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HomeMy WebLinkAboutBay State Sewage Disposal, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: LOUIS LABATE III Doing business as: BAY STATE SEWAGE DISPOSAL, INC. 105 KINGMAN STREET LAKEVILLE MA 02347 Town of Mansfield 6 Park Row Mansfield, MA 02048 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: 8 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 16V Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02046 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: kou(ls BUSINESS NAME: `/,& MAIL ADDRESS: IYJ `�p�V/, CITY/TOWN: r txfr7w STATE: AIA ZIP CODE: Oa317 BUSINESS PHONE: U�6 ��fl / 'ZtP��o BUSINESS CELL: dL)k- VbU —D 3s9 BUSINESS FAX: 5b0' 9q/—dpl�p E-mail: 02 f I Cla 's 1 e.1-tt�JQI Alt E-mail: 149 flSaWLY, Ca--v,� ID/SS NUMBER: 0'4--301 — 5L4 31 LICENSE HELD: Town Year Licensed 301 LICENSE HELD: Town 61 Law "Op- Year Licensed IX0)8 LICENSE HELD: Town 4 ' `00 Year Licensed '061 0g 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 SIGNAT DATE:�%��1'� / 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. Smx •� lilt `- VJv iJ�X \ N Signature of Individual or Corporate Name By: Corporate 01ficer (Mandatonj, if Applicable) **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. Restricted to: Hoisting Engineer HE-1 C-Telescoping Booms w/o Cables HE-2A- Excavators DIG SAFE Call Center: (888) 344-7233 In case of accident call: 508) 820-1444 For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl Commonwealth of Massachusetts e Division of Professional Licensure Hoisting; Lnc9inper HE-120757 EXplU0810212019 LOUIE LA13ATE23CHURCHILL ROAD LAKEVILLE MA,02347 Commissioner COMMONWEALTH OF MASSACHUSETTS MASS.DEP APPROVED TITLE 5 SYSTEM INSPECTOR Louis LaBate 105 Kingman St. Lakeville, MA 02347 PURSUANT TO THE GENERAL LAWS Tile Convznonrnealth of dfassachuseits r . - Departzent ref Tndustrial Accidents Of ice gfLrzvestigatr.otzs - t ,•.1' 606 Tl'ashirz,:;ton Street Boston, ;41A 02111 iv t mmass.govIdia Workers' Compensation Insurance Affidavit: Bit iI'd ers/Contract:ors/Eleetricians/:'[ttmbers plEcant Infot ntatioli _ Vleaste Priuf Lc"ial}; Name (BustyesslOrganvatio dfudividuat) BAY STATE SEWAGE DISPOSAL INC.-_ ,, ---._..._ „ Address: 105 KINGMAN STREET fit}/Stage./Zip: LAKEVILLE, MA02347 Phone fl _ _508 ----- 947.2636_ Are you an employer? Check the appropriate box: Type of project (required): I. 1 au: a enployer wild 4. _23 .___ ❑ I am a general contractor and I 6. ❑ New construction employees (full acid/or part-time). have hired the t a attachedshectors listed or, the attached shed. 7. ❑Remodeling 2. I.:uu a sole proprietor or partner- ship and have no employees These sub -contractors have g. Demolition working for me in any capacit}. employees and lr:ive workers Building: addiiion INo workers' comp. insurance ?. comp. insurance. We are [] a corporation and its I (l.❑ F,lecfrical repairs or additions required-] J. El I not a homeowner doing all work off sirs have exercised their L 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of esemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1t4), and we have no 13.Olhor SERVICE Y=�'I employees. [No workers' -- come. insurance required.] 'Any al+plicviithat ch=clrs lux #i nust also fill out tlx: section below showing their workers' compensatim, policy iIII; umaf ro;,, i' Ifonmo•wo"s who stan:iI this aflidmdt indicating they im doing all wsufi. and then hire ent ide contractors moat submit n new affidavit indicadng suoh. 'Coinramrs that check this Lsox shoot showing the name of the sub -contractors and state whether or not chose entitle, haee criployces.:f the sub-cortraaors have employees, they rum provide their a+orkars camp. policy nuurher. .. l azn an eniploi-er that ishroviding markers' coatlJensation insurance for nry emploveca. Below is the policy and job site information. Insurance Conpany Name:_ACADIA INSURANCE COMPANY .__-_._____ Poliey # or Self -ins Lie..#:WC# MAARP301685 _ --- Expiration Date ...... .lob Site Address: P.O. BOX 59143 CityiStatc,'Zip:_MINNEAP_OLLS,-MN-55459-0143 Attach a copy of the workers' compensation policy declaration page (shiriving the policy number anti expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the huposition of criminal penalties of a fine up to $1,500.00 aodror 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, he forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ _^ F,nR_aa7_9r;R i Official use on&, Do riot write irr this area, to he completer) by city or town official City or Town: Permit/License Issuing Authority (circle one): 1, Board of Ilealth 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Phone # A1 1_ CERTIFICATE OF LIABILITY INSURANCE D021092019 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Rogers & Gray Ins Agency Inc 434 Route 134 F1 South Dennis, MA026603433 CONTACT NAME Berkley Assigned Risk Services FAx (A/C. Na. Ex11: (866) 546-7431 (A/C.Nn.): (866) 215-6118 ADDRESS: assigneddsk@berkleynet.com INSURER(S) AFFORDING COVERAGE NNC# INSURED Baystate Sewage Disposal Inc PO Box 886 Lakeville, MA 02347 INSURER A. Acadia Insurance CO 31325 INSURER INSURER C: NWRER D: NSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN INSSUED 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 TYPE OF INSURANCE ADOL INSR SUBR WVD POLICY NUMBER POLICYEFF (MMMONYYY) POLICY EXP fimmwA'YYY) LIMITS WORKERS COMPENSATION AND ®WC STATU- ❑OTHER TORY LIMITS EMPLOYERS LIAMLIW ANY PROPRIETORIPARTNEW E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 A EKECUTIVE OFFIC.EMBER [N N/A ❑ MAARP301665 06/15Y2016 06/15/2019 E.L. DISEASE -POLICY LIMIT $1,000,000 EXCLUDED?(YAQ (Mandatory In NH) ❑ ❑ DESCRIPTION OF OPERATIONS I LOCATIONS/'VEHICLES (Atech ACORD 101. Additional Remarks Schedule, if mare space is raW fired) All Insured CERTIFICATE HOLDER Town of Mansfield 6 Park Row Building Department Mastield, MA 02048 CANCELLATION Entity 8aystale Sewage Disposal Inc Leonard Beef Co Inc Great WII Cap R Chaves Develapment Cory Risk Loealion 105 Kingman greet, IakeNlle MA02347 200 Norm Ave, Taunton MA02760 2394 Qanherry Highway, Wareham MA02571 95-113 Kingman g, Lakamile MA 02347 )ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE NON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PROVISIONS. ACORD 25 (2010/05) BRAC 3139 ,ate Ezo® CERTIFICATE OF LIABILITY INSURANCE DATYYY) E/4/E01g 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(les) 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 Rogers & Gray Ins. - Kingston Branch 9 Y 0 63 Smith Lane Kingston MA 02364 CO AC NAME: _ PHONfE L6 E.: 508-746-3311 ,ac No): 877-816-2156 E-MAIL AD ss: mail(@Fogemgray.com INSURERS AFFORDING COVERAGE NAICk INSURERA: Arbella Indemnity Insurance Com an , Inc. 10017 INSURED BAYSTAT-04 Bay State Sewage Disposal Inc 105 Kingman St INSURER e: Arbella Protection Insurance COm an , Inc. 41360 INSURER G: INSURER D: Lakeville MA 02347 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 476943181 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 TYPE OF INSURANCE ADDL S SUER D POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MMIDDIYYY LIMITS A X COMMERCIALGENER�" IA�L LIABILITY CLAIMS -MADE OCCUR 8500069401 1/18/2019 1/18/2020 EACH OCCURRENCE $1,000,000 PREMISES Ea occurrence $ 300,000 MED FXP (Any one person) $15.000 GENT. PERSONAL& ADV INJURY $1,000.000 AGGREGATE LIMIT APPLIES PER: POLICY Z jE'GT I I LOG OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED X NON-0WNED AUTOS ONLY AUTOS ONLY 102007999801 1/18/2019 1/18/2020 COMBINED SINGLE LIMIT Ea acciden! $110001000 BODILY INJURY (Par Person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ $ A X UMBRELLAUAB EXCESS UAB X OCCUR CLAIMS -MADE 4600069402 1/18/2019 1/18/2020 EACH OCCURRENCE $5.000,000 AGGREGATE $5.000,000 DEo X RETENTION$ in nnn $ WORKERS COMPENSATION ANDEMPLOYERS' LIABILRY YIN ANYPROPRIETORIPARTNERIEXECUTIVE ❑ IM OFFICEREMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ A Equipment Floater 8500069401 1118/2019 1/18/2020 Leased/Rented 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached 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. Health Department Town Hall AUED REPRESENTATIVE } j 6 Park Row- 1st Fir Mansfield MA 02048 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD w� ua CERTIFICATE OF LIABILITY INSURANCE OATE 02/09/2019 9/2019 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Rogers $ Gray Ins Agency Inc 434 Route 134 F1 South Dennis, MA02660-3433 CONTACT NAME: Berkley Assigned Risk Services PHONE (PHONE No ExL): (888) 548-7431 FAX 1 INC. No.): (866) 215-8118 EMAIL ADDRESS: assignedrisk@berkleynet.com INSURER(S) AFFORDING COVERAGE NAIC# INSURED Baystate Sewage Disposal Inc PO Box 886 Lakeville, MA 02347 INSURERA: Acadia Insurance CO 31325 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN INSUUED 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY Err POLICY EXP LIMITS INSR MD (MM/DDJYYYV) (MM/DDM'VY) WORKERS COMPENSATION AND STATU- []OTHER IN LIABILITY TORY LIMITS ANY PROPRIETOR/PARTNEW E.L. EACH ACCIDENT $1,00D,000 A EXECUTIVE OFFICE/MEMBER N N/A ❑ MAARP301685 06/15/2018 06/15/2019 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 EXCLUDED?(V/N) (Mandatory In NH) E.L. DISEASE -POLICY LIMIT $1,000,000 VGJVNIY I Us Vr VreKA I IUIV IwcA I IUIV I verncLea (Anacn AUUNU lUl, AnelllOodl tremmee Semantic, It MOM space Is required) All Insured CERTIFICATE HOLDER CANCELLATION Entity Sol Sewage Disposal Inc Leonard Beef Co Inc Great Hill Carp R Chaves Development Corp Risk Location 105 Kingman Street, lakeville MA 02347 200 Nation Ave, Taunton MA 02790 2394 Cranberry Highway, Wareham MA 02571 95-113 Kingman St, Lakeville MA 02347 Town of Mansfield 6 Park Row Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Masfield, MA 02048 Signature: ACORD 25 (2010/05) BRAC 3139