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HomeMy WebLinkAboutGuaranteed Builders & Developers, Inc. - 12/31/2020Town of Mansfield - Board of Health Nov 0 6 2019 Disposal Works Installer Application LICENSE NUMBER: ,,�C7 Town of Mansfield 6 Park Row Mansfield, MA 02048 APPLICANT: 1 ° l-t{YV_l' — __ 2 i ✓ -- } BUSINESS NAME: GvCty .. i MAIL ADDRESS:--.___-- CITYITOWN:I C)j,110-,S STATE: (1iCL ZIP CODE: BUSINESS PHONE: 50T-Lf7J,-15vvBUSINESS CELL: BUSINESS FAX: (5:c) _47� _^ I li - E-mail: du is C!Dr^ - Alt E-mail: t -f a ..�lrve+uSintU C�'VZo�_]'tbu" N =EDERAL ID/SS NUMBER:j a L '`'g-`_jvJ " (1'7 Lf-S - - - LICENSE HELD: Town ti w?d : Year Licensed LICENSE HELD: Town U r � -4--4 C, % Year Licensed r LICENSE HELD: Town � M s �a y y _ 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 n SIGNATURE: C _Alz, DATE: 10 �_3_)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 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. LX.xcesa-yk�4-G'`'i�.�a.= Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntary) at, 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\sleite\Desktop\Scon's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc The Commonwealth of Massachusetts Print Form` Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization )I Name: A) a rII a O +z e I d r s be Address: I fAJ Si rcL l City/State/Zip: L)rA04 � a r) ie, Phone #: 50Y y2L -I S0 0 Are yog an employer? Check, the appropriate box: Business Type (required): 1. I am a employer with � employees (full and/ 5. ❑Retail or part-time).* 6. ❑ RestauranUflar/Eating Establishment 2. ❑ 1 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. 8. ❑ Non-profit [No workers' comp. insurance required] 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]* 4. ❑ We by 1 l.❑ Health Care are anon -profit organization, staffed volunteers, n pp qq 12.[�/Other Cs io with no employees. [No workers' comp. insurance req.] � urn v7 c Y n *Any applicant that checks box # 1 must also till 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 41. I ain an employer that is providing workers' corlipensation insurance for niy employees. Below is thepo/icy information. Insurance Company Insurer's City/State/Zip: Wt. A I d V ji1 tt o Iu o— 6 aSS Policy # or Self -ins. Lic. # W h y p rl 5 i,31 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 Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains andperialties ofperjury that the information provided above is true and correct. Offrcial 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 d. Licensing Board 5. Selectmen's Office 6. Other Contact Phone #: f ACII CERTIFICATE OF LIABILITY INSURANCE lilk�019 DATE/2WDDN ) 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 3ELOW. 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(fes) 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 Marsh & McLennan Agency LLC 100 Front St, Ste 800 Worcester MA 01608 CONTACT Cindy L. Carey PHONE FAx ac No Est: 508-852-8600 AIC No:866-795-8016 ADDRESS: cind .care marshmma.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: Graphic Arts Mutual Insurance Company 25984 INSURED GUARABUILD3 Guaranteed Builders &Developers, Inc. INSURER B: Utica Mutual Insurance COm an _ 25976 14 West Street INSURERC; INSURER D: East Douglas MA 01516 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 1287693279 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF IMMIDDIYYYY1 POLICY E%P VNIMIDDITY"Y'rlLIMITS A X COMMERCIAL GENERAL LIABILITY CPP4051108 4/2/2019 4/2/2020 EACH OCCURRENCE $1,000,000 CLAIMSMADE lxl OCCUR PREMISES Ea owu ante $100,000 MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY 000000 $1V$2,OOO,O00 GEN'L AGGREGATE LI MIT APPLIES PER: GENERAL AGGREGATE PRO- POLICY JECT PRO- I LOC PRODUCTS - COMPIOP AGG OTHER: AUTOMOBILE LIABILITY 4051109 4/2/2019 4/21202D COMBINED SINGLE LIMIT Ea accidentANY BODILY INJURY(Per person) AUTO OWNED SCHEDULED ONLY AUTOSXHIRED BODILY INJURY (Per accident)AUTOS X NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE A X UMBRELLA UAB X OCCUR CULP4051112 4/2/2019 4/2/2020 EACH OCCURRENCE $8,000,000 I AGGREGATE $8,000,000 EXCESS LIAB I CLAIMS -MADE DED I X I RETENTION$ j. mur $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED'! N/A 4045631 4/2/2019 4/2/2020 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory, In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A IM Equipment Floater CPP4051108 4/2/2019 4/2/2020 Rented/Leased $125,000 From Others Actual Cash Value DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The certificate holder is included as an additional insured as respects the general liability, If required by written contract for work performed by the named insured. 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, MA 6 Park Row REPRESENTATIVE — Mansfield MA 02048 AUTHORIZED E ) l ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD