HomeMy WebLinkAboutRed Roof Inn 12/31/2006� TOWN OF MANSFIELD
I
BOARD
♦'1 OF HEALTH g
c
(�SIX PARK ROW,i 02048
In accordance with the provisions of Chapter I H. Section 12 7A of the Massachusetts
General Laws, and Regulations established by the Massachusetts Department of Public
Health (105 CMR 435.00). permit is hereby issued to:
Red Roof Inn, Inc. #7274
Ifor the operation of a ❑ Public ❑ Semi -Public ❑ Special Purpose Pool
I at.
60 Forbes Blvd.
I Method of water treatment is: Manually as required
11 Bathing load not to exceed: 55 bathers
I Number of Lifeguards required at all times the pool is open is: None
"NO LIFEGUARD ON DUTY" sign is required.
III Permit No.: 10
I Date of Expiration: December 31, 2006
Scott Leite, Health Agent Date Issued
REC'D DEC 12 2001
TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD 02048
SWIMMING POOL APPLICATION
Name of Owner: Red Roof Inn, Inc. #7274
Address:
P.O. Box 117508
City:
Carrolton
State: TX
Zip:75011
Telephone:
508-339-2323
Fax:
Fed ID/SS No.:
31-1393666
Pool Location:
60 Forbes Blvd.
Type/pool:
Concrete, In -ground
Length: 40'
Width: 20' Volume: 22,000
Min/Max. depth:
3' to 8'
Swim Area:
800sf
Dive Area:
None
Water Source:
Town
W/W Disposal:
Town Sewer
Type of Finish:
Gunite
Scum Gutter:
None
Deck Type:
None
Skmmr weir length:
Two baskets
Treatment System:
Diatomaceous
Disinfect Method:
Automatic Chlorine
Chemical Treatment: Manually as required
No. of Bathers:
55
Remarks:
Per daily testing pool maintained.
Permit No.:10
Fee per pool:
$75.00
Permit Expires December 31St yearly
SIGNATURE:
DATE: / i L;�;
DLC 2 G2 05
Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield Mail to:
Board of Health, Town of Mansfield, Sig Park Row, Mansfield, MA 02048.
RAHealth\Paft DocumelltAPERMIT APPLICATIONS\SW MMING POOLS APP -doe
The Commonwealth of Massachusetts
^� Department of Industrial Accidents
office OfINVO 1 PUGHS
600 Washington Stree4 7`h Floor
_ a Boston, Mass. 02111
Workers' Compensation Insurance Affidavit Gen*erangfl Businesses
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work site location ffidt address
❑ I am a sole proprietor and have no one Business Tie: El Retail [IRestaurantBar/Eating Establishment
working in any capacity. 1_) Office ❑ Sales (including Real Estate, Autos etc.)
f-1 I am an cmPloycr with -- em�lgees (full & part dime). Other T
I am an employer providing workers' compensation for my employees working on this job.
comaanv name -�°
no plkw Ll
address•
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c hone #-
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I am a sole proprietor and have hired the independ%nt contractors listed below who have the following workers'
compensation polices:
comnaay name•
address:
nhone #•
city
insurance
olic #
coin an name•
address:
hone #:
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Falters to tecare eoverage as regained ander Section 25A of MGL 152 can lead to We imposition of criminal penalties of a fine up to , and/or
one years' imprisonment as well as Civil Penalties in the fora. of a STOP WQRK ORDER and a fine of $11M.84 a day against me. T underabnd that a'
copy of this statement may be forwarded to the Office of Inveatigattons sf the DIA for coverage verifiattion.
I do hereby cfrtitifY under
Print name
ofperjury that the information provided above is true a d corrject
Date J,2 '/L1
Phone# `
official use only do not write in this area to be completed by city or town official
city or town permit/license t QBeildiag Department
QUcensing Board
Q
Q QftHealth Department
check it immediate response is required t ep Office
ealartment
contact person: phone #; QOther
(mvised sem. 200)) -
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.
Oez,
* Signatur f Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary)or 1
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 subiect to license suspension or revocation. This request is made under
the authority of Mass. General Laws, Chapter 62C, Section 49A.