Loading...
HomeMy WebLinkAboutPeter DeGirolamo & Sons, Inc. - 12/31/2020/j Town of Mansfield Town ®fMangield - Board oj'Flealth s Park Row Mansfield, MA 02048 &t Disposal Works Installer Application LICENSE NUMBER: APPLICANT: Joe DeGirolamo BUSINESS NAME: Peter DeGirolamo & Sons, Inc. MAIL ADDRESS: 77 East Belcher Rd CITYITOWN: Foxboro BUSINESS PHONE: BUSINESS FAX: E-mail: Alt E-mail: 508-543-7228 508-543-9212 STATE: MA ZIP CODE: 02035 BUSINESS CELL: 508-962-1344 joe.degirolamo@verizon.net ID/SS NUMBER: 04-2498634 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed Year 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 preUVIN 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. � Signature of Individual or Corporate Name . C porate ffi er (Mandatory, if Applicable) 04-2498634 "Social Security No. (Voluntary) 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\s1eite\Des1aop\ScotPs Documents\Food Establishments- Temp\TAx CERTIFICATION FORM.doo The Commonwealth of Massachusetts Department of Industrial Accidents ®ffice oflnvestigations 600 0ashington Street Boston, MA 02111 Uf wwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Ayullicti nt Information Please Print Legibly Business/Orgatuzation Name: Peter DeGirolamo & Sons, Inc. 77 East Belcher Rd City/State/Zip: Foxboro, MA 02035 Phone #:508-543-7228 Are you an employer? Check the appropriate box: Business Type (required): 1.0 1 am a employer with 15 employees (full and/ 5. ❑ Retail or part-time).` 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I ann 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. ❑ Entettaimnent then- right ofexemption pert: 152, §I(4), and we have I 10.❑ Manufacturing no employees. [No workers' comp. insurance required] 4. ❑ We area non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp, insurance req.] 12.0 Other Contractor 'Any applicant that checks box S 1 must also till out the section below showing theirworkers` compensation policy information. "If the corporate officers have exempted themselves, but the corporal ion has other employees, a worker' compensation policy is required and such an organization should cheek box III. I obn an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance company Name: AIM Mutual Insurance Companies Insurer's Address: 54 Third Ave, P.O. Box 4070 City/State/zip: Burlington, MA 01803-0970 Policy # or Self -ins. Lie. # WCC-500-5012531-2019 Expiration Date: 10/11 /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 da hereby eerldr, under(I+e jrpIns and penalties ofperjnry that the information provided above is true and correct. only. Do not write in this area, to he conipleled by city or lawn official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Deparhnent 3. City/Town Clerk 4. Licensing board 5. Selectmen's Office 6. Other _ Contact Person Phone www.nues.gov/dia A` O® CERTIFICATE OF LIABILITY INSURANCE10/11/2019 DATE (MMIDD/Y`/VV) `I 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 Marsh & McLennan Agency LLC - New England 100 Front St, Ste 800 Worcester MA 01608 CONTACT NAME: Kyle MOrfISSe PHONE _ FAX E,ty Atc No :8) 66-795-8016 (A"o888-850-9400 E-MAIL ADDRESS: MMA.NewEngland.CLines@marshmc.com INSURER(SIAFFORDING COVERAGE NAICN INSURER A: Associated Industries of MA Mut Ins Co 33758 INSURED PETERDEGIRI Peter DeGirolamo & Sons, Inc. 77 E. Belcher Road INSURER B: Chubb Indemnity Insurance Company 12777 INSURER c: Hanover Insurance Company 22292 INSURERD: Allmeric_aFinancial Benefit Insurance 41840 Foxboro MA 02035 E: _ _INSURER INSURERF: COVERAGES CERTIFICATE NUMBER: 1788972558 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 ADDL INS D SUER WVD POLICY NUMBER POLICY EFF MMIDD/1'YYY POLICY EXP MMIDD/YYYY LIMITS C X COMMERCIALGENERALLIABILITY CLAIMS -MADE 111 OCCUR ZDNH070619 10/11/2010 10/11/2020 EACH OCCURRENCE $1,000,000 DAMAGE TORENTED PREMISES (Ea occurrance)._ _5_100.000 MED EXP (Any one person) PERSONAL& ADV INJURY $ 10,000 $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: PO - POLICY JEf°1:1 LOC OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS - COMP/OP AGO $2,000,000 _ $ D AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY AWNH070686 10/11/2019 10/11/2020 COMBINED SINGLE LIMIT Ea accident $1,000,000 _ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident --- $ $ C X UMBRELLA LIAR LIAR X OCCUR CLAIMS -MADE US055790273 10/11/2019 10/11/2020 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 $ DED X RETENTION $ in nnn ZED A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERJEXECUTIVE YIN OFFICEWMEMBEREXCLUDEDP (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below I WCG5005012531 I 10/11/2019 10/11/2020 X TH- STATUTE FOR _ E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE- POLICY LIMIT $ 1,000,000 B C Tank Pollution Hmsed/Rented Eq G46823138 BKA55790273 10/11/2019 10/11/2019 10/11/2020 10/11/2020 $1,000,000 $515,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule. maybe attached if more space Is required) Disposal Works Installer Permit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE .�- © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ITEM WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC-500-5012531-2019A PRIOR NO. WCC_500-5012531-2018A The Insured: Peter DeGirolamo & Sons Inc DBA: Mailing address: 77 E Belcher Road FEIN: **-***8635 Foxboro, MA 02035-0000 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 10/11/2019 to 10/11/2020 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 000137395 INTER SEE CLASS CODE SCHEDU E Minimum Premium $575 GOV GOV STATE CLASS _MA 6217 Total Estimated Annual Premium Deposit Premium State Assessments/Surcharges $24,191.00 x 3.5100% $24,951 $6,450 $849 This policy, including all endorsements, is hereby countersigned by P �� �— 09/11/2019 Authorized Signature Date Service Office: Marsh & McLennan Agency LLC 54 Third Avenue 100 Front Street Suite 800 Burlington MA 01803 Worcester, MA 01608 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.