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HomeMy WebLinkAboutWillow Crossing 12/31/2014Commonwealth 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: 17 Pool/SPA Certification Date: May 14, 2010 PERMIT EXPIRES: December 31, 2014 pool/SPA Certification Expires: May 14, 2015 Person Certified: PAUL J. MILLER 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: B -X MANSFIELD, LLC dbaTHE VILLAGE AT WILLOW CROSSINGS for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed: ❑ Semi -Public 25 COBB STREET BROMINE 22 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent V Special Purpose Pool None Date Issued SIGNATURE, DATE: /y Please make appropriate Changes. Sign, date and enclose check payable to.Town of Mansfield. Mail to: board of . . Health, Town of Mansfield, Six Park Flow, Mansfield, MA 02049, , T4q j�J`'h Town of Mansfield Towt of Mansfield - Boat'd of Hetilth 6 Park Row b MA 02046 Mansfield, p�4paSAfl,tiyii ' Sivinitning Pool Application PERMIT NUMBER Publlc NAME OF OWNER:x, Marls' et'U •. u-'12 POOL OPERATION: [j Semi-Public d I bl el VI 105e, H Al' itd co 14 SpeClai Purpose Pool ADDRESS: ZS &bb 51ree + POOL LOCATION: 25 CITY: v(gas, oto► W j,si'-eht, STATE: �4 A zip: 02oyb TYPEIPOOL: C� Uj II'a�, 6001'0--e- TELEPHONE: [5D5)2-&/-(333 LENGTH: 37 WIDTH; I y ���J %^K(D(l�3 VOLUME: 12., SLI L4 FAX: EMAIL: I71�C����irt ©� ei1V1iI7GtS�l� •(Q/rl MINIMAX DEPTH,' 3 '& n G it FED IDISS N0; » 3 p ��8 Swi41 AREA: qg si DIVE AREA: Ald tI FEE PER POOL, WATER SOURCE: -ado Certiflcatlon Expires EvarV 6 Years. WIW DISPOSAL:-7—oton -' jv-e6- Pormit Expires Docember 31st Yparly. ` " TYPE OF FINISH: Noe gable �+-1 -G PERSON CERTIFIED: Paul V ' kIler SCUM GUTTER: NQele Poot/SPA Cettilica(lon Date: 57%1 y )2J)l D DECKTYPE: talc Q%p. PooYSPA Cettificalion Expires: 51412015 SKMMR WEIR LENGTH: 8,611 Na Ya e—'AO F PERSON CERTIFIED: TREATMENT SYSTEM: yl Pod/SPA Certification Date: DISINFECT METHOD: Cir( lne, Pool/SPA Certification Expires: CHEMICAL TREATMENT: �jI'tJPYt tn�, cortilleallon tornatks(ii nocossary): NUMBER OF BATHERS: REMARKS; NO LIFEGUARD ON DUTY" sign in tequltod. �.. .. .................................. . .... . . SIGNATURE, DATE: /y Please make appropriate Changes. Sign, date and enclose check payable to.Town of Mansfield. Mail to: board of . . Health, Town of Mansfield, Six Park Flow, Mansfield, MA 02049, 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, 9--Y MahLLe_ " 9innature of Individual or Name (Mandatory) I 1_. By: Co a e Off oer (Mandatory, If applicable) �9SS/Syzt.� �-�fert� a11) -5f 4110 ** 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 filling 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 Mrrssrrclrtrsetts Department of ltrdrrstrlal Aveltlerlts Offlee of lir vest/gatlons 600 Washington Street Boston, MA 0.2111 i PlPIP. Inass,gov/dl a Workers' Compensation Insurance Affidavit; General Businesses •Apnlicantlnformation Please Print Legibly Business/Organization Name:13-X A1�il�S�i�'Id Ild i-Afil City/State/Zip: t'-hm6.eld d Aq9 Picone /l; Q$'-Z�%-13 3 Are yqu nn employer? Check the npproprime box; Bushiess Typo (required): 5• ❑ Retail I. I mn a employer wills } 3� employees (full and/ or part-time).'" 6, ❑ ReslaumndBurlEaling Establishment 2. ❑ 1 am a sole proprietor or partnership and have no q, [] Office and/or Sales (incl, real estate, auto, etc.) employees working for mq In any capacity, [No workers' comp. insnnmcu required] g• E] Won -profit 3. ❑ We arc a corporation and its oMcors have exercised 9, ❑ Entertainment their right of exemption per c, 152, § 1(4), and wo have 10,0 Manufacturing no employees. [No workers' comp, Insurance required]*' i 1 [� Health Care 4. ❑ We arc a non-profit organization, staffed by volunteers, 1 with no employees. [No workers'.comp, insurance req,] I 12,�501hcr *Any appllcanl ihni checks box NI must nlso all out the section below showing Illcli scotkets' conlprnsallon policy hlfonnolton- `_.j ,$Irlilt cotpo1410 Monts 111.0 cxclnptcd thclnselves, but Um corpomtlon has olkciclnploycri, o troAkcts' compensolton policy is mqubcd and such an orgonImlion should chock box Ns• I ata rat enployerthnlls prorldhtg workers compettsatlon lnsitrnucc jor alp cmployecs. Belo 1P is lite policy btfOrtoallotr, Insimince Company Noma: . Arrb I115(,LYQ—mu f Q M"al7t./ Insurer's Cily/slate Policy 11 or Self -ins, Lie, ti yl ai01 SLI 9 32 !0 1 Expiration pate: W I (21) 5 - Alto ch it copy of the workers' compensn(Ion policy deeln ration pogo (shuiving the pulley number rind expiration date), t�niluro to sccuio covetuge ns requilid under Seclitin 2SA ofMOL b:152 ban iced to the irtiposhioii oCcririiinnl peilallics of h...... line rip to $1,500,00 nnd/or one-year imprisonment, as well as civil ponallics in the fonn of n STOP WORK ORDER and a file ofup to $250.00 a day against the violator, Bo ndvised that n copy ofthis statement tnay be forwarded to tho Office of Investigntlons of circ DIA for insurance coverage, ycriGealion, I tto hereby certify,,, tmdcr t1kp ports and pcnaltics of perJnryshat Phone tl' 4p�- 2- &- 3'.3 Offlclal nso only. Do not wrlle lit rbls arca, to be comptelail by city or tolpn official City or Torvut PernritlLicenso 1i above is true and correct. Issuing Authority (circle ono); I, Board of Heallit 2• Building Deportment 3, C1tyrrown Clerk d, Licensing Bonrd 5, Selectmen's Ofmc G, Qther Coutncl Person: Photic Wxw.msss.�oYtdia Information and Instructions Massachusetts Oencrtil Laws -chapter 152 requires all employers to provide workers' compensation for their employees. 1 pursuant to this statute, an vinployea is defined as ",..every person in the scrvieo of another under any contract of hire, express or implied, oral or written," i An employer is defined as "on individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing. engaged in a joint enterprise, and including lha logo) representatives of deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the . . . owner of n dwelling boost having not more than three apartments and who rosides llicroin, or the occupant of the dwelling house of another who em)iloys persons to do maintcnaucc, construction or repair work on such dwelling honse or olt_41.►t_grounds or p�tilding tlppunenpta4.41rerctp shall ao.4 hccanse of such 4mpla -ment t>_o dccmtd lo.t�c do t MOL chapter 152, §25C(6) also states that "every slate or local licensing agency shall withhold ilia Issuance or renewal ofa license or permit to uperute it business or to construct buildings in ilia commonwealth for any applicant who ins not produced accepinbio evidence of compliance with ilia Insuntnce coverage required." Additionally, MOL clinpicr 152, §25C(7) states" Neither the commonwealth nor any of its politico) subdivisions sludl enter Into any contract for tic performance of public work until acceptable evidence of compliance, with ilia insurance requirements of this chapter have been presented to the contmating mnhority." Applicants Please fill out ilia workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if necessary, supply yonr insurance company's nnmo, address and phone number along wlth n certificate of insurance. Limited Liability Compnoics (LLC} or Limited Liability Partnerships (LLP) with no employees other than the members or partners, nre not required to cant' workers' compensation insurance. If an LLC or LLP does have employees, n policy is required. Be ndvised tint this affndavll may he submiled to the Dopaniment of industrial Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be rchrmed to the city or town E (fiat the application for The pamnit or license is being rcquwlad, not the Department of Industrial Aceldonts. Should you hove any questions regarding the low or if yon are required to obtain a workers' componsation policy, please call the Department at the number listed below. Self Insured companies should enter thalr self-insurance license numlfcr on (lie appropriate lino, ' City or Town Officlals Please be sure that Ibe affidavit is complete and printed legibly. The Department has provided n space at the bottom of the affidavit for you to fill out in the event the Won of Investigations has to contact you regarding the applicant, Please be sure to fill in lite pormiVliccnso number which will be used as n reference number, In addition, an applicant that must submit multiple pennitllicanse applications in any given yenr, need only submit one affrdevil indicating current policy information (If necessary), A copy of the affidavit that has been otiiclally stamped or marked by tine city or town may be provided (o the applicant as proof (lint a valid affidavit is on into for future permits or licenses, A new affidavit ........... must be filled out each year. Where a home owner or citizen is obtnining a license or Penn!( not related to mry business or commereinl venture (t.a, a dog license or permit to burn Icnves etc,) said person isNOT required to complete this affidavit, 'Ilia Offico of investigations would likglo thank your In advance for your cooperation and should your have nny questions, Please do not hesitate to give us a call, Tito Department's addrm, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Tnvestigntlons 600 Washington Street Boston, MA 02111 Tel. // 617-727-4900 ext 406 or 1-877-MASSAFE Fax t/ 617-727-7749 mv%mass.gov/din Form Rovlscd 3-2"5 ® A6 Ro - - CERTIFICATE OF LIABILITY INSURANCE ....... DATE (MMIDDIYYYY) 07/10/2014 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 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 LTC #36-3066541 1-312-288-7700 CONTACT NAME: Sarah Benedict Willie of Illinois, Inc. PHONE Y(312) 288-7832 AC o: (312) 234-0642 Af�..Hlr.6xt Willis Tower Ab RESS; sarah.bonedict@willia.com 233 South Wacker Drive, Suite 2000 INSURER(S) AFFORDING COVERAGE _ NAIC# Chicago, IL 60606 11150 INSURERA: ARCH INS CO u INSURED INSURERS: UNDERWRITERS LLOYDS INS CO 37559 INSURER C: Benchmark Senior Living LLC I INSURERD: The Wellesley Office Park 40 William Street, Suite 350 MED EXP (Any oneperson)_...S INSURER F UUVIZKAL�11:0 -1 ' S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS 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. INS"I T. LTA TYPE OF INSURANCE ADDLISU AUTHORIZED REPRESENTATIVE POLICY NUMBER MMlbO�YY MM7DDnEYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ "'E ToRENTED PREMISES Ea .."encs S COMMERCIAL GENERAL LIABILITY MED EXP (Any oneperson)_...S CLAIMS -MADE 0 OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPlOP AGO S S COMBINED SINGLE LIMIT —1PRO- LOC POLICY AUTOMOBILE LIABILITY idem $ BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ (Per a 'de I HIRED AUTOS AUTOS $ Coll Dad Comp Dad j UMBRELLA LIAR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR HOCCUR CLAIMS -MADE ET DED RENTION S WORKERS COMPENSATION S X WCiSTATu- OTH- rte_ 41WC14987901 04/01/1 04/01/15 A AND EMPLOYERS' LIABILITY YIN E.LEACHACCIDENT $ 1,000,000 ANY PROPRIETOPJPARTNER/EXECUTIVE NIA W f4� E.L. DISEASE - EA EMPLOYE $ 1, 000 , 000 OFFICEMMEMBER EXCLUDE (Mandatory In NH) E.L. DISEASE •POLICY LIMIT $ 1, 000. 000 it yyas, describe under DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It mato space Is required) Included as an additional Named Insured: B -X Mansfield LLC Rat The Village at Willow Crossings -- 25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance tor.mi Irt,,,rt1 c nvl-uc;r% SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield - Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield , MA 02048 1�4�� I• USA -J V 1.`7oo-4V iv f% 1?d .,.......,• ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD sbenedict 40690605 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. B -X Mansfield LLC d/b/a The Village at Willow Crossings Signature of Individual or Corporate Name 27-4452440 Social Security Number (Voluntary) or Federal Identification Number** By: Corporate Officer (Mandatory, IF Appli cable) Andrea M. Teichman Assistant Secretary 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, 7818882222 TESTYU 01:47:01 p,m. 07-21-2014 2!2 . 1 0 0 Re ro O p ti th o >p -n tj Oil (fin... y rt ro ro r r ro ti ro A{