HomeMy WebLinkAboutCanoe River Campground - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Campground Permit
This is to certify that GONSALVES FAMILY
Is hereby granted a CANOE RIVER CAMPGROUND
permit for:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
137 MILL STREET, MANSFIELD, MA 02048
250 SITES
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires December31, 2019 unless sooner suspended or revoked.
Fee : $75.00 plus $1.00 per site Total Fee : $325.00
Permit Number: 1
BOARD OF HEALTH
.7 khael.7vlcClean, Chairman
Town of Mansfield
Town of Mansfield - Board ofHealth 6 Park Row
Mansfield, MA 02048
Application for Campground Permit
I hereby make application for a CAMPGROUND PERMIT, which expires on December 31st of each year.
NAME OF BUSINESS: l = t1 LS-
ADDRESS OF OWNER: f' 3 �7 l / C. C_ �'; ( r it:—L .'�f `f . C'� _� y;'
OWNER:
BUSINESS PHONE
BUSINESS FAX: 7 ? eI
E-MAIL:/ —' _-�„ = G' <'. C ;,a1
ALT E-MAIL;
FEDERAL ID/SS NUMBER: % 5 1 T
NUMBER OF SITES: ;),_ .S c
FEE: * _) S Plus $1.00 Per Site TOTAL FEE: 5
PERMIT NUMBER:
f�
SIGNATURE:
DATE: // / -7 /r''
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
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best lotowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
-(-,A 0 /
Signature of Individual or Corporate Name
By: Corporate Officer
(Mandatory, if Applicable)
"Social Security No. (Whinta y) 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\sleile\Uesktop\Scoti's Documents\Food BMblishments- 7'enipVFAx CERTIFICATION FORM.doe
'\ The Commonwealth of Massachusetts
Department oflndustHalAccidents
x I Congress Street, Suite 100
Boston, MA 02114-20I 7
www.raassgov/dia
Workers' Compensation insurance Affidavit: General Businesses.
TO BE RILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: Lc, ,� C r u r_, rjh,r,
Address: -� % / i 1 L (_.
City/State/Zip: F i n 2 -"" L f-a /ti,'A . e �r y<'Phone #: 1� (' S'
Are you an employer? Check the appropriate box: I Business Type (required):
1.1 am a employer with `"( employees (full and/ 5. ❑ Retail
or part-time).* 6. ®Restaurant(Bar/Eating Establishment
2;❑ 1 am a sole proprietor or parbtersbip 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 have 10.0 Manufacturing
no employees, [No workers' comp. insurance required]* 11 ❑ Health Care
4, ❑ We are a non-profit organization, staffed by volunteers, )
with no employees. [No workers' comp, insurance req.] 12)ZOtbor e-:-A'' t
*Any applicant that checks box 81 must also fill out the section below showing their workers' compensation policy infomation.
**Ifthe corpoodo officershave exempted themselves, but the corporation has other employees, a workers' eampensation policy is required and such"
organization should check box #1.
I am an employer that is providing )Porkers' conrpensatton brsurancefor my employees. Below is the policy information,
Insurance Company Name: -2 C-t r2 I C= f t - ;4 fd( e:: 2- ! C-4 ,-ti
Insurer's Address:
x� r�
f AKE��o��'_/-`"�-
City/State/Zip:
G ,/! l_.. -4 nu J
Policy #orSelf-ins.Lin, #- `'t (�-� - �' `� / *''/ '-`�-- iFExpiration Date: Y l /' A
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 maybe forwarded to the Office of
Investigations ofthe DIA for insurance ooverage verification.
I do hereby certify, tinder thg paint and penalties of
perjury that tlza information provided above is true and correct.
use only, Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6, Other
Contact Person
Permit/License
3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office
wwwanass.gowcia
VDAC
ZURICH WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GZZ6B-0495N75-0-18)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
INSURED:
STARLIN, INC
CAMPGROUNDS
137 MILL ST
DBA CANOE RIVER
MANSFIELD MA 02048
PRODUCER:
OF (GZZUB',-0495N75-0-17)
NCCI CO CODE: 17965
C & S INSURANCE AGENCY
310 N MAIN ST #6
MANSFIELD MA 02048
Insured is A CORPORATION
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period Is from 05-13-18 to 05-13-19=12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies tolwork in each state listed in
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB
o®
_ D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
a
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit Co be made ANNUALLY.
DATE OF ISSUE: 04-20-18 WC ST ASSIGN: MA
OFFICE: ZURICH-ORLAN 809
PRODUCER: C & S INSURANCE AGENCY 7$W2J
01644