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HomeMy WebLinkAboutWest Village Apts 12/31/2017Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 18 PERMIT EXPIRES: December 31, 2017 Person Certified: HANSEL RIVERA Pool/SPA Certification Date: March 15, 2017 Pool/SPA Certification Expires: March 15, 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 Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a [] Public ❑ Semi -Public [v-] Special Purpose Pool located at: 792 WEST STREET Method of water treatment is CHLORINATOR/SAND FILTER Bathing load not to exceed: 8-10 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan-PaCmer, Health .Agent None Date Issued Q: Town of Mansfield - Board of Mealth y ASA Swimming Pool Application NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM FED ID/SS NO: 45-1501972 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 12/9/2011 Pool/SPA Certification Expires: 12/8/2016 PERSON CERTIFIED: PoolISPA Certification Date: PoolISPA Certification Expires: certification remarks(if necessary): REMARKS: 'NO LIFEGUARD ON DUTY" sign is required. Vo lifeguard on duty. Sign is required. PERMIT NUMBER 18 FEE: $125 ❑ Public POOL OPERATION: ❑ Semi -Public ❑v Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL: SPA/HOT TUB LENGTH: N/A WIDTH: N/A VOLUME: 1500 GAL. MINIMAX DEPTH: 3.5 FT. SWIM AREA: N/A DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM:CHLORINE DISINFECT METHOD: CHLORINATOR/SAND FILTER CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 8-10 a, SIGNATURE: _ s .___ DATE: _ Please make appropriate changes. 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 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. *'Sigfiature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents y I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly rA,h Business/Organization Name i t=,, Address: u City/State/Zip A -: Are you an employer? Check the appropriate box: I am a employer with employees (full and/ or part-time).* 2:0 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' comp. insurance req.] i . Phone #:- Business Type (required): S. ❑ Retail 6, FlRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 1111 Health Care 12. ❑ 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. 1 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company N Insurer's Address; City/State/Zip: Policy # or Self -ins, Lic. # 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 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. 1 do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. 'et n / `` h. Date; I € �ismah�re_ E 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person www,mass.gov/dia Phone #: CERTIFICATE OF LIABILITY INSURANCE AT 2117 051300 r 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(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 endorsement(s). PRODUCER Aon Risk Services Southwest, Inc. Dallas TX Office CONTACT NAME: PHONE (866) 283-7122 FAX (800) 363-0105 (AIC. No. Ext): A1C. No.): E-MAIL ADDRESS: CityPlace Center East 2711 North Haskell Avenue INSURER(S) AFFORDING COVERAGE NAIC # Suite 800 Dallas TX 75204 USA INSURED INSURER A: Liberty Insurance Corporation 42404 INSURER B: Liberty Mutual Fire Ins CO 23035 Monogram Residential Trust 5800 Granite Parkway Suite 1000 INSURER C: Westchester Fire Insurance Company 10030 INSURER D: Endurance American Insurance Company 10641 Plano Tx 75024 USA INSURER E: DAMAGE TO RENTED $500,000 PREMISES Ea occurrence) INSURER F: COVERAGES CERTIFICATE NUMBER: 570066569419 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. Limits shown are as requested LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MM/DDIYYYY LIMITS C X COMMERCIAL GENERAL LIABILITY G EACH OCCURRENCE $1,000,005 CLAIMS -MADE X❑OCCUR DAMAGE TO RENTED $500,000 PREMISES Ea occurrence) - MED EXP (Any one person) Excluded X TRIA Included X NO Deductible PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 POLICY ❑ PRO X❑ LOC JECT OTHER: Max General Agg $10,000,000 B AUTOMOBILE LIABILITY AS2-Z91-467377-017 05/31/2017 05/31/2018 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY ( Per person) ANY AUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED AUTOS X NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accident DUMBRELLALIAB X OCCUR x5030000113401 05/31/2017 05/31/2018 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 X EXCESS LIAB CLAIMS -MADE DED RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR I PARTNER I EXECUTIVE wc7z91467377027 05/31/2017 05/31/2018 'X STATUTE oTH E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N 1 A E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 ((yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) West village - 792 West Street, Mansfield, MA 02048. (Loan 07040578). Additional Named insured: Monogram Residential west Village REIT, LLC. Certificate Holder is included as Additional Insured in accordance with the policy provisions of the General Liability and Excess policies. TRIA is included in Excess Liability policies. `m M O Z Y R U N U CERTIFICATE HOLDER CANCELLATION e SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Fannie Mae ISAOA/ATIMA AUTHORIZED REPRESENTATIVE C/o Berkeley Point Capital, LLC One Beacon Street i%%e�OrC r�st�ZiscvQ eJkGLfare Jna 14 Floor Boston MA 02108 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000064189 _ LOC #: A ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk Services southwest, Inc. NAMEDINSURED Monogram Residential Trust POLICY NUMBER See certificate Number: 570066569419 CARRIER See certificate Number: 570066569419 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Excess Liability coverage Policy Number: LHE00015282403 Issuing company: Fireman's Fund Insurance company Policy Term : 05/31/17 - 05/31/18 Limits: 25m xs 10m Policy Number: zuP21N7254A17NF Issuing company: Travelers Property casualty company of America Policy Term : 05/31/17- 05/31/18 Limits: 15m xs 35M Policy Number: ECo1856575888 issuing company: The Ohio Casualty Insurance company Policy Term : 05/31/17- 05/31/18 Limits: 25M xs 50M The ACORD name and logo are registered marks of ACORD or or IIIIII���III�I��%,��IIIIIII� _ � IIIIItIIIIIIIIUP _ t �� � Alft SII JIIIIIIIIII _ IrOCI IIIIIiIIIU�� I WA ;,IIIIIIIII� � J ids CIO I %I ;I �flllllllllllllllllllllllll ����IIIIII'11111�IIhIIi _ i, � y R} �I!111111111!114 � 111111����ipllllllllllli� �, � � �- ��� a ,�111j11111111111111�IIIli �►a ��,�� °.'+� m =Ammil n n _=n I IIIIIIIIIIIIiIiIP.� �._ �.r. I!�I�����illllllllk, I� plillllllllllllj � �y , �dlllllllllllll�i���` �� (j) o 7uIIIIIIIIIIIIIIII��HJU �� tD c II,IIIIIIIIIIIIIIII I�h = C� 5w -�ui— IIII�IIIIIU V I � C7 = N +� Q �— �1�IIIIIIIIIIIIIIII�1@1111 ����1�I111111111V,I IIIIII���III�I��%,��IIIIIII� _ � IIIIItIIIIIIIIUP _ t �� � Alft SII JIIIIIIIIII _ IrOCI IIIIIiIIIU�� I WA ;,IIIIIIIII� � J ids CIO I %I ;I �flllllllllllllllllllllllll ����IIIIII'11111�IIhIIi _ i, � y R} �I!111111111!114 � 111111����ipllllllllllli� �, � � �- ��� a ,�111j11111111111111�IIIli �►a ��,�� °.'+� m Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 16 PERMIT EXPIRES: December 31, 2017 Person Certified: HANSEL RIVERA Pool/SPA Certification Date: March 15, 2017 Pool/SPA Certification Expires: March 15, 2022 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: Town of Mansfield 6 Park Row Mansfield, MA 02048 In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Law, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00), permit is hereby issued to: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a ❑ Public W Semi -Public ❑ Special Purpose Pool located at: 792 WEST STREET Method of water treatment is CHLORINEICHLORINATOR RAINBOW 300 Bathing load not to exceed: 93 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. .filmy Donovan-PaCmer, Heaah Agent Date Issued Swimming pool Application PERMIT NUMBER 16 FEE: ,$125 ❑ Public NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE POOL OPERATION: W Semi -Public REIT ❑ Special Purpose Pool ADDRESS: 792 WEST STREET POOL LOCATION: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TYPE/POOL: GUNITE SEMI-PUBLIC TELEPHONE: (508) 261-0500 LENGTH: 56' WIDTH: 25' VOLUME: 42,000 GALLONS FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM MIN/MAX DEPTH: 4 ft. FED ID/SS NO: 45-1501972 SWIM AREA: 1,400 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN Certification Expires Every 5 Years. WM DISPOSAL: TOWN SEWER Permit Expires December 31st Yearly. TYPE OF FINISH: PLASTER PERSON CERTIFIED: HANSEL RIVERA SCUM GUTTER: N/A Pool/SPA Certification Date: 12/9/2011 DECK TYPE: CONCRETE Pool/SPA Certification Expires: 12/8/2016 SKMMR WEIR LENGTH: 8" PERSON CERTIFIED: TREATMENT SYSTEM: ASTRAL SAND FILTER POo11SPA Certification Date: DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 Pool/SPA Certification Expires: CHEMICAL TREATMENT: CHLORINE certification remarks(if necessary): NUMBER OF BATHERS: 93 REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. k SIGNATURE DATE: ` ° Please make appropriate changes. 