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Home My WebLink AboutMillhaus - 12/31/2021-z �') 0 -Irv. 7A, Town of Mansfield - Board of HealthTown of 6 Pak Rowansfield Mansfield, MA 0204 Swimming Pool Application PERMIT NUMBER FEE: $150 Re -inspection fee: $100 NAME OF OWNER: 1n1111 LL�,,O C.-1/L'CYD 7- ADDRESS: Q,&. CITY: rnClfvfiP .l d rIzA-- STATE: +r #-Z)P: (:b A41q, TELEPHONE:fi�a. FAX: /� EMAILtSQn'>I M7%d_0d,0/:r_,4a5 FED lots$ NO: 6s_-6,1',7'lf%} Certification Exoires Every 6 Years, Plirmit ExpirDecember 31st Yarly, PERSON CERTIFIED: Pool/SPA Certification Date: PODUSPA Certification Expires: PERSON CERTIFIED: Pool/SPA Certification Date: POWSPA Certification Expires: certification remarks(if necessary): REMARKS: LJJ Public POOLOPERATION:f Semi -Public [] Special Purpose Pool POOL LOCATION: j3D /eumkc' _ &Z C" TYPEJPOOL: C unr t i-C LENGTH: W WIDTH: 34 VOLUME: (Olo &)0 MINIMAX. DEPTH: fire-,' 7 f /0 f j-' SWIM AREA: Mbws.iv DIVE AREA: rime WATER SOURCE: pwi9 WIW DISPOSAL: —r4av? J ewt.r TYPE OF FINISH: SCUM GUTTER: 61-4- DECK TYPE: POnCrt% 14 SKMMR WEIR LENGTH: SLI f3 f 4~4 TREATMENT SYSTEM: 4hL11 =t Lmdb DISINFECT METHOOaAv ",1 NlIr7ty, Y" CHEMICAL TREATMENT: F' f urn Ay^V/4 1-14< ..__.._. _.. _._ NUMBER OF BATHERS: rI1ei IATURE: — DATE: _�67A/6 _— __ date and encl se check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six eld, 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. Signature of Individual or Corporate Name 4' 4 G ✓' —//9c�-- "Social Security No. (Voluntary) m- 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. CAUsersls1ei(e\,Dwktnpk8cotes Dnuuments\Food Establishments- TetnplTAX CEW11FICATIDN roRM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www:mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le2tbly Business/Organization Name: Address: City/State/Zip: m�� /tf 7,/ Phone#: / 8 ,3A�i2678 Are you an employer? Check the appropriate box: 1. L4 I am a employer with.. employees (fill and/ or part-time).* 2. ❑ 1 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. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' coliip, insurance rea.l Business Type (required): 5. ❑ Retail G. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.0 Health Care 12.❑ Other 'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information, i **If the corporate officers have excmptcd themselves, but [Ile corporation has other employees, a workers' compensation policy is required and such an organization should check. box # 1. I am an employer that is providlag workers' compensation insurance for my employees. Beloiv is the policy inforulrrtion. Insurance Company Name:--(:-! y17 c lk t„ Insurer's Address: vl e,3 40 n t 4t7J4 City/State/Zip: reth,ri, /yy; Q 17i tQ bad Lao art - Policy # or Self -ins. Lie. Expiration Datcc /t M/ 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 PIA for insurance coverage verification. the pains and Pen>;ls of perjary that the informailon provided above is true and correct. Official use only. Do nor 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 Contact Phone www.mass.gov/dia 05/27/2015 03:38 5086685201 ALL SEASONS POOL PAGE 01/05 05/27/2015 03:38 5086685201 ALL SEASONS POOL PAGE' 05/05 O C1�pc� 1 COLu Poo Ch\orlvr.Q- 05/27/2015 03:38 5086685201 ALL SEASONS POOL 4CC?Ci �- CERTIFICATE OF LIABILITY INSURANCE PAGE 04/05 DATE (MMR(D/YY'/v) 081131*2b21 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 AFPOROEO BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endoreed, If SUBROGATIONIS 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 Cortilleata holder In lieu of such endorsements . PRODUCER CONTACT NAME: PAYCHEX INSURANCE AGENCY INC 7621075S PHONE (800) 472-0072, INC, No, EKOI FAX (585) 389.7894 (AID, NV): 150 SAWGHASS DRIVE ROCHESTER NY 14820 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL: INSURERA: Hartford Fire Insurance Company 19882 INSURED INSURER B: ALL SEASONS POOL & SPA SERVICE INSURER C: 17 BONNEY RD WALPOLE MA 02081.3301 INSURER D I INSURER E: INSURER F I yTHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE, POLICY PERIOD INOICATED.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. INS LRIAR TYPE OF INSURANCE ADDL SOUR POLICYNUMEER POLICY EFF OU YEXP UNTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIM&MADE❑OCCUR DAMAGE TO RENTED ptliOn) MEO EXP (Aq Or10TE PE ONAL&ADV INJURY —_--- GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRODUCTS - COMPlOP AGG POLICY PRO- O LOG JRCT pTI1PR AUTON080.ELWeRJTY COMBINED SINGLE LIMIT I BODILY INJURY (P& pefaOA) ANY AUTO RODILY INJURY (Per aoddent) ALL OWNED SCHEDULED AUTOS AUTOS HIRED NONOWNED AU1U6 AUTOS .. PROPERTY DAMAGE (Por accMenn , UMOR6LLAUAa OCGDR EACH AGGREGATE EXCESS UAB CRAIMS- MADE ED REtENYION$ 1EMPLOYEF WORKERS COMPENSATION EAIPDYERn' LAOILrfV YIN X PERAND TANY E.L. EACH ACCIDA PROPRIETORIPARSNEWEXECLRIVE OFFICER/MEMBER EXCLUDED? NM 76 WEG AL28WE 04/09/2021 04/09/2022 E.L. DISEASE-E $1,000.000 EL DISEASE - POLICY LIMIT $1,000,000 (Mandatanrin NHl It Yee' d wdw mdsr E OE.4CR/PININ OF OPERATWNS/LOCAtION IWWCVS(ACORD 101, AddWOml RNV19*0 001`90019,wy he ANacheriH mere apace Is repuirw) ~ Thane usual to the Insurad's Opamtlorr& 4CRr1 Condominiums MIII Haus Contlominiums ' BH00L0 ANY OF THE ABOVE DESCRIBED POLICIES BE CAWCELLED SHOULD 150 RUMFORD AVE BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED MANSFIELD MA 02040 IN ACCORDANCE WITH THE POLICY PROVISIONS. AU(T+NOWLED REPRESENTATIVE C 1 uBR.h 19Ha-2U1b A1:UKU UVKR'VKAI IVN. All ngnm rasem"- ACORD 25 (2010/03) The ACORD name and logo are m9lsterad (narks of ACORD 05/27/2015 03:38 5086685201 ALL SEASONS POOL PAGE 03/05 THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 Mill HEW Gdnddminiums 150 RUMFORD AVE MANSFIELD MA 02048 Account Information: Policy Holder Details., IAll Seasons Pool & Spa Service August13,2021 `r,;) Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 287-1312 Fax: (888) 443-6112 Email: agplLgV.services(@thebartford.com Website: httos7Ubusiness.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05