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Home My WebLink AboutD. Berndt Sanitation & Excavating - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: DONALD BERNDT Doing business as: D. BERNDT SANITATION & EXCAVATING 120 MELODY DRIVE ATTLEBORO MA 02703 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: 14 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman (i�, fQQC�r:cr r,,a Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: APPLICANT: DONALD P. BERNDT BUSINESS NAME: MAIL ADDRESS: Town of Mansfield 6 Park Row Mansfield, MA 02048 CITYITOWN: ATTLEBORO STATE: MA ZIP CODE: 02703 BUSINESS PHONE: 508-222-4963 BUSINESS CELL: 508-930-3760 BUSINESS FAX: 508-226-5448 E-mail: D_aarndtsaait_at.ion_@comcast.net Alt E-mail: IDISSNUMBER: 20-4721814 ss#026-34-8161 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: o �Iq 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE RILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Business/Organization Name:D. BERNDT SANITATION & EXCAVATION Address:120 MELODY DRIVE City/State/Zip:ATTLEBORO, MA 02703 Phone #:508-222-4963 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑✓ I am a employer with 3 employees (full and/ 5. ❑ Retail orpart-time).* 6. F1RestauranUBar/EatingEstablishment 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, SEPTIC SYSTEM INSTALLS with no employees. [No workers' comp. insurance req.] 12.❑ Other ^Any applicant that checks box #1 must also till 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ACE AMERICAN INSURANCE COMPANY Insurer's Address:CHUBB COMMERCIAL LINES, P O BOX 5600 City/State/Zip: HARTFORD, CONNECTICUT 06102 Policy # or Self -ins. Lic. #6S62UB-4854P57-7-18 Expiration Date:9/22/2019 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 Phone #: 508-222-4963 that the 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia From: Tim Gilmore Fax:(765) 987-4329 To: Fax: (608) 226-5448 Page 4 of 161110512018 1:47 PM ACC>Rl' CERTIFICATE Or-�LIABILITY INSURANCE �. DATE(MWOUNYYY) 111052018 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 Wan 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: Ann -Marie Kahancwitx R S GILMORE INSURANCE AGENCY INC PHON o E t. (508) 699-7511 FAX A/C No): ADORI Sea. amkahanowitz&sgilmOre.00m 27 ELM STREET INGURER(D AFFORDING COVERAGE NAIC4 INSURER A: ACE AMERICAN INSURANCE CO 22667 NORTH ATTLEBORO MA 02761 INSURED INSURER B BERNDT DONNA DBA D BERNDT SANITATION INSURER C: INSURER D 120 MELODY DRIVE INSURER E: ATTLEBORO MA 02703 INSURER F: COVERAGES CERTIFICATE NUMBER: 333945 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. WLTR TYPE OF INSURANCE ADO S C EFF POLICY NUMBER MMIDD/YYYY POLICY flMMfDQYYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE MOCCUR EACH OCCURRENCE 5 UAMUL TORE TE PREMISES (Ea occurrence) S MED EXP(Anyone person) S PERSONAL&ADV INJURY S N/A AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT 0 LOC GENERAL AGGREGATE S GENT PRODUCTS - COMP/OP AM S 1 S OTHER AUTOMOBILE LIABILITY COMBINEDSINGL Ea accident' $ BODILY INJURY (Per person) S ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) S HIREDAUTOS NON -OWNED —PROPERTY—DAMAGE iWer accident) S S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE N/A AGGREGATE S DED RETENTIONS y A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE OF KOERM,EMSEREXCLDDED4 NIA NIA (Mandateryln NH) I/ yes, describe under NIA 6S62UB4854P57718 09/222018 09/222019+. PER X STATUTE IER .1 E.L. EACH ACCIDENT S 50Q000 EL.DISEASE-EAEMPLOYEE $ 500,000 DESC RIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be affected R more space is required) Workers' Compensation benefits will be pa Id 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 his 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-compensatiofVinvestigations/. Sole proprietor has not elected coverage. 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 REPRESENTATI VE Mansfield MA 02048 ?,._ Daniel M. CroWley, CPCU, Vice President— Residual Market— WCRIBMA ACORD 25 (2014101) 01988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From: Tim Gilmore Fax: (766) 987-4329 To: Fax: (508) 226-5448 Page 3 of 1611105/2018 1:47 PM DONN&DO-01 AKAHANOWITZ acoRo CERTIFICATE OP LIABILITY INSURANCE °A IE(MMI) 1t/05/2018 018 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 aMEACT R. S. Gilmore Insurance 27 Elm St PHONE (Arc, No, Exq: (500) 699-7511 (AAC, No):(508) 69"597 North Attleboro, MA 02760 INSURER S AFFORDINGCOVERAOE NAICa INSURER A : West American 44393 INSURED INSURER B : INSURER C: Donna & Donald Berndt 120 Melody Drive Attleboro, MA 02703 INSURER O: INSURER 6, INSURER F: COVERAGES CERTIFICATE NLIMII eevlmnu unaae�r.. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NLIPSR TYPE OF INSURANCE ADDL I BD SUBR POLICY NUMBER POLICY SEE POLIMEXP IMMIDI LIMITS A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS -MADE OCCUR X BKW57934030 D810112018 0810112019 DAMAGES REoNTED 100,000 MEDEXP An ene ersanl S 15,000 PERSONAL B ADV INJURY P 1,000,000 GENTAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY 11jpa LOG 2'000,000 PRODUCTS - COMPIOP AGO S OTHER: A AUTOMOBILE LIABILITY ( a MBMbeentSINGLE LIMIT acciANYAUTO $ 1,000,000 BAW57934030 D8101/2018 08101/2019 BODILY INJURY IPer eraon S OWNESDONLY X A�TEOSIREU BODILY INJURY(Per accldenQ S �ry ppNNOpVWyNNEEpp X AUTQS ONLY X AUTOSONIV P'FOaEiEeniQAMAGE S S UMBRELLA LIAR OCCUR EACH OCCURRENCE AGGREGATE S EXCESSUAS CLAIMSMADE DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER EL EACH ACCIDENT S A�N�YIOPROPREIETORIPARTNERIEXECUTNE ❑ (Mantletin a H�EKCLUOEDi NIA J I N If ves. dexOlne Under E.L. DISEASE - EA EMPLOYEE E.L. DISEASEPOLICYLIMITS DESCRIPTION DPTION OF OPERATIONS below T- DESCRIPTION OF OPERATIONS I LOCATIONS J VEHICLES (ACORD 101 Additional Remarks Scheduk, mny beaRached if more svice is re Wired) Town Of Mansfield is named asan Additional Insured under the General Liability when required by written contract. Town of Mansfield Board of Health Six Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. nwr co(avlmvol W1938-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. 4 t Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 026-34-8161 "*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:\Users\sleRe\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc