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HomeMy WebLinkAboutMiles of Excavating - 12/31/2019F Commonwealth 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: TIM KONOWITZ Doing business as: MILES OF EXCAVATING 242 PARK STREET WRENTHAM MA 02093 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: 46 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 11/ 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. Signature of Individual or Corporate Name *'"Social Security No. (Voluntary) or Xcleral 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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustriabAccidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: /L t Address: ,Q'1:)- -�S1 - City/State/Zip: kJOeftaMPhone #: 5-6 �` - 3Vy — R S`iC3 Are ou an employer? Check the appropriate box: Business Type (required): 1., I am a employer with 3 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]* I1.❑ 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 #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 Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: <, lt 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 Investieations of the DIA for insurance coverage verification. I do hereby-eprtiler the pains a nalNes ofp­erj-ft7y4hat the information provided above is true and correct Siynature::j `1 Date: /0 "/ t Phone#:�� Official use only. Do not write in this area, to be completed by city or town offrciaL 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 " I I. MILEOFE-01 CWOODSIDE CERTIFICATE OF LIABILITY INSURANCE DATE 0713112018Y) 07/31/2018 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or 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 License fi 1780862 CO TACT Michelle Wolf HUB international New England 600 Lon water Drive Norwell, MA 02061-9146 PHONE --- FAx IaC, No, Eztp (508) 888-2183 _ (NC, Nol: __ a DD RIbLE: michelle_wo_IfOa hubinternational.com _ MSURERISI AFFORDING COVERAGE NAIL It INSURER A: Liberty Mutual INSURED INSURER B: Commerce Insurance Company__ 34764 INSURER C_Wesco Insurance compan�r__,___ 25011 Miles of Excavating Timothy Konowitz dba INSURER D : 242 Park Street Wrentham, MA 02093 _INSURER -- E: ----- INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION MHMRER- 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 RESPECTTO 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. MSR LTR TYPE OF INSURANCE ADOLSUBR POLICY NUMBER POLICY EFF PO pCV EXP LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE XOCCUR _ TPERSONAL X BKS58621919 02/27/2018 I 02127/2019 EACH OCCURRENCE $ 1,000,000 DAMAGETOR RENTED ce s 100,000 GEHL MED EXP (Anv one person)_ _ $ 15,000 AGGREGATE LIMIT APrPL�IES PER: %PT LOG POLICY � u OTHER: _ B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,600 PRODUCTS-COMNOOP AGG 5 2,000,000 IS B AUTOMOBILE LIABILITY ANYAUTO AUUTOSSVUyLNED AUTEO�S ONLY HXX AUTOS ONLY AUTOSONLY BHDLXX 02127/2018 02127/2019 COMBINED SINGLE LIMIT 1,000,000 X 60DILV INJURY (Perparson), BOOILV INJUppRY (Per acdden0__S PeFaocRd ni)AMAGE _ 5 UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE 5 _ AGGREGATE _ 5 DED RETENTIONS S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICdERIM9MBER EXCLUDED'! � (MMan attory nNNNH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA C3365078 0812312018 ' - 0812312019 PER OTH- T TUTE R - E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE .-_ $ 500,000 E.L.DISEASE-POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CF_RTIFICATF HOI nFR I'AAIr Ml I ATInNI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield a Town of Mansfield - Board of health 6 Park Row o Mansfield, MA 02048 Disposal Works Installer Application WJECEIVEr LICENSE NUMBER:. /,a�-)f 1_ — OCT i 5 Z318 APPLICANT: BUSINESSNAME:/L1/t "s MAIL ADDRESS: ay ni CITYITOWN: _. �/i //� STATEA-t- ZIP CODE Voo BUSINESS PHONE: , BUSINESS CELL: ' � �i".9-7/ S7 BUSINESS FAX: 7-� E-mail: r_1 es �'r4_0_C(Uj1: tezt�bv, �LJ� Alt E-mail: EDERAL IDISS NUMBER: -� LICENSE HELD: Town vCrm Year Licensed LICENSE HELD: Town I_VAiJ1)/Z(0 � Year Licensed LICENSE HELD: Town uit �'� Year Licensed 2pl6 -_-_ 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 SIGNATUR . DATE: .2 "/ t 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