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Home My WebLink AboutEarthworks Industries - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: DEREK FRANKLIN Doing business as: EARTHWORK INDUSTRIES 6 HIGH STREET, UNIT 4 PLAINVILLE MA 02762 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: 18 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, 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. l�l7Ltrr�1L✓, It.1�f� fps Signature of Individual or Corporate Name 59-377 6016 "Social Security No. (Voluntan/) 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. 0Users\s1eite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial 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: P Cn A' bo("A_- -f— � ju (__Uip f T! - , Phone #: (1;60ye —Llyzo Are you an employer? Check the appropriate box: Business Type (required): 1.5� I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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 LEI Health Care with no employees. [No workers' comp. insurance req.] 12.UOtherEY),Vj ✓?-V)0, _C4?' C�h }rl(C *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 the corporation has other employees, a workers' compensation policy is required and such an organization should check box 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:A + I Inv, f "1 L L jl Ct v t-7 Insurer's Address: dS /yl ( Gib L h Cr /d(v7 St" City/State/Zip: I'I'% A O Z Policy # or Self -ins. Lic. # b )) ( � / OJ2 �1 -7.)--] 4 --] Expiration Date: 91I -,> ) I q 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 of the DIA/)'or)insurince coverage verification. I do hereby certiA,'n#4 th f pains 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www,mass.gov/dia Phone #: ACCO o® CERTIFICATE OF LIABILITY INSURANCE DATE 10/18201818120/8 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 pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the tome and conditions of the policy, certain policies may require an ondoreemont A statement on this Certificate does not confer rights to the certificate holder In lieu of such ondorsoment(s . PRODUCER Decoy insurance Agency 631 Main Street East Greenwich RI 02HIN NA Michael T. Dacey PHONE EM: (401)3B8'fl02D AIC No: 1AICNe ADORERS: mikc@daceylnsumnoc.com _ INSURERS) AFFORDING COVERAGE RMCN INSURER A: Westchester Surplus Lines Ins. Co. 10172 INSURED FAnhwork Industries, Inc. Six High Slrecl Unit #4 Plainville MA 02762 INSURER a The Selective Insurance Co. of the Southeast 25658 INSURER C: Atlantic Charter Ins. Co. 44326 INSURER O: NSURERS: 1 INSURER F: . ...�6•cec POOTICIrtATF NUAsaFN• 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WINCH THIS CERTIFICATE MAYBE 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. IN5KUB TYPEOFINSURANCE DIEDVNO POLICY NUMBER MMIO DO UNITS A y( COMMERCIAL GENERAL LIABILITY TCUIMSJAADE ❑X OCCUR "XCU"coverage Y G27595765004 04/26/18 0426/19 EACH OCCURRENCE 6 1,000,000 PREMISES Eo ocavrenro S 50,000 X MED EXP IAny one Petcon) S 5,000 X I "Pollution Liability" PERSONAL B ACV INJURY 6 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY rX PEOT [:]LOC OTHER: GENERAL AGGREGATE 6 2,000,000 PRODUCTS -COMP/OP AOG S 21000,000 S BOWNED AUTOMOBILE LIABILITY PANYAUTO SCHEDULED AUTOSONLY AUTOS AUTOS ONLY X AU70S ONLY Y A9105017.1 01/27/18 01/27/19 LIMIT Ee actlden0 E t,000,000 _ BODILY INJURY(Pat Person) 5 BODILY INJURY IPer aeadan0 6 Per acadenl 6 3 A JX UMBRELLAUAII EXCESSLMB X OCCUR CLAIMS -MADE Y G27595777 OD4 I 04/26/18 04/26/19 EACH OCCURRENCE $ 5,000.000 AGGREGATE $ 5,000,000 DEO I X I RETENTIONS 10,000 S C WORKERS COMPENSATION NDEMPLOYERTUABILITY YIN FRCEReR(EdBE�ARTHEEO ECUTIVE❑ Mandslory In NH) 11�ea daeblPTION DouMd ESCRIOF OPERATIONS W NIA MA certificate alUclled STATIRE ER EL. EACH ACCIDENT E E.L. DISEASE• EA EMPLOYEE S E.L. DISEASE• POLICY LIMIT S A Pollution Liability Y 0527595765 004 04/26/18 04/26/19 Each Occurrence General Aggregate $1.000,000 S1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addillonal Remarks Schedule, may be tractor! If MOM $pace is mqulredi 26 Edgewood Street, Mansfield, MA NOTE: Town of Mansfield is included as "Additional Insured" in regards to the Commercial General Liability, Auto Liability and Umbrella Liability as per written contract. 