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HomeMy WebLinkAboutWind River Environmental #2 - 12/31/2020�. 0 €3 0 i4�5 TOHJn of Mansfield - Board of Health Disposal Works Installer Application Town of Mansfield B Park Row Mansfield, MA 02040 LICENSE NUMBER: _ S!_13'Ie9____ APPLICANT: __._. J r �jr\\L_2S CPneSeo_ BUSINESS NAME: Q', t IPr ! n, r •r _ dn.e L_ 1 `�- MAIL ADDRESS: LC �'r �bT- --C--- ; CITYffOWN;( `�qr r�U� STATE: Ala_ ZIP CODE: BUSINESS PHONE: nL?aBUSINESS CELL: BUSINESS FAX: J-7 - E-mail: Ile��l���Vlr, n�MPt1� Cc�M Aft E-mail: �'4�-rii•C<'�^� WP'CnV'1`c9nMP�"�z,(<lpM FEDERAL ID/SS NUMBER: LICENSE HELD: Town 1 n!20 �,1 Year Licensed _ R[Dj LICENSE HELD: Town line _ Year Licensed LICENSE HELD: Town �{Y'� jjn r. Year Licensed o_ 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 31st yearly. FEE: $ 100.00 SIGNATURE: �- DATE: ���•7 ��� 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. AJ A P" [A 1/4V.4ri e Signature of Individual or Corporate Name By: Corporal fficer (Mandatory, if Ap licable) *"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\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc y.r \ LUY 4VIIf II/Vif IYYNLLIi Vf tYI UJVW4.I/NJY44J ciSYa 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 99 f j Please Print Legibly Business/Organization Name: 1 .11.IcA Kiyc(- Fqv;roo Me'n4�, i Address: OLP Li -oo4c-, I6sY v -k? - City/State/Zip:ki-t,-16wL,-10, %4 Q(75� Phone#: Are you an employer? Check the appropriate box: Business Type (required): 1. K( lam a employer with f" employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $. ❑tion -profit [No workers' comp, insurance required] 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per e: 152, § I (),andwe have we 10.0 Manufacturing 4.0 no employees. [No workers' comp, insurance We 11.❑ Health Care are a non-profit organization, staffed by vohmteers, with no employees. [No workers' comp. insurance req.] 12•M Other __- 'Anyapplicant that checks box #1 must also till out the section below showing their workers' compensation policy infomtatian. ' '"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 nil. 1 our an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Lr)c k n Insurer's Address: 1 �j rj N 4y( rr7� .� tree ti V City/State/Zip: �: 7 A tg r f A C',z=/-z Policy # or Self -ins. Lic. # jtDV00C'),329 \ Expiration Date: 6 Sts ' G CN 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 tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of 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. 1 do hereby corm o, under the pains and penalties ofperjury that the information. provided above is true and correct. Xw1 Th Signature: o- Date: 7 b�o //9 1 Phone #: rr-- ijor�i - /&4Saa Official use only. Do not write in this area, to be completed by city or town offielat City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department B. City/town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mss.sov/dia Phone ACORO® CERTIFICATE OF LIABILITY INSURANCE 6/30/2020 DATE (MMIDDYYYY) 7/3/2019 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(les) 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 Oil. this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lockton Insurance Brokers,LLC CONTACT NAME: CA License #OF 15767 777 S. Figueroa Street, 52nd O. Los Angeles CA 90017 PHONE FAX E.0- AIC No): E-MAIL ADDRESS: 1000090512191 213-689-0065 INSURER 5 AFFORDING COVERAGE NAIC It INSURER A: Starr Indemnity &Liabilit Company_38318 INSURED Wind River Environmental, LLC 1448815 46 LIZotte Dr. INSURER B:*** SEE ATTACHMENTs""' INSURER c: Marlborough MA 01752 _ INSURER D: INSURER E: UCTS-COMP/OPAGG $ 4 000 000 _OTHER: INSURER F : COVERAGES WINRIOI CERTIFICATE NUMBER: 16182381 REVISION NUMBER: XXXXXXX 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. !NSR LTR TYPE OF INSURANCE ADDLSUBft Me POLICY NUMBER POLICY EFF IMMIODNMI POLICY EXP IMM/13DAYNY)LIMITS A XCOMMERCIAL GENERAL LIABILITY _ CLAIMS -MADE L� OCCUR N N 1000090512191 6/30/2019 6/30/2020 OCCURRENCE $ 2000000 ., DAMAGERENTED ISES Ea occurrence $ 300 000 EXP one person) $ 10000 NAL 8 ADV INJURY $ 1,000.000 <GENL AGGREGATE LIMIT APPLIES PER: [ JEC LOC RALAGGREGATE $ 4000000.......POLICY UCTS-COMP/OPAGG $ 4 000 000 _OTHER: $A AUTOMOBILE XANY LIABILITY AUTO SCHEDULEDY ONLY AUTOS AUTOS ONLY AUTOS ONLY AUTOS ONLY Com /Coll D IX Various N N 1000198837191 ((MA) 1000198836191 (AOS) 6/30/2019 6/30/20!9 6/30/2020 6/30/2020 accE NSIN LE LIMIT $ 2 000 000A if Y INJURY(Per person) $XXXXXXXOWNED INJURY(Per accident) $ 7AUTOS _ __ _ XXXX_X_XXHIRED ERTY DAMAGE _- -- ccident $XXXXXXXX s XXXXXXXB UMBRELLA UAB EXCESS LIAR X OCCUR CLAIMS -MADE N N See Attached 6/30/2019 6/30/2020 OCCURRENCE $ 14000000_.__• EGATE $ 14.000,000 DED RETENTION$ _ $ XXXXXXX... A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY VIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below NIA A N 1000003291 6/30/2019 6/30/2020 �, PER OTH- STATUTE ER 1 E.L. EACH ACCIDENT $ 1.000.000 E.L. DISEASE - EA EMPLOYEE1 $ 1,000.000 E.L. DISEASE POLICY LIMIT $ 1,000,000 , DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) 16182381 Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEFdRE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED- - IN ACCORDANCE WITH THE POLICY PROVISIONS. --- AUTHORIZED ©1 ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD All rights reserved.