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HomeMy WebLinkAboutD. Berndt Sanitation & Excavation - 12/31/2020O �o �6,1`�� - Town of Mansfield Torun of Mansfield - Board of Health 6 Park Row . Mansfield, MA 02048 Disposal Works installer Application LICENSE NUMBER: APPLICANT: DONALD P. BERNDT BUSINESS NAME: D. BERNDT SANITATION & EXCAVATION MAIL ADDRESS: CITY/TOWN: ATTLEBORO STATE: MA ZIP CODE: 02703 BUSINESSPHONE: 508-222-4963 BUSINESSCELL: 508-930-3760 BUSINESS FAX: 508-226-5448 E-mail: D.BerndtSanitation@comcast.net Alt E-mail: ID/SS NUMBER: 026-34-8161 LICENSE HELD: Town ATTr FRnRn Year Licensed LICENSE HELD: Town SEEKONK Year Licensed 1974 LICENSE HELD: Town NORTH ATTLEBORO Year Licensed 1974 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:�_� DATE: 11��tiw %�n19 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. Signature of Individual or Corporate Name U16•134-9161 "Social Security No. (Voluntary) or Federal Identification Number 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\sleite\Desktop\Scotrs DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts Department oflndustrialAccidents 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: D. BERNDT SANITATION & EXCAVATION City/State/Zip: ATTLEBORO, MA 02703 Phone#: 508-222-4963 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 2 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 10.0 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.®OtheISEPTIC SYSTEMS, UTILITIES *Any applicant that checks box # I 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: ACE AMERICAN INSURANCE COMPANY — CHUBB Insurer's Address: P O BOX 5600 City/State/Zip: HARTFORD, CT 06102-5600 Policy # or Self -ins. Lic. # 4854P577 Expiration Date: 9/22/2020 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 herefiy'cert*, under ifte pains Oulpenaldes gfperjury that the information provided above is true and correct. 11/26/2019 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.mass.gov/dia From: Tim Gilmore Fax: 17659874329 To: Fax: (500) 226-5448 Page: 2 of 4 11/2512019 3:42 PM ACORL�® CERTIFICATE OF LIABILITY INSURANCE lllk� DAM(MINCONYYY) 1 11252019 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 INSUREMS), 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 NAME: Ann -Marie Kahanowitx R S GILMORE INSURANCE AGENCY INC P�NNo Ext: (508) 699-7511 Are No: EMMNIL amkahanowitz rs Ilmore.00m ADDRESS: � 9 INSURER(S) AFFORDING COVERAGE NAIL 9 27 ELM STREET INSURER A: ACE AMERICAN INSURANCE CO 22667 NORTH ATTLEBORO MA 02761 INSURED INSURER B BERNDT DONNA INSURER C: INSURER D: DBA D BERNDT SANITATION 120 MELODY DRIVE INSURER E: INSURE F: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 477676 REVISION NUMBER: THIS IS TO CFRTIFY THAT THE POI ICIFR OF IN51)RANCF 1I8TFR RFI OW HAVF RFFN 15R1IF0 TO THE INSURFI) NAMFN AHOVF FOR THE POI ICY PFRIOU INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE IS£U9D 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. LJTR TYPE OF INSURANCE gp yryp POLICY NUMBER MNJDDIYYYY MWDO� LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S CLAIMS -MADE n OCCUR PREMISES ne occurrence) 6 HIED EXP(Any one person) S PERSONAL&ADV INJURY S N/A GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S POLICY ] JET 0 LOG PRODUCTS - COMP/OP AGG S S OTHER AUTOMOBILE LIABILITY COMBINED SINGLE Ea accident' S BODILY INJURY (Per person)ALL 6 ANYAUTO OW AUTOS NED AUTOSSCHED N/A BODILY INJURY(Peracciden) S HIREDAUTOS AUeOSWNEO er PPROPERdTYI DAMAGE S S UMBRELLA LIAR OCCUR EACH OCCURRENCE S AGGREGATE S_ EXCESS LAB CLAIMS -MADE N/A FED RETENTIONS S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE OFFICERNEMBEREXCLUDED7 N/A NIA N/A 6562U84854P57719 09222019 09/222020 STATUTE Eft E.L.EACH ACCIDENT _ S 50Q000 — E.L. DISEASE - EA EMPLOYEE $ 500,000 IMandstorymNH) R yes, describe under DE SCRIPTICNOFOPERATIONSlIdw EL DISEASE -POLICY LIMIT S 50QOOD N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101. Additional Remarks schedule, maybe attached M more space is required) Workers' Compensatlon benefits will be ps ld to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees In states other than Massachusetts if the Insured hires, or has hired those employees outside of Massachusetts. This certiricate of Insurance shows the policy In force on the date that this certificate was Issued (unless the expiration date on the above policy precedes the Issue date of this certHicate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www. mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Crowley, CPCU, Vice President —Residual Market— WCRIBMA ©198&2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) Tha ACORO name and logo are registered marks of ACORD From: Tim Gilmore Fax: 17659874329 To: Fax: (500) 226.5448 Page: I of 4 DONN&OO.01 11/2512019 3:50 PM AKAHANOWITZ 44caJZ6 CERTIFICATE OF LIABILITY INSURANCE �--� DAM 11125/ 0V2019 1l29 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 CT R. S. Gilmore Insurance 27 Elm St North Attleboro, MA 02760 PHONE FAX (A/C, NI,o, Exq: (508) 699-7511 (AM, Na):(508) 6963597 Ohm INSURERS AFFORDING COVERAGE NAICB INSURER A : West American 443393 INSURED INSURER 8: INSURER C: Donna & Donald Berndt 120 Melody Drive Attleboro, MA 02703 INSURER o : INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER' REVISION NURMICR. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUEDTOTHE INSURED NAMED ABOVE FOR THE POLICYPERIOD 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NCR TYPE OF INSURANCE ADoI 6UBR POLICY NUMBER PW pY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY FACHOCCURRENCE b 1,000,000 CLAIMS -MADE u OCCUR X EKW57934030 8/1/2019 8/112020 DAMAGE TOR ELATED nce b 100,000 MED EXP CAny oneperson) $ 15,000 PERSONAL &ADV INJURY S 1,000,000 GENT AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY�j �LOC PRODUCTS-COMPIOP AGE 2,000,000 S OTHER: A LIABILITY COMBINED SINGLE LIMIT La accident) 1,000,000 $ ANWYryAUTO BAW57934030 8/112019 8/1/2020 BODILY INJURY Per erson S POMOBILE AUgT�O�S ONLY X SCHEDULED SSVUyLNEEDD BODILY INJURY(Per accMent) S AU TO.SONLY X AUTOSONLV Pe CeRJmIQAMAGE S UMBRELLA LIAR OCCUR EACH OCCURRENCE AGGREGATE S EXCESS LIAB CLAIMS -MADE OLD RETENTION b WORKERS CONDENSATION AND EMPLOYERS'UABILITY YIN MY PRgOPRIIETTgO�WpPARTNEWEXECUTME ❑ Wm `datoryln NHI EXCWDEdt N/A PER OTH- STATUTE ER E.L. EACH ACCIDENT E. L. DISEASE -EA EMPLOYEE S Ityes, descnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT t DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe aeached if more svice is regalr.d) Town Of Mansfield is named as an Additional Insured under the General Liability when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPREgSE_NTATIVE )ve r ACORD 25 (2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD