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HomeMy WebLinkAboutWillow Crossing 12/31/2013 (2)Commonwealth of Massachusetts Y Town of Mansfield 9�r 1�4�_• Board of Health Permit to Operate a Swimming Pool Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 17 Pool/SPA Certification Date: May 14, 2010 PERMIT EXPIRES: December 31, 2013 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: BVII NEW ENGLAND, 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, .3-f'eaCth Agent W Special Purpose Pool None c� 1 3 Date Issued Swimming Pool Application PERMIT NUMBER 17 FEE: $125 NAME OF OWNER: BVII NEW ENGLAND, LLC dbaTHE VILLAGE AT WILLOW CROSSINGS ADDRESS: 25 COBB STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-1333 FAX: (508) 237-4663 EMAIL: jtortolano@benchmarkquality.com FED ID/SS NO: 20-8030098 Certification Exvires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAUL J. MILLER Pool/SPA Certification Date: 5/14/2010 Pool/SPA Certification Expires: 5/14/2015 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): ❑ Public POOL OPERATION: ❑ Semi -Public n Spacial Purpose Pool POOL LOCATION: 25 COBB STREET TYPE/POOL: GUNITE CONCRETE LENGTH: 32' WIDTH: 14' VOLUME: 12,544 MIN/MAX DEPTH: T6" to 3'9" SWIM AREA: 448 sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: BLUE MARBLEITE SCUM GUTTER: NONE DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8.5" TREATMENT SYSTEM: HAYWARD C-50OLF BROMINATOR DISINFECT METHOD: BROMINE CHEMICAL TREATMENT: BROMINE NUMBER OF BATHERS: 22 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. it I 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. TAX CERTIFICATION FORM 1 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. 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** p9 By: Corporate Officer (Mandatory, IF Applicable) Andrea M. Teichman Assistant Secretary 11 -is license will not be issued uriless 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le0bly es isr. Business/Organization Name b .. � U D -t _ f r s m .. v ; i Address: x City/State/Zip: Phone #: Are yo an employer? Check the appropriate box: 1. I am a employer with / employees (full and/ or part-time).* 2. ❑ I 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.] Business Type (required): I 5. []Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11.❑ 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 # I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: { CCJ1`, 5,= t F / t A Insurer's Address: e , A 7C I k City/State/Zip: Policy # or Self -ins. Lie. # / 2 � 2 � �'��` 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 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 Investiiations of the DTA for insurance coverage verification. I do hereby certify, under the Phone #: of perjury that the information provided above is 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. Cityrrown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www,moss.gov/dia Phone Ps 2auu2si u2 7 ® CERTIFICATE OF LIABILITY INSURANCE DATE15/2 IY3 rq� ® 11/15/2013 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS -- POLICY EFF 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 I IMMIDDIYYYYI REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. p IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pol)cy(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 EACH OCCURRENCE $ certificate holder in lieu of such endorsement(s). PRODUCER LIC $36-3066541 1-312-288-7700 CONTACT Natalie Gomez DAMAGE TO RENTED Willis of Illinois, Inc. c^y `o PHONE FAX C. No Ext�312) 288-7412 312 2340642 _ __-_ _—__���; () - Willis Tower E-MAIL natalie.gomez@Willis.COm CZ 233 South Wacker Drive, Suite 2000 _ ' Chicago, IL 60606 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ARCH INS CO 11150 PERSONAL 8 ADV INJURY INSURED INSURER B: Chubb Custom Insurance Cc 24856 $ Benchmark Senior Living LLC INSURER C: Scottsdale Ins Co 41297 INSURER D: PRODUCTS - COMP/OP AGG The Wellesley Office Park GENL AGGREGATE LIMIT APPLIES PER: 40 William Street, Suite 350 Wellesley, MA 02481 INSURERS: $ INSURER F: AUTOMOBILE LIABILITY COVFRAnFS CFRTIFICATF NtIMRFR- 36955144 REVISION NUMBER - 04/01/14 COMBINED SINGLE LIMIT 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 AbOL SUER -- POLICY EFF ---------- POLICY EXP ------------------------- LTR TYPE OF INSURANCE POLICY NUMBER IMMIDDIYYYYI IMMIDDNYYY� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS -MADE I OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GENL AGGREGATE LIMIT APPLIES PER: PRO LOC POLICY I $ A AUTOMOBILE LIABILITY 41CAB4987800 - MA Only 04/01/1 04/01/14 COMBINED SINGLE LIMIT $ 1,000,000 41CAB4987700 09/01/1 04/01/14 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALLOWNED SCHEDULED $ BODILY INJURY (Per accident) AUTOS AUTOS PROPERTY DAMAGE _ X X NON -OWNED HIREOAUTOS AUTOS (Per accident) $ X Coll Ded X Comp Ded B UMBRELLA LIAB X OCCUR 79578773 04/01/1 04/01/14 EACH OCCURRENCE S 10,000,000 X EXCESS LIAB CLAIMS -MADE AGGREGATE $ 10, 000, 000 DED I RETENTION $ $ A WORKERS COMPENSATION 41WCI4987900 04/01/1 04/01/14 X WCSTATU- ER T RY LIMITS ER AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERNEMBER EXCLUDED? a N I A E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Excess Liability-Occ Form XLS0087328 04/01/1 04/01/14 Occ/Agg 5,000,000 Annual Aggregate 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is included as an additional Named Insured. Evidence of Insurance CERTIFICATE HOLDER CANCELLATION B -X Mansfield LLC d/b/a The village at Willow Crossings 25 Cobb Street ansfield, MA 02048 f � ACORD 25 (2010/05) ngomez 36955144 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE USA I ^' ©1988-2010 ACORD CORPORATION. All rights reserved. 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