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Home My WebLink AboutBay State Sewage Disposal, Inc. - 12/31/2020a 1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: -1,0UIS- LCU)m—c ta -. BUSINESS NAME: MAIL ADDRESS: 16 7 _ K � L.Pi (in-- //fi�nn CITY/TOWN: _[ aO Its _- STATE: MA_ZIP CODE: BUSINESS PHONE: (D)gy7 01 0 � BUSINESS CELL: BUSINESS FAX: (9hN).q19 - 3octo E-mail: CV-bqs_f(;1hm Alt E-mail: EDERAL ID/SS NUMBER: A3ui LICENSE HELD: Town Pjahl ul I G ____ Year Licensed 19620 LICENSE HELD: Town __c e- K 011LL Year Licensed —.2u 2 O LICENSE HELD: Town LOCVi_I(L Year Licensed AU 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". 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. ,I,,, 4a Sig lure of Individual or Corporate Name By:/Corporate Officer (Mandatory, if Appl "Social Security No. (Vol antanj) 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 FOAM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Snite 100 Boston, MA 02114-2077 wwwanass.gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Rlectricians/Plumbers. TO DE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organintion/Individual): City/State/Zip: -( ti I It I IM A Q' � I{ Phone M 50 9 q' E - A b 3 � Are you an emplyver? Check the appropriate box: Type of project (required): 1.41 am a employer with employees (full and/or partdime).* 7. New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers' comp. insurance required.) 9. ❑ Demolition 3.Q 1 am a homcoamer doing all work myself [No workers' comp. insurance required.) t 10 � Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct atl work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 1 LQ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5.M I am a general contractorand I have hired the sub -contractors listed on the attached sheet. 13. ❑ Roof repairs These sub -contractors have employees and have workers' comp. insurance.: 14.[gOther 6.Q We are a corporation and its officers have exercised their right of exemption per MCL e. �� VV%L f 152, §1(4), and we have no employees. f No workers' comp. insurance required.] -Any applicant that checks boxki must also fill out the section below showing their workers' compensation policy information. } Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such. tContrackas that chccktIm; box must attached an additional sheet showing the name of the sub -contractors and state whetter or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I ant art employer drat is providing workers' coinpensation itsurartcefor my employees. Below is the policy and job site information• Insurance Company Policy # or Self -ins. Lie. G U 6 Ll Q 3 1. X. 0 !7 0 19 Expiration Date: 0 � 5 I rAb (- Job Site Address: h 7 O0 City/State/Zip: ty p: u a r acyd I o U �I o ? � Oh ��'� ,ft,f Attach a copy of the workers' cmpen satiot policy declaratioupage (showing the policy number and expiration date). Failure to secure coverage as required under Iv1GL a 152, Q25A 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. 'penalties ofperjury Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License MUM is true and correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone A��® `Vv.-"rrVnn-�" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYT7 2/4/2019 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 Rogers & Gray Ins. - Kingston Branch 63 Smith Lane Kingston MA 02364 CONTACT NAME: PHONE Arc E D 508-746-3311 INC,No: 877-816-2156 ADDRESS: mail ro ers ra .COm INSURERS AFFOROINGCOVERAGE NAIC4 INSURER A: Arbella Indemnity Insurance Com an ,Inc. 10017 _ INSURED BAYSTAT-04 INSURER B: Arbella Protection lnsurance Company, Inc. 41360 Bay State Sewage Disposal Inc 105 Kingman St INSURER C: -_ Lakeville MA 02347 INSURER D: E : _INSURER INSURER F: COVERAGES CFRTIFICATF NIIMRFR-47RA431A1 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 ADDLSUBR POLICYNUMBER POLICY EFF MMIDDIYYVY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Lxl OCCUR 8500069401 1/18/2019 1/18/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO -PREMISES Ea omurtDence $ 300,000 MED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [X] JPE` T I K LOG OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OP AGG $2,000,000 B AUTOMOBILE LIABILITY ANY AUTO OWNED [Jfl SCD AUTOS ONLY AUTOHEULED S HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY Ix 102007999801 1/18/2019 1/18/2020 COMBINED SINGLE LIMIT Ea accitlenl $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Pe�ac tlen DAMAGE $ $ A X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE 4600069402 1/18/2019 1/18/2020 EACHOCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED X RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORRARTNERIE%ECUTIVE F OFFICEWMEMBER EXCLUDED't (Mandatory in NH) If yes, describe antler DESCRIPTION OF OPERATIONS below NIA STAH TUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Equipment Floater 8500069401 1/18/2019 1/18/2020 LeasedrRenled 100.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 'a"Ic'""E HOLLER CANCFI I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Health Department Town Hall 6 Park Row - 1 st Fir AU ED REPRESENTATIVE Mansfield MA 02048 (91988-ZU15 ACUKU CUKPUKAI IUIV. AD rlgnTs reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/03/2019 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 endorsement(s). PRODUCER ROGERS &GRAY INSURANCE AGENCY INC CONTACT NAME: Heather Woods a"c° N Est: (508) 747-6582 FAX No: E-MAIL ADDRESS: hwoods@rogersgmy.COm INSURERS AFFORDING COVERAGE NAIC# 434 ROUTE 134 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 SOUTH DENNIS MA 02660 _ INSURED INSURER e INSURERC: BAYSTATE SEWAGE DISPOSAL INC & INSURER D : INSURER E: PO BOX 886 INSURER F: LAKEVILLE MA 02347 COVERAGES CERTIFICATE NUMBER: 421462 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. IOLICY LTR TYPE OF INSURANCE ADOL INSD SUBR POLICYNUMBER MMIOO/YYErr EXP MMIODN"Y LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES Ea occurtence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY _$ N/A GENT. AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ PRODUCTS-COMPIOPAGG $ POLICY PRO- ❑ LOC ECT $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accitlent $ BODILY INJURY (Per person) _ $ ANYAUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS H N/A PROPERTY DAMAGE Per accident $ $ BRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ rEXCESSLIAB CLAIMS -MADE NIA RETENTIONS $ I A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERJEXECUTIVE NIA (Mandatory in NH) NIA NIA 6S60UB4N31205019 06/15/2019 06/15/2020 �/ X STATUTE ERH E.L. EACH ACCIDENT - $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid 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 certificate 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 certificate 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/. nPPTIPICATP Hnl FIER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE `, - Mansfield MA 02048 -, Daniel M. Cro CPCU, Vice President — Residual Market— WCRIBMA v�ey, 9)1988.2014 ACORD CORPORA I [ON. All rights reservers. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD