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HomeMy WebLinkAboutCanoe River CG 12/31/2006TOWN OF 1 BOARD OF QX PARK ROW9 MANSFIELD 02048 In accordance with the provisions of Chapter 111. Section 127A of the Massachusetts General Laws, and Regulations established by the Massachusetts Department of Public Health (105 CMR 435.00). permit is hereby issued to: Canoe River Campground for the operation of a ❑ Public ['Semi -Public ❑ Special Purpose Pool at: 137 Mill St. Method of water treatment is: Automatic Bathing load not to exceed. 94 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Permit No.: 1 Date of Expiration: December 31, 2006 6.- � -- C) (�, Date Issued TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 SWIMMING POOL APPLICATION Name of Owner: Canoe River Campground Address: 137 Mill St. City: Mansfield State: MA Zip:02048 Telephone: 508-339-6462%�% Fax: 508 -339-5237 X ���� Fed ID/SS No.: 04-2375571 5 Pool Location: 137 Mill St. Type/pool: Cement Length: 57' Width: 30' Volume: 60,000 Min/Max. depth: 3'-10' Swim Area: 57'x30' Dive Area: None Water Source: Town W/W Disposal: Private Leach Type of Finish: Cement Scum Gutter: Deck Type: Cement Skmmr weir length: 4 Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: Automatic No. of Bathers: 94 Remarks: Permit No.:I Fee per pool: $75.00 Permit Expires December 31S` yearly SIGNATURE: DATE: Please make appropriate changes. Sign, date and enclose checkpayable to Town ofMansfteld. Mail to: Board of Health, Town ofMansfteld, Sig Park Row, Mansfield, MA 02048. RR\Heallh\Pafs Documents\PERMIT APPLICATIONS\SWIPIMING POOLS APP.doc The Commonwealth of Massachusetts Department of]-ndustrial Accidents III ceOf!/i0SU 890 is 600 Washington Street, 7`6 Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - General Businesses name: .S LAAL I WK, b C AAJ yr '41 VL—De- address: L—De-address• 13 7 / � i r` ` % 4", q state: zip: L� ��phone # .� 31 ` �f work site location (full address): ❑ I am a sole proprietor and have no one Business T)rpe: ❑ Retail ❑ Restaurant/Bar/Eating Establishment working in any capacity. E] Office [:]Sales (including Real Estate, Autos etc.) I am an employer with' employees (full & part time). [0 Other C A.A4 /' C-4- c z.t v I am an ernployer providing ;, overs' c: n por=tion for my employees working on this job. company name: address• l 3 % l L 1. S. % - . city �� , ���(� C 1 ✓4 0- c),o _ phone #; ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name: address: city; phone #: insurance co. policy# company name: address: city: phone#: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to $1,500.00 and/or one yeah' imprisonment as wen 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 of perjury that the information provided above is true and correct Signature Date Print name Phone # official use only do not write in this area to be completed by city or town official city or town: - _ permitnicense # ❑Badding Department ❑Licensing Board ❑ check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone #; ❑Other (—L -d sepL 2003) ry that ledge ri I certify under the penalties of pe u paid all (State taxes trequired underdaw!ief, have filed all State tax returns andp * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number 9- Ca y _ � -7 .� `� * This license will not be issued unless the certification clause is signed by the applicant ** Your Social Security numberdeterminl be e whether Dd to the Massachusetts epartment of Revenue 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 r revocation. 2C, Section request 49Ais made under the authority of Mass. General LaChapter TOWN OF MANSFIELD BOARD SIX PARK ROW5 MANSFIELD 0' �I 1 1' '• 1 ' 1 1 of the ts In accordance with the provisionsestablished b 1 I I. Section 12 the Massachusetts Department of Putblic General Laws, and Regulations Y Health (105 CMR 435.00). permit is hereby issued to: Canoe River Campground for the operation of a ❑ Public Semi -Public ❑ Special Purpose Pool W 7� t �,� at: 137 Mill St. Method of water treatment is: Automatic Bathing load not to exceed: 94 bathers Number of Lifeguards required at all times the pool is open is: None 14NO LIFEGUARD ON DUTY" sign is required. Permit No.: 2 Date of Expiration: December 31, 2006 66 1 - � Scott Leite, Health Agent �_)-c►C Date Issued TOWN OF MANSFIELD, BOARD OF SIX PARK ROW, MANSFIELD 02048 SWIMMINGPOOL APPLICATION Name of Owner: Canoe River Campground Address: 137 Mill St. City: Mansfield State: MA Zip:02048 Telephone: 508-339-6462 Fax: 508-339-5237 Fed ID/SS No.: 04-2375571 Pool Location: 137 Mill St. Type/pool: Cement Length: 40' Width: 22' Volume: 22,440 Min/Max. depth: 3' Swim Area: 40'x22' Dive Area: None Water Source: Town W/W Disposal: Private Leach Type of Finish: Cement Scum Gutter: None Deck Type: Cement Skmmr weir length: 2 Treatment System: Sand Disinfect Method: Chlorine Chemical Treatment: Automatic No. of Bathers: 94 Remarks: Permit No.:2 Fee per pool: $75.00 Permit Expires December 315` yearly SIGNATURE: DATE: Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield Mail to: Board of Health, Town ofMansfreld, Six Park Row, Mansfield, MA 02048. 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