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Home My WebLink AboutJ. Hockman, 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: JASON HOCKMAN Doing business as: J. HOCKMAN, INC. 11 SHERWOOD DRIVE MA 02056 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: 21 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. �i 06CkMA A) In Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) oy3y9CtSea "*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 a Department oflndustrialAccidents E I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ApnlicantInformation Please Print Legibly Business/Organization Name: J HOCKMAN INC Address: 11 SHERWOOD DRIVE City/State/Zip: NORFOLK Phone #:508-384-1400 Are you an employer? Check the appropriate box: 1. 0 I am a employer with 14 employees (full and/ or parmime).* 2. ❑ I am.a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their.right of exemption per c."152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We arc anon -profit organization, staffed by volunteers, with no emnlovees. fNo workers' comm insurance rea.l Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I L E] Health Care 12.0 Other SEPTIC & EXCAVATING CO *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 Comuanv Name: HOLLIS INSURANCE AGENCY Insurer's Address: 140 MARION ROAD City/State/Zip: WAREHAM, MA 02571 Policy # or Self -ins. Lic. # 4219101 Expiration Date:6/20/2019 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 a, pdWepaides of perjury that the information provided above is true and correct. VVV-VV?-1-tVV Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # .. 4 � 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 UTICA NATIONAL INSURANCE GROUP WC 000001A 180 GerleS�e Stroll New Hartford, NY 13413 ante Company ATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: 4219101 Information Page Prior Policy Number: 1. The Insured and Mailing Address: J. HOCKMAN, INC. Producer: C.L. Hollis Ins Agency C/O GL HOLLIS INSURANCE 140 Marion Road 140 MARION ROAD -' MA 02571 " Wareham, MA 02571 WAREHAM Producer Number: 70102 Entity of insured: 'Cos;�o'ah; SIC#: 1711 Other workplaces not shown above: NCCI Company Number: 15717 Insured's I.D. Number: 043496500 Risk I.D. Number: MA:000409854 2. The policy period is from 06/26/2018 to 06/26/2019 - _.12:01 AM Standard Time at the insured's mailing address. pe: Part One of the policy applies to the Workers Compensation Law of the states 3, A. Workers Comensation Insuranc listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Each Accident Bodily Injury by Accident $1,000,000 policy Limit Bodily Injury by Disease $1,000,000 Each Employee Bodily Injury by C. Other States Insurance: Part Three of the policy applies to thg states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, Wy - D. This policy includes these endorsements and schedules: 4. The premium for this policy will bedetermined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by Premium Basis Rate Per $100 Estimated Annual Code Total est. Annual Of Premium See Extension of Information Page No. Remuneration Remuneration Classifications Minimum Premium: $ 460MA '- Employer's Liab Minimum Premium: $ If indicated below, interim adjustments of premium shall be made: Expense Constant $ Total Estimated Annual Premium $ Deposit Premium $ NY 13413 Date of Issue: 06-20-2018 Countersigned by Issuing office: New Hartford, Copyright 1988 National Council of Compensation Insurance 8-D-WC Ed. 08-2008 BILLING NO. 100948457 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield. MA 02048 Disposal Works Installer LICENSE NUMBER: APPLICANT: J AJ6 /V tloCILVPIH'W W R L BUSINESS NAME: _� MAIL ADDRESS: r I S e� lQ)O0 d CITYITOWN: 1 / cj e I V L-k _ STATE: ZIP CODE: 5p�� BUSINESS PHONE: �3 6 BUSINE SS CELL: _�U BUSINESS FAX: 57�� —� U y — 00 oy19 E-mail: lnl YL,- t l (�r. OPM Alt E-mail: ! �,} H C� P LGG� 'EDERAL ID/SS NUMBER: D 3 J LICENSE HELD: Town ._ L.Do I Year Licensed Oi e LICENSE HELD: Town 1 V ni-y %'� Year Licensed LICENSE HELD: Town U)f- On -f(i" Year Licensed :�2eo 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: ------ 1. �� 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