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HomeMy WebLinkAboutSherman & Jackson Funeral Home - 4/30/2020Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Funeral Home Permit Permit Number: 00-2 This is to certify that: MARK A. CEDARFIELD 55 NORTH MAIN STREET Is hereby granted a SHERMAN & JACKSON FUNERAL HOME permit for.- This or: This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expire Thursday, April 30, 2020 unless sooner suspended or revoked, Fee : $50.00 BOARD OF HEALTH MichaeCHeaCey, Chairman b j, Town of Mansfield - Board of Health Application for Funeral Home Permit Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: I hereby make application for a FUNERAL HOME PERMIT which expires on April 30th of each year. NAME OF BUSINESS: Aerm ckfA d fo�CLO✓1 AZIY AA 41 4 Alp ADDRESSOFFOWNEJJR: n— Cedar 4/malr1 5-6 ''�l�f m 0409'aOWNER: Mar- C A• (..ivLt'arJ elt"1 BUSINESS PHONE: '2C000 BUSINESS FAX: .S0 d6/-- &J-/ EMAILADDRESS: _�kC'r'rYlCAA rx/\C,\j � AC k1J0A 124 yhCtitCo✓1, - FEDERAL ID/SS NUMBER: O t/ ' J lIq Oq q FEE: $ 25.00 SIGNATURE: DATE: Jl Ll Ja1q 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 In idual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) DCf- asyyogq *"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. Town of Mansfield Town of Mansfield - Board of Health a Para Row Mansfield, MA 02048 Application for Funeral Home Permit PERMIT NUMBER: I hereby make application for a FUNERAL HOME PERMIT which expires on April 30th of each year. NAME OF BUSINESS: ADDRESS OF OWNER: OWNER: BUSINESS PHONE: BUSINESS FAX: EMAIL ADDRESS: FEDERAL ID/SS NUMBER: FEE: JUN 13 2019 .1 $ 25/ D -" SIGNATURE: DATE: �✓�P !_ / The Conintonivealth ofMassdchuseffs Department of Indushial Accidents 1 Congress Street, Suite 100 Boston, AIA 0211 4-2 01 7 U1F www.mass.gov/dia Workers' Compensation Insurance Affidavit; General Businesses. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Business Type (required): 1, © I om a employer with .2 employees (full and/ Please Print Legibty Business/Organization Name: 5�P(Y✓)C\n 3.J TT / , d- r;G oyn t eleIr-1 ma City/State/Zip: So 0' -3&g — Are you an employer? Check the appropriate box: Business Type (required): 1, © I om a employer with .2 employees (full and/ 5. ❑ Retail "'part-time).* 6.[]RestaurantBar/EadngEstablishment 2.0 1 am a sole proprietor or partnership and have no ?, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g• ❑ Non-profit [No workers' comp. insurance required] 3,E] We are a corporation and its officers have exercised 9, ❑ Entertainment their right of exemption per D. 152, § 1(4), and we have 10, ❑ Manufacturing no employees. [No workers' comp, insurance required]* 1 Cera 4, ❑ We are a non-profit organization, staffed by volunteers, FUneI6 with no employees• [No workers' comp, insurance req.] 12.tY1 other ioP ,94"OOther *Any applicant that checks box #I must also fill out the swtion bolow showing their workers' compensation policy Information. **u the corporate officers have excmpled themselves, but the corporation has other employs", aworkers' eompcnsation policy is required and such an organization should check box''#l. am an employer that is pro),V' workers'' compensation insurance for my employeeesr. Below is the policy inforinatior' Insurance Company Name: Insurer's Address; IQ Policy # or Self -ins, Lie, #- Cu .17A)6-07 / ?� Expiration Date: I 1 �)Z—laOl Ci 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 statemeat may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, un�der the paths and enaldes ofperjury that the inforrnation provided above is true and correct Signature•I-Ai -" Date . -T(-)K e &. sy)/q Official use only. Do not write in this area, to be completed by city or town official City or Town: PermiULicease # 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#: w V.mass.gov/dia fo /I soft-�4f 7J9y OJ �,jf5f 4p�rQ/ SHER&JA-01 LVAGGETT AC RO a' CERTIFICATE OF LIABILITY INSURANCES DATE tMM100/YYYYI �f 9/6/2019 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, sul oct to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer N ht6 to the certificate holder in lieu of such endorsement(a). PRODUCER CDM CT Robert W. Eames Ins. Agency, Inc. 125 North Main St, PO Box 289 ac°, No. all: 808) 399.7913 PI1% nP ; 508 339-1835 Mansfield, MA 02048 A (NSURER(Bi AFFORDING COVERAGE CM INSURERA: Massachusetts Bay Ins. Co. 22306 OON73413267 INSURED INSURERS: Hanover Insurance Company 22292 INSu ERC: Sherman & Jackson Funeral Home, Inc. INSURFAD: 55 North Main Street Mansfield, MA 02048 INSURERS I IN511RFA F COVERAGES CERTIFICATE MLIMRFR• REV!S!0N N"MHEo. 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 RFQUI REMENT, 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. -NSR OFINBURANCE AOOL BUB POUCYNUMBER POLIbY EFP POLICY EXP LIMITSTYPE A X COMMERCIALOMERAL.LIABILITY C4aIM6+MOE O OCCUR OON73413267 7/2512018 772612019 EA !OCCURRENCE 8 1,100,000 DAMAGE TO RENTEDSESF 380,000 MEOEXP An dne e 8 6,001 PERSONAL&ADVINJURY 1,000,001 N'LADGREOATE LNtTAPFLIEB PER: K POLICY ❑ j��T LOC GENERALAGGREGATE 2,000,000 PRODUCTS•COMP/OPA S 2,001,000 4 OTHER AVTOM091LE MABIUTY COMBINED GINGLE LIMIT $ SODILY INJURY Per ersnn 8 ANY AUTO FV��TEOpBDONLY AANVnpTOnS,Ow�ULN}EeFDnI� BODILY INIURV Pet BCGdenl 8 MA ONLY W1101TO 40,E NRd y AMAGE UMBRELLA DAS OCCUR EA N URRENCE PXCCOS ILIAD CLI1IMSWADE 0OREGA7E DED RETENTIONII 13 WORRERSCOMPENSATION ANO EMPLOYERS' LIABILITY ANY PROFRIETOR/PARTNER/EXECURVE YIN ppppFl RIMEMg�) EXCLUDED? ❑N IManmry,n NNI Ilyee.doaalnulde! DESCRIPTION OF OPERATIONS bel NIA WHNS419180 712612018 7/2612119 X PER OTH- E HACCRIENT 100,000 E.L. 018EABE-CYL EMPL YE 101,101 EL. DISEASE.P LIMIT 8 510,010 OEBCRIPTION OP OPERATIUNB I LOCARONS I VEHICLES (ACORO tot, AddlUCnAI RaMeRW SCO9dUla, May be aNnchad Itmem ePBCe 10 V001rad) Town of Mansfield Attn: Health Dept. 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORVXU RrPRROSENNTA�TFIR WE 1YBB•L015^CORD CORPORATION. All rights reservad. The ACORD name and foga are registered marks of ACORD i&W-4 4 iTI" b-la-rq (11CMI)ab 93 518 a SHER&JA-01 °?Vi* P4DAGGETT Mlmj-0I d` DATEIMMMOty"Y) CERTIFICATE OF LIABILITY INSURANCE 108 6/6/2019 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 Ileu of such andomement(s). PRODUCER ffigjAOT Robert W. Earner Ina. AgenCy, Inc. Na 126 North Main St PO Box 289 PxONE PAX Ac k}I : 508 339-7913 Aro xa :608 339.1836 Mansfield, MA 02548 EOpAIL INSURER(Si AFFORDI NO COVERAGE NAICa 7/25/2020 INSURER A: Massachusetts Bay Ins. Co. 22305 DAE AG Er EOOH D 9 300,000 INSURED I g: INSURERC: Sherman &Jackson Funeral Home, Inc. IN9u ERD: 66 North Main Street Mansfield, MA 02048 INBU E: INSURER F 1 AUTOMOBILE COVERAGES CERTIFICATE NUMBER' RFVISION NUMRFR: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EKCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR TYPE OFINSURANCE ADDL INSO SUER VIVO POLICY NUMBER PO 1 EFF P LILY ESP 4MR9 A X LOOMMEIROUu. OENERAL LIABJLITY c1AIMSMADE FX OCCUR 0ON7340267 712612019 7/25/2020 EACH ENCE a 11000,060 DAE AG Er EOOH D 9 300,000 MED EXP (Any we eraon S 61000 PERSONAL&ADVINJURY S 1,000,000 GENL AGGREGATE LpIMpIT�APPLIES PER X POLICY ❑JECT LOC OTHER; GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMPMPAGG s 21000,660 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AVqr�CISONLY A TOOSµ�Fp AUTOS ONLY AUTOS OMVOa�RdYM GOMBINEO SINGLE LMR S LY INJURY Per Ron e BODILY INJURY Par accaent AMAGE 9 UMBRELLA UAB EXCESSLIAIS OCCUR CLAIMSMADE EACH OCCURRENCE AGGREGATE DED I I RETENTIONS A WORXFNSAT ON PET AND EMPLCOMPENSATION OYT, ANY PROPRIETORIPARTNERIEXECUTIVE YIN �FFICERIMEMDER EXCWDEOt ❑N (Mentlelory In NH) 11 m desabe under P 10NSbabW NIA WDN5419188 7/25/2019 712612020::. E.L. EACH ACCIDENT 100,000 E. DI EASE -FA BMPLOYE S 100,600 E.L. DIS EASE-POUCY LIMIT S 600,600 099CRIPrION OF OPERATIONSILOCATIONS I VEHICLES (ACORD 101, AddManAl Romuke 6911a6019, MRW be Attached R more space In regWred( Town of Mansfield Attn: Health Dept. 6 Park Row Mansfield, MA 02048 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OF CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1988.2015 ACORD CORPORATION. All rights reserved. the ACORU name and logo are registered marks of ACORD