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HomeMy WebLinkAboutPonte Bros., Inc. - 12/31/2019I Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: JODY PONTE Doing business as: PONTE BROS., INC. 101 BLOSSOM ROAD WESTPORT MA 02790 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: 52 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman 6LI. Disposal Forks Installer LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: CITY/TOWN: ,0 2$r &T _ STATE: Yi� V�__ BUSINESS PHONE: 3z)P; (a S --)141 BUSINESS CELL: BUSINESS FAX: t E-mail: Alt E-mail: ID/SS NUMBER: LICENSE HELD: Town Lia mrvAoc 11\ Year LICENSE HELD: Town 7 w GL V" S C ei Year LICENSE HELD: Town A- c, u'$t-,.A et— Year I have read 310 CMR 15.00, the State Environmental co Requirements for the subsurface Disposal of Sanitary Si regulation titled "Minimum Standards for the Subsurface I understand that deviation from them may be cause for Permit Expires December 31st yearly. FEE: $ 100.00 SIGNATURE: DATE: L - { — Z ev 9 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. Pn1-e. Ores. 1,% ,L.L /,, � - " 141 /�yL Signature of Individual or Corporate Name y: Con orate Officer (Mandatory, if Applicable) Q �f— L�F;Iq�;cA "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\Scou's 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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Letribly Business/Organization Name: (�A l f✓ ,.i 0 Address: ( o/ �i �dd t v 5;S o m R City/State/Zip: OBJ l f 07-790, Phone #:Are you an employer? Check the appropriate box: Business Type (required): 1. u 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] g• E] 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]* Il.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.[0 Other L PLi E l i V4 // Z g-- *Any applicant that checks box # t must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation bas other employees,.a workers' compensation policy is required and such an organization should check box #1. lam 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: 7 - 2 7 ' Z tai 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, er thj t nd penatties of perjury taat the enjormaaon proviaaeo amore is true unu correcu G l � Date, "SJO/ 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 Person 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. Man 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 permit/license 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 A� �® CERTIFICATE OF LIABILITY INSURANCE DATE ( Y 03/2712019 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). PRODUCERONTACT John Andrade Insurance Agency, Inc. 559 Hope Streetcviei"@johnandradeinsuranm.com Bristol RI 02809 NAME: Christina Vleira A/ONNO Ext: (401)253-6542 ac No: (401)253-5070 ADDRESS: _ INSURER(S) AFFORDING COVERAGE NAICY INSURERA: Main Street America Assurance 29939 INSURED PONTE BROTHERS CONTRACTORS INC & POINTE BROS INC 101 BLOSSOM RD WESTPORT MA 02790-3303 INSURER B: National Grange Mutual Ins CO 14788 INSURER C: INSURER D: INSURER E: 1 INSURER F: COVERAGES CERTIFICATE NUMBER: CL18911322854 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE INSD Me POLICY NUMBER EFF MMMD GYEXP MM/Y DDA(M) LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGE TO RENTFD PREMISES Ea occurrence $ 500,000 MED EXP (Any one mon) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 A MPT1692G 07/27/2018 07/27/2019 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,booxo POLICY [] JELOG LOC Data Compromise $ 25,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ee accident BODILY INJURY (Per person) $ ANYAUTO BIOWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON.OWNED AUTOS ONLY X AUTOS ONLY M2T1692G 07/27/2018 07/27/2019 BODILY INJURY (Per aWdent) $ PROPERTY DAMAGE $ Paracddenl Underinsured motorist BI $ 50,000 UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ B WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANY PROPRIETORJPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDEDY (Mandatory In NH) N/A WCT1545P 07/27/2018 07/27/2019 PER OTH. STATUTE ER ,_ _ E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT § $00,000 if yes, descdbe under DESCRIPTION OF OPERATIONS below ITI DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORDIC1,AEditlonal Remarks Sohedule,maybeaftachedifmarespacelsrequired) CERTIFICATE HOLDER CANCELLATION ©1988-2815 ACORD CORPORATION. All right. r_cc^•^•_'. AC..___._. __.__, T: ------ _... 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`�f,A_.gt-��p_,d rrsso ? ©1988-2815 ACORD CORPORATION. All right. r_cc^•^•_'. AC..___._. __.__, T: ------ _... 5�nr s License # 48 °4a COMMONWEALTH OF MASSACHUSETTS y TOWN OF SWANSEA SACHUSti Board of Health This is to certify that: Jode Ponte - Ponte Brothers Excavating 101 Blossom Road, Westport, MA 02790 IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLERS LICENSE" TO CONSTRUCT, ALTER, INSTALL OR REPAIR. Individual Sewage Disposal Systems This license is granted in conformity with the State Environmental Code Title 5, Regulation 2.2, and expires December 31, 2019. Unless sooner suspended or revoked. January 1, 2019 Date Issued Zacka abu , Health Agent/Director y_ / 1, Commomt IX or nwss =sats TOWN OF ACUSHNET PERMIT NO. FEE 2019-24T $200.00 This is to certify that Ponte Bros. Construction 101 Blossom Road Westport, MA 02790 IS HEREBY GRANTED A TEMPORARY DISPOSAL WORKS INSTALLERS PERMIT TO CONSTRUCT, ALTER, INSTALL OR REPAIR INDIVIDUAL SEWAGE DISPOSAL SYSTEMS This permit is granted in conformity with the State Environmental Code Title V, Regulation 2.2 and expires December 315`, 2019, unless sooner revoked. Date: March 7, 2019 ?dow" 9 ?actin Re" vede&114 Daaid 7J4"7*W Parting Ways Building ♦ 130 Main Street, Acushnet, MA 02743 ♦ TEL:(508) 998-0200 FAX:(508) 998-0277 ztr.CiM,"A (;0V q0..