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Home My WebLink AboutUS General, Inc. - 12/31/2020wv.on 2Og9 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield; MA 02048 Disposal Works Installer Application�'{�� LICENSE NUMBER: / APPLICANT:lt�su� BUSINESS NAME: MAIL ADDRESS: S� CITY/TOWN: y / // STATE: � ZIP CODE: BUSINESS PHONE: �/� 9 Oy �Oy BUSINESS CELL: SOFT 9�/% ail 77 BUSINESS FAX: E-mail: Alt E-mail:00 I/ EDERAL ID/SS NUMBER: t-, - i LICENSE HELD: Town Year Licensed LICENSE HELD: Town �a(\ Year Licensed _ram LICENSE HELD: TownYear Licensed 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: /,, � — e 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, 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\sleite\Desktop\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UIV www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibl z�y Business/Organization Name: �%S Ph acel 16 [aToTW ZA Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail part-time).* 6. ❑ Restaurant/Bar/Eating Establishment �rf�or 2. t�t.�I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) l employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I1.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box 41 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 91. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 a st the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DrKfor insurance coverage verification. I do hereby certotder th ns and penalties 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Forth Revised 5-26-05 CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DDNYYY) 10/21/2019 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 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 Bearce Insurance Agency, 670 Pleasant Street MA 02301 CONTACT J Salkovitr PH (AID (508) 586-34(41c00 FAX wa).(508) 586-3700 EMAIL isalkovitz@bearce.com AFFORDINGo aINSURER A ,AIM Mutual Insurance Cc INSURED US General Inc 430 School St Mansfield MA 02048- INSURER 5.Commerce/MAPFRE 34754 INsu ,Selective Insurance Company INSURES D, INSURER 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 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 ADDL SUBR X POLICY EFF POLICY EXPITR LIMITS C X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X S2090096 9/05/2019 9/05/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 MED EXP(Any one erson $ 10,000 GENT PERSONAL B ADV INJURY s 1,000,000 AGGREGATE LIMITAPPLIES PER: POLICY a jECT LOC OTHER GENERAL AGGREGATE 3,000,000 PRODUCTS-COMP/OPAGG 3,°°°,OOO $ B AUTOMOBILE LIABILITY ANY AUTO ALLOWNED X SCHEDULED AUTOS AUTOS IX HIRED AUTOS X NON -OWNED OS X BBXC61 9/05/2019 9/05/2020 COMBINED SINGLE LIMIT BODILY I NJURY(Per person) $ 1,000,000 $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (12aiaccidam) g InC C X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE X S2090096 9/05/2019 9/05/2020 EACH OCCURRENCE 2,000,000 AGGREGATE $ 2,000,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE MN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under N/A AWCAOO-7029660-2019 9/06/2019 9/06/2020 X I PERTUT OTH- E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE- EA EMPLOYEE 1,000,000 E. L. DISEASE -POLICY LIMIT 1,000,000 —DES DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is req ul red) Town of Mansfield is listed as additional insured with respects to the general liability. CERTIFICATE HOLDER CANCELLATION AI 028855 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Eleanor ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall AUTHORIZED REPRESENTATIVE Mansfield MA 02048- L Fax: (508)261-7467 @ 1888.2014 ACORD CORPORATION. All rights reserved. Town of Mansfield 6 Park Raw, Nlanfield, Massacbusetts 02048 Health Department Amy Donovan -Palmer, MPH, KS Health Agent October 18, 2019 Onsite Disposal Works Installer: Your current Disposal Works Installer Permit will expire on December 31, 2019. To renew your permit, please submit the following documents and payment to the Health Department. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. ❑ Disposal Works Installer Permit Application (Attached) ❑ Tax Certification Form (Attached) ❑ Workers' Compensation Insurance Affidavit: General Business. (Attached) ❑ Workers' Compensation policy declaration page. The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address. The current Mansfield BOH fee is $100. Please contact the Health Department if we can be of any additional assistance. Sincerely, / a QOhu�.ew.-Q�1mAl\_ Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Emailadpal)wer@mansfieldiva.com