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HomeMy WebLinkAboutPaul's Title V Services - 12/31/2019U Town of Mansfield Town of Mansfield - Board of Health 6 Park Row A Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT:Iv-)JAW to W -C i E: j BUSINESS NA PA (-) 1 d MAIL ADDRESS: T)Ah �^ CITYITOWN: C� '7// STATE: !- �" �- ZIP CODE: od BUSINESS PHON'J(aU BUSINESS CELL: BUSINESS FAX: E-mail: Alt E-mail: 1�76�9R�L41-3�:i LICENSE HELD: T Year Licensed LICENSE HELD: Town �a� r U� Year Licensed LICENSE HELD: Town Year Licensed C,201 i 7 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: SIGNATI 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: /1 & City/State/Zip: Phone #: '-360 -TTS'G Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or -time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. 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 10.0 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.❑ Other *Any applicant that checks box 41 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 qI. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Nar 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance aweraae verification. I do hereby ceofy, a der tit, I lns rd penalties ofperjury that the information provided a/b�yve is/tre and correct. Si nature: jt, Date: //e/_/1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mms.gov/dia Commonwealth. of Massachusetts DIVIslon of Professional Licensure Ho e#in'g Lnfjpr�eer HE•162555iplres: 05/0812020 PAUI J GOUVEIA- - 96 DANFORTH,$T --- -,'' REHOBOTH MA 02769 Commissioner c!'_- �� I M 11-11 iN it Ukl ' ZZOVO£19 £tOUSWU - MUIS i e 69LZ0 tlW ,9iogoyaa e1®ni1O0 fined 80103dSNl W318AS 9 3116103AOHddV l I iSllt �:I��t iltJ ly F itH of Taunton )300rd of health 1 !6[hool �5trcct Masaad)III)MO 02780-3212 Permit #: 13 - 2019 Permit Fee: $100.00 This is to certify that: Name: Paul Gouveia, Paul's Title V Service Address 86 Danforth Street, Rehoboth, MA 02769 BOARD MEMBERS DR. BRUCE E. BODNER DR. THADDEUS A. FIGLOCK DR. CHARLES A. THAYER HEATHER L. GALLANT, MPH, RS, CHO EXECUTIVE DIRECTOR ADAM S. VICKSTROM ASSISTANT EXECUTVE DIRECTOR ...is hereby granted a "Disposal System Installer's Permit" to construct, upgrade, expand and abandon on -site sewage disposal systems in conformity with 310 CMR 15.000, The State Environmental Code, Title 5 Type of permit and any restrictions: Disposal System Installer's Permit Permit expiration date: December 31, 2019 unless sooner suspended or revoked Date issued: January 3, 2019 BOARD OF HEALTH - APPROVED THADDEUS A. FIGLOCK, M,D. CHAIRMAN TAUNTON, MA Adam S. Vickstrom Assistant Executive Director Original: Installer cc: Taunton Board of Health Regional Environmental Engineer, DEP 'Cdephmle (>os) $21.1100 , fax (Jos) 821 1103 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ATTLEBORO BOARD OF HEALTH NO: DW 215-18 This is to certify that: Paul Gouve a 86 Danforth St Rehoboth, MA 02769 IS HEREBY GRANTED A LICENSE FOR FEE: $100,00 This permit is granted in conformity with the State Environmental Code Title V, Regulation 2.2, and remains in effect until the expiration date unless sooner suspended or revoked. PERMIT ISSUED: December 5, 2018 PERMIT EXPIRES: October 31, 2019 Board of Health Permit Number: I19-02 Fee: $100.00 The Commonweafth of Massachusetts Town of Rehoboth Board of Health This is to Certify That: Paul Gouveia Doing Business As: Paul's Title V Services Mailing Address: 86 Danforth St, Rehoboth, MA 02769 Located at: Same IS HEREBY GRANTED A PERMIT TO PERFORM TITLE V SERVICES WITHIN THE TOWN OF REHOBOTH AS SYSTEM INSTALLER This permit is granted in conformity with the State Environmental Code (Title V) and the Rehoboth Board of Health Rules and Regulations, and expires December 31, 2019 unless sooner suspended or revoked. -jj I t . Rachel Smith, Chairman Tony aucher, Vice Chairman c TheresaMottozo, CJer George Kellum, Member Mark Hass, Member Issued: November 27, 2018 ' I 1 FAULI-J OF ID, MfV ,4lkk. i o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/09/2019 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 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 endorsements . PRODUCER 508-824-5875 Allan M. Walker & Co., Inc. 120 High Street P.O. Box 1067 CONTACT PHONE 50"24-5875 F C Not.508-880-5056 ac, No, E-MAIL Taunton, MA 02780-0960 ESS,- INSURFRTS) AFFORDING COVERAGE Michael R. Quinn CIC _ INS_URERA: ROCkhlil Insurance Co. INSURED Paul's Title 5 Services Paul Gouveia 86 DanfortV.1 treat Rehoboth, A 62769 INSURER B INSURER C INSURER D: INSURERS: _ INSURER F: COVFRAGFS CFDTIFICDTF NIIIMDCD• -- 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. ILTR NSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMSMADE OCCUR ENV20190147-01 01/12/2019 01/12/2020 EACH OCCURRENCE 11000,000 DAMAGETORENTED 50,000 MEDEXP An oneoersonl 5,000 X contractors pollu PERSONAL&ADV INJURY 11000,000 GENT AGGREGATE LIMIT APPLIES PER: pH POLICY ❑ JECT LOC GENERALAGGREGATE 210001000 PRODUCTS-COMP/OPAGG 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT UeA ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS yyyy AUTOS ONLY AVTOSO EDY BODILY INJURY Per erson BODILY INJURY (Per accumn Pe PT YDAMAGE BRELLALMS OCCUR EACH OCCURRENCE JUED AGGREGATE LCESS LMB CLAIMS -MADE RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORRARTNEFUEXECUTIVE OFFICEpgIMEMBEREXCLUDEO? It yes, dtory In and yes, describe under NIA PER OTH- EL. EACH ACCIDENT $ EL. DISEASE- EA EMPLOYEE E.L. D S SE -POLICY LIMIT DESCRIPTION DE 1 ION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace Is required) MANSF-1 Town of Mansfield Building Dept 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M, VRU LU JAU Iolwp ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD # 2019-02 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF LAKEVILLE BOARD OF HEALTH This is to Certify that Paul's Title V Services 86 Danforth Street Rehoboth, MA 02769 IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO CONSTRUCT, ALTER, INSTALL OR REPAIR Individual Sewage Disposal Systems "Licensee is required to have the proper equipment so that the grades are set as established b the he engineered plan This permit is granted in conformity with the State Environmental Code Title V, Regulation 310 CMR 15.019, and expires December 31, 2019, unless sooner suspended or revoked. December 21, 2018 Issued ( / Kevin Bernardo, Board of Health 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. or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc