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HomeMy WebLinkAboutL & L Heating - 12/31/2020t0Oei NOV i r INC?, .. Town of M n d q M Town of Mansfield - Board of Health 5 Park Row o Mansfield, MA 0 asxu� < Disposal Works Installer Application LICENSE NUMBER: APPLICANT: I�_Gf BUSINESS NAME: L JJc,rr fx MAIL ADDRESS: f r /,/ �P I/ b,_- -4 �, CITY/TOWN: 14r7_11 STATE: P, ZIP CODE: BUSINESS PHONE( �GfS/6� �BUSINESSCELL: BUSINESS FAX: E-mail: Alt E-mail: ID/SS NUMBER: LICENSE HELD: Town p`"yT"I LICENSE HELD: Town ��� � /` 4, Year Licensed y ' Year Licensed Z_�* %�_ c, ' LICENSE HELD: Town /1 IA� J h t' �l11 Year Licensed 14- ;r - - � 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 SIGNATURE: / I p 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. ir5 gniiture of-Yindivjd" or Corporate Name By: Corporate Officer (Mandatory, if Applicable) Oct— -->lj **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\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe 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: e—*� �✓ L `1 Address: City/State/Zip: ✓T / /, /s,,, Phone .62y / �',rl'— (_,� ��% Are you I am a employer with ❑ employer? Check the appropriate box: Business Type (required): 1. L l 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 (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑ 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 have1 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0Other q 1L-.lo4 b -j sltv'[ PY4'� *Any applicant that checks box #1 must also fill 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 ani mn employer tlmt is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Z-np' �� Insurer's City/State/Zip: Policy # or Self -ins. Lic. 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, ung theins and penalties ofperjury that lite information provided above is true and correct Official use only. Do not write in this area, to be completed by city or tours official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitytTown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.govtdia A� Q® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD YYY) 11/1312019 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 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 CONTACT NAME: Karen Martin fArPHONN Bid, E (508) 678-8341 pc No: HERMAN W LAPOINTE JR INSURANCE AGENCY INC E-MAIL ointeins.com karenm la ADDRESS: karenm@lapointeins.com INSURER(S) AFFORDING COVERAGE NAIC 0 1777 PLEASANT ST INSURERA: ACE AMERICAN INSURANCE CO 22667 FALL RIVER MA 02723 INSURED INSURER B: INSURER C: LOGAN RAYMOND DBA L & L PLUMBING AND HEATING INSURER D: INSURER E: 1011 HILLSIDE AVE 1 INSURER F: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 472780 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 OF INSURANCE ADDLITYPE VISO SUER POLPOLICYNUMBEft MMIDOYIYYFYI' POLICY YIYEYYY LIMITS Daniel M. Cr ey, CPCU, Vice President— Residual Market— WCRIBMA COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE DOCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ N/A GEN'L AGGREGATE LI MIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- ❑ ECT LOC PRODUCTS - COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident)$ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS NIA PROPERTY DAMAGE $ Peraccidenl $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE N/A DED I I RETENTION$ I $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERIMEMBER EXCLUDED? ORIPARTNER/ExEiCUTIVE NIA (Mandatory in NH) NIA NIA 6S62UB4579P92019 03/24/2019 03/24/2020 X /� STATUTE Eft E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 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 certlfcate 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/investigationst. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 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. 6 Park Row AUTHORIZED REPRESENTATIVE f t��Mansfield MA 02048 Daniel M. Cr ey, CPCU, Vice President— Residual Market— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 01V111111111111ICE111 KMARTIN `—� CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDYYYY) 1 111 312 01 9 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 on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON EaCT Isabel Carreiro H W Lapointe Jr Ins Agency, Inc Fall River, MA 02723 PHONE Paz (AIC, No, Ext): 207 (A/c, Ne):(508) 678.0438 EO R'Ls. icarreiro@lapointeins.com INSURERS AFFORDING COVERAGE NAIC It 8/23/2020 INSURER A: Travelers Casualty Insurance Co of America 19046 DAMAGETORENTED 300,000 PREMISES E occu a c� INSURED INSURER E: INSURER C: Raymond Logan DBA L & L Plumbing & Heating INSURER D: 1011 Hillside Ave Attleboro, MA 02703 INSURER E INSURER F: _... _.. _.... AUTOMOBILE 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 MAYBE 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. INSRrypE L OF ADDL SUER O POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR6804A644596 X 8/2312019 8/23/2020 EACH OCCURRENCE $ 500,000 DAMAGETORENTED 300,000 PREMISES E occu a c� MED EXP LAny one erson 5'000 PERSONAL &ADV INJURY 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E JECT [:] LOC OTHER: GENERAL AGGREGATE 110001000 PRODUCTS - COMPIOPAGG 1,000,000 $ AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSyyNEp AUTOS ONLY AUOTOS ONLY COMBINED SINGLE LIMIT Eaaccidenl $ BODILY INJURY Per persom $ BODILY INJURY Per accident $ PerOacEcRrJen, AMAGE $ b UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ AND EMPLOYERS' COMPENSATION YIN ANY PRRROIIPMMRIETOERRIPARTNER/EXECUTIVE � (Mantlatcry In ME cry a Ifyes, describe under DE SCRIPTION OF OPERATIONS below NIA P RTUTEA ERH- E.L. EACH ACCIDENT $ E.L. DISEASE-EAEMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD Im, Additional Remarks Schedule, maybe attached If more space Is required) Town of Mansfield 6 Park Row Mansfield, 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. AUTHORIZED REPRESENTATIVE f&,L a. rxa . ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD