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Home My WebLink AboutJ. F. McNamara & Sons, Corp. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health I Hauler's Permit This is to certify that: ZIM7TIriaG>: JAMES F. MCNAMARA J. F. MCNAMARA & SONS, CORP. 161 MORTON STREET, P.O. BOX 6 STOUGHTON, MA 02072 is hereby granted a permit for a HAULER. This permit is granted in conformity with the Statues and Ordinances relating thereto, and expires December 31, 2019 unless suspended or revoked. REGISTRATION No: J68799 P73189 FEE PER TRUCK: $25.00 BOARD OF HEALTH -%IichaeCHeaCey, Chairman Town of Mansfield - Board ®f Health Y � M 0 AAS A O�yl4` Hauler's Applieation Town of Mansfield 6 Park Row Mansfield, MA 02048 DEC 3 0 2010! 4�e PERMIT NUMBER: TOTAL FEE: BUSINESSNAME: a},F- I i U ( UVk 0 r --rrn Si BUSINESS ADDRESS: 7 0 \�)0� 1 TOWN I STATE / ZIP: S- O AC)ww Aa ()' 0 "ja- NAME OF OWNER:.,/ &Vyu S F. AQ\J am /k.o- TELEPHONE NO: '11 1- 3 V - `I 0 O' CELL NO: �J b�- qL� I - AN I FAX NO: E-mail: 'C'vy) Alt E-mail: FED ID/SS NO: 0 H _ aq (.) 0 0c). REGISTRATION NO: p 1 3 1 1 1 ( `f NO OF TRUCK(S): o FEE PER TRUCK: $76.00 Permit Expires December 31st yearly. E: �, i' Please,mLke apbrdpdatQ changes Sigrti;date and enclose check payable: to Town of M'1nsfield.`Mail to: 8gard of Health, Town of Mansfield, Six Park aoiti, 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. Signature of Individual or Corporate Name By: Corporates e Officer (Mmrdatory, if Applimble) *"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\sleile\Desktop\Scotl's Docmneni food Establishments- TempYTAX CERnPICKrION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p wwwanass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: J , F ' Address: Oftoln City/State/Zip: Phone #: / $ 1- .3qq ` q6i Td- Arey��"n employer? Check the appropriate box: Business Type (required): N 1. I am a employer with j j% 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] 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 WE Manufacturing no employees. [No workers' comp. insurance required]* I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box N 1 must also fill out the section below showing their workers' compensation policy information. **If die corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box R. I am an employer that is providti:g workers' compensadon hisurance for my employees. Below Is the policy infonnation. Insurance Company Name: U UY1 Insurer's Address: T• U . Box (3 4, 6 City/State/Zip: ?-103 (`olU) MO Policy # or Self -ins. Lic. #Rd V� Lr tf t{ i 7 Expiration Date: _ `1 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, render the pains and penalties ofperjury that the information provided above is trite 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.mass.gov/dia MCNAM-2 ACORC>•" CERTIFICATE OF UA'Bi LITY INSURANCE DATE 12512018 10/25/2018 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 endorsements . PRODUCER 781-247-7800 Rodman insurance Agency, Inc. 145 Rosemary St., Bldg. A Needham, MA 02494-3238 Jim Stoller c CT Jim Stoller P♦iONE 781-247-7800 FAx 787-044-0090 (A C, No, Exi); (AIC, No): XMSS: INSURERS AFFORDING COVERAGE NAIC f INSURERA:AmGUARD Insurance Company INSURED JF McNamara & Sons Corp PO Box 6 Stoughton, MA 02072 INSURER S: Commerce Insurance Company 34754 Atain Specialty Insurance INSURER C: P Y INSURER D: Evanston Insurance Co INSURER E : NSURER F : 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 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRC TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLIICCY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY CLAWS -MADE T OCCUR CIP333105 09/06/2018 09/0612019 EACH OCCURRENCE $ 1,000,000 DAMAGES RENfEa cu D PREMISEMED $ 100,000 EXP (Any one erson $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENT X AGGREGATE LIMIT APPLIES PER: POLICY O JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS- COMP/OP ASS $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS yy Ep X ALRTOy ONLY X BOO 18SCMWYD 09/17/2018 09/1712019 MRRIINEDNEDSINGLE t CEa aO 1,000,000 $ BODILY INJURY Perperson) BODILY INJURY Per accident $ PROeeERdY DAMAGE $ D UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE XOBW7297517 09/06/2018 09/06/2019 EACHOCCURRENCES 3,000,000 X AGGREGATE S 3,000,006 DIED RETENTION$ A WORItERS COMPENSATION ANDEMPLOYERS'LIABILnY ANY PRRO/PREIETORIPARTNERIEXECUTIVE YIN IMB EetorylnBEH)EXCLUDED? � NN If yes, describe under DESCRIPTION OF OPERATIONS below NIA R2WC944417 02120/2018 02120/2019 X PER OTER H- U E E. L EACH ACCIDENT 500,000 $ E.L. DISEASE � EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached x more space Is re lulred) CPRTIPICATP NOI DPR OANCEI. I. ATION MANSFIE 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, Board of Health 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 (n� ACORD 25 (2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD