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HomeMy WebLinkAboutMiles of Excavating - 12/31/2020t 1-,, Town of Mansfield - Board of Health aCT 26 2019 Disposal Works Installer Application i Town of Mansfield 6 Park Row Mansfield, MA 02048 Lj��NSE-rwnnBER � if- - L� S h%� oZ APPLICANT: oTz-IV 16oAiaLti! i Z - --- -- BUSINESS NAME: A4,LCri of Z''4rA91L),H /n MAIL ADDRESS: 67vot CITY/TOWN: ( LID / iJ) STATE:,W_-�V_ ZIP CODE:6Z69.3 BUSINESS PHONE: BUSINESS CELL: `�02� -IJ ICJ' gr715 BUSINESS FAX: E-mail: M R I�XDC6 _ �iI�ZX�: Ccdiy\ Alt E-mail: ID/SS NUMBER: LICENSE HELD: Town dfN�vl Year Licensed LICENSE HELD: Town fLX/ 0 Year Licensed c.;2Of G LICENSE HELD: Town Year Licensed _U_(�_2___ 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 at yearly. FEE: $ 100.00 SIGNATUR I DATE: l b 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. I 4 Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) i a urit/� l" **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\sleite\Desktop\Scotts Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc The Coinn►onivenith of Mnssncbnsetts Deparin►ent of LtdnstrinlAccidents i 1 Congress Street, Snite 100 r Boston, MA 02114-2019 lvlvw.mnssgov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Are ou an employer? Check the appropriate box: 1, I am :employer with —� employees (full and/ !!lilt ��- or part-time).* 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 officer's have exercised their right of exemption per c. 152, § 1(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.) g. Non-profit 9. © Entertainment 1011 Manufacturing It,[] Health Care 12,© Other *Any applioaut flint cheoks box HI must also fill out the section belowsho%ving f icinvorkors' eompensotion policy intonnanon. **If the corporato ofncers hove oxempfed Themselves, but the corporation loss other employees, a workers' compensation pulley is requlmd and such an . organization should check box H r. I Rut Rt► eutpioyer t/tR! is providing ivorlrers' comp nliat tasrrrnuce for t eatployoes. Below is iGe policy liilor»►atial, Insurance Company Failure to secure coverage as required under Section 25A of MOL c, 152 can lead to the Imposition or criminal penames of u fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy oflhis statement may be forwarded to the Office of Investigations of the DIA for Insurance coverage verification. I tlo hereby Penalties of a #: v — Official oise only. Do not lvrite hl this area, to be completed by city or tolva offlcial City or Town: Permit/License above Is true wid correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, City/Town Cleric 4. Licensing Board S. Selectmen's Office 6.Other Contact Persons Phase ___­ssN MILEOFE-01 CWOODS109 A� R" CERTIFICATE OF LIABILITY INSURANCE °ATE (MMIDDNYYY) 12612019 8/26/2019 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 endorsements . PRODUCER License 41780862 HUB International New England 6o0 ell,%At02 61-9rive Norwell, MA 02061-9146 fiRMIACT Michelle Wolf alc°°, No, Est): (508) 886-2183 jprc, Nol: Eo �,,michelle.wolf@hub'international.com - _ INSURER $ AFFORDING COVERAGE NAICN INSURERA: Liberty Mutual INSURED Miles of Excavating Timothy Konowitz dba 242 Park Street Wrentham, MA 02093 INSURERS: Commerce Insurance Company 34754 msuRERC: Wesco Insurance Company 25011 INSURER D: - _ INSURER E : INSURER F: CATE NUMBERREVISION mill' — COVERAGES CERTFFI 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 CONTRACTOR 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. INSR TYPE OF INSURANCE POOL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR X BKS58621919 2/2712019 212712020 DIt AMAGETO RENTED 300,000 15,000 MED EXP An one person)$ 1,000,000 PERSONAL S AOV INJURY GENERAL AGGREGATE 2'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2'000'UU0 POLICY w,) LOC PRODUCTS-COMPIOPAGG COMBINED SINGLE LIMIT $ OTHER: B AUTOMOBILELIABIDTY e BODILY INJURY Per arson $ AUTO BHDLXX 2127/2019 2127/2020 ODILY INJURY Per accident) BPectlen 1,000,000 a OWNED XSCHEDULED AUTOS MAGE a, A 1000'000 AS ONLY OMEN X X aANY UMBRELLA LIAB OCCUR EACH OCCURRENCE a AGGREGATE EXCESS LIAR CLAIMS -MADE DED RETENTION$ PER,TP X OTH In COMPENSATION E.L. EACH ACCIDENT 500,000 $ AND EMPLOYERS' LIABILITY YIN VVWC3366078 8/2312019 812312020 ANY PROPRIETORIPARTNERIEXECUTIVE Q�entlapoMEMgr) EXCLUDED? NIA E.L. DISEASE -EA EMPLOYEE_�__,__ 500,000 Im 1 ry 1n NH) DESCRIP70N OF OPERATIONS below nder E.L. DISEASE - POLICY LIMIT $ 5Q0,000 T: DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addithmal Remarks Schedule, may be attached if more space Is required) Town of Mansfield Board of Health 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 ACORD 25 (2016103) V laDe-LU ID NVVr[v c.vrcrvnn,rv,.. ran us,. ,-------- The ACORD name and logo are registered marks of ACORD