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 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) LJ 15 - Social Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. t Informa The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. e Print sfiP°� d ` F t ;3� `' xit``,_...C.. i Business/Organization Name: -_ ' r Address: k ' `S Phone #: L City/State/Zip i �_'i =.�� Are you an employer? Check the appropriate box: j I am a employer with employees (full and/ or part-time).* 2.0 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 e. 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' comp, insurance req.] Business Type (required): 5. ❑ Retail 6. nRestaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing I I. ❑ Health Care 12, ❑ 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 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 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 -cert, under the pains andpenalties of perjury that the information provided above is true and correct. r Phone #: 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, Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mass.gov/dia Phone ® 4.� CERTIFICATE OF LIABILITY INSURANCE DATACS 05/30/201) 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) 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 endorsement(s). PRODUCER Aon Risk services southwest, Inc. Dal 1 as Tx office CONTACT NAME: PHONE (866) 283-7122 ,, (800) 363-0105 (AIC. No. Ext): A1C. No. E-MAIL ADDRESS: CityPlace Center East 2711 North Haskell Avenue INSURER(S) AFFORDING COVERAGE NAIC # suite 800 Dallas TX 75204 USA INSURED Monogram Residential Trust INSURER A: Liberty Insurance Corporation 42404 INSURER B: Liberty Mutual Fire Ins Co 23035 5800 Granite Parkway suite 1000 Plano TX 75024 USA INSURER C: Westchester Fire Insurance Company 10030 INSURERD: Endurance American Insurance Company 10641 INSURER E: PERSONAL & ADV INJURY $1,000,000 INSURER F: GENERAL AGGREGATE $2,000,000 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. Limits shown are as requested INSRPoucy LCR TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X❑ OCCUR 'INS -DI UnID POLICY NUMBER C' EFF MMIDD 1/ POLICY EXP MMIDD 05/31/2018 LIMBS EACH OCCURRENCE $1,000,000 PREM SES Ea occu ence $500,000 MED EXP (Anyone person) EXcI uded One Beacon Street 14 Floor X TRIA Included Boston MA 02108 USA X NO Deductible PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO F_X_1 LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 OTHER: JECT Max General Agg $10,000,000 B AUTOMOBILE LIABILITY As2-Z91-467377-017 05/31/2017 05/31/2018 COMBINED SINGLE LIMIT $1,000,000 a accident BODILY INJURY ( Per person) ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) PROPERTY DAMAGE AUTOS ONLY AUTOS X HIRED AUTOS X NON -OWNED ONLY AUTOS ONLY Per accident D X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE XSC30000113401 05/31/2017 05/31/2018 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 DED RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR I PARTNER/ EXECUTIVE N WC7Z91467377027 05/31/2017 05/31/2018 PER OTH- STATUTE ER , E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 OFFICERIMEM8ER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE -POLICY LIMIT $1,000,006. If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) West village - 792 west Street, Mansfield, MA 02048. (Loan 07040578). Additional Named insured: Monogram Residential West Village REIT, LLC. Certificate Holder is included as Additional Insured in accordance with the policy provisions of the General Liability and Excess policies. TRIA is included in Excess Liability policies. M m m 0 CERTIFICATE HOLDER CANCELLATION c r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Fannie Mae ISAOA/ATIMA AUTHORIZED REPRESENTATIVE c/o Berkeley Point capital, LLC One Beacon Street 14 Floor �/ J Boston MA 02108 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000064189 LOC #: A o ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk services Southwest, Inc. NAMED INSURED Monogram Residential Trust POLICY NUMBER see Certificate Number: 570066569419 CARRIER see Certificate Number: 570066569419 NAC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Excess Liability Coverage Policy Number: LHE00015282403 Issuing Company: Fireman's Fund Insurance Company Policy Term : 05/31/17 - 05/31/18 Limits: 25M xs 10M Policy Number: zuP21N7254A17NF Issuing company: Travelers Property Casualty Company of America Policy Term : 05/31/17- 05/31/18 Limits: 15M xs 35m Policy Number: ECO1856575888 issuing Company: The Ohio casualty insurance Company Policy Term : 05/31/17- 05/31/18 Limits: 25M xs 50M The ACORD name and logo are registered marks of ACORD �IIU11���9 a� Hol MWW t 'g0 �„ Y �i�il111 1 � w 11��iNIN111111 ` - (hIINNNIINii� �11111N' _ IIINN t��� n; N. 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Town of Mansfield 4 6 Park Row, Mansfield, Massachusetts 02046 ' 508-261-7366 f Health Department Amy Donovan -Palmer, Health Agent NAME OF POOL ,� `l ADDRESS OWNER ADDRESS DATE OF _ `�'� POOL CAPACITY 9 INSPECTED BY INSPECTION`v�d # OF GALS METHOD OF WATER i��f BATHER # OF LIFEGUARDS WAT R SOURCE: TREATMENT LOAD Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435,000. Items marked with a "✓" are satisfactory. REGULATION X/✓ VIOLATIONS/COMMENTS .03 Bathhouse and sanitary facilities adequate lighting; ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching w/ latch 4 ft above ground. .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter Effluent flow meter reading: \\(J gpm. # of turnovers very 4 •?�(.i: h� 06 Suitable automatic equipments disinfection of pool water. .06 Carbon dioxide (CO2) equipment for pH control adequate. CO2 cylinders anchored. Inaccessible to public, adequate ventilation provided. .08 Inlets and outlets - Inlets located to produce uniform circulation. Over rim fill spout 6" above maximum water level. Properly shielded and located. .08 Main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without the use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain provided. .08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump, properly located and plumbed. .08 Suction outlet covers in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools .08 Special purpose pool and wading pools equipped with emergency shut off pump switch. Accessible and prominently marked. .09 Cross connections. Portable water supplied through air gap. .10 Skimming facilities. 50% of recirculation drawn from surface of pool. .12 Line with floats separates non -swimmer area from deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. .15 Diving equipment in safe condition. .17 Pool supervision - Pool supervision provided. Effective Jan. 1, 1999, pool supervisor certified as pool operator from YMCA or NSPF. .21 Permit requirements - Permit issued. Adequate maintenance and testing records maintained. Records initialed by person making tests. .22 Health regulations: Signs posted. Health warning signs posted for special purpose pools. .23 Lifeguards required: Yes ❑ No If lifeguards required. Proper credentials, proper suits and garments worn. Whistle and bullhorn provided .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. .25 Emergency Communication System at the pool and in working order. Emergency communication device in unlocked area and available at all times to staff and the public. Operating instructions and emergency numbers posted. .26 Waste and backwash water disposal properly discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. .29 Chemical standards POOLSLDE READINGS Bromine _ 2.0-6.0 mk Alkalinity 50-150 m Cyanuric Acid (30-100 ppm) Water Temp. 1104°F. * parts per million .29 Pool water tested with appropriate frequency. .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools. .31 Water clarity .32 Water clarity maintenance. Filtration system operating continuously. .32 Special purpose pool drained, cleaned and every 14 days. Maximum Operating Temperatures for Special Purpose Pools. (SPP). .33 a. Thermostatic control provided for each SPP. b. Thermostatic control only accessible to the pool operator .38 General sanitation V If'�' .f M Total Chlorine Free Chlorine 1.0-3.0 m Comb. (0.0-0.2 ppm) / Chlorine ✓ / pH level (7.2-7.8) Other p'- Town of Mansfield y 6 Park Row, Mansfield, Massachusetts 02048 508-261-7366 r Health Department Amy Donovan -Palmer, Health Agent STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING LS, 105 CMR 435.000 INSPECTIONSWIMMING