HomeMy WebLinkAboutRalph Excavating - 12/31/2020Town of Mansfield
w Town of Mansfield d Board of Health s Park Row
10V 0 6 t Mansfield, MA 02048
4
Disposal Works Installer Application
LICENSE NUMBER: y_
APPLICANT: _". A pS a\tom
BUSINESS NAME:
MAIL ADDRESS:
CITY/TOWN: ' -ee— iN STATE: W ZIP CODE: CM00
BUSINESS PHONE: 4 b? XK 1 E Z BUSINESS CELL:
BUSINESS FAX: bQ6 C5--�CNZ
E-mail:
Alt E-mail:
ID/SS NUMBER:
LICENSE HELD: Town !) Year Licensed �t✓ � i � T—
LICENSE HELD: Town _ Year Licensed{ r'
LICENSE HELD: Town Cil9 \f Year Licensed } ,
I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage".
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires December 31st yearly.
FEE: $ 100.00
SIGNATURE: 7
DATE: 91 ' 7� ? C) �
Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield.
Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048
The Commonwealth of Massachusetts
Department of IndustrialAccidems
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Business/Organization Name: � i
-; r
� e e e _ tP% 0
Address:
i
City/State/Zip:.
Are you an employer? Check the appropriate box:
t. Q 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.
[No workers' comp, insurance required]
3. ❑ 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, insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance rea.l
Phone #:
Business Type (required):
5. ❑ Retail
6. El Restaurant/Bar/EatingEstablishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. F1 Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.0 Other
*Any applicant that checks box #1 most 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 #1.
I am an employer that is providing workers' co7q+pe'nsatlon insurance for my employees. Below is the policy information.
Insurance Company Name: A
4
Insurer'sAddress:`}-k 11rNI'd iPWe' . {'0
City/State/Zip:ye
Policy # or Self -ins, Lic. # !t ' l eai 1 s Expiration Date: L-1 ` Z ` 0
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 hereby certify, under the pains penahes of perjury that the information provided above is true and correct.
Siianature: * �p Date:
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: k
Phone
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.
Signature of Individual or Corporate Name
LA� ) k,
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*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.
C:Wsers\sleite\Desktop\Scott's Documents\Food Establishmeuts- Temp\TAX CERTIFICATION FORM.doc
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26168
POLICY NO. VWC-100-6007138-2019A
PRIOR NO. VWC-100-6007138-201 IA
ITEM
1. The Insured: Dana Ralph
DBA:
Mailing address: 110 Holmes Road FEIN: "-"'9112
North Attleboro, MA 02760
Legal Entity Type: Sole Proprietor
Other workplaces not shown above:
2. The policy period is from 04/22/2019_ to 04/2212020 12:01 a.m, standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications _ Premium Basis Rates
Code
Estimated
Per $100
Estimated
No.
Total Annual
Of
Annual
Remuneration
Premium
INTRA 000318766
Vfeemuneration.
INTER SEE
CLASS CODE SCHEDU
E
Minimum Premium $500 Total Estimated Annual Premium
GOV CLGOV Deposit Premium
STATE ASS
MA 6306 State Assessments/Surcharges
$4,228.00 x 3.8300% - >
This policy, including all endorsements, is hereby countersigned by C 03111/2019 _
Authorized Sign2fure Dale
Service Office:
54 Third Avenue
Burlington MA 01803
WC 00 00 01 A (7-11)
Include$ copyrighted material or the National Council on Compensation Insurance,
used with its permission.
Willis Mackinnon Ins Agcy Inc
5 Man Mar Drive
Plainville, MA 02762