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HomeMy WebLinkAboutGrant Brothers - 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: LUTHER C. GRANT Doing business as: GRANT BROTHERS P.O. BOX 11 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: 43 FEE $100.00 BOARD OF HEALTH MichaeCblcCCean, Chairman TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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 (Mandatonj, if Applicable) **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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of dndustrial 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: Address: City/State/Zip: C� (�T �C i �� Phone #: S�Z,� — 5� �� - 6, Are you an employer? Check the appropriate box: Business Type (required): 1,❑' 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 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]* 11❑Health Care 4. ❑ unteers. We are a non-profit organization, staffed by vol , { with no employees. [No workers' comp, insurance req.] 12.Q'Other Ly *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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties 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 Phone www.mass.gov/dia ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOONYYY) 12/10/2018 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 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 endorsements . PRODUCER CONTACT Dean C Chadbourne NAME: The Hills Insurance Agency, Inc. MICN u Es) (781) 585 4410 _. _. (A/c , Ne): (781) 585-8011 P.O. Box 157 E- ADMAIL DRESS: dean@hillsia.com _ _ INSURER{S) AFFORDING COVERAGE NAIC q Hlympton MA 02367 INSURERA; NAUTILUS INSURANCE COMPANY INSURED INSURER 5:.SAFETY IND INS CO 33618 Grant Brothers Associates INSURER c : LIBERTY MUTUAL INSURANCE COMPANY 440 Ware St INSURER D: INSURER E : Mansfield MA 02048 INSURER 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. IN SR TYPE OF INSURANCEADOLSUBRI. POLICY EFF POLICY EXP LTR POLICY NUMBER MMIODIYI'YY MMIDO/YYYY LIMITS - COMMERCIAL X. LIABILITY EACH OCCURRENCE I$ 1,000,000 OCCUR MADE OCCUR _. _� { DAMAGE TO RENTED PREMISES LEo «'rune...) { S 100,000 j MED EXP(Any onsperson) $ 5,000 A NN888830 12/23I2017 12/23/2018 PERSONAL&ADV INJURY ;;S 1,000,000 GL�EN L AGGREGATE IIT APPLIES PER - GEENERAGGREGATE $ 2,000,000 PLI X. � POLICY: I. JECT LOG I PRODUCTS-COMP/OPAGG $ 1,000.000 OTHER. S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ 250,000 B OWNED SCHEDULED _'AUTOS ONLY ^ AUTOS 1634257 01/23/2018 01/2312019 BODILY INJURY (PeracadenU$ 500,000 HIRED NON OWNED :, PROPERTY DAMAGE S 100,000 AUTOS ONLY I AUTOS ONLY _ Per accitlenl _ —.. 1 $. 'UMBRELLA LIAR -_' OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE'. AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY YIN __STATUTEER ANY PROPRIETOR PARTNER: EXECUTIVE EL EACH ACCIDENT S 100,000 C OFFICERIMEMBER EXCLUDED? N❑ N/A WC5-31S-340548-057 06/06/2018 06/06/20,9 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE S 100.000 If yes. describe under DESCRIPTION OF OPERATIONS bola, E.L. DISEASE POLICY LIMIT $ 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Town of Norfolk 1 Liberty Lane IBGTiG11' MA 02056 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 ©1988.2015 ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD All riahts reserved. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: 4 / APPLICANT: (��i T<>' BUSINESS NAME: � fl MAIL ADDRESS: CITY/TOWN:` > t l� �'°� STATE: C�ZIP CODE: BUSINESS PHONE: ��� BUSINESS CELL:T- BUSINESS FAX: 7 G' — 7 E-mail: Alt E-mail: FEDERAL ID/SS NUMBER: 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: ;, J 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