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Home My WebLink AboutMansfield Children's Center 12/31/2014Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health [Permit�WQ�pera�teaSwimming Pool PERMIT NUMBER: 8 Pool/SPA Certification Date: April 16, 2014 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: April 16, 2019 Person Certified: KEVIN FALLON Pool/SPA Certification Date: Pool/Spa Certification Expires: Person Certified: 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: MANSFIELD CHILDREN'S CENTER for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: Fv] Semi -Public 1100 SCHOOL STREET CHLORINE 43 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent ❑ Special Purpose Pool None Date Issued Swimming Pool Application PERMIT NUMBER 8 FEE: $125 NAME OF OWNER: MANSFIELD CHILDREN'S CENTER ADDRESS: 1100 SCHOOL STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-9211 FAX: EMAIL: FED ID/SS NO: 04-2725454 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: KEVIN FALLON Pool/SPA Certification Date: 4/22/2009 Pool/SPA Certification Expires: 4/22/2014 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: 'NO LIFEGUARD ON DUTY" sign is required. ❑ Public POOL OPERATION: F./I Semi -Public ❑ Special Purpose Pool POOL LOCATION: 1100 SCHOOL STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 41' WIDTH: 25' VOLUME: 30,000 MINIMAX DEPTH: 3' SWIM AREA: 1000sf DIVE AREA: NONE WATER SOURCE: TOWN WM DISPOSAL: PRIVATE TYPE OF FINISH: LINER SCUM GUTTER: DECK TYPE: 5' CEMENT SKMMR WEIR LENGTH: 2 SKIMMERS TREATMENT SYSTEM: DIATOMACIOUS EARTH DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: NUMBER OF BATHERS: 43 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. 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. * 1 ature of ividual or Corporate N me (Mandatory) f O(Manda porat fficer , if applicable) 7 Z? ** 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 Office of Investigations IF 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: // r l e, IuA 1*e?+,8fCe « 0_/"%'G raa e Address:' City/State/Zip: o4~e#: 5" ®-3. a`1)./// Are you an employer? Checktheappropriate box: I Business Type (required): 1. ❑ I am a employer with J V employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc,) employees working for me in any capacity. ,-, [No workers' comp, insurance required] 8.n -Profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I I. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy infonnation. **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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 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 Investieations of the DIA for insurance coverage verification, I do hereby that the information provided above ij 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mass.gov/dia Phone A UTICA NATI(7WAL INSURANCE GROUP WC 000001A Or180 Genesee'Street New Hartford, NY 13413 ssuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page 1. The Insured and Mailing Address: MANSFIELD CHILDREN'S CENTER, INC. 1100 SCHOOL STREET MANSFIELD MA 02048 Entity of Insured: Corporation Other workplaces not shown above: Insured's I.D. Number: 042725454 Risk I.D. Number: MA: 000165573 2. The policy period is from 10/07/2013 to 10/07/2014 Policy Number: 2066058 Prior Policy Number: Producer: Wm, F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 Producer Number: 77377 SIC#: 83517 NCCI Company Number: 15717 12:01 AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ $100,000 Each Accident Bodily Injury by Disease $ $500,000 Policy Limit Bodily Injury by Disease $ $100,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, WY D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ❑ Extension of Information Page Classifications Code No. Premium Basis Total est. Annual Remuneration Rate Per $100See of Remuneration Estimated Annual Premium Minimum Premium: $ 200 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 6,766 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 6,766 Issuing Office: Date of Issue: Countersigned byt 8 -D -WC Ed. 08-2008 Copyright 1988 National Council of Compensation Insurance UNIBILL NO. 100362146 09-20-2013 LIMO ao 66 L6'OV9'66L le AdSN auoydajaa 'uolaeai;iJan JOJ N "00� � T)t0 T r Q r CS �■�I0 N LL 1. Claam N CL (D C L 110110 G ;; Rte o ■ am L @z e a' _ Z° o = FL ,0 Q L am(19 u ( ■_W M 4.v ■r 4111 a 0 v w y ■ �a a� �o a LIMO ao 66 L6'OV9'66L le AdSN auoydajaa 'uolaeai;iJan JOJ