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Home My WebLink AboutWind River Environmental #1- 12/31/202006 2019 Town of `Mansfield - Board of Health Disposal Works Installer Application Town of Mansfield 6 Park Row Mansfield, MA 02048 F.... -,*------- LICENSE NUMBERrr APPLICANT: 1—c-er( SLk_i n _ BUSINESS NAME:_ -- MAIL ADDRESS: ((� {I I% ✓`i a "1--}e_- -i-)t. v, CITY/TOWN:—I'�ari�nr'�u STATE: _ /a ZIPpCODE:__��7 — BUSINESS PHONE: BUSINESSCELL: BUSINESS FAX: E-mail; Faux', �1r��V; nnMarrtc�i..CeNt Alt E-mail., kwt.lnM ID/SS NUMBER: LICENSE HELD: Townt XboW g Year Licensed LICENSE HELD: Town �r Year Licensed p Ot� LICENSE HELD: Town _{ j [� f2Year Licensed QI__ 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 $f 00.00 payable to Town of Mansfield, Mail to: BOBrd of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 MASSACHUSETTS COMMERCIAL. [DRIVER'S LICENSE ' ' r tits t '� 12512018 " 5v � S28 S828878253 y t2712623 65l27/1981 NONE N FREDER CK FRANCIS BLU CO USUMSRd 0212 I6 06/27/61 t :IP,I[JIt�ll aJ,'l ti ti3'!�t',`n;';•1J APPROVED TITLE 5 SYSTEM INSPECTOR Fred 17: swain 10 South Center st, seningham, MA t12019 SI851 .'".�_.... - 31161199E B[�11.'Q22 i �U[i"A fr�j'i`i 'itiJ k'hii: �;lE: E'ai' FIFI.. L?•�'J� Now ; Vi j Commonvrealth of Massachusetts t3a twon apt Prcrtessionat i_iCensure HE-161487 TM a x FREDERICK F.SWAIN 10 S CENTER Commissioner in 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. Vvinr �-il T— Signature of Individual or Corporate Name By: Corporat f icer (Mandatory, ifAp licable) *"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:\Usem\sleite\Desktop\Scott's Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc .(�,. \ L IaY VVIIiIILV IOIYYN4{'IY V,r t Nu _ _ dSlu` Department oflndustriatAecidentsu Office of Investigations 600 Washington Street' Boston, MA 0211.1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lee lily Business/Organization Name: W11jnrA �i VP_l- FnW(ra, Min-, I Address:_ _Wp Li-zz o4t—, i Jsiv _ City/State/Zip; t-�t�� , Z� Q175,,. Phone #; — l l— ([n B Are you an employer? Check the appropriate box: Business Type (required): a 1. K( I am n employer withemployees (full and/ 5.. ❑ Retail' or part-time).* 4. ❑ RestaurantlBar/Eating Establishment 2. ❑ I am a sole proprietor or partnership. and have no j. Office and/or Sales (in'ch real estate, auto; etc:) employees working for me in any capacity. S. ❑ 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, §I(4), and we have Io:❑ Manufacturing ❑ no employees. [No workers' ccmp, insurance required]* We 11.❑ Health Care4. are a non-proft organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.M Other SD _ j-. S, ; *Any applicant that checks box pl_must also till out the section below showing their workers' compensation policy information. '*If thecorporateofficers have exempted themselves, but the corporation has other employees, aworkers'. compensation policy is iequired.and sech'an organization should check box M. I am an employer that isproviding workers' compensation insurance far my employees. Below is the policy information. Insurance Company Name: Lockr7n Insurer's Address: City/State/Zip: Lra Anuv� cA 9=/'I Policy # or Self -ins. Lie. # 100000,3 q ( Expiration Date: to r 3 C C> 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'eriminat penalties of a fine up to $1,500.00 and/or one-year, imprisonment, asrwell as civil penattimin the form of a STOP WORK ORDER and -a fine of up to $250.00 a day against the violator. Be advised thafa eopyof this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eerrii� �uund�err the pains and penalties, ofperyury that the information provided above is true and correct SignatureDate: Phone #: `5C•7 a - t I - 16'a Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Par lit/License # Issuing Authority (circle one), 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office. 6. Other Contact Person: Phone#: www.mass.gowdut ACCM& CERTIFICATE OF LIABILITY INSURANCE ATE D7/3/2 IDDn'YYY) �/ 6/30/2020 7/3/2019 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 Lockton Insurance Brokers,LLC NAMEACT PHONE Ez AIL No CA License #0F15767 777 S. Figueroa Street, 52nd fl. E-MAIL ADDRESS: Los Angeles CA 90017 213-689-0065 INSURERS AFFORDING COVERAGE NAIC 17 INSURER A : Starr Indemnity & Liability Company 38318 INSURED Wind River Environmental, LLC INSURER B:***SEE ATTACHMENT*** INSURER C 1448815 46 Lizotte Dr. INSURER D: Marlborough MA 01752 INSURER E INSURER F: COVFRAGFS WFNR101 CERTIFICATE NUMBER: 161 R71R1 REVISION NUMBER: XXXXXXX 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 VHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL -.'HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR 7ypE OF INSURANCE ADDLS INSD BR D POLP'Y NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDM'VY LIMITS A TCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE [A]OCCUR N N 1000090512191 6/30/2019 6/30/2020 EACH OCCURRENCE — _ $ 2000000MAGE TO RENTED PREMISES Me occurrence $ 300,000 MED EXP (Any one parson) $ 10,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4000000.,,c:., .. POLICY [X]... ❑X LOG PRODUCTS - COMPIOP AGG $ 4 00O 000 _: $ OTHER: A A AUTOMOBILE LIABILITY X ANY AUTO N N 1000198837191 ((MA) 1000198836191 (AO) 6/30/2.019 6/30/2019 6/30/2020 6/30/2020 COMBINED SINGLE LIMIT Ea accident $ 2000000 BODILY INJURY (Per person) $ XXXXX3Ct_ _ BODILY INJURY (Per accident) $ 7:: OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY XXXXXXX. PROPERTY DAMAGE Per accident $� $ X Con/Coll D IX Various B UMBRELLA LIAR X OCCUR N N See Attached 6/30/2019 6/30/2020 EACH OCCURRENCE $ 14,000,000.. — X AGGREGATE $ 14 00O QOO ... EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ XXXXXXX- A WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY YIN OANY FFICER/MEMBER E%CLUDEDPECUTIVE FNJ (Mandatory in NH) NIA N 1000003291 6/30/2019 6/30/2020 X STATUTE I I EORTH- E.L. EACH ACCIDENT 7 $ 1,000,000 E.L. DISEASE - EA EMPLOYEE - $ 1,000,000If E.L. DISEASE POLICY LIMIT $ 1000000.,- DESCd..c be under RIPTION OF OPERATIONS belm DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional, Remarks Schedule, may be attached if more space is required) s.. CERTIFICATE HOLDER CANCELLATION See Attachments " 16182381 Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF13k THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 114 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR .{.. 91888-2016-AC( RD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD