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Home My WebLink AboutGuaranteed Builders & Developers - 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: DUANE HEERDT Doing business as: GUARANTEED BUILDERS & DEVELOPERS, INC. 14 WEST STREET DOUGLAS MA 01516 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: 20 FEE $100.00 BOARD OF HEALTH MichaeCHealey, 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. oJiy ,p P_eC 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\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc T 11e Commonwealth of Massachusetts Pfint Form Department of Industrial Accidents Office of Investigations k1wi I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information II Please Print Leeibly Business/Organization Name: A t t A r a n Le e 4 1 d? r s Address: City/State/Zip: 00 a4 l� (A r) 16 Phone #: S 0 � - q? 6 -) S v D Are yoq an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 40 employees (full and/ 5. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inel. 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. ElManufactoring no employees. [No workers' comp. insurance required]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, re /J g �7 [ with no employees. [No workers' comp. insurance req.] 12. Other (/ / /ems c �t ( bdl'a 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 #1. I am an employer that is providing workers; cogrpensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Vt� City/State/Zip: ' V AJ t I A `J (h A 0 1M) — 6 ASS Policy # or Self -ins. Lie. # LJ& q 0U 5i.31 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. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisorunent, 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,, tinder the pains and penalties ofperjury that lire 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 Person: Phone #: www.mass.gov/dia A`� CERTIFICATE OF LIABILITY INSURANCE DAT3130/2D18 3/30/2018 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. ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 1r 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 Marsh & McLennan Agency LLC 100 Front St, Ste 800 Worcester MA 01608 CONTNAMEACT Cindy L. Care PHONE Arc No Er1) 508-852-8600 ac Not: 866-795-8016 EMAIL ADDREss: _clndy_carey@marshmma.com INSURERS AFFORDINGCOVERAGE NAIC# INSURER A: Graphic Arts Mutual Insurance Company-_25984 INSURED GUARABDILD3 Guaranteed Builders &Developers, Inc. 14 West Street INSURERS: Utica Mutual Insurance Company 25976 INSURERC: — East Douglas MA 01516 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 110g5399 wF%1IQIAu wrnn000. 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, _FA__ INSR LTR TYPE OFINSURANCE SUER POLICY NUMBER POLICYEFF IMMIDDNYWI POUCYEFP fMM1DD/YyYYILIMITS A X COMMERCIAL GENERALLIABILITY CLAIMS -MADE OCCUR CPP4051108 4122018 4122019 EACH OCCURRENCE $1,G00,000 DA A NTE RED PREMISES E NTErence $100,000 — MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $1,000,W0 GENT AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG _ $2,000.000 POLICY E jE [�] LOC $ OTHER: ti.-.. AUTOMOBILE LIABILITY 4051109 4/2/2018 42/2019 COMB ED SINGLE LIMIT Ea accitlent $1 ANY AUTO BODILY INJ URY(per person) .000000 $ OWNEAUTOS ONLY X AUTODULED BODILY INJU RY(Paraccidenp $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY X PROPERTYDAMAGE Per accident $ A X UMBRELLA LIAR OCCUR CULP4051112 1/2/2018 4/22019 EACH OCCURRENCE $8.000,000 AGGREGATE $8,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE /M OFFICEREMBER EXCLUDED? NIA 4045631 4/2/2018 4122019 I.,X PER OTH- STATUTE ER E.L. EACH ACCIDENT $1,0W,W0 E.L. DISEASE - EA EMPLOYEE $1.0W,000 (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $1,000,00D DESCRIPTION OF OPERATIONS below A Equipment Floater Equipment Floater CPP4051108 4/22018 4r22019 Rented/Leased Actual Cash Value $100.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) The certificate holder is included as an additional insured as respects the general liability, if required by written contract for work performed by the named insured. Town of Mansfield, MA 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. 5 ACORD CORPORATION_ All rinhts: ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD b `6/ �d(p4G1NCr ��d ,e a Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: ,' C, APPLICANT: ' - r H A 4- BUSINESS NAME: JJ MAIL ADDRESS: I v r, e, Town of Mansfield 6 Park Row Mansfield, MA 02048 Fr OCT319n Yt 4 CITY/TOWN: STATE: j.. ZIP CODE: 0, BUSINESS PHONE 14--7 BUSINESS CELL: CIV, `dr BUSINESS FAX: 50 147,— 1 E-mail: 4 A Alt E-mail: EDERAL ID/SS NUMBER: i f, is 1 ➢ LICENSE HELD: Town�.;� Year Licensed r.� LICENSE HELD: Town �."c`�s Year Licensed LICENSE HELD: Town 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: qU €t� 10� 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