Loading...
HomeMy WebLinkAboutWillow Crossing 12/31/2013Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a SwimmingPool 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, Health .Agent V Special Purpose Pool None P_�<4__l Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 17 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: @benchmarkquality.com FED ID/SS NO: 20-8030098 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAUL J. MILLER Pool/SPA Certification Date: 5/14/2010 Pool/SPA Certification Expires: 5/4/2015 PERSON CERTIFIED: — ,5 � . ll _ f iC Pool/SPA Certification Date: 6 2- sV o Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. ❑ Public POOL OPERATION: ❑ Semi -Public W Special Purpose Pool POOL LOCATION: 25 COBB STREET TYPE/POOL: GUNITE CONCRETE LENGTH: 32' WIDTH: 14' VOLUME: 12,544 MIN/MAX DEPTH: 3'6" 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 a, SIGNATURE: DATE: --- �l -- - - �� 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. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER: 17 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: mbornstein@benchmarkquality.com FED ID/SS NO: 20-8030098 FEE PER POOL: $75.00 Certification Expires Every 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: PAUL J. MILLER Pool/SPA Certification Date: 5/14/2010 Pool/SPA Certification Expires: 5/4/2015 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: ❑ Public POOL OPERATION: ❑ Semi -Public Special Purpose Pool POOL LOCATION: 25 COBB STREET TYPE/POOL: GUNITE CONCRETE LENGTH: 32' WIDTH: 14' VOLUME: 12,544 MIN/MAX DEPTH: 3'6" 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 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) By: orporate Officer (Mandatory, if applicable) ** 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 w"I be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. I G The Commonwealth ofAlassachusetts- Department of Industrial Accidents T �' Office of Investigations 600 Washington Street Boston, AM 0211.1 www.inass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ` Please Print Legibly. Business/Organization Name: the. V t� � lau— c— 4 G 1 low MUSS t I lft ,� Address: -) co66 `> , City/State/Zip: r'�a.i'1S ► tt G+ t;y6Phone#: 5 � 1- / 3.3 Are y7an employer? Check the appropriate box: I. ET 1 am a employer with [,&D 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' camp, 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, ❑ Non-profit 9, ❑ Entertainment 10. ❑Ma ufacturing 11, D 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#1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:"nc:-F1r� nC'e i A3 insurer's Address: :5-ot L) �. l - si S 'go D City/State/Zip: , S P4 U f r Y •ice I O I Policy # or Self -ins. Lie. # -'11 UX i'4 q'J GI 0 0 Expiration pate: 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 WORT{ 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 Phone #: penalties ofperjury that the information provided above is true and correct a-�i- 1333 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 Pe www.mass.gov/dia Phone #: NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by . insuring with: Arch Insurance Company NAME OF INSURANCE COMPANY 30 East 7th Street, Ste. 2270, St. Paul, MN 55101 ADDRESS OF INSURANCE COMPANY 41 WC14987900 4/1/2013 to 4/1/2014 POLICY NUMBER 280 Newtonville Ave. EFFECTIVE DATES Willis of Illinois, Inc Newton, IL 60606 312-288-7412 NAME OF INSURANCE AGENT ADDRESS PHONE # 700 Chickering Road _Benchmark Assisted Living, LLC North Andover MA 01845 EMPLOYER ADDRESS March 26, 2013 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER CIA a� Jane Doucette From: Joseph Tortolano<jtortolano@bench markquality.com> Sent: Saturday, July 06, 2013 8:18 AM To: Linsley Coyle; Jane Doucette Subject: RE: Workman's Comp Proof Jane, We are not putting my name on the permit anymore, we are just going with Paul Miller's certification. -----Original Message ----- From: Linsley Coyle Sent: Wednesday, July 03, 2013 8:37 PM To: Joseph Tortolano Subject: FW: Workman's Comp Proof Joe, Jane does need the workman's comp paper work that I just sent her and now she needs Pauls certificate, that I know we made copies of a few weeks ago. Can you scan that to Jane Friday? Thanks, Linsley -----Original Message ----- From: Jane Doucette [mailto•Jdoucette@mansfieldma.comj Sent: Wednesday, July 03, 2013 3:35 PM To: Linsley Coyle Subject: RE: Workman's Comp Proof Yes, thanks, but I need one more thing -I do not have the pool certification for Joseph A. Tortolano -his certification expired 1/28/2013. -----Original Message ----- From: Linsley Coyle [mailto•lcoyle@benchmarkguality•comj Sent: Monday, July 01, 2013 2:22 PM To: Jane Doucette Cc: Joseph Tortolano Subject: FW: Workman's Comp Proof Jane, Is this what you are looking for for the Pool permit Application. Please let Joe know. Thanks, Linsley Linsley Coyle 1 The Village at Willow Crossings 25 Cobb Street Mansfield, Ma 02048 508-261-1333 CONFIDENTIALITY NOTICE: The information contained in this e-mail is privileged and confidential and it is intended only for the use of the individual or entity to whom it is addressed. If the reader of this message is not the intended recipient, you are hereby notified that any viewing, dissemination, distribution, or copying of this e-mail message is strictly prohibited. If you have received and/or are viewing this e-mail in error, please immediately notify the sender by reply e-mail, and delete this e- mail from your system. CONFIDENTIALITY NOTICE: The information contained in this e-mail is privileged and confidential and it is intended only for the use of the individual or entity to whom it is addressed. If the reader of this message is not the intended recipient, you are hereby notified that any viewing, dissemination, distribution, or copying of this e-mail message is strictly prohibited. If you have received and/or are viewing this e-mail in error, please immediately notify the sender by reply e-mail, and delete this e- mail from your system.