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Home My WebLink AboutA.G.A., Inc. - 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: ALDO RUSCITO Doing business as: A.G.A., INC. 4 PORTER STREET 2ND FLOOR STOUGHTON MA 02072 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: 3 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman R V ii Disposal Works Installer Application LICENSE NUMBER: APPLICANT: _14_14C� a SGi \-C) BUSINESS NAME: MAIL ADDRESS: y \ OC I eC and CITY/TOWN: __3c on STATE: f j__a_ ZIP CODE: Q 0- _) BUSINESS PHONE: BUSINESS FAX: E-mail: BUSINESS CELL: _ r � _n � Cocvci ocops��es/v, AIt E-mail: Q e V 5C-4 t`�i � r. � , C. r7 T ID/SS NUMBER: n i_i _ `]'7 � ) 0,, -, �``'+ �� CoCbo�(•c�C�t LICENSE HELD: Town y0 n Year Licensed OF LICENSE HELD: Town _ rCgnr oY) Year Licensed o ! LICENSE HELD: Town h O kc (, o Year Licensed a c? I 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: DATE: 1G d s 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 co", 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. A 6A, Uc- Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0LI-'a-17)gn-7 "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 DocumentsNood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Departmenrof Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: A Address:9 it>tAe.c ' n4 �loa City/State/Zip: } ,gyp_ 0�,� Phone #: ( 7 Are you an employer? Check the a propriate box: Business Type (required): 1. [9- I am a employer with id employees (full and/ S. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (met. 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.❑ Manufacturing no employees. [No workers' comp, insurance required]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. rNo workers' comp. insurance req.] 12.[�Other *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 an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: c(,Ayy less Cei-Aj Cn5ucMl C,nq �q�- a11401.�Y' R Insurer's Address: )9a0 LgLeir,("r1-1 Ave St, aoct City/State/Zip: C I L) n r-jl PL -1� a 8 I q Policy # or Self -ins. Lic. # -1 C S U fS_ k 1-I 2 4 Sat I A —1 g Expiration Date:0S -Oa — a 01 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 Investieations of the DIA for insurance coverage verification. I do hereby certify, under rans and penalties of perjury that the information provided above is true and correct. Phone #: (L,� }) 7 Gi 7, 0.6 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 Contact Person: Phone #: www.mass.gov/dia VDAC TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB-8H24391-A-18) RENEWAL OF (7PJUB-8H24391-A-17) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. INSURED: AGA INCORPORATED PO BOX 287 RANDOLPH MA 02368 NCCI CO CODE: 13579 PRODUCER: MASON & MASON INS AGCY PO BOX 750 INTERVALE NH 03845 Insured Is A CORPORATION Other work places and identification numbers are shown In the schedule(s) attached. 2. The policy period Is from 08-06-18 to 08-o6-19 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA os b� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in b"' Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: b COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 08-07-18 JT ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: MASON & MASON INS AGCY 237XM 002560