The URL can be used to link to this page

Home My WebLink AboutR. J. Gabriel Construction Co. - 12/31/2020�fflv� ansfiehl - Board of Health Disposal Works Installer Application LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: Town, Mansfield 6 ParkAbw Mansfield,,11A 02048 - 4s , zr CITY/TOWN: 7J/ __ _ STATE. kQ _ ZIP CODE: Qo Ja BUSINESS PHONE: 2 � BUSINESS CELL: BUSINESS FAX: .S262-6 !� 216 E-mail: w�7_J21(L/X Alt E-mail: O ID/SS NUMBER: o 4-a 31.-5—'), `j L LICENSE HELD: Town LICENSE HELD: Town �v V LICENSE HELD: Town Year Licensed Year Licensed Year Licensed 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 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 The Commonwealth of'Massachusetts Department of'Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ritas's.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 795 City/State/Zip: /` - hone #: -Tag—(oqr7y,7 7 f Are you an employer? Check the appropriate box: Business Type (required): 1.g I am a employer with 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 (met. 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. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Car with no employees. [No workers' comp. insurance req.] 12.0Other l�yt tb& *Any applicant that checks box #1 must also till out the section below showing theirworkers' 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 Ml. I am an employer that is providing rvorkers' eornpeiisation insurance for nq, enployees. Below is the policy information. Insurance Insurer's City/Stat Policy # r. r Attach a copy of the workers' compensation po ' declaration pa (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 Investigati9nsrttf the DIA for jtlsuranee coverage verification. I do hen6bv eertilfv, under 'perjury 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/die Phone 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 tinder law. e �L110 /( _/�/, Signature of Individual or Corporate Name By: Cor orate Officer (Mmrda nrg, if Applicable) 64-23[-saq� "Social Security No. (Voluntary) or Federal Identification Nunnber *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\slei(e\])esktop\Scott's Documents\food Establishments- Temp\TAX CERTIFICATION FORM.doc CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 11/15/2019 TWLSGEKTIFICATE 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.I IC E 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER STARKWEATHER & SHEPLEY PO BOX 549 PROVIDENCE, R1 02901 22HHX CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAICp INSURED R J GABRIEL CONSTRUCTION CO INC 795 BEDFORD ST BRIDGEWATER, MA 02324 INSURER A: ACEAMERICAN INSURANCE COMPANY INSURER e: INSURER C: INSURER D: INSURER E: INSURER Ft COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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 HERON IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR FIR TYPE OF INSURANCE OD INSR UBR WVD POLICY NUMBER POLICY EFF DATE (MMIDDIWYY) POLICY EXP DATE (MWDMYYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE DOCCUR. ;ACH OCCURRENCE $ DAMAGE TO RENTED REMISES (En or rrnm.) $ ED EXP (Any one person) $ ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PROJECT [—]LOG GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULE AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ A WORKER'S COMPENSATIONAND EMPLOYER'S LIABILITY YIN ANY PROPERITOWPARTNEWEXEGUTIVE OFFICER/MEMBER EXCLUOEDI El (Mandatory In NH) It yes, deecrlbeander DESCRIPTION OF OPERATIONS belay NIA USAN591808-19 09/13/2019 09/13/2020 X WCSTATUTORY LIMITS OTHER 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/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS TIES REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERT'IFICA'TE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF MANSFIELD 6 PARK ROW MANSFIELD, MA 02048 SHOULD ANYOF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL V DELIV ED IN ACCORDANCE WITH THE POLICY PR01j1S10 AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1980.2010 ACORD CORPORATION.. All Fights reserved. OtA of Taunton )Board of health 15 �6011001 �&CW M0080111UBttt6 02I80.3212 BOARD MEMBERS DR. BRUCE E. BODNER DR. THADDEUS A. FIGLOCK DR. CHARLES A. THAYER HEATHER L. GALLANT, MPH, RS, CHO EXECUTIVE DIRECTOR ADAM S. VICKSTROM ASSISTANT EXECUTIVE DIRECTOR DISPOSAL SYSTEM INSTALLER'S PERMIT Permit #: 3 — 19 Permit Fee. 100.00 This is to certify that: Name: David A. Gabriel, R.J. Gabriel Construction Company, Inc. Address 785 Bedford Street, Bridgewater, MA 02324 ... is hereby granted a "Disposal System Installer's Permit" to construct, upgrade, expand and abandon on -site sewage disposal systems in conformity with 310 CMR 15.000, The State Environmental Code, Title 5 Type of permit and any restrictions: Disposal System Installer's Permit Permit expiration dat : December 31, 2019 nless sooner suspended or revoked Date issued: January 3, 2019 BOARD OF HEALTH APPROVED THADDEUS A. FIGLOCK, M.D. CHAIRMAN TAUNTON,MA Adam S.. Vickstrom Assistant Executive Director Original: Installer cc: Taunton Board of Health Regional Environmental Engineer, DEP TdQl)0nc (508) 821.140 COX s) 821.110 NO 19-27 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF EAST BRIDGEWATER BOARD OF HEALTH This is to certify that RJ Gabriel 785 Bedford Street Bridgewater, MA 02324 FEG: $1 �0.00 is hereby granted a Disposal Works Installer's License to construct, alter, install or repair, individual sewage disposal systems. `Phis permit is granted in conformity with the State Sanil expires December 31, 2019, unless sooner suspended or rep Board Of Health id U) F- LU M Q LL nin LLJ Z 5 U LLJ F- w ui z 3: LL O 0 rn N N m x (0 LL 0 0 W ro 0 a m m 0 0 c m 2 d O c 0 m h3 3� v o a a N �� fri m V J W. k •� co T r O O O N a � CD r O N � a r r c NUMBER:wt The cotumonwealtbof fdaMMEWWW la w wa w. " - , This is to Certify David A. Gabriel R.J. Gabriel Construction Co, Inc 785 Bedford Street Bridgewater, MA 02324 310 berebp grauteb a 05pmsal Voth>f �JnotaCCer's permit Ito coamuct, Ater, 3ftt.otall or Aepair 3fubibibual sewerage �Bigmd �&Potemo Tf)is permit i.5 grauteb (it toufortuitp Witt) the 6tate 01biroutuetttal Cobe title W, 310 COR aub expireb December 31, 2010 uuleoo ooAter bubpeubeb or rebolteb. /L $tebe t Mary o} -ulp 1011, 2010 �BAt ' C�Pourttier Client#: 97768 RJGABRIE ACORD., CERTIFICATE OF LIABILITY INSURANCE DATEfYYYY) 1 11I14/20412019 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(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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER Starkweather & Shepley (WW) Insurance Corp. f MA P- NAME: CONTACT Lauren Luke PRONE 781320-9660 wC,Nmh 1-320-9901 EMAINI.o'Ea� liuke starshe com ADDRESS: � P- POBox549 Providence, RI 02901-0549 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Employers Mutual ITS 21415 INSURED RJ Gabriel Construction Co., Inc. 786 Bedford Street Bridgewater, MA 02324 INSURERB: INSURER C INSURER D (--- INSURER E INSURER F 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 LTR TYPE OF INSURANCE ADDL BUBB WO POLICY NUMBER POLICY EFF MMIDDN POLICY EXP MM( /DOIYY - LIMITS A X ____INSR COMMERCIAL GENERAL LIABILITY 5D36437 09/13/2019 09113/202 EACH OCCURRENC_E__ $1 D_0_O 0_0_D_____ L CLAIMS -MADE X OCCUR _ pq�q CAE STOE}2ENTE0 PREMI aoccur_ease)_.......$3 _3 _ qoo Per Written Contract MEDEXP(Anyoneperson) $10000 PERSONAL &ADV INJURY $1 000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 GENT PROT E LOC POLICY ❑ JEC PRODUCTS - COMP/OP AGO $2,000,000 $ OTHER : A AUTOMOBILE LIABILITY 5Z58586 _ 9113P1019 _ 09l13/202 COMBINEDSINGLELIMIT $1,000,000 BODILY INJURY (Per person) $ ANVAUTO BODILY INJURY (Per accident) S _ OWNED SCHEDULED AUTOS ONLY X AUTOS xHIRED NON -OWNED X AUTOS ONLY — AUTOS ONLY PROPERTY DAMAGE Peraccides $ UMBRELLA LIAR OCCUR EACH $ -OCCURRENCE AGGREGATE _ $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY yIN ANY PROPRIETORWARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA PER OTH- STAT TE ER _ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NHj EL DISEASE. POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached If more space is required) CFRTIFICATE HOLDER CANCELLATION Town of Mansfied SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Amy Donovan -Palmer ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE l bra. —4— Mansfield, MA 02048 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S13970511MI363870 PAT3