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Home My WebLink AboutJ. J. Bosse Construction Co., Inc. - 12/31/2020Town of Town of Mansfield - Board of Health 6 Pak Rowansfield b 'LO Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: Cn rol i n e, �t^ aA CITY/TOWN: So__EaSA0r) STATE: 1`� ZIP CODE: BUSINESS PHONE: —� tt��rr77 BUSINESS CELL: BUSINESS FAX: __T9_r 3 E-mail: boas' LQ_( Q1'�Q�Q*. n p—+ Alt E-mail: ID/SSNUMBER: (pq-3o?96ID6 LICENSE HELD: Town gm- `l__-___ LICENSE HELD: Town F: �I AGC' WGL�Ir LICENSE HELD: Town w 9(- t At? i>ya.Ae_r Year Licensed )q q0 tb Year Licensed IG 90 to V(-eso^+ Year Licensed viiv-.tp p 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: y� DATE: 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 To: J J BosSe Page 3 of 3 2019-10-24 14:02:07 (GM I) DATE (MMMDNYYYI AC[ R CERTIFICATE OF LIABILITY INSURANCE 1012412019 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 all ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the felons and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder to lieu of such endomement(s). JADORES-s: PRODUCER Donna Benoit 'I _ WILLIAM L GOODRICH INSURANCE AGENCY INCv,. (617) 698.6544 ac Nal: dhenoft@wgoodrichins.com_ ..--�424 ADAMS ST INSURER(SIAFFORDINO COVERAGE NAICMILTON MA 02186_�ISERTYMUTUAL FIRE INS CO ____ 23035INSURED-- ---_._:J J BOSSE CONSTRUCTION CO INC C: 35 CAROLINE ROAD DOWIY111M NIMMRFR• COVERAGESTHIS INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD fS TO CERTIFY THAT THE POLICIES OF REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS INBR :0—M B POLICYy EFF POLICY EXP LIINTS TYPE OF INSURANCE POLICY NUMBER MMIODIVYF MlhorvyYYY LTR COMMERCIAL GENERAL UABIUTY BAC H OCCU RRENCE S DAMAGE TO RENT D CLAIMSF MADE OCCUR PREMISE�s, ocw1-0t-J_ — MED EXP(NtY One befs S N/A PERSONAL B ADV INJURY S GEML AGGREGATE UNIT APPLIES PER: GENERALAGOREGATE S ] PRO PRODUCTS-COrd Plop AGG S LOG POLICY JECT I ,_ OTHER: COMBINED SINGLE LIMIT S AUTOMOBILE LIABILITY i Pwziwt BODILY INJURY(Peipenmd $ ANY AUTO ALL OWNED SCHEDULED NIA BODILY INJURY(Pe,aridenp $ AUTOS AUTOS PROPERT/DAMAGE Por AuidenG b H HIREDAUTOS AUTos, 5 UMBPELLALIAB OCCUR EACROCCURRENCE S AGGREGATE 4 EXCESS LIAR CLPIMB-0fADE NIA 5 DEO RETENTIONS �/ PER OTH X BUT ER WORHERSCOMPENSAVON E.L. EACH ACCIDENT S 100,OD0 AND EMPLOYERVUABIUTY YIN A ANYPROPRETORPARTNERJEXECUTIVE OFFICER/AIEIADEREXCLUDED'I NIA NIA NIA WC2315317826049 04/05/2079 04/D5/2020 E.L. OISEPSE-EA EM1IPLOTEE S 100,000 If1¢a, tl¢sctb¢ under EL.DISEASE-POLICY LIMIT 5 50D,DDD DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES IADDRD 101, Additional Ramada Sehedulry maybe atlechetl it mP�e space is,equireAl 1NOrk•ers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B. no authorization is given to pay claim3 for benefits 10 employees in stales other than Massachusetts if lire insured hires, or has hired those employees outside of Massachusetts. This i;ergificate of insurance shows the policy in torte on the dale thatlhis cenfOcale was issued (Unless the expiration date on the above Policy precedes the issue date of this certificate at fnsumnce). The status of this coverage CRT be monitored daily by accessing the Pmnt of Coverage- Coverage Verification Search tool at mm.mass.gov/iwdAnofkeis-conipeasatioll/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield SIX Park ROW AUTHORIZED REPRESENTATIVE Manufteld MA 02048 Daniel,M. Crow By. CPCU, Vice President — Residual Market — WORIBMA -- n 1988.2014 ACORD CORPORATION. All rights reserved. ACO RD 26 (2014101) The ACORD name and logo are registered marks of ACORD TO: J J BosHe Page 2 of 3 2019-10-2414:02:07 (GMT) lot /ov lovHo n�nc. vvnna, 1orz4/zols Ac"RV CERTIFICATE OF LIABILITY INSURANCE DATOr2412019 THIS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS THIS CERTIFICATE IS ISSUED AS A NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES 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 conter rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: DOOOa BeD01l PHONE (617)698-5544 Ac, No: (617)693-8515 C No Ex : William L. Goodrich Agency, Inc. ADDRESS: dbenoilQwgoodrichins.com 424 Adams Street#102 INSURPRfAu AFFORDING COVERAGE NAIC Or Milton MA 02186 INBURERA: Hanover Insurance Company 22292 INSURED' INSURER B: Allmerlca Financial Benefit 41B40 INSURER c: Liberty Mutual Fire lns:ARWC 16586 J J Bosse Construction Co., Inc. INSURER 0: 35 Carolina Road INSURER E : INSURER F: South Easton MA 02376 COVERAGES THIS IS TO CERTIFY THATTHE 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. CTR IN FCOWCA�R7 LAIMS.AIADE Tol"IPOLICY 0 NUMBER MMIUOI YYY U Flo YYVY LIMITS EACH OCCURRENCE $1,000.000 PREMISES(Ea occurrence) g 10,0000 NED EXP JAW Me parson) $10,OD0 A ZHN912c,15208 0610612019 0610612020 PERSONAL 8 ADV INJURY $ 1,000.000 GIiNL AGGREGATE LIMIT APPL!EB PER. POLICY ®jE0 MLOC GENERALAGOREGATE $ 2,000,000 PRODUCTS AGO 2,000,000 $ Lessees Owners or Lessees Owners $ B OTHER. AUTOMOBILE LIABILITY ANY AUTO OWNED x SCHEDULED AUTOSONLY AUTOS HIRED x NON -OWNED i� AUTOSONLY X AUTOSONLY Y AWN9107254 0610612019 0610812020 COMBINED SINGLE UABT Ea accident $ BODRYINJURY(Perpe,wru $ 1,000,000 BODILY INJURY (Per ecc.Hent) $ 1,000,000 PROPERTY DAMAG Peraceldwe $ 1,GW,000 $ UMBRELLA LIAR OCCUR EAGHCCCURRENGE $ AGGREGATE S EXCESS LIAR CLAIMS!dADE DED RETENTIONS WORKERS COMPENSATION PER OTH STATUTE ER S EL EACH ACCIDENT $ G Alto EMPLOYERS' LIABILITY YIN AIIY PROPRIETORSPARTNERIEXECUTiVE ❑ OFFICEW'MEMBER EXCLUDED? (Randelory in JIM NIA Provided directly by carrier EL. DISEASE - EA EMPLOYEE $ E L. DISEASE -POLICY LI!MT $ If ies, desco center DESCRIPTION OF OPERATIONS Who DESCRIPTION of OPERATIONS I LOCATIONS I VEHICLES (ACORD tet, Additional Remmke Schedule, may be attached if morn e W ca!s required) Town of Mansfield and any other parties required by specific written contract are added as an additional insured with respect to the general liability and automobile liability insurance on a primary and non-contributory basis. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Twin of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Six Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 All riuhter reserved. ACOIRD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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 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/Aicense 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 Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Fomi Revised 5-26-05 The Commonwealth ofMassachusetts . B Department dflndustria(Aecidents j a Office oflnvestigations 600 Washington Street Boston,11LI 02111 www.mass.gopldia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIeetTiciam/Plu-mmb.ers' Applicant Information Please Print Legibly Name(Busmess/Orgauization/individnol) Address: Are you an employer? Check the appropriate box: 11LI am a employer with E 4. ❑ I am a general contractor and I employees(fnlland/orpart-time).* have hired the sub -contractors 2. Ej I am a sole proprietor or partner- listed on the attached sheet t Ship and have no employees These sub -contractors have working for me in any capacity: workers' comp, insurance. [No workers' comp. insurance 5- ❑ We are a corporation and its required] officers have exercised their 3. ❑ I.am a homeowner doing all work, right of exemption perYGL myself- [Nq workers' coffip. c, 152, §1(4), and we have no insurance required,] t employees. [No workers' Type of project (required): 6. ❑ New construction 7. Remodeling. 8. Demolition 9. El Building addition ME] Electrical repairs or additions 11-❑ Plumbing repairs or additions 13z? O ofrsegaits , ('v'( l3 � Others L�'.r \9'/, *Any applicantthatsubmitsb a1m t )3oameownas ustabofillcutthesectionbelowshowingtheirworkers'compensationpolicyinforreation- who suhmitthis affidavitindicatmg they are •doing all work and then hire outside contractors must submit anew affidavit indicating such. tCoutmcfots that check this box.must attached ao "ationai slieet showing the name of the subcontractors and they worker;' comp, policy information. ZdYn ins employer that isproviding.workers' compensation insurmmee for my employees. Below is the policy and job site . nfdrmizaon. .. Insurance Company Name: f e Policy # or Self ins. Lic. #:� .` S . °� 91011, 0�� Expiration Date: e fhb Site Address: City/State/Zip: Attach a copy of the .workers'compensation polidq decLrrition page (showing the policy number and expiration date). -. ]?aliv e to'secgm coverage as regtiirediuider Seatlon 25A of MGL c.`152 sari lci to the imposition of ri n;nal penalties of a. fine up tb, $1,500.00 and/or one-year imprisonment, as *well as civil penaltiesin the foun of a STOP. WORK ORDER and a fie'. of lip to $250,00 a -day agamsf,the violator. Be advised thaf a copy ofthis statementmay be forwarded to the Office of,' ` lfldestigatior s of the DIAL for insurance coverage veaCication I do hereby 4r/rfj under fling pains m/t�peimalties ofperjury that the inforii f b?1 provided abo9e is true and correct (/ 1 ate: . �% .- �'�� -- � • Offlgial use only. •Do not write-in this area, to be completed by city or tows offeial _city or Town: Permitff,icelMe.# 7ssrdng Authority (circle one): A. Board of ilealth 2. Bm1d l4Department 3- City/Town Clerk 4: IIectrical Inspector: S. Plumbing Inspector 6. Other Contedt Person: -- Phone #: