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HomeMy WebLinkAboutSoares Pumping, Inc. - 12/31/202026 2019 9f Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 APPLICANT: LohyC� - �)oG ce_ S �j('_ �USINESSNAME: SC)cmS �Vh1p1 oLar_ Zr1C MAIL ADDRESS: 11/5 T hcrnShe?G CITY/TOWN: 7_aoo4'on STATE: PAVI ZIP CODE: W BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX: 5055'- 5-a y. %�f a E-mail: SAleS Q S-mi-tS'powlOi� nd Alt E-mail: ID/SS NUMBER: N - 3L/ (O 5 93 G LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed 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 31 st yearly. FEE: $ 100.00 SIGNATURE: DATE: I U 61 `6' �q 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 Industrial Accidents Of/ice o/'Investigations 600 Washington Street Boston, MA 02111 wwiv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Infornnation Please Print Leilibly Business/Organization Name: Address: iq5 % kIC%SVNu City/State/Zip: TCl.010) X1, IMVi QL?7'�I) Phone #: `yOFi• 'bZ9C%' Dye? Are you an employer? Check the appropriate box: 1. I am a employer with 0 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, § t(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 req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (inch. real estate, auto, etc 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.[Z Other Se-Q 'Any appI ic:mt that checks box nil must also fill out the section below showing their workers' compensation policy intonnEll ion. **If the corporate officers have exempted themselves, but the corporation has olhor employees, a workers' compensation policy is required and such art organization should check box 9I. am an employer that is providing workers' compensation insurance for my employees, Below is the policy injbonatiar. Insurance Company Name: �' tly� =Yl�il9JCCnInC Insurer's Address: Da c-) W%I11Ken Z) City/State/Zip: Policy 17 or Self -ins. Lic, # �� ' ��101� 7 5 (O Expiration Date: 1 /a3I ao Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late). Failure to secure coverage as required under Section 25A of MGL c. 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 it tine of up to $250.00 a day against the violator. Be advised that a copy orthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certlfy, under the pains and pe\r`m//l tt iies of'perjwy that the information provided above i true and correct. Cionattn.a�� � V Dale : Id a U �1 Phone #: Official use only, Do nol ivrile in this area, to be completed by city ar town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of ilealth 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone #: www.n lO N,i;U VHnJ 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 By: Corporate Officer (Mandatory, if Applicable) oN - 3y(o 593G "Social Security No. (Voluntary) or Federal Identification Nuinber *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:\Users\sleite\Desktop\SeotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants i Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Off►ce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www,mass.gov/dia .nm Revised 5-26-05 SOARSAN-02 PAMARAI 1 ACORo' CERTIFICATE OF LIABILITY INSURANCE �./ D 10/28/2019 Y) 10/28/2019 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 have ADDITIONAL INSURED provisions or 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 License # 1780862 HUB International New England 222 Milliken Boulevard Fail River, MA 02721 CONTACT Megan Bodyul NAME: _ PHONE 508 235-2231 PAX (ac, No, Eke: ( ) (Arc, No): _ noD"BESS, megan.bodyul@hubinternational.com INSURER jSj AFFORDING COVERAGE NAIC If INSURER A: Selective Insurance Company of South Carolina 19259 _ INSURED B:Safety Insurance COm an 39454 -INSURER INSURERC:Ironshore Specialty Company__25445 Soares Pumping Inc INSURER D : 195 Thrasher Street Taunton, MA 02780 _ INSURER E INSURER F: COVERAGES CERTILICATR Mu"ai R- RPVISION 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. INSR LTR TYPE OF INSURANCE ADDLSUBR N POLICY NUMBER POLICYEFF M p POLGYEXP pD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR S2190987 1/1/2019 1/1/2020 DAMAGE TO RENTED PREMISES 131 QF F9rrence 500,000 MED EXP An one ersonj �^ 15,000 _ _ PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3,000,000 PRODUCTS - COMP/OPAGG. $ 3,000,000 _ POLICY [XX]jPa [X] LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY Per erson _ ANYAUTO 2707821 1/22/2019 1/2212020 AUTOSONLV X AUTOSULED BODILY INJURY Per accident $ 1,000,000 _ ROPER AMAGE Per aca ent _. $ E AUTOS ONLY —_ AUT 9 ONLY $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 EXCESS LIAB CLAIMS -MADE S2190987 11112019 1/1/2020 AGGREGATE $ DED RETENTION$ S 3,000,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANNFICEWM�MBEREXCTNERIE ECUTIVE ❑ (Mandatory m NH) NIA PER EORH _..._.. E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below C Pollution / Envlronm 002617503 1/1/2019 1/1/2020 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORO 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER r'ANCFI 1 ATInIJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE / 14'�T ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SOARPUM-01 PAMAR ACO CERTIFICATE OF LIABILITY INSURANCE GATE(MM/ODNWY) 10128/2019 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 have ADDITIONAL INSURED provisions or 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 License # 1780862 1 un°ji CT Megan Bodyul INSURED England Scares Pumping, Inc 195 Thrasher Street Taunton, MA 02780 235.2231 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADOLSUSR INSO =0 POLICY NUMBER POLICY EFF IMIWDD POLICY EXP DD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE S DAMAGE TO RENTED PREMISES Ea occurrence MED EXP (Anyone dersond GEHL PERSONAL 8 ADV INJURY AGGREGATE LIMIT APPLIES PER: POLICY ❑ jECT LOG OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ _AUTOMOBILE _ LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS H RED NON -OWNED A�TOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident BODILY INJURY Perperson). $ BODILY INJURY Per accident $ _.... PpROPERTY AMAGE _(reracatleni $ $ _ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE S DED I I RETENTION$ A WORKERS COMPENSATION AND ANY PROPRIETORIPARTNER/EXECUTIVE YIN F SEMMn NH EXCLUDED? ( story,) If yea describe under DESCRIPTION OF OPERATIONS below NIA WC9080203 1/23/2019 1123/2020 X PER ERH E.L. EACH ACCIDENT S 500,000 E.L. DISEASE-EAEMPLOYE $- 500,000 E.L. DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101. Addltlonal Remarks Schedule, may be aaached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Mansfield 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ?9/'4,:T ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD