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HomeMy WebLinkAboutS & L Construction, Inc. - 12/31/2020m Town ®f Mansfield - Board of Health NOV 12 2019 APPLICANT: V0 BUSINESS NAME: 7- L%��✓E✓ �� I fir` ii MAIL ADDRESS: -Y\ �0 S � Town of Mansfield 6 Park Row Mansfield, MA 02048 CITY/TOWN: r �� 4 �j STATE:(✓1✓I ZIP CODE: O 1 l BUSINESS PHONE°`? `'° i BUSINESS CELL: �_1 BUSINESS FAX: E-mail: i SS r't ( �� ✓0,, L Alt E-mail: EDERAL ID/SS NUMBER: t� LICENSE HELD: Town LICENSE HELD: Town �N �r� trJ p t- Year Licensed L i — l 4' Y Year Licensed /;7 C' t LICENSE HELD: Town -j'AU rLJGj(r Year Licensed z v I 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: r DATE: I 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 Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: `- L& C lg", -C/ -W h `y vl� m ✓ L eL) iN i; Phone #: ` > ?� .. 4 Are yo n employer? Check the appropriate box: Business Type (required): 1. I am a employer with j employees (full 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] 8. ❑ 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, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #I mast 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 mid such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. di Insurance Company Name: t_1 ( & A A L�1,-, ` 1 v SL a �'P`C Insurer's Address: tupc A City/State/Zip: ilul V'- W ��^^ II Policy # or Self -ins. Lic. # C7 V u r,7- � F � 1) t -7— 11 Expiration Date: 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 Investieations of the DIA for insurance coverage verification. I do hereby,certify, under t p •ns and penalties of perjury that the information provide Bove is true and correct. Signature:' C` Date: [ t� 1 Phone k t/ jZ G- �,f�i 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 if: www.mass.gov/dia A� V CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDn'YYY) 10/08/2019 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 CONTACT Steven Saccoela NAME: Ora Andrews Insurance Agency, Inc. Px�N o (508) 285-4322 Fa (508) 285-6968 E.l : c No: E-MAIL steve@oraandrewsins.com 114 West Main St. ADDRESS: INSURERS) AFFORDING COVERAGE NAIC# P. O. Box INSURERA: Travelers Insurance Co 19046 Norton MA 02766 INSURED INSURER B: Abele Protection Insurance CO 41360 INSURER C: Robert Salvo OBA S&L Construction Co. INSURER D: 26 Newcomb St INSURER E: INSURER F: Norton MA 02766 COVERAGES CERTIFICATE NUMBER: CLI94105657 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 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER POLICY EFF (MWDDfmyl POLICY E%P IMMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 ;;/ CLAIM&MADE OCCUR DAMAGETORENTED PREMISES Ea occurrence S 300,000 MEO EXP(Any one person) S 5,000 PERSONAL BADV INJURY $ 1,000,000 A 6802572P450 12117/2018 12/17/2019 GEN'L AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2.000,000 X POLICY ❑ PRI LOC PROOVCTS-COMP/OPAGG $ 2.00D,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccklent $ SCDILY INJURY (Per person) s 100,000 ANYAUTO g OWNED x SCHEDULED AUTOS ONLY AUTOS 1020017281 04/14/2019 04/14/2020 BODILY INJURY (Per accident) s 300,000 X PROPERTY DAMAGE Pe accident $ 250,000 HIRED x NON -OWNED AUTOSONLY AUTOSONLY S UMBRELLAUAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION S $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA 6HUB-9F50518-2.19 01/25/2019 0112572020 �/ PER OTH- X STATUTE ER EL. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Add%lonal Remarks Schedule, may be allachad It more space Is required) Sole Proprietor, Robert Salvo Sr, is excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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 `�-��-2 **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:\UsemWeite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc