Loading...
HomeMy WebLinkAboutAdvanced Metals Engineering, Inc. - 12/31/2020d00, y' C.1yID r3� c LICENSE NUMBER: 2 APPLICANT: John J. DlSangro BUSINESS NAME: Advanced Metals Engineering, Inc MAIL ADDRESS: 52 Production Road CITYITOWN: Walpole STATE: MA BUSINESS PHONE: 508-668-0024 BUSINESS CELL: BUSINESS FAX: 508-668-9514 E-mail: advmetalseng@advgrp.net Alt E-mail: ID/SS NUMBER: 04-2751448 LICENSE HELD: Town Mansfield LICENSE HELD: Town Walpole LICENSE HELD: Town Norwood Town of Mansfield 6 Park.Row Mansfield; MIA 02048 ZIP CODE: 02081 508-400-2103 Year Licensed 2019 Year Licensed 2019 Year Licensed 2019 6 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 I10�e•W SIGNATURE: DATE: I ( � ae 1 (9 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. mff I (MI. ���e s Ine.eti„4 plc• Signature of Individual or C rporate NUne By: rporate fficer (Mandatory, if Applicable) 04-2751448 "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\Scon's Doeuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: s a ?�Ltc,—bon 1Zt�a� v V City/State/Zip: Phone #: 568'-6 (PR-00aY Are ygu an employer? Check the appropriate box: Business Type (required): 1. E I am a employer with 3 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, —� with no employees. [No workers' comp. insurance req.] 12.b Ether ftsL (aahD v-) *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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company N Insurer's Address: City/State/Zip: W�lly 1 tk.fi. 5�(k t oa . Rogy Policy # or Self -ins. Lic. # WC S ' 31 S — (P 15 01 Q ' O] 9 Expiration Date: (P f2?l I20 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 and pepalties ofperjury that the information provided above is true and correct. 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AR INFORMATION PAGE Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-613070-019 RENEWAL OF: WC5-31S-613070-018 Account Number 1-613070 1. Insured and Mailing Address ADVANCED METAL ENGINEERING INC 52 PRODUCTION ROAD WALPOLE, MA 02081 175 Berkeley Street Boston, MA 02116 Issuing Office 016C Issue Date 06-10-19 Sub Account 0000 RISK ID 000001114 Status 03 — CORPORATION Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 06-23-2019 to 06-23-2020 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 235 (MA) Total Estimated Annual Premium $ 761 Premium will be billed ANNUAL Producer 0004-012426 EASTERN INSURANCE GROUP LLC 77 ACCORD PARK DRIVE NORWELL MA 02061 WC 00 00 01 A ©1987 National Council on Compensation Insurance,lnc. Ed. 07/01/2011 All Rights Reserved WC 00 00 01 B (CA) Page 1 of 1 Broker Copy