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HomeMy WebLinkAboutWest Village Apts. 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health ��termito Operate a Swimming Pool PERMIT NUMBER: 18 Pool/SPA Certification Date: December 09, 2011 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: December 08, 2016 Person Certified: HANSEL RIVERA 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: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a ❑ Public ❑ Semi -Public Special Purpose Pool at: 792 WEST STREET Method of water treatment is CHLORINATOR/SAND FILTER Bathing load not to exceed: 8-10 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 Date Issued Town of Mansfield - Board of Health Swimming Pool Application NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM FED ID/SS NO: 45-1501972 Certification Expires Evert/ 5 Years. Permit Expires December 31st Yearly. PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 12/9/2011 Pool/SPA Certification Expires: 12/8/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS:" NO LIFEGUARD ON DUTY" sign is required. No lifeguard on duty. Sign is required. SIGNATURE: Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 18 FEE: $125 ❑ Public POOL OPERATION: ❑ Semi -Public ❑ Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL: SPA/HOT TUB LENGTH: N/A WIDTH: N/A VOLUME: 1500 GAL. MINIMAX DEPTH: 3.5 FT. SWIM AREA: N/A DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINATOR/SAND FILTER CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 8-10 DATE. 5', ' ( (�,, 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. * Sign ure of Individual or Corporate Name (Mandatory) By: Corporate 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 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 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: Address: %G(Z We, City/State/Zip: oogcwN1 CP � &tA t-� C I . 'no Are you an employer? Check the appropriate box; Ida 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.] Phone #: SQ& 76% 0,S'0() *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: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. 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 the DTA for insurance coverage verification. I do hereby certify, under the pains �aannd penalties of perjury that the information provided above is true and correct �IDate: 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: Phone www.mass.gov/ala AC R ® CERTIFICATE OF LIABILITY INSURANCE DAT E(MMBIDD/YYYY) O 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Southwest, Inc. Dallas TX Office CONTACT ' NAME: PHONE FAX (800) 363-0105 (AIC. No. Ext): (866) 283-7122 AIC. No. E-MAIL ADDRESS: CityPlace Center East 2711 North Haskell Avenue INSURER(S) AFFORDING COVERAGE NAIC # suite 800 Dallas TX 75204 USA INSURED INSURERA: Zurich American Ins co 16535 INSURER B: Monoqram Residential Trust 5800 Granite Parkway suite 1000 INSURER C: INSURER D: Plano TX 75024 USA INSURER E: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY INSURER F: COVERAGES CERTIFICATE NUMBER: 570062144908 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. Limits shown are as requested INSRPOLICY LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER EFF MMIDD POLICY IzXP MMIDOIYYYY LIMITS COMMERCIAL NERAL LIABILITY CLAIMS -MADE r_1 OCCUR EACH OCCURRENCE D AGES(TO RENTED PREMISES Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑ LOC JECT OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY COaMaccidenBINED tSINGLE LIMIT BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE eraccident UMBRELLA LIABOCCUR EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DEDI IRETENTION A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE—EMBER EXCLUDED? (Mandatory in NH) If es, describe under DESCRIPTION OF OPERATIONS below N I A wc017929401 Workers Comp 05/31/2016 05F31/2017 X STATUTE ETH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Monogram Residential west village AUTHORIZED REPRESENTATIVE REIT, LLC 792 west street 'Q4. ��iGt(rc�d t� ieae �Jna Mansfield MA 02048 USA ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD m m 0 on v t N 0 0 r u� 0 Elk 1��rPq�Rg ,t �} vtuul- •rte ol,wi - fis 0 Elk 1��rPq�Rg ,t �} vtuul- NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT TVPF nF PnnT _• PT TRT 4C I 1 r CPF.C'.TAT . P1 TRPnSsF. PnnT. a`„ NAME OF POOL ) IADDRESS OWNER ADDRESS DATE OFPOOL INSPECTION CAPACITY # OF GALS INSPECTED BY : K � tk METHOD OF WATER TREATMENT BATHER LOAD # OF LIFEGUARDS WIAAUWR SOURC : 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 circulatioation systems. Filter Effluent flow meter reading: filtrgpm. # 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 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. .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 ppm? Cyanuric Acid Water * parts per million .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 Xotal Chlorine Free Chlorine Comb. Chlorine pH level Other REGULATION I NO. I THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/,/ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. P SIGNED Operator 01 ✓'; SIGNED Board of Health/Health Department Sheet4 TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURERS No. DEPT: BOARD OF HEALTH Date: MAY 12, 2016 Type of Payment: 1ACCOUNT NO: 01512-445006 'FROM WHOM AMOUNT WEST VILLAGE POOL PERMIT POOL PERMITS $250.00 CASH 00 No. Dept: BOARD OF HEALTH To the Departmental Officer making the payment _ Receipt of: $250.00 for the period ending MAY 18, 2016 -- Collections as per schedule of this date and filed in my office. I Page 1 Town of Mansfield - Board of Health r Swimming Pool Application NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMkES.COM FED ID/SS NO: 45-1501972 Certification Expires Every 5 Years. Permit Expires December 31st Yearly, PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 12/9/2011 Pool/SPA Certification Expires: 12/8/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS, I "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 16 FEE: $125 ❑ Public POOL OPERATION: © Semi-Public�`:i,r'(q��i ❑ Special Purpose Pool`°'i POOL LOCATION: 792 WEST STREET HAy 2016 CHEC TYPE/POOL: GUNITE SEMI-PUBLIC AMT LENGTH: 56' WIDTH: 25' VOLUME: 42,000 GALLONS MIN/MAX DEPTH: 4 ft. SWIM AREA: 1,400 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN WNW DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: ASTRAL SAND FILTER DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 93 DATE: Csl (8� I U v 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 - Board of Health Swimming Pool Application NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261=0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM FED ID/SS NO: 45-1501972 Certification Expires Every 6 Years. Permit Expires December 31st Yearly PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 12/9/2011 Pool/SPA Certification Expires: 12/8/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires. certification remarks(if necessary): REMARKS:I "NO LIFEGUARD ON DUTY" sign is required. No lifeguard on duty. Sign is required. SIGNA Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER 18 FEE: $12' Q Public ---.------- POOL OPERATION: ❑ Semi -Public © Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL' SPAIHOT TUB LENGTH: N/A WIDTH: N/A VOLUME: 1500 GAL, MINIMAX DEPTH: 3.5 FT. SWIM AREA: N/A DIVE AREA: N/A WATER SOURCE: TOWN WNW DISPOSAL: TOWN SEWER TOWN OF MANSFIELD TYPE OF FINISH: PLASTER PAID SCUM GUTTER: N/A MAY 1 $ 2016 DECK TYPE: CONCRETE CIH# SKMMR WEIR LENGTH: 8"T�;;�_ TREATMENT SYSTEM: CHLORINE DISINFECT METHOD: CHLORINATORISAND FILTE CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 8-10 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. Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health EPer:��it:t:o:�*erate a Swimming Poo PERMIT NUMBER: 16 Pool/SPA Certification Date: December 09, 2011 PERMIT EXPIRES: December 31, 2016 Pool/SPA Certification Expires: December 08, 2016 Person Certified: HANSEL RIVERA 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: MONOGRAM RESIDENTIAL WEST VILLAGE REIT for the operation of a ❑ Public at: Method of water treatment is Bathing load not to exceed 0 Semi -Public 792 WEST STREET ❑ Special Purpose Pool CHLORINE/CHLORINATOR RAINBOW 300 93 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 Date Issued Town of Mansfield Town of Mansfield - Board of Health 6 Park Row` Mansfield, MA 02048 Swimming Pool Application PERMIT NUMBER 16 FEE: $125 NAME OF OWNER: MONOGRAM RESIDENTIAL WEST VILLAGE REIT ADDRESS: 792 WEST STREET CITY: MANSFIELD STATE: MA ZIP: 02048 TELEPHONE: (508) 261-0500 FAX: (508) 261-0501 EMAIL: DIANE.THOMPSON@MONOGRAMRES.COM FED ID/SS NO: 45-1501972 Certification Expires Every 5 Years. Permit Expires December 31st Yearl . PERSON CERTIFIED: HANSEL RIVERA Pool/SPA Certification Date: 12/9/2011 Pool/SPA Certification Expires: 12/8/2016 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): REMARKS: I "NO LIFEGUARD ON DUTY" sign is required. SIGNATURE: ❑ Public POOL OPERATION: Pj Semi -Public ❑ Special Purpose Pool POOL LOCATION: 792 WEST STREET TYPE/POOL: GUNITE SEMI-PUBLIC LENGTH: 56' WIDTH: 25' VOLUME: 42,000 GALLONS MIN/MAX DEPTH: 4 ft. SWIM AREA: 1,400 sq. ft. DIVE AREA: N/A WATER SOURCE: TOWN W/W DISPOSAL: TOWN SEWER TYPE OF FINISH: PLASTER SCUM GUTTER: N/A DECK TYPE: CONCRETE SKMMR WEIR LENGTH: 8" TREATMENT SYSTEM: ASTRAL SAND FILTER DISINFECT METHOD: CHLORINE/CHLORINATOR RAINBOW 300 CHEMICAL TREATMENT: CHLORINE NUMBER OF BATHERS: 93 DATE: k� I El � �_)Ot U 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. 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: Corporate Officer (Mandatory, if applicable) L-.I'_�bI`71i �+D_ ** 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 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: 1We Address: City/State/Zip: VAGV�S r , a� Phone �Irean employer? Check the appropriate box: Business Type (required): ama 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 10.0 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.] 12.Other "2Vd e,r h4 Yv�Gv�� eiMex� *Any applicant that checks box # l 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 Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 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 e. 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-��!l l certify, under the p"M_aand penalties ofperjury that the information provtaea anove is rrue ana correct. 0:—_...... 1 01 ,( � 1 l,l�t`SYI, (-- r)arP. �(� ( �_P Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dla Phone ACS ® CERTIFICATE OF LIABILITY INSURANCE DATE05YY) 5/19/20 6 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Southwest, inc. Dallas TX Office CONTACT NAME: PHONE (g66) 283-7122 FAX (800) 363-0105 (AIC. No. Ext): AIC. No. E-MAIL ADDRESS: CityPlace Center East 2711 North Haskell Avenue INSURER(S) AFFORDING COVERAGE NAIL q Suite 800 Dallas TX 75204 USA INSURED INSURER A: Zurich American Ins CO 16535 INSURER B: Monoqram Residential Trust 5800 Granite Parkway Suite 1000 INSURER C: INSURER D: Plano TX 75024 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570062144908 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. Limits shown are as requested LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1-1OCCUR Mansfield MA 02048 USA tit A.�,s J EACH OCCURRENCE DAMAGE 0 RENTED PREMISES Ea occurrence MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F-1 PRO- ❑ LOC JECT OTHER: GENERAL AGGREGATE PRODUCTS - COMPIOP AGG AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident UMBRELLA LIABOCCUR EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/ PARTNER / ❑ EXECUTIVE N OFFICER/MEMBER EXCLUDED, (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC017929401 workers Comp 05/31/2016 05/31/2017 X STATUTE �RH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of insurance CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 00 0 m v N 0 0 III N O Z Y V w 1: d U SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Monogram Residential west village AUTHORIZED REPRESENTATIVE REIT, LLC 792 west Street Mansfield MA 02048 USA tit A.�,s J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 00 0 m v N 0 0 III N O Z Y V w 1: d U X. NAME OF CITY OR TOWN STATE SANITARY CODE: CHAPTER V, MINIMUM STANDARDS FOR SWIMMING POOLS, 105 CMR 435.000 SWIMMING POOL INSPECTION REPORT i'VDR nu nnnT • DITnT Tr rl QRTAT-PTTRT Tr CPFrTAT. PT TRPORF. MOT. n NAME OF POOL ADDRESS e OWNER ADDRESS DATE OF i � � POOL CAPACITY INSPECTED BY }' a INSPECTION '� # OF GALS METHOD OF WATER BATHER # OF LIFEGUARDS WATER SO CE: TREATMENT LOAD 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 & ration systems. Filter Effluent flow meter reading: d * 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 .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 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. .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 1 (2.0-6.0 vvmi Cyanuric Acid Water Temp. 104°F. * parts per million .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 r Total Chlorine Free Chlorine Comb. Chlorine nH level REGULATION I NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE X/✓ .34 Closure of the pool. POOL MUST BE CLOSED UNTIL IT MEETS THE STANDARDS OF 105 CMR 435.29 THROUGH 435.31. SIGNED Operator SIGNED Board of Health/Health Department