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Home My WebLink AboutPlainville Pump & Excavating, Inc. - 12/31/2020Town of Mansfield - Board of Health Town. of Mansfield 6 Park Row Mansfield, MA 02048 O'P rA n Disposal Works Installer Application LICENSE NUMBER: APPLICANT: BUSINESS NAME: i� AT iN'I t NA�_ Ic XC ci u'< _Lli C <<d MAIL ADDRESS: fJ � l /i j'} $ J C r i t CITY/TOWN: Yaw')V � t � STATE: 1')_'�14 ZIP CODE: C'-� 701->- BUSINESS PHONE: BUSINESS CELL: _ �F BUSINESS FAX: 3, LV I.,?_, E-mail• jylz,�b> jGylvi y iILQ a CUya r Alt E-mail: 'EDERAL ID/SS NUMBER: LICENSE HELD: Town a `w Year Licensed _�2 ' ! LICENSE HELD: Town Year Licensed 2- LICENSE HELD: Town p �. Year Licensed 2 �L 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. \u ature of Indivi aL» orpo ate By: Corporate Officer Wandatorl , if Applicable) C J S> , "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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc PLAINA OP ID: CY ACORO' CERTIFICATE OF LIABILITY INSURANCE `.� DATE(MM/DDIYYYY) 01/25/2019 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Eastern States insurance Agency, Inc. 50 Prospect Street Waltham, MA 02453 CONTACT NAME: ac No E.1:781-642-9000 FAX No: 781.647.3670 SS: certificaterequest@esia.com ADDRESS: INSURERS AFFORDING COVERAGE NAICN INSURERA:Acadia Insurance Company 31325 INSURED Plainville Pump & Excavating, Inc. INSURERB:Arbella Protection Insurance 41360 Jemco Disposal, Inc. INSURER C : INSURER D : Maplehurst Farms, LLC 38 Forest Street LLC 18 High Street Ste 4 INSURER E INSURERF: Plainville, MA 02762 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DD D POLICY NUMBER POLICY EFF MWDDNYYY POLICY EXP MMIDD/YYYY LIMITS A TCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE N OCCUR X CPA6381873 01125/2019 01/25/2020 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 250,000 MED EXP(Any one person) $ 6,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LI MIT APPLIES PER: POLICY PRO- JECT LOD OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 PD & BI $ DED: $1,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS X AUTOS X NONn,OWNED HIREDAUTOS AUTBam rX MAA5381874 01125/2019 01/25/2020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident)$ PROPERTY DAMAGE Peraccitlent $ ComplColl ACV $ See Page A X UMBRELLA LIAR EXCESS LIAB X -CUR CrCLAIMS-MADE CUA5381875 0112512019 01/2612020 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 DED I X RETENTION$ 10,000 $ A B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? OFFICERIME NH) If yes, tl'scribe under WeOF OPERATIONS below IN WCA5381876-PLAINVILLE 4220058164-JEMCO 01125/2019 1010112018 01125/2020 10101/2019 )t STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EAEMPLOYE $ 500,000 E.L. DISEASE- POLICY LIMIT $ 500,000 A Contractors Equip Floater CIM5336089 DED: $1,000 OV25/2019 01125/2020 Scheduled See Belovy RentlLeas 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more apace is required) RE: Drainlayer's License The Town of Mansfield is included as Additional Insured with regards to General Liability where required by written contract or agreement. MANSMA- Town of Mansfield Attn: Engineering Dept 6 Park Row Mansfield, MA 02048 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 REPRESENTATIVE ACORn CORPORATION. All rinhfs racerved ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth o f Massachusetts Department oflndustrialAceidents I Congress Street, Suite 100 Boston, MA 021I4-20I7 wwHi.mass.gov/dia rkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Ltdividual):�%��Gl Andress /,7 A/l qA J7�-,' . STUI �C- Z (lt -fle, p2 I 42 one Are you an employer? Check the appropriate box: Type of project (required): I.RIamaemployerwithemployees (full and/or part-time).*-- %. New construction 2.r_1 I am a sole proprietor or partnership and have no employees working for me in $, ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. Demolition ❑ 3.EJ I am a homeowner doing all work myself. (No workers' comp. insurancerequired.] r 4.r—] 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 10 Building addition ILEJ Electrical repairs or additions proprietors with no employees. 12. Q Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet 13�Roof repairs . These sub-conh'actors have employees and have workers' comp. insumnce.I L 14.00ther 6.❑ We are acoryoration andits officers have exercised their right ofexemption per IAGLe. Se wer- 152, §1 (4), and we have no employees. [No workers' comp. insurance required.] -Any applicant that checks box Rl most also fill out the section below showing their workers' Compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this boa must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' emnp. policy Dumber. I au art employer tliat isprorieling mockers' coupeusatiott insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 19G(jclllZ, y^7 Q v �7 / I Policy # or Self -ins. Lie. #: ,7 J U O f 6 "— �� Expiration Date: .�e.� 2 0 Job Site Address: Va-rl e-5 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance Official use only. Do not nndte in this area, to be completed by city or town official. City or Town: Pernlit/License # Issuing Authority (circle one): I. ,Board of Health 2. Building Department 3. CiUT/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone