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Home My WebLink AboutSherman & Jackson Funeral Home - 4/30/2018Commonwealth 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 Monday, April 30, 2018 unless sooner suspended or revoked. Fee : $25.00 BOARD OF HEALTH MichadMcCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 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 (50 BUSINESS FAX: (508) 261-9351 EMAIL ADDRESS: RCEDARFIELD@AOL.COM FEDERAL ID/SS NUMBER: 04-2544099 FEE: $ 25.00 SIGNATURE: _ DATE:Gi/f �� - 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 IndiN,4dual or Corporate Name aN Ds✓('tg0gC1 "Social Security No. (Voluntary) or Federal Identification Number Pl_&J lc Pel By: Corporate Officer (Mandatory, if Applicable) *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\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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 PERMITTING AUTHORITY. Business/Organization Name: JhPrMaA Address: S�S"- Wo ( M a.i t Pt hone #: �C�� S ' .3,N �LXJU Are you an employer? Check the appropriate box: Business Type (required): 1. El I am a employer with % employees (full and/ 5. M Retail or part-time).* 6. []Restaurant/Bar/Eating Establishment 2. El I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 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. F1 Manufacturing no employees. [No workers' comp. insurance required]* I l El Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, l / 10 12.® Other �n i /_ with no employees. [No workers' comp. insurance req.] fi- r *Any applicant that checks box #I 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 #i. lam an employer that is providing workers' compensation insurance for my�employees. Below is the policy information. Insurance Company Name: rkitt1 ouei' -LrU U1CId(e CO--4Gckto PS ..Lrk Iufc,.4CP ZV enr"tt Insurer's Address: 4,) /VMe j n (54? 1 J City/State/Zip: l i) Cj/ l (1 1 jZ H 0 b Policy It or Self -ins. Lic. #. '7 M I F9 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 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office Phone 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 ajoint 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 house 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(7) 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 511 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 should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should 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/license number which will be used as 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 etc.) 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-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 FROM :EAMES INS FAX NO. :508-339-1835 Apr. 13 2017 10:32AM P1i1 LD ►CC11IR Ci' CERTIFICATE OF LIABILITY INSURANCE g5lo2ws 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 certlficats holder Is an ADDITIONAL INSURED, the pollcy(lae) must be endorsed• If SUBROGATION IS WAIVED, eulrJect to the terms and Conditions of the policy, certain policies may require an endorsement, A statement on this Certlficste does not confer rights to the Eames Ins, Agcy. Inc Main St, PO Box l89 MA 02048 INSURea Sherman & Jackson Funeral Home, Inc. 55 North Main Street Mansfield, MA 02048 ._ ... F PHONE A%IAIC�NdL—_„ AtC.8e�6xs: - '-- MAIL ADDRESS: J22;2992. INSURER(9)AFFORDING COVERAGE _ _._AILS Hanover Insurance CompanyINSURER e:__. D; kit uaraee. COVERA C9 van nrl..n rcnwa,ocn. --- - OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBW TYPE OFINBURANCE AOa4 INS pO1.lOY NUMBER MMID PP PGLp � LIMITS THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN GENErMLLIARILITY ACCORDANCE WITH THR POLICY PROVISIONS. Attn: Health Dept. AUTHORIZED REPRESENT E 6 Park Row EACH OCCURRENCE ... COMMERCIAL- GENERAL LIABILITY DAMA6ET67&,'NTEO.... FREM18FSf5oow'it—n __ $ CLAIMS�MAOE u OCCUR--- MED EXP (AnYP616M) !T! S '-- PERSONAL a ADV INJURY S GENERAL AOORF,GATE S __..., . GEN'L AGGREGATE OMIT APPLIEfi PER: PRGOUCTS-COMPIOP A00 E „_-__ POLICY FRO- LOG LIMIT -COMBINED$ AUTOMOBILE LIABILITY ff9 eOtBINGLG 8 BODILY INJURY (P& penton) ...-. E ANY AUTO ...... .... BODILYINJURY(Peraccldent) ALL OWNED ISCHEDULED E .._. AUTOS -AUTOS $ P16PERTY�- NON9WNE0 HIREDAU'r08 AUTOS a cGtlanl __, __ _ UM001,1-A One OCCUR EACHOCCURRENCF. E%CESS LIAR CLAIMS -MADE AGGREGATE $ .__ $ DEb ST TUR - X A aNRATITI WORKERS COMPENSATION ANO EMPLOYERS' LIABILITY YIN ANY PROPMETORIPARTNERIEXEOUTIVE WHN5419189 07!26118 97!25/17 TQC E,L EACH ACCIDENT y_ 160,68 OFFICERIMEMOER EXCLUDED'/ LJ NIA E.L. DISEASE-EAEMPLOYEF. $ 100,06 (MandarorY In NM) _ Ir Vyee, Uaeelbe N E6.DI8EASE-POLICY LIMIT der DESCRIPTION OF OPERATIONS b01oW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLBS (Aeach ACORD 101, Additional Remarks Schedele, If more apace is recoiled) W Ivan -AV IV ^V W nv vvnrMnn „vrv. nn nan.a ,vee, rc... ACORD 26 (2010105) The ACORD name and logo are registered merke of ACORD MANSF-i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN Town of Mansfield ACCORDANCE WITH THR POLICY PROVISIONS. Attn: Health Dept. AUTHORIZED REPRESENT E 6 Park Row Mansfield, MA 02048 ` y 'y, C,44"d'4 , W Ivan -AV IV ^V W nv vvnrMnn „vrv. nn nan.a ,vee, rc... ACORD 26 (2010105) The ACORD name and logo are registered merke of ACORD