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HomeMy WebLinkAboutRepublic Services - 12/31/2020? NOV 0 6 2049 3�6-;4q6 Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Hauler's Application BUSINESS NAME: Republic Services BUSINESS ADDRESS: 1080 Airport Rd TOWN / STATE / ZIP: Fall River, MA 02720 NAME OF OWNER: Don Slagger TELEPHONE NO: 774-488-3519 CELL NO: FAX NO: E-mail: kpankowski@republicservices.com Alt E-mail: bpenney@republicservices.com FED ID/SS NO: 86-1024452 REGISTRATION NO: NO OF TRUCK(S): 3 FEE PER TRUCK: $75.00 PERMIT NUMBER: TOTAL FEE: $225.00 DATE: 10/23/19 Please make appropriate changes. Sign, date and enclose check 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 Ulf www.niass.gov/Ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_ Address: City/State/Zip: kin J�-( UfY ),-)-1 Phone #: �()() 15 , `7fl Are you an employer? Check the appropriate box: Business Type (required): I,❑ I am a employer with employees (full and/ 5. Q Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7, ❑ Off -tee and/or Sales (incl. real estate, auto, etc.) employees working for the in any capacity. [No workers' comp, insurance required] $. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. E] Entertainment their right of exemption per c. 152, §1(4), and we have IO.Q Manufacturing no employees. [No workers' comp, insurance required]* i l Q Health Care 4,E] We are a non-profit organization, staffed by volunteers; with no employees. [No workers' comp, insurance req.] 121�:POther Tok)��k,t� •Any applicart that checks box #1 must also fill out die section below shoving their worked' compensation policy information. **If the corpomte officers have exempted themselves, but the corporationhas other employees, a worked' compensation policy is required and such an organization should check box #I. I alrr an employer ibrrt Tsproxblbrg woAkersI connpensadon insurance for try employees. Below is the policy information. Insurance Company Insurer's Address: "IA D teal nu j . s � fU (Doe 1w)6 d City/State/Zip:PodA icn t (e 19 /bU -3205 Policy # or Self ins. Lie. # u, 0 ( a UU-16393 Expiration Date: (.P�301a() 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 forst 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 Investittations of the DIA for insurance coverage verification. I do hereby certify, under re pains and penabies ofperjury drat lire information provided above Iss true and correct. Sivrntl VP' / / r,..• /]'a/--1 ! Phone #: 0 n o �a 5�5 (�;b 0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License it Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone #: www,.tu=.gov/dia 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 By: Corporate Officer (Matulrrtory, if Applicable) 0 0 )00 �l "Social Security No. (Votuntanj) or federal fdetltiflcaticot Nuotber *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. CAUserstSleite\DesktuptScotrs DocumentslFood Esmblishments- TempVI A% CERTIFICATION FORM,doc Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required, Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and elate the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year, Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bur leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia fnmi Revised 5.26•n5 COI Issuance Page 1 of t ACORD CERTIFICATE OF LIABILITY INSURANCE Ye'e1U2 )A—F, ON2713a1F THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NORIGHTSUPON 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 an this certificate does not confer rights to the certificate holder In lieu of such endomemenl(s). CANNON. COCHRAN MANAGEMENT SERVICES, INC. 17015 N. SCOTTSDALE RD SCOTTSDALE. AZ 65255 REPUBLIC SERVICES, INC. ISWO N. ALLIED WAY PHOENIX, AZ 85050 =wcnrav=a THIS IS I C CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOb INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIIONS AND CONDITIONS OF SUCH POLICIES, LIMITSTAIN, THE URANCE SHOWN HONK MAY HAVE BEEN REDUCERDED By THE D BY PAIDIES SCLLAIM$ HEREIN IS SUBJECT TO ALL THE TERMS. I R LTR A TYPEOFINSURANCE X MME AL OEN LIABIM CLAIMS -MADE � OCCUR ADD INSO UBR VAID POUCY NUMBER HDO U115]Oa1a POLICY EFF IMMmDAWYI OOJ.kN2649 POLICY EXP IMPAXINYYYI 031'!8/2010 LIMITS EACH OCCURABJCE $b.900,aoD DAMAGE TO RENTED $ 50Oe,080 PREMISES(Ea OMtmanta) MED EXP (AmY Dna Parson) sign PERSONAL&ADVINJURY 55,090000 GENL AGGREGATE LIMIT APPLIES PER POLICY ©PROJECT &LOC OTHER GENERALAOGREGATE 55,000,090 PRODUCTS�COMPXDPAGG 55,000,088 Lease Slates A UTOMOBILELIA011-TIY XIANY AUTO X OWNEDAUTOS �SCHEDULFb ONLY AUTOS X HIREDAUTOS ONON-OWNED ONLY AUTOS ONLY ISA W529]605 08r30I2019 05(!0/2010 LOMBINEDSINGLE LIMIT SSDK000 fria aeddm0 BODILY INJURY(PMpe,son) BODILY INJURY W.110( to PROPERTY DAMAGE (Par a®deii) MBRELLALIAB CUR CESSUAS CLAIMS -MADE BED RETENTIONS UCHREWE RENCE B A C A D DITHERS COMPENSATION YIN AND EMPLOYERS'LIABILRY Y PR9PPIETOfbPARTNER,F]IECULIYE N FIGEILMEMeER EXewoEO] ❑ MM,dMwY In NHI fyos, describe under DESCRIPTION OF OPERATIONS belay NIA WLR C0004rD00-AOS WLR CfSO40343-CA(MA�OR SCFCE6OW22-W ACU C6BM046A- OR XS THIS C66221 1 59 TX NSXS 081=9 04f3NS019 owwo19 O6FJOr1019 06=01a 05902020 (19f�a/2020 O0r,1(V1020 oe,=020 0800/1020 X mNre � EL. EACHACCIDEtfT S3,OW,0W EL.bAUHAU.EAE PL YEE 53009 E1.DISEA5E-P000YLIMR 143,000.000 DESCRIPTION OF OPERATIONS / LOCATIONS i VEHICLES (ACORD 101, Additional Remark. Sthadula, may be attached if more apace b ragViretl) Division Number: 4097 - Named Insured Indudes: AIOed Waste Services Of Ma"QduSaDa, LLC - Ube: Allied Waste Services of Fall River 11 Republic Services of Fall River ,.cn nn,.n,c nvcucn SHO OULD ANY OFXPIRA ABOVEDATE NOTIIESpLLCANCELLED VE BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THEREOF, ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Tovmq MaRsfiaW Aun: board Of Hours) sign 6 Pad, Roy Mansfield, MA 02048-2433 Lease Slates a �nea nn.• � nnnn nnoonUa T,/1iJ Aa Anal rv�arvnd. Download Q01 in PDF format AGENCY CUSTOMER IO: https:llsecure.smartcomplianceine.com/SECURE/WebForms/External/coi.aspx?htm=1&b... 11/21/2019 C01 Issuance ADDITIONAL REMARKS SCHEDULE Pop 2012 Page 2 of 2 AGENCY NAMED INSURED REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY PHOENIX, AZ 85054 POUCYNUMBER See First Page CARRIER See First Page IWC CODE EFFECTIVE DATE; THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. FORkr NUMBER: 25 FORMTITLE: CERTIFICATEOF LIABILITY INSURANCE The following provisions apply when required by written Contract.. As used below, the term certificate holder also includes any person or organization that the insured has become obligated to include as a result of an executed contract or agreement. GENERAL LIABILITY: Certificate holder is Additional insured including on-going and completed operations when required by written Contract Coverage is primary and nont nb bulory when required by written Contract. Waiver of Subrogation lo favor of the certificate holder Is included when required by written contract. AUTO LIABILITY: CeMficale holder is Additional Insured when required by written contract. Coverage is primary and non-contributory when required by written contract. Waiver of Subrogation in favor of the certificate holder Is Included when required by written contract WORKERS COMPENSATION AND EMPLOYERS LIABILITY: Waiver of Subrogation in favor of the certfirare holder Is included when required by written Contract where allowed by state law. Stop gap coverage. for NO, WA and WY is Covered under policy no. WLR 066040360 and stop gap coverage for ON Is covered under policy no. WCU C6604046A, as noted on paged of this Certificate. TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY: Insured is a registered non -subscriber to the Texas Workers Compensation Act. Insured has filed an approved Indemnity Plan with the Texas Department of Insurance which offers an alternative In benefits to employees rather than the traditional Workers Compensation Insurance In Texas. The excess policy (#TNS C65221159) shown on this ceRiflcate provides excess Indemnity and Employers Liability Coverage for the approved indemnity Plan. Contractual Liability is included in the General Liability and Automobile Liability Coverage farms. The General Liability and Automobile Liability policies do not Contain endorsements excluding Contractual Liability. Separation of Insured (Cross Liability) Coverage is provided to the Additional Insured, when required by written contract, per the Conditions of the Commercial General Liability Coverage fort and the Automobile Liability Coverage form. The ACORDnameandlogoaremgla .dmaksof ACORD Download COI in PDF formal https;L/sectire.smarteoniplianceine.com/SECURE/WebForTnslExtemal/coi.aspx?htm=1 &b... 11/21/2019