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Home My WebLink AboutMoreshead Excavating - 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: WILLIAM MORESHEAD Doing business as: JOSEPH F. MORESHEAD DBA MORESHEAD EXCAVATING 250 MANSFIELD AVENUE, UNIT #79 NORTON MA 02766 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: 40 FEE $100.00 BOARD OF HEALTH .rtichaeCHeaCey, 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. J i �� J� v✓T du'/ /Y, Gi li fl f�ii Too" d91C+' , l J �' 'CwG.�✓ Signature of Individual or Corporate N By: 4rporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntanj) or Federal Identtfication 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:\Uscm\sleite\Desktop\Scoffs Dacuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.massgov/din Workers' Compensation Insurance Affidavit: General Businesses Aoolicant Information Please Print Leaibl Business/Organization Name:_ `�,( ('t,�h_XGc cthC�Inc-, Address: I sn Uwe~ on'c -74 Phone #: % 7 `' " � Cx) Are Are u an employer? Check the appropriate box: Business Type (required): 1. am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ElI am a sole proprietor or partnership and have no y, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. S• ❑ 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]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers , with no employees. [No workers' comp. insurance req.] 12.0 Other -Any applicant that checks box #I 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: p�. Q< G�>( t-i Q City/State/Zip: vtt�n5�ie-{c� / 1144, Policy # or Self -ins. Lic. # �C S' 3 V S G �� -> _ 4 Expiration Date: dl 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. u Phone #: 77 L� - _z 9� - 78 3L--> Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License �ri11� 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 www.mass.gov/dia `� H CERTIFICATE OF LIABILITY INSURANCE DA03/14/2019 ) 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; Mark. Souza Insurance Connection Agency, Inc. P.O. Box 401 Mansfield, MA 02048 PAHICNE a, Fall, 508-386-2291 A/c No): 508-386-2298 E-MAIL ADDRESS: PRODUCER CUSTOMER ID 9- INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Nautilus Insurance Co. JF Moreshead Excavating, Inc. 250 Mansfield Avenue, Unit # 79 Norton, MA 02048 INSURER B: Liberty Mutual Insurance Co. INSURER C INSURER D INSURER E : INSURER F : 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, INSR LTR TYPE OF INSURANCE ADOL INSR SUER MD POLICY NUMBER POLICY EFF MMIDDIYYI'Y POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR "�' NC329299 12/09/2018 12/09/2019 EACHOCCURRENCE $ 1000,000 PREMISES Eaccwrmnce 8 ion ono MED EXP(Any one person) $ 5000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECTLOC PRODUCTS - COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NONOWNEO AUTOS COMBINED SINGLE LIMIT (Ea accidenq $ BODILY INJURY (Par parson) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE (Par acadent) $ $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS-MADEr I � F EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANY PROPRIETOWPARTNEMEXECUTIVE OFFICERIMEMBER EXCLUDED9 [flNIA If In NH) fIf yes, describe under C, WC5-31S-620830-019 02/23/2019 02123/2020r __...TORY X MS TATU- GETS E.L. EACH ACCIDENT $ 100000 E.L. DISEASE -EA EMPLOYE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of Mansfield ( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 6 Park Row POLICY PROVISIONS. Mansfield, MA 02048 e _ "' reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application -- --� LICENSE NUMBER: GIN 51? VW s � S ` APPLICANT: V� ill it° �1 l�J`t��C� BUSINESS NAME: l MAIL ADDRESS: o\,fe—° U R i i- -%`T CITYITOWN: C )� STATE: M,I ZIPCODE: 0;�7i� BUSINESS PHONE: BUSINESS CELL: �O'-t`C�k-AC7 ?167,� BUSINESS FAX: � E-mail: 11nfiYaiatn�,.;Y,='a,�%4�i; CA�FY7(fi,(1c'�{' Alt E-mail: ERAL IDISS NUMBER: LICENSE HELD: Town /cYear Licensed J ,� LICENSE HELD: Town Year Licensed LICENSE HELD: Town '% 4 f u/ Year Licensed D i 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: L7f DATE: 2 - .1 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