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HomeMy WebLinkAboutStation Pointe Apts.#2 12/31/2018old - Board of Health Sivilursting Pool Application. NAMEOFOWNER:�,LL.rAJI(�UI�III�W A0ORESS: q it,ac. JniY Awil"' CITY: k4an uielW..::. " 20 (}, STATEWA ryq/�ZIP:O.(V�lS TELEPPH�O�yNIZ:: /�� Q0-� jJJ� - *,IV, FAX::ItrD-u 1-`tT -q % �y�, EMAIL: -jy (PI?Vq1/f1l)/1QI.f1 1 Uls'. wn FED IDISS NO: 62 -mol I e FEE PER POOL: $12.V Certification Explres EVery 6 Years. Permit Expires December031st YearlyyQ PERSON CERTIFIED.,iVtfty) a.V Pool/SPA Cedification Data. S/1417 POO)/SPA Certification Expires M012Z PERSON CERTIFIED: Pool/SPA Certification Date: PooVSPA Certification Expires: corlitication romarks(It necessary): REMARKS: I -No LIFEGUARD ON DUTY" sign Is required. Town of Mansfield 6 Park ROW Mansfield, MA 02048 PERMIT NUMBER FEE: $125 9 Public POOL OPERATION: [cij'Semi-Public E3 Special Purpose Pool POOL LOCATIONJI1Vn ff� lie TYPEIPOOL: MalAND) LENGTH: 4 �'01 VOLUME: MINIMAX DEPTH,.d l -/ SWIM AREA: U/W WATER SOURCE:"r0 V1 1 W��0/ �ryIDTH; llJ WAN DISPOSAL:"" TYPE OF FINISH: 11h/o SCUM GUTTER: vV�IntO, DECK TYPE: I,UI tm, SKMMR W EtR LENGiH: 9 0 TREATMENT SYSTEM: if DISINFECT METHOD: Ion n C/ CHEMICAL TREATMENT: 11,1Y1 r-1 NUMBER OF BATHERS: - 1 SIGNATURE: fKQ DATE; ! Please make p ropriale changes. Sign, date and enclose check payable to Health, Town o Mansfield, Six Park Row, Mansfield, MA 02048. DIVE AREA: rtl(t, of Mansfield. Mall to: Board of 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. tbO- of Individual or Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal'ldentification 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 Connnonwealt/t ofMassachuselis Department oflndastrlaMecidenis Office ofinvestigations 600 Washington Street Boston, MA 02111 u,p www.ntass,gov/dia Worlcers' Compensation Insurance Affidavit: General Businesses Business/Organization o5 Ac ou an employer? Choc c thea proprinte box: 1.W 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. kilo workers' comp. insurance required] 1 ❑ 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. insurancercquned]' 4. ❑ We are a non-profit organization, staffed by voluntecra, with no employees. [No workers' camp. insurance req.] Phone Business Type (required): 5. [:]Retail 6. ❑ Restaurant/BartEating Establishment 7. [] Office and/or Sales (incl. real estate, auto, eteJ 8, ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing I l.❑ Health Care , �J� 12)2 Other jW;1 Pec l' rtri *Any applicant fiat checks box 8t must also as out the section below showing their workers' compensation policy information. **If iho corpomto officers havo exempted themselves, but tho corporation has other employees, a workers' compcnsatlon policy is required and such an organization should check box al. / am an employer tint Is prov diag Ivo' Jerscornpensadon lnsrrrai�ae for my employees. below is the policy i+rfortnatlon, Insurance Company Insurer's City/State/Zip: Policy 8 or Self -ins. Lie. Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Pailuru to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a tine 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 No 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 Invostivations ofthe DIA for Insurance coverage verification. I do hereby certify, of perktry thrd the hrfornradou provgyd abope is true and correct. use only. Do not write In this area, to be completed by city or town official City or Town: Permit/Lleenso 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 +v+vw.mess.govtdia Phone A� CERTIFICATE OF LIABILITY INSURANCE DAM YVY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 1/12/20 12/20 8 18 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 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 Alliant Insurance Services, Inc. 2415 East Camelback Rd Suite 420 CONTACT NAME;PHONE .6O2-707-1900 FAX aC No, 480-333-6973 E-MAIL DDRESS Phoenix AZ 85016-4266 INSURERS AFFORDING COVERAGE NAIC # INSURER A -Libertv Mutual Fire Ins. Co. 23035 INSURED Continental Pools, LLC 8520 Corridor Rd., #B Savage, MD 20763 INSURER B: Liberty Surplus Insurance Corp10725 10/25/2018 INSURERC AXIS Surplus Insurance Company 26620 INSURER D:First Mercury Insurance Company 10657 INSURER E: Navigators Insurance Company 42307 INSURERF:Ohl0 O8SUalt Insurance Com an 24074 DA AGETORE D PREMISES Eacccunence $1,000,000 COVERAGES CERTIFICATE NUMBER: 1671569023 REVISIO N NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF IN 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. INSR LTR TYPE OF INSURANCE INSD Won POMCY NUMBER POLICYEFF MM/DDIYYYY) POLICY E%P (MMIDDIYYYYl LIMITS B X COMMERCIAL GENERAL LIABILITY 100001724608 10/25/2017 10/25/2018 CLAIMS ❑X EACH OCCURRENCE $1,000,000 DA AGETORE D PREMISES Eacccunence $1,000,000 -MADE OCCUR MED EXP (My one person) $Excluded PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY O jEO El LOC PRODUCTS - COMPIOP AGG $2,000,000 Policy Aggregate $$10,000,000 OTHER: A AUTOMOBILE LIABILITY AS2661066678027 10/25/2017 70!25/2076 MB IN T EaaCcidenl $1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS ROPERT AMAGE § Per actltlent $ C UMBRELLA LIAB H OCCUR ELU790250012017 10/25/2017 10/25/2018 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMSMADEAGGREGATE $1,000,000 DED I I RETENTION$ $ A WORKERS COMPENSATION WA766DO66678017 10/25/2017 10/25/2018 XSTATUTE AND EMPLOYERS' LIABILITY YIN EORH E.L. EACH ACCIDENT $1,000.000 ANY PROPRIETORIPARTNER/EXECUTWE OFFICEMMEMSER EXCLUDED? NIA E.L. DISEASE -EA EMPLOYE $1,000,000 (Mandatory H) In ander 8yes,atoryIdescribe E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below E Excess GUEL NJEX000005872903 10/25/2017 10/25/2018 Each OCUAggregate $10,000,000 F Excess Auto SF17EXC7048301V 10/25/2017 10/25/2018 Each OCC/Aggregate $10,000,000 Excess over D & E ECO1856322216 10/25/2017 10/25/2018 Each Occ/Aggregate $10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be amached if more space is required) EXCESS LIABILITY OVER "P' Indian Harbor Insurance Cc NAIC#36940 Policy#SXS0050794 10/25/17-10/25/18 Each Occ/Aggregate $15,000,000 GERT iFiCA I E HOLDER rAMCPI I ATInM - Proof of Insurance Continental Pools 8520 Corridor Rd, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Suite B AUTHORIZED Savage MD 20763 ©1988-2014 %CORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Ellis & Associates ILTP Course Completion 02F International Lifeguard Training Program Trainee Information Photo: Credential Number: Date of Birth: Scan Code: 1060-6577 07/02/1998 Q N Full Name: Abdulazeez Mohammed Email Address: azizmohammed9872@gmail.com Training Information Credential Description: REN302 - Renewal - Pool ILTP Course Completion. Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet -excluding open water environments. AAOS/ACEP (Emergency Care & Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Training Depth: 8 ft 12.4 m Credential Issued To: State: Country: ILTP - Continental Pools, Inc MD RCCMD ID: Comptetion Date: Expiration Date: 1004-4227 February 25, 2018 February 25, 2019 Training Agreement I acknowledge that I have received and understand the ILTPTM Training Program curriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPTM course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM does not provide any protection whatsoever to my employer or myself. Name (Please Print): Signature: AbdulveeZ Aldvmmred, Abdulazeez Mohammed Trainer Validation I hereby certify that the holder of this ILTP TM Course Completion Credential has successfully met all required skills competencies (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramTM for the lifeguard classification indicated above. I have also reviewed the ILTPTM Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment. Trainers Name (Please Print): Trainer's Signature: V1�Gir�1M t��savwera William Alsamerai For additional information regarding the Ellis Educations Services please call or write to: Jeff Ellis & Associates, Inc. Business office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 Email: business@jellis.com Ellis & Associates ILTP Course Completion International Lifeguard Training Program Trainee Information Photo: Credential Number: Date of Birth: Scan Code: r 1068-3600 06/03/1999 N AM Full Name: Arianna Visocchi ' , Email Address: arivis1l@hotmail.com Q Training Information Credential Description: REN302 - Renewal - Pool ILTP Course Completion. Training includes conscious, unconscious and suspected neck and back rescue skills for water depths not exceeding 16 feet -excluding open water environments. AADS/ACEP (Emergency Care & Safety Institute-ESCI.org) Healthcare Provider CPR, AED, Oxygen Administration and Standard First Aid training included. Training Depth: 8 ft 12.4 In Credential Issued To: State: Country: ILTP- Continental Pools, Inc MD RCCMD ID: Completion Date: Expiration Date: 1004-4227 February 25, 2018 February 25, 2019 Training Agreement I acknowledge that I have received and understand the ILTPTM Training Program curriculum and demonstrated said skills and knowledge to required competencies. I further understand that it is my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPTM course through regular and consistent in-service training. It is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard. I further understand and acknowledge that Ellis & Associates and/or ILTPTM does not provide any protection whatsoever to my employer or myself. Name (Please Print): Signature: AYlavim VtSDuA Arianna Visocchi Trainer Validation I hereby certify that the holder of this ILTP TM Course Completion Credential has successfully met all required skills competencies (including but not limited to Prerequisite screening, rescue skills, BLS Skills, written and practical exams) and curriculum requirements as prescribed by the International Lifeguard Training ProgramTM for the lifeguard classification indicated above. I have also reviewed the ILTPTM Course Completion Acknowledgment with its holder and am satisfied the card holder clearly understands said acknowledgment. Trainers Name (Please Print): --T7 Trainer's Signature: Willia William Alsamerai vt >4fxera For additional information regarding the Ellis Educations Services please call or write to: Jeff Ellis & Associates, Inc. Business Office, 508 Goldenmoss Loop Ocoee, FL 34761 Office: 1-800-742-8720 Facsimile: 407-654-1723 E-mail: business@jellis.com 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: 11 PERMIT EXPIRES: December 31, 2018 Person Certified: SVETOSLAV A. KAZAKOV Pool/SPA Certification Date: March 10, 2017 Pool/SPA Certification Expires: March 10, 2022 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: BEACON COMMUNITIES, LLC for the operation of a [ I Public ! i Semi -Public i i Special Purpose Pool located at. STATION POINTE 2 Method of water treatment is CHLORINE Bathing load not to exceed: 54 bathers Number of Lifeguards required at all times the pool is open is: None "NO LIFEGUARD ON DUTY" sign is required. .Amy Donovan -Palmer, Health .Agent Date Issued