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HomeMy WebLinkAboutCryan Landscape Contractors, 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 l This is to certify that: DAVID FLYNN Doing business as: CRYAN LANDSCAPE CONTRACTORS, INC. 41 WALTON STREET ATTLEBORO MA 02703 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 : 49 FEE $100.00 BOARD OF HEALTH MichaecHeaCey, Chairman f 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. 61Jrr,t lit(; , 1..1 _. - Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Of ' r (Mangy, datory, if Applicable)F *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 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application" ACT13 _�di. LICENSE NUMBER: y APPLICANT: "—DGi.V LJ BUSINESS NAME: MAIL ADDRESS: � �l_ (�4LtM1 __S � ` CITY/TOWN: - I� V� STATE: M-4- . ZIP CODE: BUSINESSPHONE: (p_3 BUSINESS CELL: BUSINESS FAX: E-mail: Alt E-mail: 77b..1:III 141: OMI dM LICENSE HELD: Town T� C �adN Wl Year Licensed LICENSE HELD: Town Year Licensed _d0 F Z_ sct6 1t, MlV Year Licensed LICENSE HELD: Town _ rv}ter 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: 10IS�_ 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 Coinnionwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N Address: Phone #: Soy 3J(03 Are you an employer? Check the appropriate box: Business Type (required): l T I am a employer with 35' employees (full and/ 5. ❑ Retail or part-time),* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no T ❑ 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 c, 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 1 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance re( 12.(X' Other CK(q 64 471.1 �[_, ,r Ip j_osa '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 die corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is pro vidbW workers' canpensatioa,insnrance for my emptoy¢es_Betoty iy the policy information. Insurance Company Name:_ il. Insurer's Address: , ((,�_:S: R f Ue r S t W r I i CS ` &IzaC Pl+ -70 City/State/Zip: Policy # or Self -ins, Lie. # /0 y3S 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I rto hereby certify, undA the ofperjury that fire information provided above is true and correct. Offrcial use only. Do trot 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 Off -lee 6. Other Contact www.mass.gov/dia Phone ACORhis CERTIFICATE OF LIABILITY INSURANCE 1%, DATENAM/oOnYYY) 10/31/2018 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 endomement(s). PRODUCER ACT NAME: Loretta Brown FBINSURE LLC PHONE. E (508) 824-8666 AIC No: Ws: loretta@fbinsure.com INSURERS AFFORDING COVERAGE NAIC p 128 DEAN ST INSURERA: AMGUARD INSURANCE CO 42390 TAUNTON MA 02780 INSURED INSURER B : INSURER C: CRYAN LANDSCAPE CONTRACTORS INC INSURER D : INSURER E: 41 WALTON STREET 1 INSURER F: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 332275 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 TVPEOFINSURANCE AINSD DDLSUBR Won POLICYNUMBER MMIDDIYEYYY MMDDIIYLICY YYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PftEMiSE$ Ea occurrence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ N/A AGGREGATE LIMIT APPLIES PE R: GENERAL AGGREGATE $ GEN'L PRO LOC POLICY JECT PRODUCTS - COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A PROPERTY DAMAGE (Per accident) $ NON -OWNED HIRED AUTOS AUTOS _ _ $ UMBRELLA LIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A RETENTION $ $ --TIED A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) NIA NIA R2WC967357 09/15/2018 09/15/2019 X PER OERH — — EL EACH ACCIDENT $ 1,000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tot, Additional Remarks Schedule, may be attached if more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 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 ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Crowley, CPCU, Vice President — Residual Market — WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Jane Doucette From: Dave Flynn <Dave@cryanlandscape.com> Sent: Friday, November 02, 2018 6:02 AM To: Jane Doucette Subject: FW: WC Cart for Town of Mansfield Attachments: certificate.pdf Good morning, I dropped of an application for septic installers license the other day. I did not have a copy of our workers comp cert with me. It is attached here. Please let me know if you need anything else. Thank you for your consideration. Regards, Dave Flynn Site Construction Manager CRYAN LANDSCAPE CONTRACTORSINC u :x!.ie wmteaiera necexuau��: Cryan Landscape Contractors Inc. www.cryanlandscape.com www.cryanlandscape.com/site-services/ From: Cryan Landscape Accounting <Account@cryanlandscape.com> Sent: Thursday, November 1, 2018 3:10 PM To: Dave Flynn <Dave@cryanlandscape.com> Subject: FW: WC Cert for Town of Mansfield Thank you, Diana Gomez Accounting Assistant LANDSCAPE CpNTt?AGTQR MG 41 Walton Street Attleboro, MA 02703 508-226-3363 508 399-8809 (f) Like us on Facebook www.cryaniandscape.com 1 From: Loretta L. Brown <loretta@fbinsure.com? , Sent: Wednesday, October 31, 2018 1:53 PM To: Cryan Landscape Accounting <Account@cryanlandscape.com> Subject: WC Cert for Town of Mansfield Here's Mansfield Diana. Please don't hesitate to contact me if you require anything further. Thank you, and have a great day. insure', "• � buyarrd kis.iraK7. dnSurvK). ow Loretta L. Brown Certificate Specialist 508-824-8666 p 800-734-6604 t 508-880-0142 f This electronic message and any attachment is intended only for the use of the individual (s) or entity named above and may contain information which is legally privileged, proprietary, and/or confidential. If you are not the intended recipient, be aware that any disclosure, copying, distribution, dissemination or use of the contents of this message is strictly prohibited. If you have received this message in error, please notify the sender immediately by email and permanently delete the original copy, any additional copies, and any printouts.