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HomeMy WebLinkAboutL & L Heating - 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 RAYMOND E. LOGAN, JR. Doing business as: L&L HEATING 1011 HILLSIDE AVENUE ATTLEBORO MA 02703 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: 26 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, 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. %6ature of Indi44ual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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:\Usem\sleite\Desktop\ScotCs 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 U1V§1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / Please Print Legibly Business/Organization Name: 7•-/ z'� n � Address: % r / / /J" 1(,_, f , h � City/State/Zip: C'� �' Phone #: �'� Are yo employer? Check the appropriate box: Business Type (required): 1. ff 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers' comp. insurance req.] 12. ' Cher ate/e" *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 Hl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:' Insurer's Address: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pn rind penalties of perjury that the information provided above is true and correct. Signature: Date: elrf/-fG Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mws.gov/dia Phone #: AC R RAYMLOG-01 _ ICARREI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,- � GCluucafe nolaer Is an ADDITIONAL INSURED, the pol BRO If SUGATION IS WAIVED, subject to the terms and conditions of the this certificate does not confer rights to the certificate holder in Ilea of such PRODUCER 1 W Lapointe Jr Ins Agency, Inc -all River, MA 02723 INSURED Raymond Logan DBA L & L Plumbing & Heating 1011 Hillside Ave Attleboro, MA 02703 must have ADDITIONAL INSURED provisions or be endorsed. certain policies may require an endorsement. A statement on nnent(s), NAME:_- ....__.._-. PHONE g _JA/c No ex:. (508) 678.8341 (AAlc, No) (508)_678-0438 EMAIL _ADDRESS INSURER($)_ AFEORDJNG COVERAGE, NAIC II _ NsuRERA;Travelers Casualty Insurance Co of America 19046 INSURER B: - INSURER C : -- INSURER D:.__.._ INSURERE - __ _ _ ncvrolVry rvUiVItlCK: _ "-HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVv11 HS1"ANDING ANY REOIAREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, HIF INSORANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT rOALL THE TERMS, EXCLUSIONS AND CONDCHON6 01 SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN _REDUCED BY PAID CLAIMSRI AODL SUUR---- _-"— - _ B_ TYPE OF INSURANCE POLICY EFF POHCY E%P- ---�-- .__._____- POLICY NUMBER / LYYYY) IMM/17P/YYVY _LIMITS X COMMERCIAL GENERAL LIABILITY -- _ _I CLAIMS MADE X OCCIII: LA(H OGC(IRRFNCL $ 101,000 I _I X �6804A644596 08/23/2018 08/23/2019 PiMM hsOILacyEr ppca)_ $ 300,000 -__.. ._._.—....- MEO EXP (Any one persun)_ $ 5,000 -- PERSONAL & ADV INJURY $ 500,000 I GFNLA('G[iLOArr tIMITAPPI.IFSPFR'. GENERAL AGGREGA LE 11000,000 _l i POUCY JLCOT I 1 LOC -- $ _�_�)rurle — 1,000,000 - PRODUCTS COMPIOP AOG $ AUTOMOBILE - LIABILITY kiD SINGLE LIMIT - '-- ANY AUTO Id 0 _ $___-- �OVJNEU SCHH)ULED INJURY persgnj $ A11T05 ONLY AUTOS -. H112CD NON-< yyNE) A 1OS )NIY 8N&� INJ(1RY {I or accigent) -,IYpAMACF $ _ M1T0 Nn I) - UMBRELLA Llqe1 O6( UR---E%GCBs LIAR CI AIMS MADE CCURRLNCEGATE10N$ FDISU�E AND RERSCO RS' LI ATIONILIT EOPRIETRS'LIATNERT Y(N TI —AND A'rU ANY PERIMEMSERIPARTNEIe Lt� 1. D?SCUT{VF aorylnNH{ F%CLUOBD? _.....I N/A H ACCIDENT yea, describe antler EASE EA EMPLOYEE $ -- DESCRIPTION b.If..r. _..._._..-1— DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Atltlitlonal Romarka Schotlulo, may bo altachod if more apar.o Is requlredl Town of Mansfield 6 Park Row Mansfield, MA 02048 314OULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AV inonictu REPRESEENTAAgTIVE ACORD 25 (2016/03) ------- ----------- © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered (narks of ACORD acoizu® CERTIFI^CATE� OFL,ABILITY INSURANCE DATE(mmmwyyyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 09/05/2018 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, I 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 nndnrsnmc, nisi PRODUCER CONTACT Isabel Carrelro HERMAN W LAPOINTE JR INSURANCE AGENCY INC -NAME PHONE FAX _tactic ExU _(508) 678 8341 (Arc,, Nod _ icarrelro@lapolnteins com 1777 PLEASANT ST _ABOREss. —- FALL RIVER INSURERLS1 AFFORDING COVERAGE NAIC If MA 02723 INSURER A ACE AMERICAN INSURANCE CO INSURED -- _... 22667 LOGAN RAYMOND DBA L & L PLUMBING AND HEATING INSURER B - — wSURERc: INSURER D 1011 HILLSIDE AVE ATTLEBOROM - INSURER E :: 2703 INSURER F COVFRArFS KLVISION NUMBER: THIS IS TO CERTIFY 'IIIAT 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 CONI'RACIOR OTHER DOCUMENT WITH RESPECT '1"0 WHICLI Tills CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY iI E 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 _... __. __.