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Home My WebLink AboutAll Seasons Septic, 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 KEVIN S.ORLANDO Doing business as: ALL SEASONS SEPTIC, INC. 200 CUSHING STREET, SUITE 7 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: 5 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 1/ Town of Mansfield Town of Mansfield - Board of Health s Park Row Mansfield, MA 02048 Disposal Works Installer LICENSE NUMBER: - Sl_2 4 e ' APPLICANT: JAN 18 Ijgjq r n BUSINESS NAME: MAIL ADDRESS: CITYITOWN: SO&,r r ti STATE: 1jg1V ZIP CODE: D.,Ld A.) BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX: `�F% ��✓ �'P F E-mail: 0// f,�o <rir�fo��iiU l2J�i//ane), c'orrj Alt E-mail: IDISS NUMBER: p yl 3 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed 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 31 st yearly. FEE: $ 100.00 SIGNATURE: DATE: Please make appropri to chang . 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 Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0,/ 3 -,V i' A9 ,�'_3 "Social Security No. (Voluntary) 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 of Massachusetts Department of 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 Leeibly Business/Organization N Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. E]Restaurant/Bar/Eating Establishment 2. F1 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. F1 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No 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 ane an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company N Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify, under thepains andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www,mass.gov/dia Department of Industrial Accidents Office oflnvestigadons 600 Washington Street Boston, IPM 02111 ' www massgov/dia Workers' Compensation Insurance Affidavit-'Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lefdbly Name (Business/Organization/fndividual): All Seasons Septic Service, Inc. Address: 200 Cushing St., Ste. 7 IVIH uGull- tipple the uuu-uc.�-vu-,v Are you an employer? Check the appropriate box: 1.0 1 am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time)-* have hired the sub -contractors 2_ ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.$ 5. ❑ We are a corporation and its required ] 3_ ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' - coum. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I0.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.® Other *anv a,n,licant that cheelm box #l.must.also fill out the section below showing theirwodm' compensation policy information. T Homeowners who'submitthis affidavit indicating they are doing all work and then hire outside contractors must submit anew atndavrt marcanng sucn. (Contractors that check this-boxz must attached an additional sheet showing the name of the sub -contractors and state whether ornot those entities have employees. If the sub-connuca ts.have employees, they mustpmvide their wodrers' comp. policy number. I am an employer information. workers' compensation insurance for my employees. Below is the policy and job site Insurance Company Name- Utica National Insurance Group Policy # or Self -ins.. tic. #. 4101564 Job Site Expiration Date: 4/14/2019 City/State/Zip: 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 c n sans and penalties ofperjury that the information/pFovidedov�el true y and torted O,Jj'icial use only. Do not write in this area, to be completed by city or town offciaL City or Town: _ Permit/License Issuing Authority (circle one): 1. Board of Health .2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: AC6Rp® CERTIFICATE OF LIARIL'ITY INSURANCE L V OATS (MM 00 YN 7/16/2018 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 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 A,E, Barnes Insurance Agency, Inc. 141 Pleasant Street P. O. Bo% 85 South Weymouth MA 02190 CONEACT Maria Andrade PHONE N (781)335-1589 MC 10^1781)335-0257 E -MAI mand 83rade@aebarnes.com DD : INSURER(S) AFFORDING COVERAGE NAIC# _ -_ INSURER Ikepublic-Franklin Ins Co 12475 INSURED All Seasons Septic Service, Inc; Orlando 5, Inc. 200 Cushing Street #7 Stoughton MA 02072 INSURERB:Pil rim Ins. Co. 21750 INSURERC:Utica Mutual Ins Co,___, _ INSURER D: INSURER E: INSURER F: COVFRAGFS CERTIFICATE NUMBER:CL1S41746262 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 DESCRI13ED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I` R _.._ 'TYPE OF INSURANCE B POLICY NUMBER ICY EFF IMMI10D POLICY EXP IDD LIMITS A MERCIAL GENERALUABIUTY TCLAIMSWADE ❑X OCCUR CPP4104067 2/12/2018 2/12/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE ID NEW I ED PREMISES,.1We,Pce e m 3 500,000 MED EXP (Any one arson) $ 15,000 PERSONAL &ADV INJURY $ 1,000,000 GENS. AGGREGATE LIMIT APPLIES PER: X POLICY ❑Pk0• 0LOG JECT OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALLOWNED X SCHEDULED AUTOS NONOS -OWNED X HIRED AUTOS X AUTOS CSC000010O1473 2/12/2018 2/12/2019 C SIN Da19NGLE LIMIT $ 1_000,000 Us L.__ _ BODILY INJURY (Per Pecan) $ BODILY INJURY(Pm.Wdent) $ PPROPEGRa ; DAMAGE $ Urmaumd motodsl combined $ 25/50 4 UMBRELLA LIAR EXCESS UAB OCCUR CLAIMS -MANE EACH OCCURRENCE S AGGREGATE S DED RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNEWEXECUHVE ((Y-N� (MandaEiory In N., II yes, tleec,ibe under DE6C IPTION OF OPERATIONSbelow NIA 4101564LJ 4101564 4/14/2018 4/14/2019 X PEAT X ER . EL EACH ACCIDENT $ 1,000,000 EL. DISEASE • EA EMPLOYE $ 1 000 000_ E.L. DISEASE POLICY LIMB 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addalamd Remarks Schedule, may be aaached if more space is requlredl PROOF OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE Ston Hoffman/MAT 'J, ��^i'T.�,If"e•, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025o,,mil