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HomeMy WebLinkAboutDick Morse Excavating, Inc. - 12/31/202015. of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: 17 APPLICANT: DICK MORSE BUSINESS NAME: DICK MORSE EXCAVATING, INC. MAIL ADDRESS: 351 MOUNTAIN STREET CITY/TOWN: SHARON BUSINESS PHONE: BUSINESS FAX: E-mail: Alt E-mail: 781-784-3136 781-784-7176 Town of Mansfield 6 Park Row Mansfield, MA 02048 STATE: MA ZIP CODE: 02067 BUSINESS CELL: 781-467-8810 dickmorseexcavating@gmail.com ID/SS NUMBER: 04-3515477 LICENSE HELD: Town of Sharon LICENSE HELD: Town of Foxboro Year Licensed 1985 Year Licensed 1978 LICENSE HELD: Town of Stoughton Year Licensed 1987 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: „✓�!Yrnr DATE: % 0/,�) P J 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. Dick Morse Excavating, Inc. Signature of Individual or Corporate Name Fed. I.D. 04-3515477 "Social Security No. (Voluntary) or Federal Identification Number fotjfn „ By: Corporate Officer (Mandatory, if Applicable) *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\sleile\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAeeidents Office of Investigations 600 Washington Street Boston, MA 02111 lug www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Letlibly Business/Organization Name: Dick Morse Excavating, Inc. Address: 351 Mountain Street City/State/Zip: Sharon, MA 02067 Phone #: 781-784-3136 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 4 employees (full and/ 5. ❑ Retail orpart-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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I LE] Health Care with no employees. [No workers' comp. insurance req.] 12.® Other Installer Disposal Works -Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inronnation. x*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 #1. I ani an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: See Attached Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 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, undeerr thepains and penalties ofpeljury that the information provided above Is trite and correct Signature: DI �4n411� Date: }6k-_A 781-784-3136 Ofjieial 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 Person: Phone #: www.mass.gow'dia AC61Z ®® CERTIFICATE OF LIABILITY INSURANCE OATE 4/9/0192�) 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 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 Eastern Insurance Group LLC 233 West Central St Natick MA 01760 NAME CT Select Dept. PRONE E.U. (800) 333-7234 X66807 FAC No:781-5e6-B244 E-MAIL ADDREss:selectwork@easterninsurance.com INSURERS AFFORDING COVERAGE SAID N INSURERA:Trav Ind of CT 25682 INSURED Dick Morse Excavating, Inc. D.M. Equipment Inc. 351 Mountain Street Sharon MA 02067 INSURER B:Travelers Cas & Surety of IL 19046 INSURER C:Travelers Indemnity Co 25658 INSURERD:Wesco Insurance Company 5011 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBERMASTER 19-20 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. INSR LTR rypE OFINSURANCE ADD S S BR D POLICY NUMBER POLICY Err MMIDDNYYY POLICY ESP MMIDD/YYYV LIMITS ACLAIMS-MADE GENERAL LIABILITY TCOMMERCIAL GENERAL LIABILITY OCCUR 6BO6671P535 4/3/2019 4/3/2020 EACH OCCURRENCE S 1,000,000 PA MISES Eaoccurrence S 300,000 NEED EXP(Any one person) S 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN1 AGGREGATE X1 POLICY LIMIT APPLIES PER: P" LOC PRODUCTS - COMP/OP AGG S 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS HIREDAUTOS X ANONNOSWNED A8M7e3722 4/3/2019 4/3/2020 COMBINED ISINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accitlenl) $ PROPERTY DAMAGE S L. X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE LP6673PS6S /3/2019 /3/2020 EACH OCCURRENCE S 1,000,000 AGGREGATE $ 1,000,000 DEU I I RETENTIONS $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY I OFFICERIMEMBEREXCLUDED7 ECUTIVE� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA C3344604 5/27/2018 /27/2019 5/27/2019 /27/2020 X WC STATU- I OTH- E.L. EACH ACCIDENT S 500 D00 E.L. DISEASE -EA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT I S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ABORT) IN, Additional Remarks Sshedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION 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 Building Dept AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 John Koegel/PKG ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. 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