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HomeMy WebLinkAboutDick Morse Excavating, 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 This is to certify that: DICK MORSE Doing business as: DICK MORSE EXCAVATING, INC. 351 MOUNTAIN STREET SHARON MA 02067 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: 17 FEE $100.00 BOARD OF HEALTH NichaeCHeaCey, 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. Dick Morse Excavating, Inc. Signature of Individual or Corporate Name Fed. I.D. 04-3515477 "Social Security No. (Voluntanj) or Federal Identification Number Du 4Wyy_1_1 By: Corporate Officer (Mandatory, if Applicable) *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\ScoWs Documents\Food EsWisbments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf tvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Dick Morse Excavating, Inc. Address: 351 Mountain Street City/State/Zip: Sharon, MA 02067 Phone #: 781-784=-3136 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 4 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. 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]* I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.® Other Installer Disposal Works *Any applicant that checks box It 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: See Attached Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: 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. I S2 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 WORIZ 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 the pains and penalties ofperjnry that the information provided above is true and correct. /�` "' Sumature: Date: I(-1)kAk16 Phone #: 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 Phone #: www.mass.gov/dia ``CCARCERTIFICATE OF LIABILITY INSURANCE D) /26 10/26/2018018 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 endorsement(s). PRODUCER Eastern Insurance Group LLC 233 West Central St CONTACT Select Dept. PHONE (800)333-7234 X66807 lac o:781-586-9244 E-MAIL DS_selectwork@easterninsurance.com INSURER(S) AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERA:Trav Ind of CT 25682 INSURED INSURERS ,Travelers Cas & SuretY of IL 19046 Dick Morse Excavating, Inc. INSURER Travelers Indemnity Co 25658 D.M. Equipment Inc. INSURERD:Wesco Insurance Company 5011 351 Mountain Street Sharon MA 02067 INSURER E: _ INSURER F: GOVEKAGEJ UEKIIFICATENUMBER:I1:1-19 CERT 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 AO LSUBR POLICYNUMBER POLICY EFF fMM/.DIfYTYI, POLICY EXP IMMIODrYYYY)LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 6806671P535 /3/2018 /3/2019 DAMAGETO RENTED PREMISES Ea occunence $ 300,000 MED EXPAny oneperson) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 2,000,600 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT ( 11000,000 BODILY INJURY (Per pereon) $ B ANY AUTO ALLOWNED SCHEDULED X AUTOS AUTOTOS S 698SP956 /3/2018 /3/2019 BODILY INJURY (Peramldent) $ X HIREDAUXAUTOS NON'S"ED r PROPERTY DAMAGE Perawident $ $ 1 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 11000,000 `. EXCESS LIAB CLAIMS -MADE DEC I I RETENTION IS UP6673P565 /3/2018 /3/2019 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORPARTNEREXECUTIVE (Mandatory In NH) CLUDED? Xyes,RIPTION order NIA C3344604 /2'1/2018 /27/2019- X WC STATU- OTH- E.L. EACH ACCIDENT $ 500 000 E.L. DISEASE -EA EMPLOYE $ SOO OOO E.L. DISEASE -POLICY LIMIT $ SOO OOO DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additianal Remarks Schedule, it more .,.On Ia required) CERTIFICATE HOLDER CANCFI I ATInN 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. Building Dept AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 02048 John Koegel/KH3 C= ACORD 25 (2010105) INSn25 nn,nncl m ©1988.2010 ACORD CORPORATION. All rights reserved. Tho mu.Irc of Arnan 2019/04/09 09:41 :53 2 /2 .I l* O' CERTIFICATE OF LIABILITY INSURANCE ..-�'� OATS (MMIDDIYYYY) 4 /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(les) 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 Eastern Insurance Group LLC 233 West Central St Natick MA 01760 CONTACT NAME: Select Dept. PHDNE� BI: (800) 333-7234 X66807 FAXNo:Tel-5e6-e249 E'MA .selectwork@easterninsurance.com INSURER(S) AFFORDING COVERAGE NATO# INSURERA:Trav Ind of CT 25682 INSURED Dick Morse Excavating, Inc. D.M.-Equipment Inc, 351 Mountain Street Sharon MA 02067 INSURER B:Travelers Cas & Surety of IL 19046 INSURER C:Travelers Indemnity Co 256SS RERD:Weoco Insurance Company 5011 !ms NSURERE: INSURERF: COVERAGES CERTIFICATE NUMBERNASTER 19-20 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTft TYPE OF INSURANCE ADM INSIRWVDPOLICY SUSR NUMBER POLICYEFF MMIDDIYYYY POLICY E%P MMIDDIYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMFRCWL GENERAL LIABILITY ­DAlAPREMISES Ea occuvnce $ 300,000 A. CLAIMS-AADE oOCCUR 6806671P535 /3/2019 /3/2020 MED E%P We one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY ..ERCT TOG $ AUTOMOBILE LIABILITY MBINED Ea ..,dent GINGLE LIMIT 1.000.000 BODILY INJURY (Per person) $ B ANY AUTO ALL OMEO X SCHEDULED 8M783722 /3/2019 /3/2020 BODILY INJURY (Per accoorl) $ X HIREDAUTOS X AUTOAUTOS NON-0NNED-PROPERTY Pr,.r dent AMAGE $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 `. EXCESS LIAR CLAIMS MADE CEO PETENTIONUi $ OP6673P565 /3/2019 /3/2020 WORKERS COMPENSATION AC STATU- OTH- X TORY LIMITS ANDEMPLOYERS'LIABILITY YIN EL EACH ACCIDENT $ 500,000 ANY PROPRIETORIPARTNERIETECUTIVE D OFFICERIMEMBER EXCLUDED? N (Mandatory in NH) N/A 3344604 /27/2018 ': J27 /219 0 E.L. DISEASE - EA EMPLOYE $ 500 000 Ifge, descrW under DESCRIPTION OF OPERATIONS below /27/2019;: /27/2020 EL.DISEASE - POLICY LIMIT $ 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Aeach ACORD TOM, Additional Remarks Schedule, if mom space Is required) Town of Mansfield Building Dept 6 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. AUTHORIZED REPRESENTATIVE Koegel/PKG--� e01988-2010 ACORD CORPORATION. All table reserved. INS025 (201005101 The A(.ORn names and Inns am rani.tDm i mark. of ACORn Town of Mansfield Town of Mansfield v Board of Health 6 Park Row Mansfield, MA02048 Disposal Works installer Application LICENSE NUMBER: APPLICANT: Dick Morse BUSINESS NAME: Dick Morse Excayatl MAIL ADDRESS: 351 Mountain Street CITYITOwN: Sharon BUSINESS PHONE: 781-784-3136 BUSINESS FAX: E-mail: Alt E-mail: , Inc. STATE: MA ZIP CODE: 02067 BUSINESS CELL: 781-784-7176 dickmorseexcavating @gmail.com ID/SS NUMBER: 04-3515477 LICENSE HELD: Town of Sharon LICENSE HELD: Town of Foxboro Year Licensed 1985 Year Licensed 1987 LICENSE HELD: Town of Stoughton Year Licensed 1987 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: a h� 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