1,000.000D
F
Excess of CGUBxcess AulelEL
Excess of CGUAuto/EL
Excess of CGUAutoIEL
80878032
G71835388 001
0312.6637
10/25/2020
10/26/2020
10/25/2020
10/25/2021
10/25/2021
10/25/2021
currence a Agg
currence a Agg
currence a Agg
3.000,000E
5,000,000
5,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES tACORD 101,Additional. Remarks Schedule, maybe attached if more space is required)
EXCESS LIABILITY: Navigator's EXCESS AUTO LIABILITY policy is follow form of primary/underlying Federal AUTO LIABILITY limits, and
Lexington, Westchester and Allied World EXCESS LIABILITY policies are follow form of primary/underlying Old Republic COMMERCIAL GENERAL LIABILITY
limits, of Navigators EXCESS AUTO LIABILITY limits and of Federal WORK COMP/EMPLOYER'S LIABILITY limits, and all are subject to policy terms and
conditions.
UGKI IrIGAI C HULUt:K CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Proof of Insurance
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
N
Y
Tsae-ZUTD ACUKU CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD