HomeMy WebLinkAboutMilhaus 12/31/2004i
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Name of Owner:
Address:
City:
State: MA
Telephone:
Fax:
Fed ID/SS No.:
Pool Location:
Type/pool:
Length: 60'
Min/Max. depth:
Swim Area:
Dive Area:
Water Source:
W/W Disposal:
Type of Finish:
Scum Gutter:
Milhaus @ MansCondo Trust
150 Rumford Avenue
Mansfield
Zip:02048
508-339-7531
04-6551192
150 Rumford Ave.
Gunite
Width: 30'
4', 7',10',14'
18,000sf
None
Town
Town sewer
Concrete
yes
Volume: 66,000
Deck Type: Concrete 16'
Skmmr weir length: 4, 8' apart
Treatment System: Haywood 3000
Disinfect Method: Automatic Chlorinator Marc Mac, 22 psi
Chemical Treatment: Sodium Hypochlorite
No. of Bathers: 70
Remarks:
Permit No.:9
Fee per pool: $75.00
Permit Expires December 31ST yearly
SIGN
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.
R Health\PaPs DocumentAPERMIT APPLICATIONSISWIMMING POOLS APPA%:
The Commonwealth of Massachusetts
Department of Industrial Accidents
/lice Oflnvesfiff8dons
600 Washington Street, 7`" Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit - General Businesses
❑ I am a sole proprietor and have no one l'Business Type: ❑ Retail ❑ RJ�taurant/Bar/Eating Establishment
working in any capacity. ❑ Office ❑ Sales (including Real Estate, Autos etc.)
❑ I am an employer with employees (full & part time). ❑ Other
❑ I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city phone #:
insurance co policy #
FJ I am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices: 11
address J Z7 1),l f e
city: phone # r`1 art 6 l
insurance co policy #
company name:
address:
city phone M
insurance co policy # _
Attach additional sheet if necessary,•
Failure to secure coverage as. requircd under Section 25A of RSG;., 152 can lead to the impasition of cr -.mnal penalties of a fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Print name
official use only do not write in this area to be completed by city or town official
city or town:
❑ check if immediate response is required
contact person:
(mvised Sept. 2003)
permittlicense # ❑Building Department
❑Licensing Board
❑selectmen's Office
❑Health Department
phone #; ❑Other