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Home My WebLink AboutPond View Excavation Corp. - 12/31/2020NO V 18 2039 Town of Mansfield T"own of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: _ _3_1_ APPLICANT:C�'L�Ll/�tl�/l yr BUSINESS NAME: 1jQ12pt- (/�G'uJ MAIL ADDRESS: u� D __ ! (Pea(�Y1y� CITYITOWN: _r ! e/w6c� 1STATE: / //� - ZIP CODE: 0,2,; P % BUSINESS PHONE:/�'-3 3(0-�CoLoS BUSINESS CELL: , BUSINESS FAX: 7O/ — 113Y-C2I1 _.. E-mail: Alt E-mail: �J FEDERAL ID/SS NUMBER: LICENSE HELD: Town Year Licensed LICENSE HELD: Town ee/Co4t K Year Licensed LICENSE HELD: Town 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: �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 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. Pnnd /�� c�x��« oh ( 6 Signature of Individual or Corporate Name By. pora O icer (Mandator , if Applicable) 6 y 3e) 3/ "Social Security No. (Voluntary) or Federal Identification Number *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\s1ei1e\Desktop\Seotfs Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc 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 1,evibly Business/Organization Name: Address:_ �PnCl 66 City/State/Zip: t��IIL/s/l�EII/�/�t1'ov Are you an employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part -thee).* 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, § I (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 (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 1 12.� Other xl'a Ilcrill on *Any applicant that checks box #1 must also nu our um �� vi, �� w. �••� •• •••a --.ir workers' compensation policy mrormanon. **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 #l. I ain an employer that is providing workers' eonrpensationinnsurance for my employees. Below is the policy information. Insurance Company Name: % IfjerTT Insurer's Address: P.0 . (,Q(Q ()o City/State/Zip: y YI- -&eov G/_ Policy # or Self -ins. Lic. # t u/C 1S o t ci 229 0n2% Expiration Date: "1 1"aWZQ 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 andpenalties of perjury that the infortation provided above is true and correct. me #: D a Co — ` u 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 Phone Contact Person: www.mass.gov/dia l ® A� O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/0512019 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 Cross Insurance, Inc: RI CONTA T Sandra O'Regan NAME: _ AID No Ext. (401)431-9200 AIC, No; (401)431-9201 A'MAIL s: riceOlficates@cfossagency.com DDRE 376 Newport Avenue INSURER(S) AFFORDING COVERAGE NAICIt P. O. BOX 4830 INSURERA: Naufiluslns CO 17370 East Providence RI 02916 INSURED INSURERS: Selective Insurance CO Of Southeast 39926 INSURER C; Pond View Excavation Corp. INSURER O: Foley Excavation LLC INSURERE: 50 French Street INSURERF: Rehoboth MA 02769 THAT THEPOLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED, NOTWITHSTANDING MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD MD POLICY NUMBER POLICYEFF MMIDDNYYY POLICYEXP MWDDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 PREMISES Ea occurrence $ 300,000 CLAIMS -MADE ❑X OCCUR 15,000 MED EXP(Any one person) S q ECP202719310 09/21/2019 09/21/2020 PERSONAL a ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 3,000,000 X POLICY JECT Lon PRODUCTS - COMPIOPAGG $ $ OTHER: COMBINED SINGLE LIMIT Eas¢idenl $ 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (PeraaiaenU $ B OWNED X SCHEDULED A 9091349 03/20/2019 03/20/2020 AUTOS ONLY AUTOS HIRED NCO -OWNED X X PROPERTY DAMAGE per accident $ AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE S EXCESS LIAB CLAIMS -MADE DED RETENTION If PER OTH- $ WORKERS COMPENSATION STATUTE ER E.L. EACH ACCIDENT 5 AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA CARRIER WILL SEND DIRECT E.L. DISEASE - EA EMPLOYEE b OFFICERIMEMBER EXCLUDED? (Mandatory In NHL E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below Limit $1,000,000 POLLUTION LIABILITY ECP202719310 09/21/2019 09/21/2020 Deductible $5,000 A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if more space is required) Town of Mansfield 6 Park Row SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Mansfield MA 02048 I 6"4..w 1 n 19RH.201S ACORD CORPORATION. All rights ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD