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HomeMy WebLinkAboutBrunelle Contracting LLC - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: JOHN BRUNELLE Doing business as: BRUNELLE CONTRACTING LLC 50 MAPLE STREET MANSFIELD MA 02048 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 : 10 f FEE $100.00 BOARD OF HEALTH .7vlichaecHeaCey, Chairman ,�t to r21 LICENSE NUMBER: APPLICANT: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application /4,(�� BUSINESS NAME: trs MAIL ADDRESS: _50 L`Z, ` CITY/TOWN: STATE: /%%/� ZIP CODE: BUSINESS PHONE: ' "��`�1-YL/ BUSINESS CELL:' BUSINESS FAX: S-00 ' ,2-6�,Vq 9 E-mail: ArU&G//e eo✓* Alt E-mail: 'EDERAL ID/SS NUMBER: ),© 320 7 �) 2— 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: 1---20 —I GI 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) ,�),v --'/ 3 2-v .7 3 2- "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. CAUsers\sleiuADesktop\Scotrs DocumentsTood Establishments- TempWAX CERTIFICATION FORMA= The Commonwealth of Massachusetts Departrttem"ofIndustrial 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: Address:- Z jp 16/1/6 57 - tP- /. L C City/State/Zip: V)9V-P,& 4 Phone #:� "7— Y z07_ 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. El-Restaurant/Bar/Eating Establishment - - 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 7• ❑Office and/or Sales (incl. real estate, auto, etc.) [No workers' comp. insurance required] $• ❑ 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]" 4. ❑ We are a non-profit organization, staffed by volunteers, I LEI Health Care with no employees. [No workers' comp, insurance req.] 12.❑ Other�(�/j Zhy nppbcam mar checks box ar must also tilt out the section below showing their workers' compensation policy information. f 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: t'�/,e c wy_ e1_ /ti 3 N o , 0 ra 4 Al 4PJ2 1,,- 4 Insurer's Address: Pro.. t3j ox J 71 y 6 0 City/State/Zip: PJ hW-,;,t -ao _ P4- t5 2,670 Policy # or Self -ins. Lic. #_ WC- 90d / P1 ) e l % q Expiration Date: �'� t 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 MGLc. 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 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 Cleric 4. Licensing Board 5, Selectmen's Office 6. Other Contact Person: Phone ACORH CERTIFICATE OF LIABILITY INSURANCE `� DATE(MM/DD/YYYY) 1/16/2019 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 endorsement(s). PRODUCER Marsh &McLennan Agency LLC -New England 100 Front St, Ste 800 Worcester MA 01608 CONTACT Thomas O Neill PHONE FAX ! 888-850-9400 ac No:866-795-8016 ADDRESS: MMA.NewEn Iand.CLines marshme.com INSURER(S)AFFORDING COVERAGE NAICIf INSURER A: Selective Insurance Company of America 12572 INSURED BRUNECONTR Brunelle Contracting, LLC R 50 Maple Street INSURER B INSURER C: Mansfield MA 02048 INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 820958828 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. ILTR TYPE OF INSURANCE 102 WVD SUER POLICY NUMBER MMIUDIYYYY MMIOD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR S2021887 7/27/2018 7/27/2019 EACH OCCURRENCE $1,000,000 D G PREMISES Ea occurrence $100,000 MED EXP (Any one person) $10,000 PERSONAL B ADV INJURY $1,000000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑JECT MLOC OTHER: GENERAL AGGREGATE $3,000,000 PRODUCTS - COMP/OP AGO $3,000,000 $ A AUTOMOBILE LIABILITY ANYAUTO OWNED X SHEDULED AAUT030NLV NCTNOWNED AUTOS ONLY AUTOS ONLY A9098706 7/27/2018 7/27/2019 COMBINED SINGLE LIMIT Ea accident $1000.000 BODILY INJURY (Per person) $ BODILY INJURY(Peraccidenn $ PROPERTY DAMAGE Per accident $ A X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE 82021887 727/2018 7/27/2019 EACH OCCURRENCE $3,0DO,000 AGGREGATE $3,000,000 DED I X I RETENTIONS n $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE -- OFFICEWMEMBER EXCLUDED? (Mandatory In NH) If yes, describe undo, DESCRIPTION OF OPERATIONS below N/A WG9024934 3/19/2018- W19/2019 PER OTH. STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE S1,000,ODO E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORO 101, Additional R mark Scharer, a, ba aftachad Hmore apace la 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 Manfield MA 02048 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD