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Home My WebLink AboutSherman & Jackson Funeral Home, Inc. 4/30/20190 Commonwealth 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 permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires on Tuesday, April 30, 2019 unless sooner suspended or revoked. Fee : $25.00 BOARD OF HEALTH MichaeCMcCCean, Chairman Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Application for Funeral Home Permit I hereby make application for a FUNERAL HOME PERMIT which expires on April 30th of each year. NAME OF BUSINESS: SHERMAN & JACKSON FUNERAL HOME ADDRESS OF OWNER: 55 NORTH MAIN STREET OWNER: MARK A. CEDARFIELD BUSINESS PHONE: (508) 339-2000 CELL (500) 509-4910 BUSINESS FAX: (508) 261-9351 EMAIL ADDRESS: RCEDARFIELD@AOL.COM FEDERAL ID/SS NUMBER: 04-2544099 FEE: $ 25.00 SIGNATURE: DATE: APS, The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information// Plen�a//se PrintLel?ibl op Business/Organizatin Name:: 15A(?r1nc.n ' a 4 c 4jon L=Udj f' e eJ 1Cyae Address: 537- -)0PG(4 446t(✓I S6' City/State/Zip: Man dan S 1 ,r U t M' 661OyPhone#: S D a —,' 2 —.10 Are yon an employer? Cheek the appropriate box: 1. �I am a employer with T%employees (full and/ or part-time).* 2:lam a sole proprietor orpartnership and have no employees working forme in any capacity. [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. LNo workers' comp, insurance required)' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] that checks box # I must also fill out the section below Business Type (required): 5. F1 Retail S. Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment I0, ❑ Manufacturing 11. ❑ Health Care 12,❑ Other compensation policy information. *°lf the corporate of ecrs have exempted themsdvcs, but the corporzbm has ower employees, a worrmrscompeosanou poney is requueo aeo suca as organization should check box' #]. lam an employer that is providing>forkers' compensation insurance for my employees. Below is the policy informadori. Insurance Company Insurer's Address: C/N �/I C 1 V\ Cryo 1 Yl S56 {"✓�A City/State/Zip: (1aUc C j LS'Yt 0j p� �3 Policy # or Self -ins, Lic, #-W .141V �GI Ll l OCi Expiration Date: olSl Attach a copy of the workers' compensation policy declaration page (sbowing the policy number a&J 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 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 Phone #: w .masa.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "..,every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling bo -ase or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C() states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit sbould be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Sbould you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/liomse number which will be used m a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year, Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves eta) said person is NOT required to complete this affidavit The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1 -877 -"SAFE Fax # 617-727-7749 www.mass.gov/dia Form Rcvised 02-23-15 FROM :EAMES INS FAX NO. :508-339-1635 Apr. 12 2018 10:29AM P1i1 ACORL7° SHEAW-01 LOU �..� CERTIFICATE 4F LIABILITY INSURANCEDAT15( IaomvYl THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEf R, 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 pollay(las) must have ADDITIONAL INSURED provisions or he endorsed. If SUBROGATION 19 WAIVED, subject to the terms and condition of the policy, certain policies may require an endorsement. A statement an PRDDis Earuflcate does not confer rights to the certificate holder In lieu of Such andorsamont(s . INSURED Inc. Sherman 6 Jackson Funeral Home, Inc. 66 North Main Street Mansfield, MA 02046 6M bD8) 339.7913 IN yn: o08) 339-1535 _. IN9aRERletAp�pIN0BA0EN lea a_Haltover lnaurance Comuany 22282 ACORD 26 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWn of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ann: Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row _ Maheflold, MA 02048 AUTNORIZEO REPRESENTATIVE ��s��'E"AatiTMV 2016103) 01060.2016 ACORD CORPORATION, All rights reaervel The ACORD name and logo are registered marks of ACORD