POOL 9-JDV f-1 nnnr . UT TRI W n CFMI-Pi TRLIC: ❑ SPECIAL PURPOSE POOL NAME OF POOL v , ` `\` v \` ADDRESS OWNER ADDRESS DATE OF INSPECTION POOL CAPACITY `�, # OF GALS v uC INSPECTED BY�� METHOD OF WATER TREATMENT BATHER LOAD # OF LIFEGUARDS WATER SOURCE: wN Regulation 105 CMR 435.000 The items marked below with an "X" indicate the violated provisions of 105 CMR 435.000. Items marked with a "✓" are satisfactory. REGULATION X/✓ VIOLATIONS/COMMENTS .03 Bathhouse and sanitary taciuties adequate ugnang; ventilation; sanitary condition. .03 Adequate enclosure around pool. Gate self -latching w/ latch 4 ft above ground. .04 Sewage Disposal .05 Location, structural stability, finish. .06 Water circulation & filtration systems. Filter Effluent flow v/ meter reading: \d C7 gpm. # of turnovers .06 Suitable automatic equipment for disinfection of pool water. .06 Carbon dioxide (CO2) equipment for pH control adequate. CO2 cylinders anchored. Inaccessible to public, adequate ventilation provided. .08 Inlets and outlets - Inlets located to produce uniform circulation. Over rim fill spout 6" above maximum water level. Properly shielded and located. .08 Main drain suction outlets covered with suitable protective covers or grates. Cannot be removed without the use of tools. Open area does not provide entrapment of fingers, toes, etc. At least one antivortex drain provided. .08 Each system outlet protected against user entrapment by antivortex cover or other means. Minimum of 2 suction outlets provided for each pump, properly located and plumbed. .08 Suction outlet covers in place, unbroken and secure and cannot be removed except with the use of tools. Close pool immediately if outlet covers missing, broken, loose or can be removed without tools %C\' .08 Special purpose pool and wading pools equipped with emergency shut off pump switch. Accessible and 2.0-6.0 m* prominently marked. V j( .09 Cross connections. Portable water supplied through air Free Chlorine 1.0-3.0 m ✓ gap. V .10 Skimming facilities. 50% of recirculation drawn from Water Temp. surface of pool. pH level (7.2-7.8) .12 Line with floats separates non -swimmer area from IOther deeper water. .12 Water depth markings on deck and walls. Properly spaced. Boundary line on pool floor and walls. Step edges marked with contrasting color. .13 Walkway and decks 4 feet wide, safe condition. .14 Ladders, steps - one per 75 feet. Not less than 2 ladders. 2.0-6.0 m* .15 Diving equipment in safe condition. V j( .17 Pool supervision - Pool supervision provided. Free Chlorine 1.0-3.0 m ✓ Effective Jan. 1, 1999, pool supervisor certified as pool V operator from YMCA or NSPF. Water Temp. .21 Permit requirements - Permit issued. Adequate pH level (7.2-7.8) maintenance and testing records maintained. Records IOther initialed by person making tests. .22 Health regulations: Signs posted. Health warning signs posted for special purpose pools. .23 Lifeguards required: Yes ❑ No If lifeguards required. Proper credentials, roper suits and garments worn. Whistle and bullhorn provided .24 Safety equipment. Ring buoys and rescue hook provided. Rescue tube and backboard with straps at pools attended by a lifeguard. .25 First Aid equipment provided. V/ .25 Emergency Communication System at the pool and in working order. Emergency communication device in unlocked area and available at all times to staff and the public. Operating instructions and emergency numbers posted. .26 Waste and backwash water disposal properly discharged. No direct connection to sewer system. Separation tank provided for diatomaceous earth filter backwash water. .29 Chemical standards POOLSIDE READINGS Bromine 2.0-6.0 m* Total Chlorine Alkalinity 50-150 m Free Chlorine 1.0-3.0 m ✓ Cyanuric Acid (30-100 ppm) Comb. (0.0-0.2 ppm) Chlorine Water Temp. 104°F, pH level (7.2-7.8) * earts eer million IOther .29 Pool water tested with appropriate frequency. .30 Water testing equipment. DPD kit provided for chlorine and bromine. Unbreakable thermometer for special purpose pools. .31 Water clarity .32 Water clarity maintenance. Filtration system operating continuously. .32 Special purpose pool drained, cleaned and every 14 days. Maximum Operating Temperatures for Special Purpose Pools. (SPP). .33 a. Thermostatic control provided for each SPP: b. Thermostatic control only accessible to the pool operator .38 General sanitation wA, A\' -u