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HomeMy WebLinkAboutPeter DeGirolamo & Sons, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: JOSEPH J. DEGIROLAMO Doing business as: PETER DEGIROLAMO & SONS, INC. 77 EAST BELCHER ROAD FOXBORO MA 02035 Town of Mansfield 6 Park Row Mansfield, MA 02048 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: 29 FEE $100.00 BOARD OF HEALTH AichaeCHeaCey, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 LICENSE NUMBER: APPLICANT:. _Joe DeGirolamo BUSINESS NAME: Peter DeGirolamo & Sons Inc MAIL ADDRESS: 77 East Belcher Rd___ CITY/TOWN: Foxboro STATE: MA ZIP CODE: 02035 BUSINESS PHONE: 508-543-7228 BUSINESS CELL: BUSINESS FAX: 5G8_-5_43_-9212___ E-mail: woe degirolamn@verizon.net Alt E-mail: ID/SS NUMBER: 04-2498634 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town 508-962-1344_Joe D,_ Year Licensed Year Licensed 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: $ SIGNATt 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 TAX CERTIFICATION FORM I certify tinder 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. Peter DeGirolamo & Sons Inc e< 'f 1 041 Signature of Individual or Corporate Name 4: eorp r to Off(er (Mandatory, if Applirnble) 04-2498634 **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 munber 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. CAUsers\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A� Ro® CERTIFICATE OF LIABILITY INSURANCE DATE (MM DDYYYY) 70/4/2018 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(has) 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 Marsh & McLennan Agency LLC - New England 100 Front St, Ste 800 Worcester MA 01608 CONTACT NAME: Kyle Morrissey PHONE FAX INC Na E.q: 888-850-9400 ac Not: 866-795-8016 _ ADDRESS, MMA.NewEngland.CLines@marshmc.com _ INSURERS AFFORDING COVERAGE NAICq INSURER A_Liberty Insurance Corporation 42404 BKW65790273 INSURED PETERDEGIRI Peter DeGlrolamo & Sons, Inc. 77 77 E. Belcher Road INSURER B: Associated Industries of MA Mut Ins Co 33758 IN Chubb Indemnity Insurance Company 12777 INSURER D: Foxboro MA 02035 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 788524498 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 AODL SUBR POLICY NUMBER MM/DDPOLICY EFF MWDDPOLICY�P LIMITS A X COMMERCIAL GENERAL LIABILITY BKW65790273 10/11/2018 10/1112D19 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTEsoca CLAIMS-MAGEI—XI OCCUR PREMISES Faeceu Iftoo," MED EXP (Anyone person) $10,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 POLICY ❑ jE T [X] LOC PRODUCTS _COMP/OP AGO $2,00.000 $ OTHER: A AUTOMOBILE LIABILITY BAW55790273 10/112018 10/112019 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident -1-X X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB I I OCCUR US055790273 10/11/2018 10/112019 EACH OCCURRENCE $5,000,000 $5,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTION$ _AGGREGATE $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE --1 W005005012531 10/11/2018 10/11/2019X STATUTE ERH E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDEDP NIA - (MandaturyinNH) E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1000000 If yes, describe under DESCRIPTION OF OPERATIONS below C A Tank Pollution Leased/Rented Eq G46823138 BM65790273 10111/2016 10/11/2018 10/11/2019 10/11/2019 $1,000,000 $400,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Disposal Works Installer Permit CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth bfMassachusetts Department of l`ndusYrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: PETER DeGIROLAMO & SONS INC Address: 77 EAST BELCHER RD City/State/Zip: FOXBORO, MA 02035 Phone #: 508-543-7228 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 15 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I alt 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 l0.❑ 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.® Other CONTRACTOR "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 tlmt is providing workers' compensation insuurrarce for my employees. Below is t/te policy infotniation. Insurance Company Name: MARSH & MCLENNAN INSURANCE AGENCY Insurer's Address: 100 FRONT ST STE 800 City/State/Zip: WORCESTER MA 01608 Policy # or Self -ins. Lie. # WCC -500-5012531-2018 Expiration Date: 10/11/2019 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. Ida hereby cer#y, raider jjte painspnd penalties of perjury that lite information provided above is true and correct Official use only. Do not write ire this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle rare): 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 Phone Information and, Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05