Hawthorne Commons Pool Permit Application 3-26-2020 w
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ECEIVED
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6�K/Zf C APR 0 7 2020
'ITY OF SALEM PublicHealth
ARD OF HEALTH
f,,JMBERLEY DRISCOLL DAvrr)(.-.,RbENBAL1A4
HEiv-,filAGENT,
APPL
SWIMMING POOL
Hawthorne Commons, 205 Highland Ave, Salem, MA 01970
LOCATION OF POOL
NAME OF APPLICANT Dobrin Dobrev, CPO TEL# 857-271-6374
MAILING ADDRESS 100 Magazine St, Unit 4, Boston, MA 02119
EMAIL ADDRESS dobrin@highsierrapools.com I anirsa@highsierrapools.com
CERTIFIED POOL OPERATOR
Name: Dobrin Dobrev Cert#: CPO-521780TEL# 857-271-6374
DATES OF OPERATION(if not annual):_
DAYS &HOURS OF OPERATION: Monday-Sunday: 1 Oam-8pm
TYPE OF POOL
Public
Semi-Public X
Special Purpose
Surface Area 750 sf Volume—30000 gallons Bather Load 25
FEE: $210.00 for year-round pools $140.00 for seasonal $40.00 Non-Profit
(Please pay y total with one check payable to the City of Salem)
Tlus permit is not transferable and must be reissued upon change of ow-riership.
In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MG1,Chapter 63C,Section 49a,I certify Linder the pains and penalties of perjury that 1,to my best knowledge and belief,
haN,e filed all state tax returns and paid all state taxes required under the law.
/ 54-205-2031
Signature ,Mte SS4 or Federal Identification Number
This section for office use only
)/?I
Check A2)2qTAt__Date II Amount_���
CPO'-R
Certif ic
Name: Dobrin 1. Dobrev {�
Date Dertifie�U April 22, 2-415
Certification Number: CPO-521780 --
Instructor Name: Krasimir Simeonov
Pob I ivanov . -
Certification Expirs: April ,-202't
�- - � � 6
124578- 14064 .
� I-
ate``
CPO®R Certif ication
Name: Dobrin #. Dobrev Y�
Date Certified.: April 22, 2016
Certification Number: CPO-521780
Instructor Narfte: Krasimir Simeonvv
Pghi iva nov
' Ex iris. April f2,, 2021 _ �.���
Certification p
124578-614054
Certificate of Completion
Natasa Javorac
has successfully completed requirements for
Lifeguarding/First Aid/CPR/AED
conducted by
American Red Cross
Date Completed:04/09/2019
Valid Period:
2 Years
Instructors:Marko Popovic
Y
I
Certificate ID:GXLRBO
To verify,scan code or visit:https://www.redcross.org/take-a-class/grcode?certnumber=GXLRBO
Certificate of Completion
Radovan Lamos
has successfully completed requirements for
Lifeguarding/First Aid/CPR/AED
conducted by
American Red Cross
Date Completed:02/24/2019
Valid Period:2 Years
Instructors:Matej Halasa,Rita Bernatova
❑:R ��❑i
Certificate ID:GXE16V
To verify,scan code or visit:https://www.redcross.org/take-a-class/grcode?certnumber=GXE16V
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
s Boston,MA 02114-2017
e www.mass.gov1&a
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le iblv
Business/Organization Name: High Sierra Pools, Inc.
Address: 2704 Columbia Pike
City/State/Zip:_Arlington,VA 22204 Phone#: 703-920-1750
Are you an employer?Check the appropriate box: Business Type(required):
1.0 I am a employer with 175 employees (frill and/ 5. ®Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7• ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
_ [No workers' comp. insurance required] g• Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp. insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers, Pool Management and Service
with no employees. [No workers'comp. insurance req.] 12.❑✓ Other g
*Any applicant that checks box#1 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 91.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy information.
Insurance Company Name:HMS Insurance Associates, Inc.
Insurer's Address: 2704 Columbia Pike
City/State/Zip: Arlington VA 22204
Policv#or Self-ins.Lie.# 30WELJ4825 Expiration Date: 3/1/2021
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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 herebv certify,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 044Z� Date: 3/1/2020
Phone#: 781-605-8337
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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 Person: Phone#:
www.mass.gov/dia