30 days notice of cancellation applies, except 10 days for non-payment of premium. 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. c/o Dept. of Public Works I AUTHORREOREPRESENTATIVE 6 Park Row Mansfield, MA 02049 Marel,w 5. Darwwj CORPORATION. All rights ACORD 25 (2016103) The ACORO name and logo are registered marks of ACORD 0/19/2018 07:01 AM PDT TO:14013988017 FROM:6174886501 AC a® CERTIFICATE OF LIABILITY INSURANCE Y ISSUING Page: 2 DATE IMM•ODRYYYI 10/1912019 fE HOLDER. THIS 3Y THE POLICIES I(S), AUTHORIZED IMPORTANT: if the cortifcato holder is an ADDITIONAL INSURED, the policy(los) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A siotemont on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 01776- 001 fipRMIAC Dace Insurance Agency, Inc. StreetE�L1i,��I.fo, E.D; bin (401)390.8020631 f�6, No.: (401)398.0017 East Greenwich, nwich, RI 02818 AMOS: INSURER(SI AFFORDING COVERAGE NAICe wsURERA: Atlondc Chartor Insumnco Company VDAC 44326 INSURED Earthwork industries, Inc. INSURER 8: 6 High Street, Unit 4 INSURER C Plainville, MA 02762 INSURER D: INSURER E TYPE OF INSURANCE I'M IN, GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO LOG JECT AUTOMOBILE LIABILITY ANY AVTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED ADIOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS WDE CEO RETENTION E L�L,,'rrIJPJyy�pp�pp��pp@pSp3�EE{{P��FSpp�Cppr��p1p'�NN4EEibp FF A oFFICENMFM1rBER EXGLVOEOECUTNEYN" NIA Wnndcyliiq iin� NNIO 6ftb VICON&OPERATIONSWb POLICY NUMBER WCV00972707 Policy Coverage State: MA (AMboYYYYY) IM11r.1 ooWAI L- POLICY PERIOD TO WHICH THIS ALL THE TERMS. LIMITS EACH OCCUPRENCE S DAMAGE TO PEN IED S PREMISES IE,i occuuwaol LIED EXP(Ar, uro S PERSONAL a ADV IBJURY S GENERAL AGOLLGA I L $ PRODUCTS - COMP OP AGG S COMBINED SINGLE LIVIT S IE.,x-cdpml BODILY IIUUWIIVu l .som S nDDILY ItO11PY IPnr n:<awum S PROPERTY DAMAGE S IPnI nu Aunty 1 LACH OCCUWIFNCE S AGGREGATE S E x iY6S I'llY5 "Lit" 8/1312018 R'13/2019 GL.EACHACCIDEYT S 1,000,000.00 E.L. DISEASE- EA EIAMOYLE S 1,000,000.00 E.L.DISEASE-IIOLCYLII,H S 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AIW4 AC040101, 4d 111enalRpmprb SCh.dub, it more ppa<o In nwun.d) Town of Mansfield. Department of Public Works SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 0 Pork Pow BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY klonsliold, MA 02048 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE rigllls reserve � ACORD 25 (2014!01) The ACORD name and logo are rogistmod marks of ACORD 1900-2014 ACORD CORPORATION. AI CERTIFICATE HOLDER COPY Town of Mansfield Town of Mansfield -Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: Derek Franklin BUSINESS NAME: Earthwork Industries, Inc. MAIL ADDRESS: 6 High St., Unit 4 CITYITOWN: Plainville BUSINESS PHONE: (508)643-4430 BUSINESS FAX: (508)643-4421 STATE: MA ZIP CODE: 02762 BUSINESS CELL: (508)245-7316 E-mail: sales@earthworkindustries.com Alt E-mail: dfranklin@earthworkindustries.com ID/SS NUMBER: 59-377 6016 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed Year Licensed T 2 5 2018 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 61MkiJ_1101:44 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