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HomeMy WebLinkAboutWind River Environmental - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Disposal Works Installer's Permit This is to certify that., FRED SWAIN Doing business as: WIND RIVER ENVIRONMENTAL 46 LIZOTTE DRIVE MARLBORO MA 01752 is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or repair individual sewage disposal systems. This permit is granted inconformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER: 41 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman Town of Mansfield - Board of Health Disposal Works Installer Application : Town of Minsfield 6 Park Raw Mansfield, MA 02048 LICENSE NUMBER: APPLICANT:lG-- BUSINESS NAME: MAIL ADDRESS: CITYITOWN:r BUSINESS PHONE: �112- &ja BUSINESS CELL:q�fP1 BUSINESS PAX:' E-mail: Ei� u�>~ i `ro/� l ARE -mail; JLii� (t)f`!^nkLL7¢L+t2tQp�.1.eOA-, EDERAL IDISS NUMBER d.�-y. 1-{�%j"' y -7-7 LICENSE HELD: Town STATE; M Q ZIPCODE: 617,459A..— Year licensed LICENSE HELM Town _- �tY trC'S- 4i'f IrX Year Licensed LICENSE HELD: Town 1 o4-ha-1 kb20 _ Year Licensed I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage". I understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31st yeady. FEE $100.00 SIGNATURE:. DATE: Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to ?'own of Mansfield: Mall to: Board of Health, Town ofManstleld, Six Park Row, Mansfield, MA 02048 � .I Au4 r e t 0512512018 '_28816253 r P $12712023 05/2711961 EIM NE N N FREPERIdK FRANCIS 10 SOUTH,CENTER ST BELUNGHAM,MA02019.1741 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Jndividual or Corporate Name Qq --34` P&77 **Social Security No. (Voluntary) or Federal identification Number CIC'f-- By: Corpor e fHcer (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:\Uscrs\sleite\Desktop\Scotts Dounnents\Food Gstnbhshments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of hulustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 wlvnv, inuss,gon/(flit Workers' Compensation InsuranceAffidpvtit: General Businesses Alxhrlicaut Information Please Print I.,eeilily Business/Organization Nauxe:.nv_er vxv (cn and z✓� Address: x4 (C LI,7c7Tx-tz_ \)e— City/State/Zip: Are o i an employer? Check the appropriate box: I am a employer with `1 cb employees (full and/ oi- part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me 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. [No workers' comp. iosm ance required]' 4. ❑ Wo are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone Business Type (required): 5. ❑ Retail 6. ❑ RestaurnnttBar/Eating Establishment 7, ❑ Office and/or Sales (Intl. real estate, auto, etc.) & ❑ Non-profit 9. ❑ Entertainment ME1 Manufacturing 11.❑ Health Care 12.tD Other Qwwe�c4_ =Fury applicant that ehacks box HI mmst:dso fill out the section below showing their workers' compensation policy information. n*If the corporate officers have exempted Ihemseives, bon the corporation has other employees, a workers' compensation policy Is required and sewn fin organization should check box # 1. I an mr employer afrr(is providing Ivnrkers' cunnpensntion insrrrmnce far my enrpinyees. Below Is the police hnfarmntlnn, Insurance Company Name:�c,�,,�;�� _'�h v,� ,•,.,ter• pr��-v j __�., Insurer's City/State Policy # or Self -ins. Lie. #_�_p( ppQExpiratlon.Date:_�, �_�o _�-..._ 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 mid/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 it day against the violator, Be advised that a copy of this statoinent may be forwarder] to the Office of Investigations of the DIA for insurance coverage verification. I rho hereby certify, under that are Informntiau provided above to (rue and correct Of use only. Do not write in this area, to be completed by city or• town offrcinl. 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 ACORO® CERTIFICATE OF LIABILITY INSURANCE Ilm/ 6/30/2019 DATE(MMIDDTYYYY) 1 7/2/2018 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(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 Insurance Brokers,LLC CONTACT NAME: CA License #OFI 5767 725 S. Figueroa Street, 35th fl. Los Angeles CA 90017 _ PHONE ExQ A/C No AIC. No.E-MAIL ADDRESS: 213-689-0065 INSURER(S) AFFORDING COVERAGE NAIC I7 INSURER A: Evanston Insurance Company 35378 INSURED Wind River Environmental, LLC 1448815 46 Lizotte Dr. INSURER B: Endurance American Specialty Insurance Co. 41718 INSURER c .Liberty Surplus Insurance Corporation 10725 INSURER D: Starr Indemnity & Liability Company 38318 Marlborough MA 01752 INSURER E: _ INSURER F : COVERAGES WINRIO1 CERTIFICATE NUMBER: 15473701 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 rypE OFINSURANCE AOOL INSD SURF Me POLICYNUMBER MMIDDPOLICYEFF M MMIDDY/YYYY LIMITS D X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR N N 1000090512181 6/30/2018 6/30/2019 EACH OCCURRENCE $ 1 OOO 000 PREMISE Ea occur ante $ I OO 000 MED EXP(Any_one person) $ 5000 __---- _ _ _ __ PERSONAL &ADV INJURY $ 1,000,000 GENERALAGGREGATE_ $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � JECOT u LOC PRODUCTS-COMPlOPAGG $ 2 000 000 _ $ OTHER: D D AUTOMOBILE LIABILITY ANY AUTO N jet 1000198837181 ((MA)) 1000198836181 (AOS) 6/30/2018 6/30/2018 6/30/2019 6/30/2019 COMBINED INGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) $ XXXXXXX OWNED AUTOSONLYNACUTHOESSDULED BODILY INJURY(Per accident) $ XXXXXXX HIRED NON -OWNED AUTOS ONLYAUTOS ONLY PROPERTY DAMAGE$XXXXXXX Peraccidenl X $ XXXXXXX Com /Coll D Various UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX _ AGGREGATE _ $ XXXXXXX____ EXCESS LIAB CLAIMS -MADE DED RETENTIONS S XXXXXXX D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEWMEMBER EXCLUDED? � N/A N 1000003291 6/30/2018 6/30/2019s PER OTH- X STATUTE I ER E.L. EACH ACCIDENT $ 1000000 ---- E.L. DISEASE - EA EMPLOYEE ---- $ 1,000,000If (Mandatory in NH) yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1000000 A XS Auto Liab N N MKLV5EUL101095 1110,2018 1111,1019 Limit: $3,000,000 A XS General Liab MKLVSEUL101095. 6/30/2018 6/30/2019 Limit: $4,000,000 B 2nd XS Layer ELD30000710700 6/30/2018 6/30/2019 Limit: $SM xs $5M C 3rd X 100030507901 6/30/2018 6/30/2019 Limit: $6M xs $l OM DESCRIPTION OF OPERATIONS LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Excess Liability limits for Evanston Insurance Company (Policy # MKLV5EUL 101095) include $3,000,000 excess the primary Auto Liability and $4,000,000 excess the primary General Liability and Employers Liability. Evidence of Insurance 15473701 C/o Wind River Environmental, LLC 46 Lizotte Dr. Marlborough MA 01752 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1 reserved. ACORU 25 (2015103) The ACORD name and logo are registered marks of ACORD