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HomeMy WebLinkAboutDepot I & II 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: 5 Pool/SPA Certification Date: October 10, 2012 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: August 31, 2017 Person Certified., NEMANJA NIKIC Pool/SPA Certification Date: April 20, 2012 Pool/Spa Certification Expires: April 19, 2017 Person Certified: SVETOSLAV A. KAZAKOV 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: THE VILLAGE AT MANSFIELD DEPOT II - BEACON COMMUNITIES LLC for the operation of a ❑ Public Fvj Semi -Public ❑ Special Purpose Pool at: THE VILLAGE AT MANSFIELD DEPOT II - 9 FRANCIS AVENUE Method of water treatment is CHLORINE Bathing load not to exceed: 54 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Scott leite, Heaah .Agent Jy Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swin Ming Pool Application PERMIT NUMBER S FEE: $125 Q Public NAME OF OWNER: a POOL OPERATION: Seml•Pubtic Y a 0 Special Purpose Pool ADDRESS: `A v CITY: STATE: ZIP: i TELEPHONE FAX: EMAIL:r e'er FED IDISS NO: S2 _ z FEE PER POOL: f Certification Expires Every 6 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: Pool/SPA Certification Date. Z l Pool/SPA Ceriification Expires: PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires.' : �l 'i certification ramarks(lf necessary): REMARKS: "No LIFEGUARD ON DUTY" sign Is required. SIGNATURE.` POOL LOCATION: 1 , r. - ({ �� .. � � .� ` ``"".. ! TYPEIPOOL: J, 1' - LENGTH: VOLUME: MINIMAX DEPTH: SWIM AREA: WATER SOURCE: 4 'v WIW DISPOSAL:`( TYPE OF FINISH: \iVi ,- SCUM GUTTER: Ok E DECKTYPE: i OVN�JC e SKMMR WEIR LE14GTN: TREATMENT SYSTEM. DISINFECT METHOD: tit CHEMICAL TREATMENT: NUMBER OF BATHERS: l WIDTH: DATE: t DIVE AREA: ` f / 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. Ellis & Associates ILTPTM Course Completion International L ifecuard Training ProClraM TM i Personal Information Last Name: First Name: Middle Name: Date of Birth: Certificate Number: C. WA-L1�15K1 ;�'�0 %�� IL 7/-Zt/ �s 101-300-1023-4{957 Mailing Mailing Address: Citty:- St Postal Code: {� MA Country: Email: Home Phone: Work Phone: A C. 9a 3 - Z-'0 4 72S C) V--C2G-7 Co'I�trs Orlnfnitatlan - x - }L T P Course -type: (Please Check One) Training Course Type: F1 Shallow Lifeguard ® Pool Lifeguard E] Special Lifeguard 0 New - Original ❑ Renewal ❑with Open Water Shallow Lifeguard Pool Lifeguard Special Facilities Lifeguard Training includes conscious, unconscious and Training includes conscious, unconscious and suspected Training includes conscious,uneonscious and suspected neck and back rescue skills for water depths neck and back rescue skills for water depths not suspected neck and back rescue skills for water not to exceed 5 feet, excluding open water exceeding 16 feet excluding open water environments. depths not exceeding 16 feet including wave pools environments. AAOSIACEP (Emergency Case & AAOSJACEP (Emergency Care & Safety Institute- and open water environments. AAOStACEP Safety Institute-ESCI.org) Healthcare Provider ESCLorg) Healthcare Provider CPR, AED, Oxygen (Emergency Care & Safety Institute-ESCLorg) CPR, AED, Oxygen Administration and Standard First Administration and Standard First Aid training included. Healthcare Provider CPR, AED, Oxygen Aid training included. Administration & Standard First Aid training included. Training Center of Record:City: State: ILTP - Continental Pools, Inc Savage MD Completion Date: Expiration Date: 2Di t''OU 1ncko 10 dg e� :s 1 acknowledge that I have received and understand the ILTPTM' Training Program curriculum and demonstrated said skills and knowledge to required competencies. 1 further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPT"s course through regular and consistent in-service training. it is also the responsibility of my e -m. Ployer to provide site seer c ofientation and in-servicetraining prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM' does not provide any protection whatsoever to my employer or myself. LifeguardName(Plea/se Print): Lifeguard Signature: j �nsru#gr�dnAtfttorm�Itrlon _.... . I hereby ce, ,u y ulat u,C holder 0MIS rIs tci r Course Completion Crederiiial has successfully met all required skits competencies (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the Intemational Lifeguard Training ProgramTn" for the lifeguard classification indicated above. I have also reviewed the ILTPTM Course Completion Acknowledgment with its hold r and am satisfied the card holder dear understands said acknowledgment. 2 Max Water Depth:_{_ '�ft/p'�Updated Max Water Depth:Oft/rt(Instrudor Name: /Y Nitic InstructorID:� - J5 Date: Instructor Name (Please Print): Instructor Signature• r >} Ale�'Jff • 1 4N ft- iltL'rc W -, C ,-r - For additional information regarding the International Lifeguard Training ProgramT'-4 please call orwrite to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: businesskoieilis.com Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 1/2011 r r Ellis & Associates ILTP TM Coarse Completion _ international Lifeguard Training Program TM Personal Information Last Name: First Name: Middle Name: Date of Birth: Certificate Number: PAUL- !�'I r cl-t l 1,oP_EAJa� cl' -1119 101-300-1023-4959 Mailing Address ..^,ity: SfatelYrovince -postai Code: % ,(ep cltl '�—s-i- Mal deyl C:r21 � t - Country: Email: Home Phone: Work Phone: ex) wait cam: �o l�l`Z-3jt Coursehi_formatan ILTP Course Type: (Please Check One) Training Course Type: F] Shallow Lifeguard Pool Lifeguard E] Special Lifeguard New - Original ( ❑ Renewal []with Open Water Shallow Lifeguard Pool Lifeguard Special Facilities Lifeguard Training includes conscious, unconscious and Training includes conscious, unconscious and suspected Training includes conscious.unconscious and suspected neck and back rescue skills for water depths not to exrexr .Sfeet; excl`Winggpen stater neck and back rescue skills for water depths not etiurds,g.;s.reet suspected neck and back rescue skills for water environments AAOS/ACEP (Emergency Care & ezauding open water-envtronments, AAOS/ACEP (Emergency Care & Safety Institute- depths Mt exceeding la feet including wave pools and open water environments. AADS/ACEP Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First ESCLorg) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. (Emergency Care & Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Aid training included. Administration & Standard Fust Aid training included. Training Center of Record: City: State: ILTP - Continental Pools, Inc Savage MD Completion Date: Expiration Date: 0/-3 -,.615 ckox+vled me T I acknowledge that I have received and understand the ILTP"4 Training Program curriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is ipy personal responsibility to maintain my skills and knowledge demonstrated durrgg the ILTP oauri;e through regular and consistent -in -service training. It is also the responsibility of my employer to provide site specific orientation and in-sefvtce training prior to working as a lifeguard. [further understand and acknowledge that Ellis & Associates and/or ILTPTm does not provide any;protection whatsoever to my employer or myself. Lifeguard Name (Please Print): Lifeguard Signature ;< t ti ILt'PTM _006%, I hereby certify that the holder of this ILTP TM' Course Completion Credential has succes<_iully met all required skills competencies (fiduding but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramTM' for the lifeguard dassificaUan indicated above. I have also reviewed the ILTP"' Course Completion Acknowledgment with its holder and am satisfied the card holder dearly understands said acknowledgment. . , Max Water Depth:, o ft V11pdated Max Water Depthl,2 Name: AjISAY InstructorID: 00 —� 4ate: _ft/yt>Tnstructor lot instr r Name 1Please int). Instruct ' g ature: -- � t For additional information regarding the International Lifeguard Training ProgramT'•` please call or write to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business(o)iellis.com Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. CorparatC.'icadquzireos; Kngcvoud: Tn. Revised !120-} 1 I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State fax returns. and paid all State taxes required under law. RE t lIJ6 i°t.la4'"..„t E �d �S `t:. 'v * Signature bf Indivfdual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) a r 4+ ** 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 fall 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 Inrdustriad llecidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Genelrai Businesses Aimlicant Information Please Print Lealb Business/Organization Narne: `' N = IV\ ` �� "' D, ` Address: .' k I i ��- J Phone Are you an employer? Check the appropriate box: 1. Ef I am a employer with OG", employees (full 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 off icors 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.] Business Type (required): 5. Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8, Q Non-profit 9. [] Entertainment 10,❑ Manufacturing I I.[l Health Care 12 Other € _4 v,:,4t - *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation polloy information. "If tho corporate officers have exempted thcroselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 01. f ani an employer titat is providtirg ivorhers' cotnpensatlon insurance for sty employees. Belaw Is the policy ilrforinallon. Insurance Company Name: ^ 1,k, �,� , U' c i;; U ",<< Insurer's Address:_ s% City/State/zip: tS Policy # or Self -ins. Lie. X EXpiTation Attach a copy of the workers' compensation policy tlecinration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGI. 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 certify, ruder the pains and penal ies of perjury that the Infortnallos provklerl above 1s true and correct Official use only. Do not write ill tills area, to be conTletecl by city or town offlclal 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: Phone #: vnvw,mass.gov/dia �a DATE {MM/DDNY" t0off?" . CERTIFICATE F LIAR TY INSURANCE 10/28/2013 THIS CERTIFICATE 15 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 R€PRE5ENTATfVE OR PRODUCER, AND THE. CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, 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 r.rfit3r- .te holder in lieu of such endorsement(s). PRODUCER Oliant insurance Services, Inc. 1415 East Camelback Rd 420 'hoenix AZ 85016-4266 INSURED - —_. continental Pools, LLC INSURERC:LI rplus Insumn ce Co[porall k2078 3520 Corridor Rd., #13 MURERD:Navigators Insurance CQrnpanY 12307 Savage, MD 20763 INSURER E : ,ucOncn C;, -f AA--, lnr/>,r�ru-n lfnrj'�nanV S COVERAGES CERTIFICATE NUMBER: 1826910975 ., - 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 AFFOP.DED BY THE POLICIES DESCRIBED I IEREIN IS SUBJECT TO ALL THE TERNIS, ,, .,�.. unvc QED RED GF -n RV PAID CLAIMS. EXCLUSIONS ANGUI 1 iuNS OF SUCH ANL)UN TYPE OF INSURANCE NEM LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR F rui.rco. � ADDL SUER 1 SR D 100001724604 nvn , o �, . - . ..,.. , . ,• •. -- - - -- - POLICY EFF POLICYNUMBER M/DD 1012512013 I POLICY EXP MM/DD 0/25(2014 LIMITS EACH OCCURRENCE $2,000,000 fNS4R�= LT ACCORDANCE WITH THE POLICY PROVISIONS. PREMISES Ea occurrence 1$1,000,00 MED EXP (Anyone person) $ I PERSONAL &ADV INJURY $2,000,000 it GENERAL AGGREGATE 1 $2,000,000 SavageJMD 20763IF PRODUCTS -COMP/OP AGG $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- JECT X LOC Policy Aggregate $$10,0001000 A AUTOMOBILE LIABILITY r X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOSNON OWNED X HIRED AUTOS X AUTOS RI IASQR5h05791 0/2512013 0!25!2014 /Fzarident) s1.000,000 s BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Pe-rar-dderrtl I$ F B X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE N / A CAEX0000019531020/2512013 05085005189 Ii I 0/25/2013�10/26ri014 0/2512014 I EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 X WCSTATU- OTH- Dtt7 ` RtiLNiIUfYS WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY Y 1 N ANY PROPRIETORIPARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Hyes,describeundet DESCRIPTION OF OPERATIONS W.' E.L. EACH ACCIDENT _ - 511000,000 $1,000,000 E.L. DISEASE -EA EMPLOYE E.L. DISEASE - POLICY LWiT 51,000,000 D EXCESS AUTOMOBILE F13EXC7fi13611V 0125/2013 0125/2014 Each Occurrence $10,000,000 General Aggregate $10,000,000 i DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is requiredl CANCELLATION CERTIFICATt MUL.LJr-K SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof Of insurance ACCORDANCE WITH THE POLICY PROVISIONS. Continental Pools, LLC BEffY-'r =- =— d, Su. AR SavageJMD 20763IF - -.ac nn.s r. A P"a-1�sa c F'i :�l3ilwe$ i li`liii fall rinf�tc racarvar: IV r aoo-av , v n. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD S"� .is e5$3i C3`��6gg 855';3F�i I 'u 0.d y th _ v ¢iq"s a u� PHI 20;1010 (314000 CerlificationNo. 'AT&T 1+ iiires: April 19; i o eim� �iWIT � 1�,���'r) �JiStY�dCt`dlf' ffea/1(�arPfu�/s, lteitllhPllorirni•. �4,1f � �,xc.rutw rr� t'��t«�s�' �, " _ 9G1,00$U56 4p _ any&lot y :+ TW%py Ask am low _ - iI3 M AC" " CERTIFICATE OF LIABILITY INSURANCE D2 /2 IDD/YYYY) 4//2/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIOWbNLY 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 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 Eastern Insurance Group LLC 77 Accord Park Drive Unit Bl Norwell MA 02061 CONTACT Anita Chesson NAME: PHON o E 781-596-8913 FAX No): (508) 697-3261 E-MAILADDRESS: achesson@easterninsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Philadel hia Insurance Company INSURED Beacon Residential Management Limited Partnership c/o Beacon Communities LLC Two Center Plaza Suite 700 Boston MA 02108 INSURER B :NH Employers Insurance Co INSURERC:MEMIC Indemnit INSURERD:Federal Insurance Co INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:Beacon Res Mgmt 14-15 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. INSR ACCORDANCE WITH THE POLICY PROVISIONS. ADDL SUBR 6 Park Row POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE VD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ r MED EXP (Any one person) $ 1,000 A I CLAIMS -MADE Fx OCCUR PHPKII53730 4/1/2014 4/1/2015 PERSONAL 8 ADV INJURY $ 1,000,000 X Terrorism GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP/OP AGG $ 2,000,000 EBL $ $1,000,000 POLICY PRO -X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO p' ALL OWNED SCHEDULED PHPK1153720 4/1/2014 4/1/2015 BODILY INJURY (Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON -OWNED HIRED AUTOS AUTOS Per accident Medical payments $ 5,000 X Terrorism X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE DED X7 RETENTION$ 10,000 $ HUB454510 /1/2014 4/1/2015 B WORKERS COMPENSATION CC -600-4000497-2014A WCSTATU- OTH- X I TORY LIMITS ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE Mass only 4/1/2014 9/1/2015 E L EACH ACCIDENT $ 1,000,000 C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A 102802160 E L DISEASE - EA EMPLOYEE $ 1,000,000 E L DISEASE -POLICY LIMIT $ 1,000,000 If yes describe under DESCRIPTION OF OPERATIONS below on Mass D Crime 8137-7035 /1/2013 /1/2014 Employee Dishonesty $5,000,000 Deductible $25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Village at Mansfield Depot I LLC, locations 1, 3, 5, 7, 9, 11, 15, 17 and 19 Francis Avenue, Mansfield, MA. Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS025 ,201005/ 01 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield, Massachusetts 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 Ronald Cleaves/ACl ACORD 25 (2010/05) INS025 ,201005/ 01 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PI-CANXAICH-002 (05/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR CERTIFICATE HOLDER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE PART COMMERCIAL CRIME COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART --o i�mi 1 17 nc Ann1-r1n1JA1 iNCi IRFn-, OR CFRTIFICATE HOLDERS Al or CH Additional Insured or Certificate Holder Address Al Blanket — on file with Insurance Company The following is added to A. CANCELLATION of the Common Policy Conditions of the above applicable coverage part: A. In the event we cancel the policy in accordance with the policy's terms and conditions, we will endeavor to mail written notice of cancellation to Additional Insureds or Certificate Holders, shown in the above SCHEDULE within the time frame listed below. However, failure to mail such notice shall impose no obligation of any kind upon us, our agents or representatives. 1. g0 days before the effective date of cancellation if we cancel for any reason other than for non - payment of premium.. 10 Day notice for non-payment. Policy# PHPK1153730 Page 1of1 Jane Doucette From: Ryan O'Donnell <rodonnell@continentalpools.com> Sent: Tuesday, May 20, 2014 10:52 AM To: Jane Doucette Subject: FW: MANSFIELD POOL PERMITS FOR VILLAGE @ MANSFIELD DEPOT Attachments: SPO Cert Svetoslav-1.pdf Those are the guards. The CPO is Svetoslav Kazakov, attached is his CPO certificate. Just let me know if you need anything else. Thanks Ryan Ryan O'Donnell, Regional Manager Continental Pools Phone: 781-933-5005 Fax: 781-933-3054 www.contineiitalpools.com http://www.facebook.comICoiitinei-italPools Worry less and swim more. From: Kelly Merchant[mailto:lanerchantkcontinentalpools.com] Sent: Tuesday, May 20, 2014 10:44 AM To: Ryan O'Donnell Subject: Fwd: MANSFIELD POOL PERMITS FOR VILLAGE @ MANSFIELD DEPOT 1 Kelly Merchant Administrative Manager Continental Pools 8520 Corridor Road, Suite B Savage, MD 20763 Direct Line 240-374-5902 Direct Fax 1-844-211-8208 www.continent@ools.com Worry less and swim more. https://www.facebook.coin/ContinentalPools ---------- Forwarded message ---------- From: Jane Doucette <Jdoucette@mansfieldma.com> Date: Tue, May 20, 2014 at 10:19 AM Subject: MANSFIELD POOL PERMITS FOR VILLAGE @ MANSFIELD DEPOT To: "INFO 2(CONTINENTALPOOLS.COM" <INFO a continentalpools.com> Just received your pool permits for the pools at 9 Francis Avenue. Are Nareh Sahalcian, Kelsey Letson, Mitchi Paul and Jakub Avalinski lifeguards or the certified pool/spa operators or the lifeguards? Mjwf""' NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC SPECIAL PURPOSE POOL ❑ NAME OF POOL t ADDRESS OWNER ADDRESS DATE OFPOOL INSPECTION �- 1z X CAPACITY # OF GALS INSPECTED BY METHOD OF WATER TREATMENT BATHER LOAD # OF LIFEGUARDS WATER SOURCE: 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 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: M. # 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 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 r, ladders. .15 Diving equipment in safe condition. 011 .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 warn' g 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 POOLSIDE READINGS Bromine 2.0-6.0 m* Total Chlorine chlorine and bromine. Unbreakable thermometer for Alkalinity 50-150 m special purpose pools. .31 Water clarity Free Chlorine 1.0-3.0 m .32 Water clarity maintenance. Filtration system operating Cyanuric Acid (30-100 ppm) Comb. Chlorine (0.042 ppm) Water Temp. 104°F. pH level (7.2-7.8) * parts per million Maximum Operating Temperatures for Special Purpose ther Pools. (SPP). .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 R .38 General sanitation REGULATION I NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/✓ .34( I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED Operator Board of Health/Health Department Commonwealth 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: 6 Pool/SPA Certification Date: October 10, 2012 PERMIT EXPIRES: December 31, 2014 Pool/SPA Certification Expires: August 31, 2017 Person Certified: NEMANJA NIKIC Pool/SPA Certification Date: April 20, 2012 Pool/Spa Certification Expires: April 19, 2017 Person Certified: SVETOSLAV A. KAZAKOV 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: THE VILLAGE AT MANSFIELD DEPOT I -BEACON COMMUNITIES, LLC for the operation of a ❑ Public 0 Semi -Public ❑ Special Purpose Pool at. THE VILLAGE AT MANSFIELD DEPOT IIFRANCIS AVENUE Method of water treatment is CHLORINE Bathing load not to exceed: 71 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Health Agent Date Issued Town of Mansfield Tows: of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Si'iiininting Pool Application PERMIT NUMBER 6 - FEE: $125 H Public NAME OF OWNER: : -. ;$ t POOL OPERATION: Sem(-Pub((c 0 Special Purpose Pool ADDRESS: i ' 1 t `` CITY: STATE: - ZIP: TELEPHONE,}€ F Y) FAX: m• EMAIL: FED IDISS NO: FEE PER POOL: a ,' Certification Certification Expires Every Years. 6 Years. Permit Expires December 31st Yeariy, PERSON CERTIFIED. K`. , - - a PoolISPA Certification Date: Poo/ISPA Cetfification Expires: i t I. d PERSON CERTIFIED: f ` PoollSPA Certification Date: POolISPA Certification Expires: certification remarks(If necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign Is required. POOL LOCATION. TYPEIPOOL. vN LENGTH: g WIDTH: VOLUME. MINIMAX DEPTH; SWIM AREA: � DIVE AREA: fid# WATER SOURCE: ` E 0 WIW DISPOSAL: `� �Ai Z A TYPE OF FINISH: iO vNc SCUM GUTTER: DECK TYPE: SXMMR WEIR LENC>Ttt TREATMENT SYSTEM: 1` DISINFECT METHOD: CHEMICAL TREATMENT: NUMBER OF BATHERS: 4 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. Ellis & Associates ILTP TM Course Completion International Lifeguard Training Program TM Personal Information Last Name: First Name: Middle Name: Date of Birth: Certificate Number. KG1- sr- Y EL12A&CLT%� jl5 IIK4 101-300-1023-4958 waiting Address: -City: State/Province: Postal Code: 'Ff MIA\J A�)bor+(1 MA 0150I Country: Email: Home Phone: Work Phone: USA ISQY.LefS0it] C}�(,,I.tu 0 a-0^7 -7tq-7,7 S;r4 �37 ntren 1nt�irent�nn ILTP Course Type: (Please Check One) Training Course Type: Shallow Lifeguard]( Pool Lifeguard E] Special Lifeguard Q New - Original `❑ Renewal []with Open Water Shallow Lifeguard Pool Lifeguard SneciatFacilities Lifeeuard Training includes conscious, unconscious and Training includes conscious, unconscious and suspected Training includes consaous,unconscious and suspected neck and back rescue skills for water depths neck and back rescue skips for water depths not suspected neck and back rescue skiffs for water not to exceed 5 feet, excluding open water exceeding 16 feet -excluding open water environments. depths not exceeding 16 feet Including wave pools environments. AAOSrACEP (Emergency Care & AAOS/ACEP (Emergency Care & Safety Institute and open water environments. AAOSIACEP Safety Institute-ESCI.org) Healthcare Provider ESCLorg) Healthcare Provider CPR, AED, Oxygen (Emergency Care & Safety Institute-ESCLorg), CPR, AED, Oxygen Administration and Standard First Administration and Standard First Aid training included. Healthcare Provider CPR, AED, Oxygen Aid training included. Administration & Standard First Aid training included. Training Center of Record: Cify: State: ILTP - Continental Pools, Inc Savage MD Completion Date: Expiration Date: WE Aw 1 acknowledge that I have received and understand the ILTP"" Training Program cufriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the r" ILTP'course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPT'" does not provide any protection whatsoever to my employer or myself. Lifeguard Name (Please P(int): Lifeguard Signature: e1'�,j son x I! TPTM I hereby certify that the holder of this ILTP nA Course Completion Credential has successfully met all required skills competencies (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramTm for the lifeguard classification Indicated above, I have also reviewed the ILTPTm Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said ac nowiedgment I�} Max Mater Depth: ft4K Updated Max Water Depth:��fVpi SAY LQ Instrwor Name: InstructorID:�� ,CUSIDate: t Instructor Name (Please Print): , Inst ruok5Zignalure: p t/ 'X� For additional information regarding the International Lifeguard Training Program M please call or write to --- Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business(a7-iellis.com D_aTibutione This ceriificaie is issued icor n -je E is n Assodiates, nQ- Corporate Headquariers, Kingwood, Th. RelAsed fi2011 Ellis & Associates ILTP T"' Course Completion International Lifeguard. Training Program TM r. Personal information-. Last Name: First Name: Middle Name: Date of Birth: Certificate Number. 6A�Ai\- Y,�>"o NARC li-\ QIZ1,,93 101-1-500- 023-4956 Mailing Address: City: State/Province: Postal Code: ooadi Country: Email: Home Phone: Work Phone: vtk 1 an 92.D-�Y���(� SG k . k aarse lnorna on ILTP Course Type: (Please Check One) Training Course Type: E] Shallow Lifeguard Pool Lifeguard Special Lifeguard ✓0 New - Original ❑ Renewal with Open Water Shallow Lifeguard Pool Life ucuaard Special Facilities Lifeguard Training includes conscious, unconscious and Training includes conscious, unconscious and suspected Training includes conscious,unconscious and suspected neck and back rescue skills forwalerdepths neck and back rescue skills for water depths not suspected neck and back rescue skills for water not to exceed 5 feet- excluding open water exceeding 16 feet -excluding open water environments. depths not exceeding 16 feet including wave poots environments. AAOSIACEP (Emergency Care & AAOSIACEP (Emergency Care & Safety institute- and inti water environments. AAOSfACEP Safety Institute-ESCLorg) Healthcare Provider ESCI.org) Healthcare Provider CPR, AED, Oxygen (Emergency Care & Safety institute=ESCLorg) CPR, AED, Oxygen Administration and Standard First Administration and Standard First Aid training included. Healthcare Provider CPR, AED, Oxygen Aid training included. Administration & Standard First Aid training included. Training Centerof Record: City: State: ILTP - Continental Pools, Inc Savage MD Completion Date: Expiration Date: O2— 01 - A014 _2I-- �c?15— 2` �`fl P?o?wle�gr Y _ I acknowledge that 1 have received and understand the ILTP`*' Training Program curriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTP"' rnurse through regular and consistent in-service training_ It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. i further understand and acknowledge that Ellis & Associates and/or iLTP"m does not provide any protection whatsoever to my employer or myself. Lifeguard Name (Please Print)- Lifeguard Sinatrre — 01 insfiri�cti<aonnfbrmat�on: I hereby certify that the holder -of this tL T P ^ Course Completion Credential has successiuify met -ail required skills competencies (including=but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramTm for the lifeguard classification indicated above. I have also reviewed the ILTPT"' Course Completion Acknowledgment with its holder and am satisfied tfte card holder clearly understands said acknowledgrnent. M OO q__73Q 011 -0 - Max Water Depth: I, O fVK Updated Max Water Depot:_La ft/tp(Instructor Name: A/• KjL InstructorlD: Date: Instructor Name (Please Print) 1 instructor Signature: �V / t vi. -N A 1 C For additional information regarding the international Lifeguard Training ProgramTM' please call or write to: Jeff Ellis & Associates, inc. Business Office. 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: businessna iellis.com Distribution: This certificate is issued from Jeff Ellis & Associates, Inc. Corporate Headquarters, Kingwood, TX. Revised 112011 I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns. and paid all State taxes required under law. .r 6 $v,�' 4 % r'..r "VI * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) r .6 J ** 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 fall to correct their non4iling 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. A, NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TYPE OF POOL: PUBLIC ❑ SEMI-PUBLIC SPECIAL PURPOSE POOL ❑ NAME OF POOL ADDRESS OWNER ADDRESS DATE OFPOOL INSPECTION CAPACITY !tZ' # OF GALS INSPECTED BY METHOD OF WATER TREATMENT BATHER LOAD # OF LIFEGUARDS WATER SOURCE: 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: 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 until _repairs can be made. .08 Special purpose pool and wading pools equipped with emergency shut off pump switch. Accessible and Of 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. or .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 POOLSIDE READINGS Bromine 2.0-6.0 m*/Total Chlorine Alkalin 50-150 m Free Chlorine 1.0-3.0 m Cyanuric Acid (30-100 ppm) Comb. (0,0-0.2 ppzn) Chlorine Water Temp. 104°F. pH level (7.2-7.8) *parts per million Other .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 REGULATION NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/✓ .34I I Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED Operator SIGNED of Health/Health Department