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HomeMy WebLinkAboutMilhaus 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: 9 Pool/SPA Certification Date: February 26, 2009 PERMIT EXPIRES: December 31, 2013 Pool/SPA Certification Expires: February 26, 2014 Person Certified., JOHN M. BURKETT 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: MILHAUS @ MANSCONDO TRUST for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed. ❑v Semi -Public 150 RUMFORD AVENUE ❑ Special Purpose Pool AUTOMATIC CHLORINATOR MARC MAC, 22 PSI 70 bathers Number of Lifeguards required at all times the pool is open is: "NO LIFEGUARD ON DUTY" sign is required. Scott Leite, Heaah Agent None 0 , X30 l3 Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 9 FEE: $125 NAME OF OWNER: MILHAUS @ MANSCONDO TRUST ADDRESS: 150 RUMFORD AVENUE CITY: MANSIFELD STATE: MA ZIP: 02048 TELEPHONE: (508) 339-3078 FAX: EMAIL: FED ID/SS NO: 04-6551192�� (00 FEE PER POOL: $ �� 00 Certification Expires Every 5 Years.. Permit Expires December 31st_Yearly• PERSON CERTIFIED: JOHN M. BURKETT Pool/SPA Certification Date: 2/26/2009 Pool/SPA Certification Expires: 2/26/2014 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): ❑ Public POOL OPERATION: Fvj Semi -Public ❑ Special Purpose Pool POOL LOCATION: 150 RUMFORD AVENUE TYPE/POOL: GUNITE LENGTH: 60' WIDTH: 30' VOLUME: 66,000 MIN/MAX DEPTH: 4', 7', 10', 14' SWIM AREA: 18,000sf DIVE AREA: NONE WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: CONCRETE SCUM GUTTER: YES DECK TYPE: CONCRETEI6' SKMMR WEIR LENGTH: 4, 8' APART TREATMENT SYSTEM: HAYWOOD 3000 DISINFECT METHOD: AUTOMATIC CHLORINATOR MARC MAC, 22 PSI CHEMICAL TREATMENT: SODIUM HYPOCHLORITE NUMBER OF BATHERS: 70 REMARKS:"NO LIFEGUARD ON DUTY" sign is required. (508) 339-7531 TRUSTEE NUMBER SAMANTHA CONTACT PERSON SIG -13 DATE: 7 / "! Please mak 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. * Sign Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) oV- ** 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 DI 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 Address: i -bt i rrkai Cu -t- - City/State/Zip:nA azj�o/�d /P A_ - Phone #: 3 6 � 30 5 Are you an employer? Check the appropriate box: Business Type (required): L X I am a employer with 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. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 4. F1 We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' -comp. insurance req.] 1 12.0 Other *Any applicant that checks box #I 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 providin,e workers' compensation insurance far my employees. Below is the policy information. Insurance Company �I P Y Name: - Insurer's Address: JI& & City/State/Zip: Policy # or Self -ins. Lic. # eta - 16 !22 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of theDIA for insurance coverage verification. I do��hereunlder the pains andpe Ities of perjury that the information provided abjove2is true and correct c%%7�/7r� /7 e—� Tata / �d/ /_3 Phone #• �V U �� 62 8 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other II Contact Person: Phone #: II www.mass.gov/dia 0512012013 13:00 5086685201 ALL SEASONS POOL PAGE 03103 DATE(MM/DDMI rY) CERTIFICATE OF LIABILITY INSURANCE 0512012013 THIS GERTIFICATE-I§ !§SUED AS A MATTER OF INFORMATION ONLY AND CtlNFERN NO RIGHTS UPON THE CER11FICATE HOLDER. THIS CERTIFICATE DOE$ NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOrgS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder le on ADDITIONAL INSURED, the polloy(les) must be ondoned. If SUBROGATION iS WAIVED, sublect to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer fights t&the certificate holder In lieu of such endorsement a PRODUCER 1550 SAWGRASS DRICVEACENCY, INC. 1100HESTER, NY 14620 JRED ALL SEASONS POOL & SFA SERVICE 17 BONNEY RD WALPOLE, MA 020$1 Ct7CT Paychex Insurance Agency Inc V PHONE877-266-6850 FAX 585-389-7416 E�MAI Certs(d,(paychex,Com IN9URI=R(6) AFFORDING COVERAGE HAIG ff' INSURER AI NorOUARD Insurance Company 31470 INSURER 8: POLIDV.. PR0*-= LOG INSURER C: LIABILITY AUMMO011-E LIABILIT INSURER W AWAVTP INSURER E: A"9w bsommmo INSURER F: AUTOS-- NANVM�µpSS NSRCO ailTos AUTOQO COVERAGES CERTIFICATE NUME16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THF, 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 PE 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. STYPE OF INSURANCE NSISRL UBp POLICY NUMBER POLICY OF POLICY EXF LIMITS MMIDDIYYYY) MM OD GENERAL. LIABILITY EACH OCCURRENCE S COMMERG(ALGENERAL LIABILITY DAMAGET W $ _.. �.... CLAIMS -MAC? CGUR MED EXP (Any one Person) $ PERSONAL & ApV INJURY $ GfNERALAGGREGATB $ N'I,AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG s POLIDV.. PR0*-= LOG § LIABILITY AUMMO011-E LIABILIT SINGLE LIMIT s (Ca accident AWAVTP SODILY INJURY $ A"9w bsommmo (Por ort) - AUTOS-- NANVM�µpSS NSRCO ailTos AUTOQO 8OD1LYINJURY �'orQma=tROPE $ UNaRMAUAS 00MR EACH OCCURRENCE $ AGGREGATE $ EXCM"M cum a 5 otb R NTION i - X WC STATU• �- �. woRKERsr,OMP0WTIDNAND ALWC349448 08/2112Q1 061211201' EkIlLova"wxamv E.L. EACHAGOIDENt S 100.000,00 ANY FRUPRISTDWARTHERMXECUTIVF E.L, DISEASE - EA EMPLOYEE $ 100,000.00 pFFIGEmw MtER EXGWDED7 YtN- t N/A E.L.DISEA8E-POLICY LIMIT $ 500,000,00 (M f^NN) L q�i'iaaag9dpeSlt)Or ESGRIPTION OP OPERATIONS f LOCATIONS f VEHICLW (AWCh ACORD 161, Addifional RemafRA SChedVIV, if nwPe BPRCo Is Tequit0d) 'ERTIFICATE HOLIDER CANCELLATION ANY Op THE ABOVE 00CRIBED POLICIES BE CANCELLED BEFORV THE EXPIRATION H4LISE CONDOMINIUMS MILLC ANCEWrt H11fOLIGY THEREOF, NOTICE WILL BE riT.LIVERED IN AGCOKDT DATE DO 150 FHOU5 AVE U BUCH NOTICE OR LONS, ANY REPRESH MANFIEI.D, MA 02046 FON TmeIL TIATIVES. L"LjpRoVi KIN ITS AGENTe OR LiADII,fiY OF' ANY KIND UPON T}2E GDMFANT, AUTHORIZU0 REPRESENTATIVE ` X71968.2010 ACORD CORPORATION. All rights reserved, ACORD 25 (Z01b/05) The ACORD name and logo are regletered marks of ACORD 5/21/2013 9:05:10 AM PST (GMT -8) FROM: 100005 -TO: 15082617343 Page: 2 of 2 A �® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 5/21/2013— 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 C & S INSURANCE AGENCY INC PO BOX 406 MANSFIELD, MA 02048 CONTACT NAME: PHONE AIC No Exi: FAX A1C No: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # EACH OCCURRENCE $ INSURERA: Mutual Fire Insurance MED EXP (Any one person) $ INSURED MILLHAUS AT MANSFIELD CONDOMINIUM TRUST -Liberty INSURER B : GENERAL AGGREGATE $ PO BOX 951 INSURERC: INSURERD: MANSFIELD MA 02048 INSURERE: LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOSNON-O INSURER F : COVERAGES CERTIFICATE NUMBER: 1AA11AS-1 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 LTR TY INSURANCE ADDL S SUBR D POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY -CLAIMS-MADE ElOCCUR EACH OCCURRENCE $ PREMISES Ea RENTED $_ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER; POLICY PRO- LOC PRODUCTS -COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOSNON-O (Ea aai enI $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (p par.E de tDAMAGE $ $ $ UMBRELLA LIAII EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ $ $ A WORKERS COMPENSATIONYIN AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTNE FY—] OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N JA WC2-31S-370733-012 12/20/2012 12/20/2013 p7{{ ,i TORYLAMrfS ER E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYEE $ 100000 E.L. DISEASE - POLICY LIMIT 1 $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION TOWN OF MANSFIELD 6 PARK ROW MANSFIELD MA 02048 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 Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights,reserved.l ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CgRT NO•: 161 653 CLIENT C DE: 135 822 Anne Chand1 r 5/21/2Q13 9:03:1,7 ALA P ge i01 ,1 This certificate cancels anc� supersedes A�L previously issueA certificates. 5/21/2013 9:05:10 AM PST (GMT -8) FROM: 100005 -TO: 15082617343 `From: C & S INSURANCE AGENCY INC PO BOX 406 MANSFIELD, MA 02048 Date: Delivery Via: No. of Pages: Page: 1 of 2 FAX DOCUMENT Certificate of Insurance Delivery by ecertson line T"' Anne Chandler ACORD 25 (05!10) Certificate of Uability: MILLHAUS AT MANSFIELD CONDOMINIUM TRUST 5/21/2013 FAX 15082617343 I! The attached or linked document(s) contain certification of insurance coverage for the insured named in the subject above. Your company is listed as the organization requesting receipt of these documents, If this document is sent via e-mail, you must click on the link below. The linked document is in a pdf format, and you must have Adobe Acrobat Reader installed on your system. To download the Adobe Reader for free, visit www.Adobe,com. If you have any questions regarding the content of this message, you should contact the Producer/ Agency listed on the attached/linked documents. THIS MESSAGE IS WENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAIN. IF THE READER OF THE MESSAGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE ORAGENT RESPONSIBLE FOR DELIVER6NG THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBYNOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICA710N IN ERROR, PLEASE NOTIFY US (MEDIATELY BY7ELEPHONE, AND RETURN THE ORIGINAL NIESSAGE 70 US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERVICE. © 2002 Certificate of Insurance Delivered by ecertsonline T^' Insurance Visions, Inc. All rights reserved. IN