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HomeMy WebLinkAboutEd Hart Title V Service LLC - 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: ED HART Doing business as: ED HART TITLE V SERVICE LLC 75 ROCKY MEADOW STREET MIDDLEBORO MA 02346 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: 51 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 0 ., Town of Mansfield Town of Mansfield o Bogard of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer LICENSE NUMBER: APPLICANT: BUSINESS NAME: i ��R� _ bC l✓ 5- 9V 1(e_(A c MAIL ADDRESS: -% 0­ r-cJb1,0 S 1 CITY/TOWN: iAA�b�,c �C _ STATE: a "i' ZIP CODE: BUSINESS PHONE: -7 - e 6 BUSINESS CELL: BUSINESS FAX: �'n E-mail: 5 u�2� `{N Cb�AC)�-(A, C COw� Alt E-mail: ID/SS NUMBER: c/ t ® I ,-I 1 C? c( `1 C) LICENSE HELD: Town Year Licensed `JU 11&-A _._. LICENSE HELD: Town A-AOo IJ Year Licensed v ? LICENSE HELD: Town I i TUG 0 Year Licensed _ 0/4- A 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:�� c �� DATE: 3 -cl - 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 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) cK/- HICPN-?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:\Users\sleite\Desktop\Stows DoctnwasWood F.'slablisl nrenls-Temp\TAX CERTIFICATION FORKdoe The Commonwealth of Massachusetts Depm•lntent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ' www.noss.gov/dirt Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: U d C-e L uc— Address: City/State/Zip: (,t Phone #: 7Y(— Are you an employer? Check the appropriate box: Business Type (required): L ❑ 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 forme 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 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 Other *Any applicant that checks box NI must also fill out the section below shoving 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 I. 1 out on employer ilia! is providing workers' compensation insru•(rnce for uty etttl)lwees. Belmv is the policy information. Insurance Company Name: 1-V t2o 6v P(5 T"ee , CQ Insurer's Address: i0 u[ ` - i r"\� cM City/State/Zip: n) �CX F'l.t�-d`•� )LLL.�.- --------- Policy # or Self -ins. Lie. # �;M . ►� cj a-� Expiration Date: 3-- c% — 26 Attach a copy of the wo•icers' compensation policy declaration page (shoving the policy number and expiration (late). 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 tine 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, raider 1he pails and penalties of perjury that the information provided above is trite mid correct. Phone#: 7s[—actq Official use only. Do not write iit this area, to be cmnpleted by city or tmvn ofrcinl. 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/oia A� o CERTIFICATE OF LIABILITY INSURANCE .mImavc.onr O 03/07/2019 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 endorsement(s). PRODUCER CONTACT NAME: Michele Edwards METROWEST INSURANCE AGENCY aCC N Ext: (508) 832-0404 A/C No: E-MAILDss: medwards@neinsure.com INSURERISJAFFORDING COVERAGE NAICN 648 HIGHLAND AVENUE INSURERA: ACE AMERICAN INSURANCE CO 22667 NEEDHAM MA 02494 INSURED INSURER 8 INSURER C: ED HART TITLE V SERVICES LLC INSURER D: INSURER E: 75 ROCKY MEADOW STREET INSURER F: MIDDLEBORO MA 02346 COVERAGES CERTIFICATE NUMBER: 375776 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 rypE OF INSURANCE ADDL D SUBR Won POLICY NUMBER POLICY EFF MM/OD/VYYY) POLICY EXP (MM/DD1YYYYJ LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ CLAIMS-MADE1:1 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ RO- POLICY ❑ PRO- ❑ LOC PRODUCTS - COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident)$ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A RED RE I $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUUVE Y/" OFFICERIMEMBEREXCLUDED9 WA WA WA 6S62UB1 K72069218 11/27/2018 1112712019' X STATUTE 0R" E.L. EACH ACCIDENT $ 1,000,000 — (MandatotyinNH) E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL.DISEASE - POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached It 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 - 1" (� (, S� Daniel M. Croy CPCU, Vice President— Residual Market— WCRIBMA ey, Arnnn os r9A1A/n11 @ 1988-2014 ACORD CORPORATION. All rights reserved. The Arnnn nnma nnri Inn^ arc reniefererl markQ of ArnPn T Ak..-- CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD/YYYY) 317/2019 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 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 riahts to the certificate holder in lieu of such endorsement(sl. PRODUCER NXMIV. ­ Metro West insurance Agency PHONE 648 Highland Avenue (A/C, No, Exq: (781 ) 444-6790 Needham, MA 02494 ADDRIESS, info@nelnsure.C( INSURED Ed Hart Title V Services, LLC 75 Rocky Meadow Street Middleboro, MA 02346 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. INSfl LT TYPE OF INSURANCE ADDL INSD SUBfl OD POLICYNUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD Y LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X CMP9155929 3/9/2D19 3/9/2020 DAMAGE TO RENTED PREMISES_(Ea occurrence) 100,000 $ MED EXP (Any oneperson) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC - PRODUCTS-COMP/OP AGO 2,000,000 $-_ $ OTHER: _AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE _ $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N PER OTH- _ STATUTE __ ER ANY FICERIMEMBEER/EXCLUDED7 ECUTIVE gandstory m NH) N/A EL EACH ACCIDENT $ E. L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield will be additional Insured with respects to services provided by Ed Hart Title V Services, LLC as required by written contract Town of Mansfield 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. TOWN OF FASTI'ON mart] of 19ea1th 136 E:hn Street North Eantoi,, M1V 02356 'Phnna:506-230-0620 COMMONWEALTH OF MASSACHUUSE 7i"TS NUMBER: DWI-19-0031 Board Of Health FEE: $ 100 ( $100-Unibank ) DATE ISSUED: 1/2/2019 ED HART TITLE V SERVICES LLC 75 ROCKYMEADOW ST, MIDDLEBORO, MA, 02346 IS HEREBY GRANTED A DISPOSAL WORKS fiMSTAI-LER PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires 1213112019 unless sooner suspended or revoked. ' a J Timothy Meyers For the Board of Health I PERMIT NUMBER: DWIP19-18 FEE: $150.00 OF AV�� ro z a0 O � 00 �A�9ATED E�0^',�, THE COMMONWEALTH OF MASSACHUSETTS Town of Avon Board of Health 65 East Main Street Avon, MA 02322 508-588-0414 This is to certify that: Ed Hart Title V Service LLC 75 Rocky Meadow Street Middleboro, MA 02346 IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO CONSTRUCT, ALTER, INSTALL or REPAIR, Individual Sewage Disposal Systems. This permit is granted in conformity with the 310 CMR 15.000: The State Environmental Code Title 5. This permit is granted on January 17, 2019 and Expires December 31, 2019 unless sooner suspended or revolted. Kathleen M. Waldron Health Agent � ` m LU r 0 0 2 � I c D . � / § m § )e2 )) kB§ ('o � k 2\\ \} e / \ �({ �� \« }U) q LL 7 § )E/ *, , U) I § § \)$ f� z / §\q E* 0 S `z> Ira 0 - \® ��� z \ ƒE q \ \ > D/ k b ccM § co ; ) LU $ a> @ \d