__ _.. ___ POLICYEFF POLGYEXP -- -'-'-----'___-'- LTR' I TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DDNYYY LIMITS !' occult --�— — COMMERCIAL GENERAL LIABILITY DL SUBpRyI, -1 EACH OCCURRENCE $ CLAIMS -MADE DAMAGE-O RENTEIJ "'---_-''-- PREMISES.( Ca occurrence) $ '- -- -- MED EXP(Ao one arson $ -__ _ Y person) )_.- --' -- -- - /A PERSONAL & ADV INJURY $ �ENL AGGREGATE LIMIT APPLIES PER'. GLNCRAL.A( GREGATE $ - POLICY I ....1 JECT LI LOC - --..._ PNODUC IS COMPIOP AGO $ OTHER _._... _ g AUTOMOBILE LIABILITY COMBINED SINGI F LIMIT ... _ ANY ALI ALL OWWNENW SCHEDULED D BODILY INJURY (Per person) $ - AU r05 A1/T05 N/A BODILY INJURY (Per accident) $ IAUTOS IIRED ALTOS NON-OVJNED _ AUTOS PROPC1iTY DAMAGE "— L r accNenl) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR- ------ CLAIMS -MADE N/A AGGREGATE $ DED RETEN rION$ $' AND EMPLOYERS' YERS'LIABILITY ILIT PER OTH- gNUEMPLOYER$'LIABILITY YIN ^ SrA_IU'[E ER ANYPROPRIEI'ORIPARTNF.R/EXECUIIVF. ---" -_-- A OPFICERIMEMBEREXCLUDED9 N/A) NIA NIA 6S62UB4579P92018 03/24/2018 03/24/2019 EL EACHACCIDENr $ 500,000 Titled story in NNI _-_"... ..__- II yes, describe under E1.. DISEASE' - EA EMPLOVEG $ 500,000 .__- _.. ...___..-' ___.._ U F.SCItIPTION OF OPERATIONS below _E L DISEASE POLICY LIMIT $ 500,000 I — N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES tACORD 101, Additional Remarks Sch rud e, may bo attached It Face) spa co is required) Workers' Compensation benefits will be paid to Massachusetts ompioyeos only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay Claims for benefits to employees in slates other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the dale that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certifiCi le of insurance. The Status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at wwwmass. govllwd/workers-Compensation/investigations/. LOGAN RAYMOND has elected coverage. CERTIFICATP Wrll rIOD _...J__. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. CrpW�ey, CPCU, Vice President - Residual Markel - WCRIBMA © 1988.2014 ACORD CORPORATION. All rights raservnH ••- -- t-� --� 1 I ne Hwrcu name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. CrpW�ey, CPCU, Vice President - Residual Markel - WCRIBMA © 1988.2014 ACORD CORPORATION. All rights raservnH ••- -- t-� --� 1 I ne Hwrcu name and logo are registered marks of ACORD ACORp® CERTIFICATE OF LIABILITY INSURANCE `i DATE(MMIDD/YYYY) 03/25/2019 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: Karen Martin HERMAN W LAPOINTE JR INSURANCE AGENCY INC aCo"N Exe: (508) 678-8341 Arc No: E-MAIL karenm la ointeins.com ADDRESS: @ P INSURERS AFFORDING COVERAGE NAIC q 1777 PLEASANT ST INSURER A: ACE AMERICAN INSURANCE CO 22667 FALL RIVER MA 02723 INSURED INSURER B INSURER C: LOGAN RAYMOND DBA L & L PLUMBING AND HEATING INSURER D : INSURER E: _ 1011 HILLSIDEAVE 1 INSURERF: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 381551 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 15 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 ADDLSUBR IMA POLICYNUMBER POLICY EFF MMIDO/YYYY POLICY EXP MIN DNYYY1 LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES Eaoccurrence $____,,._,.,__ MED EXP (Any one person) $ _ PERSONAL B ADV INJURY $ - N/A GENTAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ PRO- LOG JPRO- PRODUCTS - COMP/OP AGO $ $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT SEa accident $ - BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident $ - - PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACHOCCURRENCE $ AGGREGATE $__ EXCESS LIAB CLAIMS -MADE N/A DED RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YI" ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED9 NIA (MandatorylnNH) NIA NIA 6S62VB4579P92019 03/24/2019 03/24/2020 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 500,000 --'-'—' E.L. DISEASE -EA EMPLOYEE - $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 500.000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to. employees in stales other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www. mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield- Health Department 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Cro,oy, CPCU, Vice President— Residual Market— WCRIBMA 91988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD LICENSE NUMBER: APPLICANT: F : /n-.-"7 0 BUSINESS NAME: f 14 r�u"Tt' n MAIL ADDRESS: CITYITOWN: STATE: 1111 BUSINESS PHONE: �� rI ' l" �' `PBUSINESS CELL: BUSINESS FAX: XE-mail: Alt E-mail: EDERAL ID/SS NUMBER:- rf if Town of Mansfield 6 Park Row Mansfield, MA 02048 ZIP CODE: l l 7 d,- 7 LICENSE HELD: Town lA + n V : `f �Year Licensed LICENSE HELD: Town 11C% r el 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 31st yearly. FEE: $ 100.00 SIGNATURE:'' 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