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HomeMy WebLinkAboutMillhaus 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 9 PERMIT EXPIRES: December 31, 2018 Person Certified: JOHN M. BURKETT Pool/SPA Certification Date: March 19, 2014 Pool/SPA Certification Expires: March 19, 2019 Person Certified. Pool/SPA Certification Date: Pool/Spa Certification Expires: 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: MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE for the operation of a Public !V Semi -Public i i Special Purpose Pool located at. 150 RUMFORD AVENUE Method of water treatment is AUTOMATIC CHLORINATOR MARC MAC, 22 PSI Bathing load not to exceed. 70 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. .Amy Donovan -Palmer, Weaah .Agent Date Issued Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Swimming Pool PERMIT NUMBER: 9 PERMIT EXPIRES: December 31, 2018 Person Certified: JOHN M. BURKETT Pool/SPA Certification Date: March 19, 2014 Pool/SPA Certification Expires: March 19, 2019 Person Certified: Pool/SPA Certification Date: Pool/Spa Certification Expires: 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: MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE for the operation of a i 1 Public rvl Semi -Public I i Special Purpose Pool located at: 150 RUMFORD AVENUE Method of water treatment is AUTOMATIC CHLORINATOR MARC MAC, 22 PSI Bathing load not to exceed: 70 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. Amy Donovan-PaCmer, Heaah Agent Date Issued ,r e 3v?� „q�vqn of Mansfield Town of Mansfield - Board of Health -c 18 176rk Row' Mansfield, MA 02048 Swimming Pool Application NAME OF OWNER: MILLHAUS @ MANSCONDO TRUST - DAVID DOUCETTE ADDRESS: 2 HAMPSHIRE STREET t00B CITY: FOXBORO STATE: MA ZIP: 02035 TELEPHONE: (508) 339-3078 FAX: EMAIL: FED IDPSS NO: 04-6551192 Certification Expires Every 5 Years. Permit Expires December 31st Yearl PERSON CERTIFIED: JOHN M. BURKETT Pool/SPA Certification Date: 3/19/2014 Pool/SPA Certification Expires: 3/19/2019 PERSON CERTIFIED: Pool/SPA Certification Date: Pool/SPA Certification Expires: certification remarks(if necessary): POOL OPERATION PERMIT NUMBER 9 FEE; $125 1 Public V Semi -Public Special Purpose Pool POOL LOCATION: 150 RUMFORD AVENUE TYPE/POOL: GUNITE LENGTH: 60' VOLUME: 66,000 MINIMAX DEPTH: 4', 7', 10', 14' SWIM AREA: 18,000sf WATER SOURCE: TOWN WIDTH: 30' DIVE AREA: NONE WPW DISPOSAL: TOWN SEWER TYPE OF FINISH: CONCRETE SCUM GUTTER: YES DECK TYPE: CONCRETEI6' SKMMR WEIR LENGTH: 4, 8' APART TREATMENT SYSTEM: HAYWOOD 3000 DISINFECT METHOD: AUTOMATIC CHLORINATOR MARC MAC, 22 PSI CHEMICAL TREATMENT: SODIUM HYPOCHLORITE NUMBER OF BATHERS: 70 REMARKS: "NO LIFEGUARD ON DUTY" sign is required. (508) 339-7531 TRUSTEE NUMBER SAMANTHA CONTACT PERSON SI NATURE: DATE: 1441//XI17 Please ro 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. TAX CERTIFICATION FORM 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. -MO /A Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, ifAppticable) 6'1'6 & 5/l ick "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERmrrma AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: %Y1. /�`ir�i�C� /YYsrt rt aC /d e to ✓rze�oy Phone #: Z) B' JJc c--k7e Are you an employer? Check the appropriate box: Business Type (required): 1. b� I am a employer with _� employees (full and/ 5. ❑ Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2: ❑ I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3. [I We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have l0. El manufacturing no employees. [No workers' comp. insurance required]* 11. F1 Health Care 4, F1 We are a non-profit organization, staffed by volunteers, 12. ❑ Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #I 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 M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: Ptes 1006 166,;f 4-O& (/ City/State/Zip: /,"Y /nx Policy # or Self -ins. Lie. gy*) d /,o L �, "'� .s 1 /7�- Expiration Date: lAl olo,/18 Attach a copy of the workers' compensation policy dec to a8 page (showing the policy: number and expirationdate).'+ 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 DIA for insurance coverage verification. I do/h'e� er the pains and pen/¢Ities f perjury that the information provided above is trues and correct. c;/.. r,.. /. / 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 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone A�ORO® CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 12/07/22/0712017 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 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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Robert Monahan C & S INSURANCE AGENCY INC PHONE508) 339-2951 ac No: ADDRIESS: bob candsins.com INSURER(S) AFFORDING COVERAGE NAIC If P O BOX 466 INSURER A: AIM MUTUAL INS CO 33758 MANSFIELD _ MA 02048 INSURED INSURER D MILLHAUS AT MANSFIELD CONDOMINIUM TRUST INSURER C: INSURER D: DAMAGE To RENTED PREMISES Ea occurrence $ INSURER E: 2 HAMPSHIRE STREET STE 1008 INSURER F: FOXBORO MA 02035 COVERAGES CERTIFICATE NUMBER: 220273 - 1 REVISION NIIMRFR- 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. ILTH TYPE OF INSURANCE AODL SUBR .VDPOLICYNUMBER POLICY EFF MMIDD/1 W POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE 5 DAMAGE To RENTED PREMISES Ea occurrence $ MED EXP (Any one person) S PERSONAL& ADV INJURY 5 N/A AGGREGATE LIMIT APPLIES PER: POLICY JEo LOC _ GENERAL AGGREGATE $ GEN'L _ PRODUCTS-COMP/OPAGG $. $ OTHER: 1 AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ Ea accitlent' BODILY INJURY (Per person). $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accldenl) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE N/A DED F I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANYPROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBEREXCLUDED4 N/A NIA N/A VWC10060205362017A 12/20/2017 12/20/2018 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 100,600 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes, describe order — E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTIONOFOPERATIONSbelow N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD701,Addilional Remarks Schetlule, may be attached if mora apace is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the dale that this certificate was issued (unless the expiration dale on the above policy precedes the issue dale of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at w W.Mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN -(-Own Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 �D o C Daniel M. Crc(wjey, CPCU, Vice President— Residual Market— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 03/12/2012 05:32 5086685201 ALL SEASONS POOL PAGE 02/02 HAYWO Pool Products A Hayward Industries,lno, Company CERTIFICATION OF COMPLIANCE I HayWara Industrial Drive Clernntons, NC 27012 336-712.9900 WW W.naywardnet.com Contains: WG1048E of WG1048EW Description: 8" Round Suction Outlet Cover Ratings: Floor:_ 125 GPM Wall: 72 GPM Open Area: 8.1 Certified to Comply with Section 1404 of the Virginia Graeme Baker Act (VG13) Pool & Spa Safety Act Test Results can be obtained from:www_HaywaTdnet.com and/or httn://www.ns£orglCertified/Pools/ Manufactured: After December 20, 2008, by Hayward Pool Products in Jiangsu Province, China and Clemmons, NC Divisions of Hayward Industries, Joe. 620 Division Street, Elizabeth, NJ 07207, Phone 908- 355-7995 Date of Mfr: The Lot Number shown on the product label contains the Year & Month of manufacture. The first number represents the year (ex 8 = 2008) and the. second character the month (A=Jan, B=Feb, H=Aug, I is skipped, J=Sep, etc) Tested to ANSI/ASME 112.19.8-2007 (addendum 8a-2008) per Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act. Certified by NSF International, 789 N. Dixboro, Road, Ann Arbor, MI. 48105 1(800) -NSF -MARK, Date of Installation' 0a ac:A 6" SPACING BETWEEN MOUNTING HOLES ISWG1048COC Rev 13 G JOLDLINE HAMARD'PooiPmducw c� One source. Every pool. USED ON FOLLOWING SERIES: X73/4" SUCTION COVER OUTLET WG10d8E OO 0 00 It 00000 8 0000000�J0U00� 0000 00000 OOO 0 00 00 0000 000 Op OOOQc 00 O 000 000 �n 0 WG1030AVPAK2 WG1048AVPAK2 WG1049AVPAK2 WG1051AVPAK2 WG7052AVPAK2 W01053AVPAK2 WG1054AVPAK2 WG1153AVPAK2 WG1154AVPAK2 SP1030AVPAK2 SP104SAVPAK2 SP1049AVPAK2 SP1051AVPAK2 SP1052AVPAK2 SP1053AVPAK2 5P7054AVPAK2 SP1153AVPAK2 SP1154AVPAK2 G JOLDLINE HAMARD'PooiPmducw c� One source. Every pool.