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HomeMy WebLinkAboutJ. J. Bosse Construction, Co. - 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: JAMES J. BOSSE Doing business as: J.J. BOSSE CONSTRUCTION, CO. 35 CAROLINE ROAD SOUTH EASTON MA 02375 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: 22 FEE $100.00 BOARD OF HEALTH AtchaecHeaCey, Chairman J 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. Z-1 Signature of Individual or Corporate Name ZI By: Corpo(e Officer (Mandatory, if Applicable) 0q-209(as/& "Social Security No. (Voluntanj) 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:Wsem\slelte\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 wwni mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: &3? hone 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]* I I ❑Health [e 4. Elunteers We are a non-profit organization, staffed by vol, ) j with no employees. INo workers' comp. insurance real 12.[� Other ) "�l I (" Q `Any applicant that checks box N I must also fill out the section below showing their workers' compensation policy inform idan. 4*If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organivetion should check box HI. 1 am an employer that is providing workers' colt ensation insurannce fp`r my employees. Below is the policy information. Insurance Company Name:S a i 4 ((i Vi'S l"��(C`Y' l �" it `n Su mkocc L11 _d'Z�(.�, City/State/Zipjk d (_)nA Policy # or Self -ins. Lic. # WC aa,-� 1 ` 11 b a �(i (.Jt{ ( 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 imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby cert y, under the att emid iles of perjury that are information provide above l s true and correct. Si n ture: p C610_1� Dot[e: d Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact waw.mais,gowdm Phone To: J J Bosse Construction Page 3 of 4 2018.10-31 18:00:30 (GMT) 16178018048 From: William Goodrich Ac ab® CERTIFICATE OF LIABILITY INSURANCE� M^1013112040 TIfIS CERTIFICATE Ia ISSUED as A MATTER of INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, 7H1a CERTIFICATE DOES NOT AFFIRMATIVELY OR NEOATEVELY D, EXY'END OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CER71FICAVS OF INSURANCE DUES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INBURER(8), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMIYORTANT; It t O cee0ltaBto holdoT la aH AODIYtONA6.INSURED, Hho pa y(loe) rrEuet ba endorsed. F SUDR TIDN 8 WAIVE au Oat to Iht� terms dltd aOAddiona OT tl9e policy, cO14aIr pnllolae may raqutro an aAtlaraomanf. a statama0t on this est160adta deco not OOdEay Ttphla 0.O rho oail6Ncaw holder m IMH of NucN apldorasmarR(s . PAa0unUR Donna serail wl .L14M L OOOORICH INSURANCE AGE 0 rNC PNa�a e1 ee8.0044 � _ ..__.. NH ._...._............,.._, J J'BOSSE CONSTRUCTION CO INC 35 CAROLINE ROAD SOI1714 E/oSTgN Yft181H TO CERTIFY THAT THE POWCIES OR iNBURANGE LI6TB0 BELOW HAVE BEffN 188UFD TO THE tNOURED NAMED ABOVE PDR THa PO INDICATED. NOY'UtUTHSTANDINO ANY RECUIREEAEtJY, TERM OR CONDITION OP ANY CONTRACT OR OTHER DCCtREI N WITH RE WHICH TO TW I T TO T M$. CEiR71FICAYE MAY 8E 188UED OR MAY PERTAIN, YNE IN3UFNNCE AFFORDED SV YHF. POLIGIP,B DESCRIBEb HEREIN is 81N9.ECi TO ALL Tli6 YERMB. Ex;CLUB10NS AND CONDITIONS OF EUCH PCLICIEB• LIMITS SHOWN MAY NAVE BEEN RECOCEO BY PAID CLAIMS. Tds! � .-.-- TMat1PINSUNANCd P I tuY�ri _..._ LIMITS ._mm CDNMSACW.GE4JEItALL1AelUTY PA 140000RHENCa „ a f oaaln ,1 Mea CAP M,..,vAl. 3 ..._. ..,..,u.._,.._.. NfA PSAODNAI;a AO IN,R)Ry, a—E ARtinallAT�ppUppI�IWT APPLtS$PEN tlEIYRAI.A EMYE 3-...,... PRODUCT&MPI6PAOG INI POLtGY Ja LC� rr AUTOMDRU.EUASIMTV P—� ANY AUTO T- ALL CAKED aptU,HY IV) NfA aomy1Njistyj�awdwll 6 __. pgg AUTO W'" AVNp 6 UMUKUIlAL1ADLj OCCUR CACHDCCURNCNde 6 ..__�. ExilessuAa CLAIMa•MAEj WA _..a. Wnnx1111400WONSAVON —_ri .m A ANa EMpLOURS'LlAs V AµyppaPRImONNAl1YNareaXLUUYfE Yrtt OFFICEPIMEMaaReA46ua6DT wA WA WA WC231831T020040 0410001S S4NEr201g' S.I.EACH PENT ..`._ S 1Of1000 •'""..•.. LMen IVW He$ 91 04SCAM-FACNIPLOY(A 3 100000 E.L. GIUEASE.POI.fCY UAn' 80 ,000 R c eesabe rvArP T NIA De6CRIPYItln OTOPCiWTirNtlLOCAribId9l UUHlt%a9(AOORD Rdmtka SdwdUN,"yWaIgrewd ltrnm epees l®roWlredl Wtnkels' Compensation tionefits will be paid to Massachusetts employees only. pursuant to Endorsement WC 2003 00 6, no auONAiaallon Is given to pay claims for benefits to employees In elates other than MassochusoRa If the insured hkes, of has hired those employees outside of MatMChirsetta, This caNlOeale Of lairannee Shaft les policy In force an the dale that this aONl00ata was Issued (unless the oxpirat on data on the above poiloy plowdes the loom date of this caAlfleate, of Irsuranco). The status of this coverage can be monitored dally by accsssing the proof of Coverage - Coverap Verification Search tool al wawa,mass.govINMAYakOre•oompeneaddnlnuo9llgaUOnsl. u r(1 rrn.:fatO nS/uu&n_ _. r. 8HOULD ANY OF THE ASOW DESCRIBED POLICIES 09 CANQUILLK.4 BEFORE We EXPIRATION DATE THEREOF, NOTICE WILL BE DELNRWED IN Town of Mansfield ACCORDANCE MAIN THE POLICY PROVISIONS. SN Park Row AUTHOnIManWR6%1OITATNe 01 Mansfield MA 02040 'Da G Daniel M, y, GPCU. Vino prastdarit e Rosltlusi M0dtC1-• WGHIt3MA CO 1 -Z014 ACORD CORPORATION. All rights msorved. ACiORD 95 (ZO14101) The ACORD name and (620 am f"ISIOMd mOFRs Of AQUKU TO: J J Bosse Construction Page 4 of 4 2018-10-31 18:00:30 (GMT) 16178018048 From: William Goodrich wbr CERTIFICATE O�eF��� VE" LIABILITY {IYSb ®Y----D973H1 i saiiaE AB A MA'iTER OP INFORNIAYIO@d ONLY AND CONFERS NO RIGISTB UPORMAriVELY ORNEGATRfELV AtY�ND, 6AVEND � ALTER THE COVERAP INSURANCE f�E9 NOT CON5SITUTE A CONTRACT DETL1fEEN THE 19CER, AND TtSE CCJRTIpICATE MOLDER.0 Y is 0R A0 NAL N E0, I a p011cytie0) Pytua9 haYD ADOtTI N utNWcelo lNa LaYma apd CCRdldbNs 04 th0 paUCy, 6artatn p011Cto0 may YogUlYO � IDiHICysBm0h4 A & Dh Williarl L. Goodrich Aamoy, IRC. lOT r l�a•aaaa Np . :� •.w��-w•- 424 Alamo Strout 0102 N WHIRRIERVID APIMRaINO COMAW HMCo MIItOrc MA 02160 INSURERAI Hanbvor lnbutane® Corbpany _ _ 2M2 MEUntiD INSU-M-- - Aftod'COPIMIMPMER „.,,..,...._,..„..__.... 41040 J J BOasa CCn6UUClIM CO., for lusunli Uba Ny LION like Ins. -Ai 10G80 36Oman NOW South Coulon MA 0"76 lnuAmv: ,esmww. 6Ane1.x'M1W.1R 8NV9NIDN NUMRDR[ cvvr:nw�xa ........................—� _ TtX�3 i8 TO CERTIFY iHAT TH6 POLIGE8 OF INbYJRAtJCE LISTEb BELOW HAVE BCBNIEEAJED TOTFW INi :R i NAMEDABOVEFbri THE POIICV pEPoOD ItIOICATED, NOTMIISTANDWG ANY RCCUlAgNi TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT To WHIGHTHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE APFORWD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OP SUCH POLICIES. LIMITS SHOVr6V MAY HAVE VERN REDUCED BY PAID CLAIMS. :. TME�INOUNANCO IFfSB Ph'D .._ P MOEfl UNrls A aOxNORCSAL BEN®RALUABiLRY CLAW9UJAOE OGCVA ZHNC4261b207 00JO0t20I0 Commit EACH OCCURRENCE 6 9,ODD,000 p e�DeXP „_y,na�a wrea��W�,i 2 IDD,000 9C0.0D0 _ PER00NAJ.AaQVIN RY 4 1.000,000 dEHLAGi LpIMpB APPLIES PEAR poucY®dEC LOc IIER GENE .L A0C iE0ATE s 2,. Sw PROD=S•C.OW WAdo C 2,Wb,D06 OvNI@r$Or LO$9SSB � d AUTONOSILCUAINLMV AApNNyYYtNM�pIYO AUIoa ONLY x WIMOOULEO :X off p I 0 ONLY X AUiry OSO GAILY AM0107264 O000U12f19B tl6/G6{2018 d s 1,010,000 IMWXLY INJURY tPHpHtl4R) 0 EM)OILYINIUWY (Pwauldney --, b E F a U tRELLA li EXCESS UAD 0ODBA CIAB,9C*MAOE P-ACH�CUNNENCE EDATS a BED RETENTION S.— O Y us ANOEMKOVERVUAUU1TY AN PROPRIETOP IANIM840 4VTIVe YI"°�i OF7+10HINE��@�sq eWAMOP 1_J IMaAEC10r}Ilo NNI MOR of . OPERATIQNEdalra WA TO hO ISsuetl blredry by C,tvdor _ _ _ .__ _. __w..,,.. E 6 E.L. 0150PSE •EAEMPLOYEE ELon 5 .POUCYU T ,,._�,_•®„�, OEaCItIP1rON OP OPEMri0N01lOPATiONOi VENIOLOs lAbOim 9b1, AdWiWEmlRomaMo 9cAWtANe,moy tva anagm4 U Rwroap�ce 10 requlro9l Town of Ma"Weld ft Park Row Mbns9low ACORD 26 120161031 SHOULD ANY OFTHE AHOYE DESCRIBED POLICIES 90 CANCELLED WFORE TUG EXPIRATION DAYS THEREOF, NOTICE WILL BE DEUVEREI IN ACCORDANCE WITH Ti1E POLICY PROVISIONS. Tho eRD ruatio and loi MOIS14rod Mri of ADONIS Town of Mansfield '€ wri (�f Mansfield- Board Health 6 Park Row Mansfield, MA 02048 Disposal Works hisfalter LICENSE NUMBER: APPLICANT: BUSINESS NAME: 2y 4JC)J�7�`- l� MAIL ADDRESS: )�� C .0 r©I � n CITY,rrOWN: 1 STATE: MA- ZIP CODDEE0033/� J�Q BUSINESS P . J�"�t() y �n�� BUSINESS CELL: -0310 _3to 7 U BUSINESS FAX:=32-2/'�/ f3 Y1 y E-mail: CJt?®i CL.CC',n 1 �T Alt E-mail: ID/SS NUMBER: 0 4 - 3,Qq 6E I b LICENSE HELD: Town _Inij Year Licensed a ®j LICENSE HELD: Town 1FI Year Licensed 00 1 Q LICENSE HELD: Town T�k + U Do n Year Licensed a o r,/ 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: a inn nn SIGN, DATI 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