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HomeMy WebLinkAboutWind River Environmental #3 - 12/31/2020300 r own Town of Mansfield - Board of Health B Park R Mansfield �g Mansfield, MA02048 Disposal Works Installer Application LICENSE NUMBER: S% 13d3c> APPLICANT:�1�r. i a• 1�Co5 . BUSINESS NAME:-tLi11a[ }River EA-y;tPnitre tFl MAIL ADDRESS: 44LD I CITYITOWN: ._fihAr1�ar00nk STATE: 0 6 ZIPCODE: tom/7J o2.. BUSINESS PHONE: _l%� �iN I - S I�Da BUSINESS CELL: Z(Q(> -3 BUSINESS FAX: E-mall: rvy e6056,- r(P—WVeAVi, QA&le rt-, ii M ' Aft E-mail: _ kj'! It-dr-P L.Ji�nvirpnMe.ii'}z^i-lnM FEDERAL ID/SS NUMBER: 04 - 3Aj PP 7& 7 -7 LICENSE HELD: Town - fro)Ceyc:.r, h Year Licensed r;W l l LICENSE HELD: Town �. l nc kLi &nw Year Licensed 0ma LICENSE HELD: r/ Town Vt� t in �in c >n Year Licensed ealC71 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: $100,00 SIGNATURE; / 4 � a DATE: 10--2$' ZOiq 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information 99 Please Print Legibly Business/Organization Name: (tJ; nr/A giyi°t �nvlro� Min 1 Address: wp INS, V- . ,;Z Phone#: Are you an employer? Check the appropriate box: Business Type (required): 1. KI I am a employer with f" J employees (full and/ 5. ❑ Retail' or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7. El Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] S. ❑ 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 I0.❑ Manufacturing no employees. [No workers' comp., insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.M Other t,J=c L, + '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 Name: I QC ki,nn Insurer's Address: )a 5 S GArce A- City/State/Zip: Policy # or Self -ins. Lic. # jL9 dU 0CD _3;;l q k 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 D[A for insurance coverage verification. I do hereby eerti , under the pains and penalties of perjury that the information provided above is true and correct. /J ,rr o Signature: / � itil�/L�. Date: Phone #: . � - �1 - D_ 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 Person: Phone #: www.masxgovldia ACORO® CERTIFICATE OF LIABILITY INSURANCE `,/ 6/30/2020 DATE tMMIDD YVYY) 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 CONTACT CA License 4OF15767 777 S. Figueroa Street, 52nd fl. Los Angeles CA 90017 213-689-0065 PHONE FAx WCNo Ext : A/C No E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC If INSURER A: Starr Indemnity & Liability Company 38318 INSURED Wind River Environmental, LLC 1448815 46 LIZotte Dr, wsuRERe:***SEE ATTACHMENT*** INSURER C: INSURER D Marlborough MA 01752 INSURER E : INSURER F: COVERAGES WINRIO] CERTIFICATE NUMBER: 16182381 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 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 ADDL D SUDR D POLICY NUMBER POLICY EFF MMIDDrfYYY POLICY EXP MMImNYYYY LIMITS A 2C COMMERCIAL GENERAL LIABILITY � OCCUR N N 1000090512191 6/30/2019 6/30/2020 EACH OCCURRENCEDAMAGE OOO OOOCLAIMS-MADE TO RENTED PREMISES Ea occurrence 00 000MED EXP (Any one person) O O0OPERSONAL&ADV INJURYOOO [$2 OOOGEN'L AGGREGATE LIMIT APPLIES PER: F JECT LOG GENERALAGGREGATE 000 000POLICY PRODUCTS-COMP/OP AGO OOO OOOOTHER' A 'A AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Cop/Coll /Coll D 'IX Various N N1000198837191 ((MA)) 1000198836191(AOS) 6/30/2019 6/30/2019 6/30/21020 6/30/2020 EO arB,cl deentSINGLE LIMIT $ 2,00000 BODILY INJURY (Per person) $xxxxxxx BODILY INJURY (Per accident) $ XXXXXXX X PROPERTY DAMAGE Peraocceri $XXXXXXX s XXXXXXX B X' UMBRELLA LIAR EXCESS LIAR J( I OCCUR CLAIMS -MADE N N See Attached 6/30/2019 6/30/2020 EACH OCCURRENCE $ 14,000,000 AGGREGATE $ 14,000,000 DED RETENTION$ $ XXXXXXX A WORKERS COMPENSATIONPER WORKERS COMP NATION Y / N AND ANY PROPRIETOR/PARTNER/EXECUTIVE tMandaloryin NH) OFFICERNMBER EXCLUDED? Use, describe under DESCRIPTION OF OPERATIONS below NIA N 1000003291 6/30/2019 6/30/2020 H- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace is required) CERTIFICATE HOLDER CANCELLATION See Attachments 16182381 Evidence of Coverage 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 REPR 7 ©1688-20lrACQRD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Michael J. DeCosta, Jr. Cell Phone: (508) 400-8083 Email: midecosta@wrenvironmental.com MASSACHUSETTS DRIVER'S LICENSE FOR FEDERAL ID bj NUMBER 012019 '`S69384858 DOB 512025 11/05/1986 S 1i NO - 9aEND p.�ry.4sl.dV;ra - NONE NONE DCA I .. MICHAELJ,JR 224 W RIVER RD s UXBRIDGE, MA01569.1418 (/ 1PEYEV,SL SEXM166NCT5'-11„ gggg 5 q DD 1013012019 Rev 02/2V2016 "1 @/D5/86 f�l'k'eif it � LAGiI %r I%.-S�.CI_US=Y4'S lwi5� i rF APPROVED TITLE 5 SYSTEM INSPECTOR Wc11ao1 DeCosta, Jr. 8 Winter Shear Franklin, MA 02OU � Si13230 � '10191200$ ,'�Uflw-.�/%1-li TU T; O_:�Eta EriAl t.1'vv$ &30/2021 Commonwealth of Massachu-,,or, Division of Professional Licensor - Hoisting Engineer HE-161673 E-) MICHAEL J DECOSTA, .JAR. 224 N. RIVER'ROAD UXBRIDGE MA 01569 u