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HomeMy WebLinkAboutCraig Equipment Corp. - 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. CRAIG WEINSTEIN Doing business as: CRAIG EQUIPMENT CORP. 35 PILGRIM WAY EAST WALPOLE MA 02032 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: 50 FEE $100.00 BOARD OF HEALTH MichaeCHealey, Chairman 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 ature of Individual or Corporate Name By: Corporate Officer (Mandatonj, If App(cable) gto-d � zJ 01)o ) "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:\Usem\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: _AWLO 2019 CITYITOWN: C 1111 C ( D DSTATE: "A ZIP CODE: BUSINESS PHONE Ak � �I _ G�Q1A11 _�_ II JJ BUSINESS CELL: 121 `1- BUSINESS FAX: E-mail: C Yz r- G✓ e— V p (V GZD� Alt E-mail: CC9-4 ID/SS NUMBER: d Le -' l) d Le D Q 17) LICENSE HELD: Town 0" � I\ \�? b I I — Year Licensed �ip_ _9._3 Cam] LICENSE HELD: Town Year Licensed1_� ,505-3e'I-Svb'a LICENSE HELD: Town 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: DATE: 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: U R'(b � I) Vp ' Address: rdZ oy 1 City/State/Zip: . YA' Ll i kA bz Yhone #: Are you an employer? Check the, ,appropriate box: Business Type (required): 1. E�/I am a employer with employees (full and/ 5. ❑ 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 (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]* 4. ❑ We are a non-profit organization, staffed by volunteers, I L❑ Health Care with no employees. [No workers' comp. insurance req.] 12.aOther Sl4-r- u)o V [!_&X *Any applicant that checks box Hl 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 N 1. I am an employer that is providing workers' compensation ins, urance for my employees. Below is the policy information. Insurance Company Name: MU 4' lam) Insurer's Address: City/State/Zip: k( v—c 1 !, �� k- 1�j Policy # or Self -ins. Lic. #X W 0 6 5 � q 4 /—I l p Expiration Date: I- 1 3 3� 6 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 cerl y, n er the pains and penalties of perjury that Ilse information provided above is true and correct. r7 Signature: 7 17 / ` (� r� / o Date: v / Phone #: �� /` q V Q- / l 0 3 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.mms.gov/dia CERTIFICATE OF LIABILITY INSURANCE oATE1MMIoorrvYY) 01/11/2019 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 endorsements . PRODUCER Pearce Insurance Agency, 670 Pleasant Street Brockton MA 02301 CONTACT J Salkoviiz PxoNE (508) 586-3400 FAxWO M1yd.(508) 586-3700 EMAIL ADDRESSjsalkovitz@bearce.com __.. ..__.INSURER(S) AFFORDING COVERAGE NAIC@__— .Ohio Security Insurance Company JNIUJRRRAINSURED 24198 INSURER B.Ohio Security Insurance Company INSURER C.The Ohio Casualty Insurance Company Craig Equipment Corp INSURER D:The Ohio Casualty Insurance Company 35 Pilgrim Way E East Walpole MA 02032- COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY BKS58499846 1/18/2019 01/18/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE T OCCUR DAMAGE TO RENTED SES-(Eanccurre 300,000 $ 15,000 MED E%P fAn one arson PERSONAL B ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY PRI- LOC ECT GENERAL AGGREGATE $ 2,000,000 GEN'L X PRODUCTS -COMPIOP AGG $_ 2,000,000 $ OTHER A AUTOMOBILE LIABILITY BAS58499846 1/18/2019 01/18/2020 COMBINED SINGLE LIMIT $_ 1,000,000 $ ANY AUTO BODILY INJURY (Per person) BODILY INJURY(Peraccident) $ ALL OWNED X SCHEDULED AUTOS AUTOS X X 1 NON -OWNED HIRED AUTOS (AUTOS j PROPERTY DAMAGE _I Per amidenp___ $ INCL $ A X UMBRELLA LIAR OCCUR US058499846 1/18/2019 01/18/2020 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAR CLAIMS -MADE DE X RE 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNDED? CUTIVE El OFFICERIMEMBER (Mandatory In NH) NIA XWO58499846 1/18/2019 01/18/2020 X PER OTRH- E.L. EACH ACCIDENT 3 1,000,000 E.L DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 If yes, descnbe under DESR O E A Inland Marine BKS58499846 1/18/2019 01/18/2020 Leased/Rented Equip 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sohodula, may be allaohed if more space is ro abed) Town of Mansfield is listed as additional insured when required by written contract in regards to the general liability. CFRTIFICATF Hrll OFR CANCELLATION Al U3/b4U SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA 02048- AUTHORIZED REPRESENTATIVE Fax: ( ) - 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Jane Doucette From: Tara Weinstein <tcwutility@comcast.net> Sent: Monday, March 11, 2019 1:19 PM To: Jane Doucette Subject: Re: Septicjobs Ok. Thank you Sent from my iPhone On Mar 11, 2019, at 1:01 PM, Jane Doucette <Jdoucette(�i),mansfrelduia.com> wrote: I will send this afternoon. From: Tara Weinstein [ma ilto:tcwutil ity(cbcomcast. net] Sent: Monday, March 11, 2019 12:55 PM To: Amy Donovan -Palmer Cc: Jane Doucette Subject: Re: Septic jobs Hi Amy & Jane Just following up about the septic permit. I did not receive it yet. Thanks Tara Craig Equipment Corp Sent from my iPhone On Mar 11, 2019, at 12:11 PM, Amy Donovan -Palmer <adpalmer a mansfieldmaxom> wrote: Hello Tara, Thank you for this information. The Health Department secretary, Jane, will be forwarding you the Disposal Installer's permit momentarily. Amy -----Original Message ----- From: Tara Weinstein[mailto:tcwutility(acomcast.net] Sent: Monday, March 11, 2019 11:21 AM To: Amy Donovan -Palmer Subject: Septic jobs Hi Amy After speaking with Craig and the foreman on the jobs we spoke about I got some more info on the quantity of septic jobs per town. They are as follows: Sharon- 3-4 septic systems installed (so far) Wrentham- 2 septic systems installed Wayland- 2 septic systems installed Dover- 3 septic systems installed As we spoke about earlier Waylann and Dover issue their permits by installer name not company so I do not have letters from them. If you could expedite this that would lie great as the job is waiting on a plumbing inspection. Thanks Tara Craig Equipment Corp Sent from my Whone The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 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