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Home My WebLink AboutA.T.W., Inc. - 12/31/2019[�o 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: ALAN WATTERSON Doing business as: A.T.W., INC P.O. BOX 490 SHARON MA 02067 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: 7 FEE $100.00 BOARD OF HEALTH .%tichaeCHeaCey, Chairman f,(D Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application APPLICANT: R `C1 BUSINESS NAME: MAIL ADDRESS: C (� '23S I� +p1.1f'1Y ai)l I. 1 CITY/TOWN:yl K liD} STATE: Ml� ZIP CODE: Oo_aA' BUSINESS PHONE: /SI_� (�C�BUSINESS CELL: (�Q 1 7Jy 7 —%Co UU BUSINESS FAX: ' �- V E-mail: CL+I.J—'zlr (F- C6raccIS% rle Alt E-mail: EDERAL ID/SS NUMBER: , a514 % �t-55 11 LICENSE HELD: Town _)rory Year Licensed LICENSE HELD: Town 6klwcO Year Licensed LICENSE HELD: Town Kor'�V\ 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 yearly. FEE: $ 100.00 SIGNATURE: ✓ �6i _ DATE: - � (,. - I Q 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 i 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 Individual or Corporate Name 04--a�`�7 y �/ "Social Security No. (Voluntary/) or Federal Identification Number 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\sleile\Desktop\Scolt'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 Legibly Business/OrganizationNnaPIme: y, , 6cc)rpQ) lej Address: v3a 35 I "I 67un4I,tL 1 a� Phone #: -7 1 9`4 — ZP (P Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail m• 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. 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 a 152, § I (4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 11.❑ ftealth Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.FOther *Any applicant that checks box # ] must also fit I out the section below shoving 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. I ani an employer iliat is providing ivorlrers' conipensatijziiinsurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: W1 6, v:�35& Policy # or Self -ins, Lic. # 'Z PJ ) ^ J g a 1 '36 ] Expiration Date: T' i — I C1 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. do hereby certify, antler the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not virile in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.in ss.gov/dia A .o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 04/01/2019 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 endorsemenl(s). PRODUCER CONTACT Karen Forrest NAME: Morse Insurance Agency, Inc. PHONE (508) 238-0056 FAx (508) 230-8367 A/C No E t : AIQ No 285 Washington Street E-MAIL karenfonest@morseins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAICN INSURERA: Travelers Casualty Ins. Co 19046 North Easton MA 02356 INSURED INSURER B: Commerce Insurance CO. 34754 ATW, Inc. INSURER C: P O BOX 490 INSURER D: INSURER E : Sharon MA 02067 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 UR TYPE OF INSURANCE INSD WID POLICY NUMBER POLICY EFF MMIDO POLICY UP MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGET RENTED—' PREMISES IFaoccunence $ 300,000 MEDEXP(Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 A 6802A703790 04/01/2019 04/01/2020 GENT AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY ❑ JECT LOG PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accid nl $ 1,000,000 BODILY INJURY (Par person) $ ANY AUTO B OWNED X SCHEDULED AUTOS ONLY /� AUTOS BDNYXJ 04/0112019 04/01/2020 BODILY INJURY (Per accident) $ X HIRED X NON -OWNED AUTOS ONLY /� AUTOS ONLY PROPERTY DAMAGE Peramidenl $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'UABILITY YIN STATU TEER, E.L. EACH ACCIDENT $ ANY PROPRIETORIPARTNER/ OFFICER/MEMBER EXCLUDEDZEXECUTIVE ❑ NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be anached if more space is required) CERTIFICATE HOLDER CANCELLATION 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. Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048-1- @ 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ACOR®® CERTIFICATE OF LI ILITY INSURANCE '1 DaTE(Mmmomrr) 04/01 /2019 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 CONTACT NAME: Sandy Merchant MORSE INSURANCE AGENCY INC a�"N ExIt (508) 238-0056 A Re: E-MAIL sand marchant morseins.com ADDRESS: Y G INSURERS AFFORDING COVERAGE NAIC0 285 WASHINGTON ST INSURERA: TRAVELERS PROPERTY CAS CO OF A_ M 25674 NORTH EASTON MA 02356 INSURED INSURER e INSURERC: A T W INC INSURER D : INSURER E : PO BOX 490 INSURER F: SHARON MA 02067 COVERAGES CERTIFICATE NUMBER: 384327 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. INSR LTR rypE OFINSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM/DD/YYY POLICY EXP MMfDD/YV LIMITS COMMERCIAL GENERALUABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑OCCUR DAMAGE TO RENTED PREMISES Ea occurrence _ $ MED EXP lAny one person) $ PERSONAL A ACV INJURY _ $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PRO- ❑ JECT LOC _ PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLALIAB OCCUR EACH OCCURRENCE $ H AGGREGATE $ EXCESS LIAR CLAIMS -MADE N/A DED RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE Y/" RIME BE EXCLUDED? NIA (Mandatory N/A NIA 7PJUB5B27367019 04/01/2019 04101/2020 X STATUTE ERH E.L. EACH ACCIDENT _ $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 IF yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 0306 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 www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield Board of Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Cro / ey, CPCU, Vice President— Residual Market— WCRIBMA Daaniel ACORD 25 (2014/01) 01988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD