The URL can be used to link to this page

Home My WebLink AboutBrunelle Contracting LLC - 12/31/2020Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: C D APPLICANT: BUSINESS NAME: �1k0A)&L-e� c> t�i%I�l�ft%%I 11Jtr LG �' MAIL ADDRESS: D Town of Mansfield 6 Park Row Mansfield, MA 02048 "I(9 eG,g_4 p eq, ( > e, CITY/TOWN: lNi�j�VS�I �1 .1� STATE: M4—ZIP CODE: 6 2p0. 4 5 BUSINESS PHONE: 6'00-3 3R_�_'Gy��fBUSINESS CELL: BUSINESS FAX: 5b S '—�z i — qY?%_ / E-mail: 2?lvme-Ife_b2 r� ® Lid b M Alt E-mail: ID/SS NUMBER: 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 ilGNATURE: Me, DATE: /Z "-7 % — t I 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 N 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 o-y32o73z "Social Security No. (Voluntary) or Federal Identification Nninber 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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ® A� L7 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/30/2019 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 Marsh & McLennan Agency LLC - New England 100 Front St, Ste 800 Worcester MA 01608 NAME CT Melissa Pin eton PHONE AAIC, No ExD_ 888-850-9400 __ ._ tiIc No : 866-795-8016 _ E -MAIL AODREss:._MMA.NewEngland.CLines marshmc_com INSURER S AFFORDING COVERAGE NAIC H _ INSVRERA: Selective Insurance C)Om an of America 12672__ INSURED BRUNECONTR Brunelle Contracting Company, LLC R 50 Maple Street Mansfield MA 02048 INSURER B: NSURERC: _ INSURER D : INSURER E: INSURER F: rnvco nr_oc CERTIFICATE NUMBER' g3ROri REVISION NUMUtK: 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. _ ILTR """" TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EF; MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY -- l CLAIMS -MADE N OCCUR S2021887 7/27/2019 7/27/2020 EACH OCCURRENCE $1,000,000 DA ETORENT D PREMISESIEa occurrence)__. $100,000 MED EXP (Any one person) $ WOOD PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3.000,000 _ PRODUCTS .COMP/OP AGG —..-. ---.-_ $3,000,000 _._ POLICY L] PRO. I LOG JECT _ OTHER'. A AUTOMOBILE LIABILITY A9098706 7127/2019 7127/2020 COMBINED SINGLE LIMIT _(Ed accdentl $1.000000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY(Per accident) $ SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED OWNED lix XAUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per ccide 0 $ A X UMBRELLA LIAB IX OCCUR S2021887 7/27/2019 7/27/2020 EACH OCCURRENCE $3,D00,000 _ AGGREGATE $ 3,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION$ $ q WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETORJPARTNER/EXECUTIVE WC9024934 3/19/2019 3/19/2020 STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 _ OFFICER/MEMBEREXCLUDED? ❑ (Mandatory in NH) NIA E.L. DISEASE - POLICY LIMIT $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Town of Mansfield Board of Health 6 Park Row Manfield MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ACORD 25 (2016103) COZRIIfbIri61 The ACORD name and logo are registered marks of ACORD All rights reserved. The Commonwealth of Massachusetts Department of Industrial Accidents 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: .5l) m4loL—::: 5v- 14-- G- L C City/State/Zip:- %% 41t6iCle(�4 X J-P Phone #: �C' �' ` '3 2> Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with O employees (full and/ 5. ❑ Retail -- -or-part-time) * --- - - - -- -- ,6. Restaurant/BarEstablishment ❑" /Eatin g 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' camp. 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, I1.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other CZC,1jVA-'j iti (01Vr ygCjb"0 � U uypn uonu, uJUL checks box r must also tut 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. w , I Insurance Company Insurer's Address: Prot Aj8X -] 7 City/State/Zip: _/��kWTLQ P4- 11�- Z, Jj D r Policy # or Self -ins. Lic. # ' 90d / J`y Expiration Date: 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 hereby certify, under thepains andpenalties 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 Person: Phone