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Home My WebLink AboutHoliday Inn 12/31/2013Commonwealth 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: 14 Pool/SPA Certification Date: April 28, 2011 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: April 28, 2016 Person Certified: MICHAEL P. SCHOMBURG 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 HOSPITALITY, LLC HOLIDAY INN for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed ❑ Semi -Public 31 HAMPSHIRE STREET CHLORINE 6 to 8 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah .Agent W Special Purpose Pool None Date Issued 0, 2 Town of Mansfield - Board of Health ia Swimming Pool Application NAME OF OWNER: MANSFIELD HOSPITALITY, LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: EMAIL: FED ID/SS NO: 26-1196350 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAULA. ROBBINS Pool/SPA Certification Date: 2/26/2009 Pool/SPA Certification Expires: I 2/26/2014 PERSON CERTIFIED: N i c ""Ul P. Pool/SPA Certification Date: y/44.) II Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: NO LIFEGUARD ON DUTY" sign is required. "No Lifeguard on Duty" sign SIGNATURE: Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 14 ❑ Public POOL OPERATION: ❑ Semi -Public Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SPECIAL PURPOSE LENGTH: 7 WIDTH: 7 VOLUME: 863 MIN/MAX DEPTH: 3' SWIM AREA: 154 sq ft DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: BRICK RAISED SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: 10 Ib. CHLORINE DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: 6 to 8 to DATE: x Id'd 1" 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. 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: 15 Pool/SPA Certification Date: April 28, 2011 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: April 28, 2016 Person Certified: MICHAEL P. SCHOMBBURG 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 HOSPITALITY, LLC HOLIDAY INN for the operation of a ❑ Public at. Method of water treatment is Bathing load not to exceed: W Semi -Public 31 HAMPSHIRE STREET CHLORINE 83 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 ,( INcx Town of Mansfield - Board of Health v (' A s i Swimming Pool Application NAME OF OWNER: MANSFIELD HOSPITALITY, LLC HOLIDAY INN ADDRESS: 31 HAMPSHIRE STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-2200 FAX: EMAIL: FED ID/SS NO: 26-1196350 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAULA. ROBBINS Pool/SPA Certification Date: 2/26/2009 Pool/SPA Certification Expires: 2/26/2014 PERSON CERTIFIED: M i (/h . a I 1, sl� o_ `� Pool/SPA Certification Date: H IWl, 0 { 1 Pool/SPA Certification Expires: �/aSj ,)o j certification remarks(if necessary): REMARKS: 'NO LIFEGUARD ON DUTY" sign is required. 'No Lifeguard on Duty" sign Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 15 ❑ Public POOL OPERATION: W Semi -Public ❑ Special Purpose Pool POOL LOCATION: 31 HAMPSHIRE STREET TYPE/POOL: SEMI-PUBLIC LENGTH: 62 WIDTH: 23 VOLUME: 42,666 GALLONS MIN/MAX DEPTH: 375' SWIM AREA: 1426 sq ft DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN TYPE OF FINISH: FIBERGLASS SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 14' TREATMENT SYSTEM: 30 Ib. AUTO FEED CHLORINATOR DISINFECT METHOD: CHLORINE CHEMICAL TREATMENT: CHLORINE SAND FILTER NUMBER OF BATHERS: 83 P' SIGNATURE: _� _ (-f0.5 1_ 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) orpora Officer (Mandatory, if applicable) a. - rlg63so ** 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. m LN ^11C W e •yry�yq/�� V.I.J W U C� .® �O 4-j U M V) 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 Legibly Business/Organization Name: 1tAAA6F lE1.P HOW-ZTAL-27r e ac, Address: 1 vg4M A4F 4T p City/State/Zip: A4AA/$F-2D ,MA Os2o0 Phone #: Are you an employer? Checl: the appropriate box: Business Type (required): 1.�. I am a employer with /ols 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• E] Non-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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'_comp. insurance req.] 1 12.10 Other HOVZ_ *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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: RANK CAJ($TAL gCVD'f_.� ING Insurer's Address: F04 r&W,9 C 80, 540 , C' kV_Wf 54074" 0 490 City/State/Zip: "O�%' ,_ OA VQ0 Policy # or Self -ins. Lic. #_ weT �1' ��°�3 DOQy Expiration Date: r/ /.2D� 3 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 it,. 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 DTA for insurance coverage verification. I do hereby certify, ugfids an penalties of perjury that the information provided above is true and correct. 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 ® DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/2/2012 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 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). CONTACT PRODUCER NAME: =rank Crystal & Co of OR, Inc. AICDN o Ext :9 1-222- 200 Fn/c NOI:971-222-3260 =ox Tower EMAIL 305 SW Broadway Suite #480 ADDRESS: Dortland OR 97205 INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:Wausau Underwriters Insurance Coma 6042 INSURED Linchris Hotel Corp 269 Hanover Street, Unit #2 Hanover MA 02339 D: E: nnIEWIATC A1111111000• en 0000 REVISION NUMBER: vTHIS'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. ILTR TYPE OF INSURANCE ADOL INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ CLAIMS -MADE El OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ LIMIT$ AUTOMOBILE LIABILITY COMBINED SINGLE Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AO -OWNED PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB HCLAIMS-MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIMB R/PARTNER/EXECUTIVE FN NH) EXCLUDED? (Mandatory in NH) (Mandatory $ X WC Y STATULI ITS ER__ T A N I A VVCJZ91542230092 /1/2012 1112013 E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of coverage as respects Holiday Inn Mansfield, 31 Hampshire Street, Mansfield, MA 02048. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Commonwealth of Massachusetts; Department of ACCORDANCE WITH THE POLICY PROVISIONS. Industrial Accidents Office of Investigations AUTHORIZED REPRESENTATIVE 600 Washington Street �fAv"Or�d4jtk'pr Boston MA 02111 V I Juu-GV — nvvlw vv.v v.v-...v... — .U. w ...vv.... v. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD