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HomeMy WebLinkAboutWaste Management of MA, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Hauler's Permit This is to certify that: PERMIT No: 4 JOHN E. CEDERQUIST, SR. SR. DISTRICT MANAGER WASTE MANAGEMENT OF MA, INC. 100 HILL STREET NORTON, MA 02766 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: R46519; R46452; R88466; G50190;S31262; N81671; 97173; S17620;517622; FEE PER TRUCK: $26.00 BOARD OF HEALTH MichaeCHeaCey, Chairman Town of Mansfield - Board of DEC € 6 2019 Towne 6 Park 02048 11aaader's Application PERMIT NUMBER: TOTAL FEE: � (07je�" 1G/ BUSINESS NAME: ems BUSINESS ADDRESS: %�'v / V J TOWN / STATE / ZIP:/( /"/irk w/ NAMEOF I� C�CJ�Pr�Gr�f�l Sr, TELEPHONENO: CELL NO: m- FAX NO: S -7 - Y0 �GJ E-mail: `J 062d' Alt E-mail: a ba rre FED ID/SS NO: PePeAdh"6)1 ow;14�,�i i2EGIST ATI y s `7� p —�- 5 NO OF TRUCK(S): FEE PER TRUCK: $76.00 4/67J, Od Permit Expires December 31st yearly, 0SSIGN _ ATE: _ 16 30 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 (older law. Signature of Individual or Corporate Name By: ice J(('� 111datory, if Ap licable) "Social Security No. (Volmttnry) or Federal Ident ficntion 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\Scolt's DocumentsWood "Iablishments-TemfCl"AX CF.R"1'IPICA9'ION PORM.doc The Conunontvealth of Massachusetts { " Departtaent of Industrial Accidents ;� Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization N Print Ftinn City/State/Zip: Illa- %)� Phone wodoi ul Are you an employer? Check the appropriate box: Business Type (required): I.,® I am a employer with/OD f employees (full and/ 5. ❑ Retail orpart-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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12. ® Other & ✓J"Slf / repgi >1 a j ti'nx'tj a Yizvyej, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infornratkin. t/ **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 am an employer that is provii4it!g workers' conipensatiort insurance for my ernployees.,.,Below is the policy information. Insurance Company Name: / % U r_ rM C0 (_d pi Al//,S (1e�- ( om f2�v/ Insurer's Address: City/State/Zip: C, �t [ p� Policy # or Self -ins Lie.# �t�L k� C iOiJ 2ii�i.7r .�L� / . Expiration Date: / aX Attach a copy of the workers' compensation policy declaration page (showing the policy numbl6r , nd 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, under the pains and penalties of perjury that the information provided above is true and correct. Q:- 1- � - r).t- /�l - / 9 / S3 Phone #: 013 G �)� (® 13 / 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.inass.gov/dia the Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: %60 & t1511 City/State/Zip: YPhone #: Vi 6 6 i 6 Are you an employer? Check the appropriate box: Business Type (required): 1. W I am a employer with l(al f" 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 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.JOtherW�V 1&r/,t/,o 9=�( *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 requir6d and such an organization should check box #I. I am an employer that is provid�yg workers' compensation insuragee for my employees. Aelow is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: /rn /`/42/� e/G��l/l/L , %�(ZW(Z Policy # or Self -ins. Lie. # % (a y(O �a 77F- Expiration 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, under the pains and penalties ofperjury that the information provided above is true 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.mass.gov/dia ACORD' CERTIFICATE OF LIABILITY INSURANCE lh..� IM/2020 DATE tMaeDD YYYY) 12/412018 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 endomement(s). PRODUCER LOCKTON COMPANIES 3657 BRIARPARK DRIVE, SUITE 700 HOUSTON TX 77042 866-2603530 sal: '-Tir . Nel. Mae. AFFORDING COVERAGE INSURER A: ACE AR Company NWI 22667 INEVRED WASTE MANAGEMENT HOLDINGS, INC. &ALL AFFILIATED, 1300299 RELATED & SUBSIDIARY COMPANIES INCLUDING: WASTE MANAGEMENT - NEW ENGLAND MARKET AREA 26 PATRIOTS PLACE, SUITE 300 FOXBOROUGH MA 02035 INSURERS; Indmrorty Ingurencc CD of Nonh America 43575 ER C: ACE Fire Underwriters Insurance Company COVERAGES MAVVRSTRO CERTIFICATEALIMBER: 10632623 REVISIONNIIMRFR: XXXXXXX 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, TYPE OF INSURANCE ADIX IBM MR A& POLICYNUMBER I EFF LIMITS A COMMERCMJ.OENEMI-WI1LITY CINMSMADE O OCCUR XCII INCIJ IOF.O y y HDO071212993 V112019 1/1/2020 EACHOCCURRENCE s 5,000,000 R WEO MED EXP M one Pa 5,000,000 XXXXXXX IS FORMCr'AMIG411 PERSONALaAWINJURY s$000000 GENL AGGREGATE RLIMIT APPLIES PER PoLIOYO JECT E LOC OTHER: GENERALAG REGATE s 6000000 PRODUCTS-COMPXBPAGG s 6000000 E A AUTOMOBILE X X X X LIABILITY A�NWYAEEUUpTO AUTENCD ONLY SCHEOULEO HAVTGS ONLY X 104ONLY MCS-90 Y Y MMT H2527863A 14/2019 UI/2020 $ OLL ELI BODILY INJURY PW personl 3 1,000,000 SXXXXXXX BOOILYIWURY(Pn ectldonl S XXXXXXX PERtt OPAUGE $ XXXXXXX $XXXXXXX A X UMBRELLALMB EXCESS LIAR [I OCCUR CLA1W MADE Y Y XOO G27929242004 111/20I9 11I/2020 EACHOCCURRENCE $ 1$000000 AGGREGATE $ 15.000000 Imal IRtErEMIONS $XXXXXXX B A C A LIABILITY EMPLOYERS' ANDEMPLOYeRs•LWBartt ARE nNYIYBOPAIETDPPAmNTPIEXEo/rNE YIN CFRWNg'EMEERExauceo> N❑ IMeMetw MlMi loer'alxu°vno oP'oPERnnDNsn r,,. NIA Y WLRC65435846 ADS SCFC6543583(CA&MA) SCF C65435883( 0 I?I/2019 1/1/20I9 1fI12019 1JI720AV 1.1f2020` IAY2020 PER X rA E,LEAGIACpODR 33000000 EIgeEASE.FA EATI.OYEE s 3,000,000 . 10u L 3,000,000 A EXCESSAUTO LIABILITY y y XSA H25278598 =020 COMBINED SINGLE LIMIT (EACH000 ACCIDENT) DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, 1lond Remarks Schedule, may be attached Ifmore space Is feeelrod) BLANKET WAIVER OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EXCEPT FOR WORKERS' COMP/EL) WHERE AND TO THE EXTENT REQUIRED BY WRIITEN CONTRACT, CERTIFICATE MOLDER CANCELI AHUN SHOULD ANY OF THE MOW DESCRIBED POLICIES BE CANCELLED eEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROV SIONS. 10632623 AUTHORIZED REPRESENTATIVE TOWN OF MANSFIELD BOARD OF HEALTH 6 PARK ROW MANSFIELD MA 02048 ACORD 25 (2016103) 0)1988.2015 ACORD CORPORATIOW. All rights reserved The ACORD name and logo are registered marks of ACORD A` oR o` CERTIFICATE OF LIABILITY INSURANCE IA/2o19 DATE(MM/DD/YYYY) 12/11/2017 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(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 holder in lieu of such endorsement(s). PRODUCER LOCKTON COMPANIES 3657 BRIARPARK DRIVE, SUITE 700 HOUSTON TX 77042 866-260-3538 CONTACT Me. E%I : IV, No): E.MaL DRESS INSURER A: ACE American Insurance Conwany 22667 INSURED WASTE MANAGEMENT HOLDINGS, INC. & ALL AFFILIATED, 1300299 RELATED& SUBSIDIARY COMPANIES INCLUDING: WASTE MANAGEMENT - NEW ENGLAND MARKET AREA 26 PATRIOTS PLACE, SUITE 300 FOXBOROUGH MA 02035 INSURER B: Indemnily Insurance Co of North America 43575 mSURERC: ACE Fire UndenvritersInsurance Company 20702 INSURER Q INSURER r•n....... NA A\R/FQTRYI CPRTIFICATF NIIMRFR 10Ai9694 RFVISION NIIMRFR- XXXXXXX VTHIS 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. INSR1 TYPE OF INSURANCE ADDLINSO SUBR VANPOLICY NUMBER POLICY EFF 1/1/2018 POUCYEXP flMMIDONYYY I/l/2019 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR XCI I INCI I IDFD y y HDOG27873091 EACH OCCURRENCE 5000000 DAMAGE PREMISES TO RENTED E cu re c 5,000,000 X MED FXP (Any one arson XXXXXXX X KO FORM CCT00010413 PERSONAL&ADV INJURY $ 5.000000 GEN'L AGGREGATE LIMIT APPLIES PER: POUCVF JE[ 1 Fx—] LOC OTHER: GENERALAGGREGATE 6000000 PRODUCTS -COMP/OP AGG $ 6,000,000 $ A AUTOMOBILE LIABILITY X ANVAUTO X AUTOSONLV AUTOSULED X ALROS ONLY %0 AUTOS ONEY x MCS-90 y y MMTH25097890 1/1/2018 1/1/2019 oMelNpntsINGLELIMIT $ 1000000 BODILVINJURY(Perpemcn) $ XXXXXXX BODILY INJURY (Per accident $XXXXXXX PQOa ER YDAMAGE $ XXXXXAx $ XXXXXXX A ){ UMBRELLALIAB EXCESS LIAR XOCCUR I ICLAIMS-MADE y y XOO G27929242 003 1/1/2018 1/1/2019 EACH OCCURRENCE $15000000 AGGREGATE $ 15,000,000 DED I I RETENTION$ $ XXXXXXX B A C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPAftI'NER/E%ECUTIVE YIN oFFwERIMEMaER E%auoaDT N❑ (Myyarde qIn NH) �ESfFIPT10N OFOPERAT10NSW. NIA y WLR C6462278A(AOS) WLR C64622778 (AZ,CA,&MA SCF C64622791 (WI) 1/1@018 1/1/2018 1/1/20I8 1/1/2.019 3 I/I/2019 1/1/2019 TR X 6TATUTE E ELFACHAMIDEM $3ODOODO ELOISEASE- EAEMPLOYEE 3000000 E1, DISEASE - POLICY LIMIT 3000000 A EXCESS AUTO LIABILITY y y XSA H25097889 1/1/2018 1/1/2019 COMBINED SINGLE LIMIT $9,000,000 (EACH ACCIDENT) DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) BLANKET WAIVER OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT REURtED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EX EPT FOR WORKERS' COMP/EL) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER GAIVGtl- Al IVN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10632623 AUTHORIZED REPRESENTATIVE TOWN OF MANSFIELD BOARD OF HEALTH 6PARK ROW MANSFIELD MA 02048 ACORD 25 (2016/03) 01988-2015 ACORD CORPORATIOK. All rights reserved The ACORD name and logo are registered marks of ACORD ACORL>° CERTIFICATE OF LIABILITY INSURANCE ll.� 1/1/2020 DATE(MMIDDNYYV) 1 12/4/2018 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(fes) 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 LOCKTON COMPANIES 3657 BRIARPARK DRIVE, SUITE 700 HOUSTON TX 77042 866-260-3538 NCONTACT AME: A C, No, EXt: A C, No): E-MAIL ADDRESS: INSURER(5) AFFORDING COVERAGE AIC# _ INSURER A: ACE American Insurance Company 22667 INSURED WASTE MANAGEMENT HOLDINGS, INC. & ALL AFFILIATED, 1300299 RELATED & SUBSIDIARY COMPANIES INCLUDING; WASTE MANAGEMENT -NEW ENGLAND MARKET AREA INSURER B : Indemnity Insurance Co of North America 43575 INSURERR c: ACE Fire Underwriters Insurance Corriparry 20702 INSURER D : 26 PATRIOTS PLACE, SUITE 300 INSURER E: FOXBOROUGH MA 02035 NSURERF: COVERAGES MANVESTBO CERTIFICATE NUMBER: 10632623 REVISION NUMBER: XXXXXXX 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 ADEL INSO SUER Me POLICY NUMBER POLICY EFF MM/DD/YYVY1 POLICY EXP IMMIDD/YYYYlLIMITS A Xr COMMERCIAL GENERAL LIABILITY y Y HDO G71212993 1/1/2019 1/I/2020 EACH OCCURRENCE 5000000 CLAIMS -MADE � OCCUR DAMAGE TO RENTED PREMISES Ea occurcenCA) 5,000,000 X MED EXP (Any one arson XXXXXXX XCU INCLUDED X ISO FORM CG00010413 PERSONAL & ADV INJURY $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYF JE� � LOC GENERAL AGGREGATE $ 6,000,000 PRODUCTS - COMP/OP AGG $ 6,000,000 $ OTHER: A AUTOMOBILE LIABILITY Y Y MMT H2527863A 1/l/2019 1/1/2020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ XXXXXXX ANY AUTO AUTOS ONLY SCHEDULED X BODILY INJURY (Per accident $ XXXXXXX X AUTOS ONLY X AUTOS ONLY PROPERTY ac dentDAMAGE $ XXXXXXX X $ XXXXXXX MCS-90 A X UMBRELLA LIAB X OCCUR Y Y XOO G27929242 004 I/1/2019 I/I/2020 EACH OCCURRENCE $ 15,000,000 AGGREGATE $ 15OOO OOO EXCESS LIAB I 1CLAMS-MADF DEO I I RETENTION $ $ XXXXXXX B A C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEmEXECUTiVE OFFICERIMEMBER EXCLUDED? N (Mandatary in NN) DESCRIPTION OF OPERATIONS below NIA Y WLR C65435846 (A.OS) ( WI'R 65435883(WB &MA) SCF C65435$83( ) I/l/2019 I/l/2019 1/I/2D19 I/l/2020 ': 1/1/2D2D 1/1/2020 PER OTH- X STATUTE ER EL. EACH ACCIDENT $ 3 �0000� E.L. DISEASE - EA EMPLOYEE 3000000 E.L. DISEASE -POLICY LIMIT 3,000,000 A EXCESS AUTO LIABILITY Y Y XSA H25278598 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT $9,000,000 (EACH ACCIDENT) DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) BLANKET WAIVER OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT RETUIRED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EX EPT FOR WORKERS' COMPEL) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. GCK I IrlliA I C K V LUCK UANUCLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10632623 AUTHORIZED REPRESENTATIVE TOWN OF MANSFIELD BOARD OF HEALTH 6 PARK ROW MANSFIELD MA 02048 ACORD 25 (2016103) ©1988-2015 ACORD CORPORATI019. All rights reserved The ACORD name and logo are registered marks of ACORD