The URL can be used to link to this page

Home My WebLink AboutRepublic Waste Services - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 This is to certify that: Board of Health Hauler's Permit PERMIT No: 3 DON SLAGER, CEO REPUBLIC WASTE SERVICES 1080 AIRPORT ROAD FALL RIVER, MA 02720 is hereby granted a permit for a HAULER. This permit is granted inconformity with the Statues and Ordinances relating thereto, and expires December 31, 2019 unless suspended or revoked. REGISTRATION No: 1240-82701 1247-90614 3000- 90739 FEE PER TRUCK: $25.00 BOARD OF HEALTH Michael 9HeaCey, Chairman Town of l►lansfield - Board of Health Hauler's Application PERMIT NUMBER: TOTAL FEE: BUSINESS NAME: �f puW i'C- S.e wC9 /) BUSINESS ADDRESS: (u /fi f coi � jlc, TOWN/ STATE/ZIP: CA(( (2( UT (- h/1)4 03_1.�0 NAME OF OWNER: I)Lrt C TELEPHONE NO: "Pow FAX NO: Town of Mansfield 6 Park Row Mansfield, MA 02048 E-mail: K-ea Yi ()f()tLuh! i c & r L) (L4 cLO Alt E-mail: FEDIDISSNO:(�—�i�+tiL�J� ! REGISTRATION NO: 34iq'- NO OF TRUCK(S): FEE PER TRUCK: $75.00 V P0111111NMxpiresDecember31styearly. SIGNATURE: �' ) DATE: I J P 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 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 OrMcer (Mandatory, if Applicable) ,� & **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 suspensidR4 "revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C.\Users\sleite\Deskiop\Scoll's Dooments\Food Fstablishmeats- TempUAX CERTIFICATION FORM doe L\ The Commmnivealth of Massachusetts Department of Industrial AccitR M01 Office of Investigations Ulf 600 Washington Street Boston, MA 02111 rvrpip.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: Ll lb ('_ City/State/Zip:t(je V 0 P C,a:B& Phone #: Sc•)3(40 Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restau�t tt//Bar/Eating Establishment 2. ❑ I am a sole proprietor or p'atrnership and have no 1. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g• ❑Nou-profit [No workers' comp. insurance required] ��cc��tt 3.M We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance requ red]* 11.❑ health Care 4., We are a non-profit organization, staffed by volunteers, ��, (�� pp 12.� Other7�-LILL�(. q with no employees. [No workers' comp. insurance req.] t Lr ,� *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 ifi. I ma ant enry)loyer (lint is providing (porkers' compensation insarttnce for my employees. Below is the policy hiformation. Insurance Company insurer's Address: 0 1� �iQLiun.S pi5k �� ' City/State/Zip: �'�i t Qff !l (C- t pi 1 n6 b t, Policy # or Self -ins. Lic. #.lc� L ��' t11 J a�-� .� 'M*ation Date: Attach a copy of the workers' compensation policy declaration page (sbowing the policy nwnber and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of crinimal 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 cetd y, t ie rains a, d peunlltes ofpetjioy that/he htfornrntion provided above ijsth'ue nett correct. Cionnhn•e• Date: Official use only. Do not write in this area, to be completed by city or town official City at, Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License # 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone #: COI Issuance Page 1 of 2 A� Ra CERTIFICATE OF LIABILITY INSURANCE Pa9eIef2 DATE(MM/DD/YYYY) 06/2312018 THIS CERTIFICATE IS ISSUED AS 9 MATTER OF INFORMATION ONLY AND CONFER GFITS 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(ies) 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 hostler in lieu of such endorsement(s). CANNON COCHRAN MANAGEMENT SERVICES, INC. 17015 N. SCOTTSDALE RD. SCOTTSDALE, AZ 85255 REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY PHOENIX, AZ 85054 COVERAGES CERTIFICATE NUMBER- 1410d73 RFVISInN MI IMBFR• 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 TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POUCYEFF (MMIDD POU YEXP DA'YYI) LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [X-1 OCCUR HDOG71097171 on/302018 wimi2019 EACH OCCURRBICE $5,000,0m DAMAGE TO RENTED PREMISES (Ea occurrence) 55,000,000 MED EXP (Any one person) GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PROJECT F-1LOC OTHER: PERSONAL &ADV INJURY $5,000,000 GENERALAGGREGATE $5,000,000 PRODUCTS-COMP/OPAGG $5=000 A AUTOMOBILE LIABILITY X ANYAUTO X OWNED AUTOS MSCHEDULED ONLY AUTOS X HIREDAUTOS ❑NONOWNED ONLY AUTOS ONLY ❑ ISA H25159809 06/302018 06,W2019 COMBINED SINGLE LIMIT (Ea accident) $5,000,000 BODILY INJURY(Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) MBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DEB RETENTION$ EACH OCCURRENCE GGREGATE B A C A D WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE N Oandato/MEMeER EXCLUDED? ❑ (MandatoryIn NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A MR C6522576A-ADS WAR C65225712 - CAINWOR SCF C65225]97-W1 WCU C65225570-OH XS TNS C4916720-TX NSXS 06130=18. 06/302018 O6/302018 O6/3D2018 06/302 06/302019 O6/302019 O6/302019 06/302019 2019 X PER OTHER STATUTE E.L. EACH ACCIDENT $3,000,000 E.L. DISEASE -EA EMPLOYEE $3000000 E.L. DISEASE-POUCY LIMIT $3,000,0D0 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Division Number: 4097- Named Insured Includes: Allied Waste Services of Massachusetts, LLC- Dba: Allied Waste Services of Fall River// Republic Services of Fall River 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 Town Of Mansfield Ann: Beam Of Health 6 Palk Row sign Mansfield, MA 02018-2433 United States W 19tltl3016 ACURD CORPORATION. All rights reserved. Download COI in PDF formal AGENCY CUSTOMER ID: https:Hsecure.smaticomplianceinc.comISECURElWebForms/Externallcoi.aspx?htm=1 &bt... 11/5/2018 COI Issuance Page 2 of 2 AC RO D L.� LOC ADDITIONAL REMARKS SCHEDULE Page 2of2 AGENCY NAMED INSURED REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY PHOENIX, AZ 85054 POLICY NUMBER See First Page CARRIER NAIC CODE See First Page EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF 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 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. AUTO LIABILITY: Certificate 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 certificate holder is included when required by written Contract where allowed by slate law. Stop gap Coverage for NO, WA and WY is Covered under policy no. WLR C6522575A and stop gap coverage for OH is covered under policy no. WCU C65225670, as noted on page 1 of this certificate. TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY: Republic Services, Inc. and its subsidiaries are registered non -subscribers to the Texas Work0900"ensation Act. Republic Services, Inc. has fled 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 C49167295) shown on this certificate provides excess Indemnity and Employers Liability coverage for the approved Indemnity Plan, Contractual Liability is Included in the General Liability and Automobile Liability coverage forms. 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 form and the Automobile Liability Coverage form. ACDRD 1W (200101) The ACORD name and logo are registered marks of ACORD Download COI in PDF format 01988.2010 ACORD CORPORATION. All rights reserved. https://secure.smartcomplianceinc.com/SECURE/WebForms/External/coi.aspx?htm=1 &bt... 11/5/2018