Loading...
HomeMy WebLinkAboutEarthwork Industries, Inc. - 12/31/2020Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: APPLICANT: Derek Franklin BUSINESS NAME: Earthwork Industries, Inc. MAIL ADDRESS: 6 High St., Unit 4 CITYITOWN: Plainville STATE: MA BUSINESS PHONE: (508)643-4430 BUSINESS CELL: BUSINESS FAX: (508)643-4421 E-mail: dfranklin@earthworkindustries.com Alt E-mail: ID/SS NUMBER: 59-377 6016 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Town of Mansfield 6 Park Row Mansfield, MA 02048 ZIP CODE: 02762 (508)245-7316 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 31st yearly. FEE: $ 100.00 SIGNATURE: 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 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: tPrporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntan/) 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\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name �i Yin h t C 6 i i < 4 ram{ ,, ; / r , Address: City/State/Zip: ' E i 0 w` f f,_° It-� Phone #: Are ou an employer? Check the appropriate box: Business Type (required): 1. I am a employer with ) 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers' comp. insurance req.] 12� Other L f);, t *Any applicant that checks box #1 must 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 and such an organization should check box 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Afj /! ✓"1b-€ (. k�L( ` f / I 1 r f f } Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # C C� U C `l 1- % C E- 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 insuraq} e coverage verification. I do hereby certify, unrl Vepa dallies ofperjury that the information provided above is true and correct///g/p/jg���rt f,Signature: / / A natw 11 / / /? 1! `- 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 www.mass.gov/dia Phone #: A� De CERTIFICATE OF LIABILITY INSURANCE Preto 2/2019 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 eertlfieate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 Use of such andoreement a . PRODUCER Decoy insurance Agency 631 Main Sure Fast Greenwich RI 02818 NOV" Michael T. Daeey _ a NOExt: (401)399-8020 ucu — ADDRESS: mikt@deceyimurance.com INSURERS) AFFORDING COVERAGE NAIC0 mBURERA: Westchester Surplus Lines lm. Co. 10172 INSURED Earthwotk Industries, Inc. Six High Street Unit d4 Plainville MA 02162 INSURER a: The Selective Insurance Co. of the Southeast 25658 INSURERe: Atlantic Charter Ins. Co. 44326 _ INSURER D: NSURERE: INeUAaRF I -- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLSQIES OF INSURANCE. LISTED BELOW HAVE BEEN ISSUED TO THE INSURED. NAMED ABOVE FOR THE POLICY PEFUOD 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. LTR TYPE OF INSURANCE i POLICYNUMBER M D MWD LIMIT9 A )CICOMMERCAL GENERAL LIABILITY CMS -MADE ©OCCUR "XCU"covcmge Y G27595765005 04/26/19 04/26/20 EACH OCCURRENCE Is 1.000,000 PREMISES Eaoaunence i 50,000 MEO EXP(Any one Peron) f 5,000 'Pollution Liability" PERSONAL S ADV INJURY f 1.000.000 GENL AGGREGATE LIMIT APPLIES PER: POUCY ©jECT []LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS -COMPIOPAGG S 2,000,000 s B AUTOMOBILE LIABILITYEa ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS NOWNED AUTOS ONLY AAUUTT S ONLY y p 91051117-i 01/27/19 01/27/20 ardeent f I,OOD,000 BODILY INJURY (Par Person) $ BODILY INJURY(Pw=dml) S Pe F4RTT f i p UMBRELLA UAB "OROS ILIB OCCUR ClAJMS-MADE Y 027595777003 04126/19 04/26/20 EACHOCCURRENCE f 5,000,000 AGGREGATE f 5.000.000 DED I KIRETENTIONS 10,000 S C ORIAPLOYE S'LIAnON NO lMPLOYlRS' LIABILITY ECUTIVE Y❑ FICERIPMEMBER EXCLUDED? Mandatory In MR) IpsLdcaaies under ESCy11PTI0N OF OPERATIONS redow NIA MA Certificate attached S ATUTE Eft E.L. EACH ACCIDENT f E L. DISEASE• EA EMPLOYEE f E.L.gSEASE •POLICY LIMIT S A Pollution Liability Y G27595765005 04/26/19 (14/26/20 per Occurence Aggregate 1.000.000 2.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD tat, Additional Remarks Schedule, may be attached If more space Is required) To support Disposal Works Installer Permit. NOTE: Town of Mansfield is included as "Additional Insured" in regard to the Commercial General Liability, Auto Liability and Umbrella Liability as per written contract. 30 days notice of cancellation applies, except 10 days for non-paymcni of premium. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Atansfield ACCORDANCE WITH THE POLICY PROVISIONS. C.'e Dept. of Public Works I AUTROIUZED REPRESENTATIVE 6 Park Row Mara.a�S. C)eLt4ey Mansfield, MA 02048 ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD A`o v® CERTIFICATE OF LIABILITY INSURANCE IVYM °ATEINM° 119 10/23/2019 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 CONSTRUTE 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 pollcy(les) must 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 40hls to the certificate holder in lieu of such endorsament(a). PRODUCER 01776.001 Dam Insurance Agency, Inc. 631 Mein Street East Greenwich, RI 02818 fikaACT t�1E.fie. Ell), (401)398.8020 � No,: (401)398.8017 QnDINGCOVERAGE 1 ,gas A Atlantic Charter Insurance Company VDAC _Nat 44326 _ INSURED Earthwork Industries, Inc, 6 High Street, Unit 4 Plainville, MA 02762 INSURER I I .INBUnERc: INSURER D JNBUREO P • 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 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. AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN I LTA TYPEOFDISURANCE Nam POLICY NUMBER Imrj UMITS GENERAL LIABILITY COMMERCW.GENERAL LIABILITY CLAIMS -MADE OCCUR I EACH OCCURRENCE f DAMAGE TO RENTED — f MEO EXP(Any we ParwM f PERSONAL E ADV INJURY f GENERAL AGGREGATE f ENL AGGREGATE LIMIT APPLIES PER: RO )POLICY OC AUTOMOBILE LIABUTY ANY AUTO — ALTO ED SCHEDULED NON OWNED HIRED AUTOS AUTOS PRODUCTS• COMROPAGG f QMBI�O 51N H $ SODILY INJURY(P.Pelwa) �f BODILY INJURY(Pm acc4sm) f PROPERTY DAMAGE Cf UMORELUUAB EXCESS UAB OCCUR CWMSMADE EACH OCCURRENCE 'E AGGREGATE E_ DED I I RETENTION f f -- A %4Pd'EaP@53�1"e�All4fb VV�/MM ANVIPROPIi1ET0n?MTNEfUEI(ECUTIVEMN ((pMFaeFneGd.e�aEt�o�ryy�IInne N,HH,Eee(F E%ClU EG'I �uJ O SCRIPTIONMPERATIONS hoIbM NIA WCV00972708 Policy Coverage Stale:M 8/13/2019 0811312020 X T�S1SL s ` k E.L. EACH ACCIDENT __-- S 1,000,000.00 E.1015FA5E EA EMPLOYEE f 1,000,000.00 E.L. DISEASE• POLICY LIMIT f 1,000,000.00 F �I DESCI UKION OF OPERATIONS/ LOCATIONS / VEHICLES (AINch ACORD 101, Addlllondflemmke Schedule, If more spwo Is mOuaed) Town of Mansfield, Department of Public Works SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 6 Park ROW BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY Mansfield, MA 02048 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUINOflREO flepflES6NTA71VE �AM(/,i✓"� ®1986.2014 ACORO CORPORATION. AI dghi ACORD 2$ (2014/01) The ACORD name and toga are reglalered marks of ACORD CERTIFICATE HOLDER COPY