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Home My WebLink AboutPlainville Pump & Excavating, Inc. - 12/31/20195 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: GARY KETTELL Doing business as: PLAINVILLE PUMP & EXCAVATING, INC. 18 HIGH STREET, SUITE #4 PLAINVILLE MA 02762 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: 30 FEE $100.00 BOARD OF HEALTH -MichaeCHeaCey, Chairman tr flCr �� ,. % `9 Town of Mansfield - Boar D"ealrlh 201 Park R Mansfield ansfleld, MA 02048 `BYL Disposal Works Installer Application LICENSE NUMBER: 30 APPLICANT: �} t p� �'7 kez 4f_4 I BUSINESS NAME: Y �C� E _�/�� l/ uC MAIL ADDRESS: CITYITOWN: 1 �kii ki L, i e>_ STATE: AI ZIP CODE: C G BUSINESS PHONE: C, BUSINESS CELL: BUSINESS FAX: .V% 13,3 E-mail: rt 4r, cz:' /c1 Alt E-mail: ID/SS NUMBER: LICENSE HELD: Town Year Licensed -2 c / S- LICENSE HELD: Town f'U<s G°✓l Year Licensed 2u/411� LICENSE HELD: Town (i—. i-e is - AC4 �- 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: 4e% 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 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. S�igryature of Individual or Corporate Name 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\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc ` The Commonwealth of Massachusetts Department oflndustrialAceidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: /C111'I_[/lj/C? �Uorr/�r XCUi/CD'Tr�59 �`.r Address: City/State/Zip: 2 Phone #: ��U d Z, = zw � Are � you an employer? Check the appropriate box: Business Type (required): W ' 1. am a employer with / 3 employees (full and/ 5. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/EatingEstablisbment 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]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] I 12,aOther Caxt r 5'FFJ�c, *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. lam an employer that isproviding worIkers'I compenssaation insurancefor my employees. Below is the policy information. Insurance Company Name: � ( (� c 6 � Gt_ 1/ % u,tE�C"I r is �. u c ��C � t�✓»�X Sr i Insurer's Address: //00 CT OLuh cc) / on u Or City/State/Zip: 61 / Y-)c 4/ `i%-2 C�,2 Policy #orSelf-ins. Lie.# �12.200, 57y' Expiration Date: 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. / / �/�� Signature: � �U"�/�LLZ`� Date: �� Phone #: &K- t f � - Official rise 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 Person: Phone PLAIN-1 OP 12 LR AlICC>�Ro CERTIFICATE OF LIABILITY INSURANCE DA01/25/2018TE YI 01/25/2018 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 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 Eastern States Insurance CONTACT NAME: ac°N o E .781.642.9000 lac Noe 781-647-3 770 Agency, Inc, 60 Prospect Street Waltham, MA 02453 _ Ebmu IRL --or — _AODREss: CertiflCateBgUEIStG1d eSia.COm _ INSURER(S) AFFORDING COVERAGE NAIC N INSURER A:Arbella Protection Insurance :41360 INSURED Plainville Pump & Excavating, _ INSURER B: Arbella Insurance Group 141360 Inc. INSURER C: Acadia Insurance_ Company ''31325 Jemco Disposal, Inc. Ma lehurst Farms, LLC IN suRER ❑: ----------- 38 Forest Street LLC _ INSURER E: 18 High Street Ste 4 Plainville, MA 02762— INSURER F: 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 OFINSURANCE 9NSD-. D POLICY NUMBER POLICY EFF : P UCY EXP MM/DD/Y1'YY MMIDO/YYYY _ LIMITS j A X 1 COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR X : '8500041975 0112512018 01/25/2019 :EACH OCCURRENCE $ 1,000,00 -PREMISES Eaccccrrence s 250,00 MI ED EXP (Any one person) $ 5,00 GEN L AGGREGATE LIMIT APPLIES PER. POLICY X JECT !,I LOC PERSONAL It ADV INJURY 1,000,00 GENERAL AGGREGATE I$ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,00 €PD & BI $ DED: $1,00 I )OTHER I AUTOMOBILE LIABILITY A I -----I ANY AUTO rCOMBINED 1020013124 j 01/25/2018 01125/2019 SINGLE UM[ 1 �Eaaccidentl IS 1,000,00 BODILY INJURY (Per person) $ ALL OWNED - X I SCHEDULED AUTOS ;_� AUTOG X HIRED AUTOS X NON -OWNED UT OB X dye am I f ! e001LY INJURY (Per accident )I $ PROPERTYD 7AGE Per accident -- ---" $ __ ComplColl ACV _ s Sae Page X j UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,00 A EXCESS LIAR ..__..._.i___ CLAIMS -MADE 4600041974 01/25/2018 01/25/2019 _ _ AGGREGATE �$ 2,000,00 DEB X RETENTION$ 10,000 I 's WORKERS COMPENSATION AND EMPLOYERS'UABIUTY B /ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICERry inN RE%CLUDE09 B (Mandatory in NH) embe ' B es, desMEMBEder ❑ DESCRIPTION OF OPERATIONS below 4220049423 01- PLAINVILLE NIA I 4220058164 - JEl 01/2612018101126120191 10/01/2017 10/01/201 B PER TH- '. STATUTE ER El .EACH ACCIDENT f$ 500,000 EMPLOYE DISEASE EA EMPLOYEE,' $ 500,000 E. L. DISEASE -EA $ 600,000 C 'Contractors Equip CIMS336089 01/26120181 01/26/2019 ;Scheduled �I See Belo Floater ':DED: $1,000 i RenVLeas 26,00 DE5CRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: Drainlayer's License The Town of Mansfield is included as Additional Insured with regards to General Liability where required by written contract or agreement. Town of Mansfield Attn: Engineering Dept 6 Park Row Mansfield, MA 02048 MANSMA- 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'vr%U 40 t4u-14Ie'1) 1988.2014 ACORD I ne AUVKD name and logo are registered marks of ACORD reserved.