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Home My WebLink AboutAdvanced Metals Engineering, Inc. - 12/31/2019l Commonwealth 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: JOHN DISANGRO Doing business as: ADVANCED METALS ENGINEERING, INC. 52 PRODUCTION ROAD WALPOLE MA 02081 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: 2 FEE $100.00 BOARD OF HEALTH Michae(Healey, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer LICENSE NUMBER: 2— APPLICANT: BUSINESS NAME: J�hn'--DtS, OUT 2 5 2 MAIL ADDRESS: 5a, Vj-0dLCC_fi6'1 rZV6_(A Ili V CITY/TOWN: STATE: 1118 _ ZIP CODE:000' BUSINESS PHONE: ��O� _ BUSINESS CELL: BUSINESS FAX: E-mail: 0N61'Yki7M-Se --l.l'S.Y-\✓C.'�D ciC� Alt E-mail + EDERAL IDISS NUMBER: LICENSE HELD: Town Year Licensed c90(9 LICENSE HELD: Town �L l�t�L�l Year Licensed c��1pO LICENSE HELD: Town f1(7 Year Licensed t9-01 D 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 yearly. FEE: $ 100.00 SIGNATURE: � , j a DATE: lc)�2_sj I Please make appropriate changes. Sign, date, and enclose check for $100,00 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 under law. I�rl�i�tl�c1 i��ils �n�l neeyn� y+��' Signature of Individual or Cor orate Nat By: Corporate Officer (Mandatonj, if Applicable) cH - "Social Security No. (Voluntanj) 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: `J 2-- ` ax_A ucih o n Zc acA City/State/Zip: e 1 mr-�- o;?,X Phone #: Are y u an employer? Check the appropriate box: Business Type (required): 1. Are am a employer with � employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/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 vottmteers, 1 l.❑ Health Care �` with no employees. [No workers' comp. insurance req.] 12.[�Other COA5iYCU,*0h *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 required and such an organization should check box #1. I ant au employer tliat is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Nan Insurer's Address: nc> City/State/Zip: Policy # or Self -ins. Lie. y5)— p] 30jo — 01s, Expiration Date: iQ 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 theppaiins and penalties ofperjtuy that the information provided above is true and correct. Signature: (e 4tei'— 0 f)�d) , Date: IQIZ�/�0sy Official use only. Do not ivrite 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: www.mass.gov/dia Phone #: ACORD® CERTIFICATE'OF LIABILITY INSURANCE 16./ DaTE (M&voom vv) 1 10/22/2018 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(tes) must 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 CONTACT NAME: John DUXbU EASTERN INSURANCE GROUP LLC PHONE 508) 270-5312 FAX_UV Ne; _E-MAIL ADDRESS: Iduxbu aasfaminSUranCe.COM INSURERS AFFORDING COVERAGE NAICe 233 WEST CENTRAL ST INSURERA: LM INS CORP 33600 NATICK MA 01760 INSURED INSURERS: ADVANCED METALS ENGINEERING INC INSURERC: .INSURER D : INSURERE: 62 PRODUCTION ROAD INSURER F: WALPOLE MA 02081 COVERAGES CERTIFICATE NUMBER: 328142 REVISION NUMBER: 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. 1R �TR TYPEOFINSURANCE ADD L B POUCYNUMBER &IM/DO%YYYY MMIDDYEXP LIMITS COMMERCIALGENERAL LIABILITY CLAIMS -MADE 11 OCCUR EACH OCCURRENCE S DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one ersan) $ PERSONAL& ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT D LOC GENERALAGGREGATE $ PRODUCTS -COMPIOP AGO $ $ OTHER: AUTOMOaILELUIBILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL AUTOS CEO AUTO N/A BODILY INJURY (Per accident) $ NON OWNED HIREDAUTOS AUTOS PROPERTY DAMAGE Per a -dent $ $ UMBRELLA LIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE NIA DELI I I RETENTION$ $ A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCWDEM. NIA NIA NIA WC531S613070018 06/23/2018 06/23/2019.. PER OiH- %� STATUTE ER E.L. EACHACCIDENIT $ 1,000,000 E.L. DISEASE -EAEMPLOYEE $ 1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below '" E.L. DISEASE - POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached H more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage Can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at w .mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall AUTHORIZED REPRESENTATIVE Mansfield MA 02048 , (� ( � Daniel M. Cro ey, CPCU, Vice President— Residual Market — WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Hartford Casualty Insurance Company THp HARTFORD Date: October 3, 2018 Agency Name: EASTERN INSURANCE GROUP LLC/PHS Agency Code: 08 080624 Advanced Metals Engineering, Inc. 52 Production Road Walpole, MA 02081 Attn: Insured/Principal: Advanced Metals Engineering, Inc. Policy/Bond : 08BSBGA0114 Account Name/Number: Term: December 31, 2018 - December 31, 2019` Type: Surety - License & Permit Billing Type/Term: Annual Transaction Type: Renewal Transaction Effective Date: December 31, 2018 Limit: $5,000 Premium Do o As a convenience, our Bond Sales Team is available to serve you. If you require any assistance, Please contact us via phone or email as our Business Insurance Professionals want to help. Simply, call toll free 1-866-268-6404 any weekday from 8 AM ET— 7 PM ET to talk to our Sales Team. You can also email us at BondSales@thehartford com, This record is a billing record advice only. You will be billed directly by The Hartford within 15 days of the effective date of the bond. Payments can be mailed to: The Hartford P.O. Box 660916 Dallas, TX 75266-0916 Popydght 02017 by The H2,110(d. Classelieahon: Internally C"buled. All rights reserved. No pad of this document maybe used, reproduced, published 0rposW wPhoui the permission 0f The Hadlordl Continuation Certificate The Hartford Insurance Group Surety - License & Permit The Hartford Casualty Insurance Company, (hereinafter called the Company) hereby continues in force its Bond No. 08BSBGA0114 in the sum of Five Thousand ($5,000.00) Dollars on behalf of Advanced Metals Engineering, Inc. 52 Production Road, Walpole, MA 02081 in favor of Town of Walpole, Water & Sewer Dept. for the (extended) term beginning on December 31, 2018 and ending on December 31, 2019 subject to all the covenants and conditions of said Bond, said Bond and this and all continuations thereof being one continuous contract. This Continuation is executed upon the express condition that the Company's liability under said Bond and this and all continuations thereof shall not be cumulative and shall in no event exceed the sum of Five Thousand ($5,000.00) Dollars. IN WITNESS THEREOF, the Company has caused this instrument to be signed by its officers proper for the purpose and its corporate seal to be hereto affixed on October 3, 2018 . 1.0 Attest - Hartford Casualty Insurance Company Direct Inquiries/Claims to: ��u�yyy THE HARTFORD BOND, T-12 One Hartford Plaza UORNEY Hartford, Connecticut 06155 Bond.Claimsfa-)thehartford com call: 888-266-3488 or fax: 860-757.5835 KNOW ALL PERSONS BY THESE PRESENTS THAT: Agency Name: EASTERN INSURANCE GROUP LLC/PRS Agency Code: OB-080624 Hartford Fire Insurance Company, a corporation duly organized ender the laws of the State of Connecticut Hartford Casualty Insurance Company, a corporation duly organized under the laws of the State of Indiana Hartford Accident and Indemnity Company, a corporation duly organized under the laws of the State of Connecticut Hartford Underwriters Insurance Company, a corporation duly organized under the laws of the State of Connecticut Twin City Fire Insurance Company, a corporation duly organized under the laws of the State of Indiana Hartford Insurance Company of Iliinols, a corporation duly organized under the laws of the State of Illinois organized Hartford Insurance Company of the Midwest, a corporation duly Order the laws of the State of Indiana Hartford Insurance Company of the Southeast, a corporation duly organized under the laws of the State of Florida having their home office in Hartford, Connecticut (hereinafter collectively referred to as the 'Companies") do hereby make, constitute and appoint Joelle L La Pierre of Lake Mary, Florida, its true and lawful Attorney -in -Fact, to sign its name as surety(ies) only as delineated above by , and to execute, seal and acknowledge the following bond, undertaking, contract or written instrument: Bond No. 08BS13GA0114 Naming Advanced Metals Engineering, Inc. as Principal, and Town of Walpole, Water & Sewer Dept. as Obligee, in the amount of See Bond Form(s) on behalf of Company in its business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. In Witness Whereof, and as authorized by a Resolution of the Board of Directors of the Companies on May 6, 2015 the Companies have Caused these presents to be signed by its Senior Vice President and its corporate seals to be hereto affixed, duly attested by its Assistant Secretary. Further, pursuant to Resolution of the Board of Directors of the Companies, the Companies hereby unambiguously affirm that they are and will be bound by any mechanically applied signatures applied to this Power of Attorney. 2N .a ' ° A, 0.3 ►P `e+um . u3 P pl Thai P - J :'g Yx� 'i' AS ��J Atva.n IalApi. :t tea f'.: F A 97 / F la7ei._ n ''h:,� •� $°MwA� iyx :a 1' � '-'�,,„i aims �.`� John Gray, Assistant Secretary M. Ross Fisher, Senior Vice President STATE OF CONNECTICUT COUNTY OFHARTFORD ss. Hartford On this 5th day of January, 2018, before me personally came M. Ross Fisher, to me known, who being by me duly sworn, did depose and say: that he resides in the County of Hartford, State of Connecticut; that he is the Senior Vice President of the Companies, the corporations described in and which executed the above instrument; that he knows the seals of the said corporations; that the seals affixed to the said instrument are such corporate seals; that they were so affixed by authority of the Boards of Directors of said corporations and that he signed his name thereto by like authority. ��rtY.'\rly �VPrnprkFg '�icee%u&evLT �71a�n.ae.R R Kathleen T. Maynard Notary Public CERTIFICATE My Commission Expires July 31, 2021 I, the undersigned, Assistant Vice President of the Companies, DO HEREBY CERTIFY that the above and foregoing is a true and correct copy of the Power of Attorney executed by said Companies, which is still in full force effective as of October 3, 2018. Signed and sealed at the City of Hartford. nt ry tk,� �oa"pA. 9E) Nlteip P '7 riB$Y Q 9�iem.a nrP°sa�ta\j0 eg PPalbRP �' y.hiifa 70 F ��• I87a Je Ak+a♦♦i♦• 0d i° ,�........✓.:f '1raf♦' �3949 Kevin Heckman, Assist an Vice President 'MO 2uIB