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Home My WebLink AboutPond View Excavation Corp. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that KENNETH J. FOLEY Doing business as: POND VIEW EXCAVATION CORP. 50 FRENCH STREET REHOBOTH MA 02769 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: 31 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman �k Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: 31 APPLICANT: /) e,o, i e BUSINESS NAME: ioewol MAIL ADDRESS: 50 _ Fre�7(:)/___ 5hcc--- Town of Mansfield 6 Park Row Mansfield, MA 02048 4 T s . _. 4< ola CITY/TOWN: - %}cbo �%J __ _ STATE:%`1if _ ZIPCODE: BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX: E-mail: Alt E-mail: FEDERAL ID/SS NUMBER: LICENSE HELD: Town "Ij L-n Year Licensed 7 LICENSE HELD: Town IQP /I b-&o �J Year Licensed I`185 _ LICENSE HELD: Town Se-et`oitk Year Licensed l TI X 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 SIGNATURE: vl;� DATE: I L- 9 / g Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name **Social Security No. (Voluntanj) or Federal Identification Number By: Corporate qecer andatory, if A icable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. Cr\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A� o CERTIFICATE OF LIABILITY INSURANCE DATE,MMI°D Y, 11/9/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 NAME: Karen Clemente Cross Insurance, Inc.- RI PHONE (401)431-9200 C No E AIO No: loon m-soot 376 Newport Avenue ADD ricertificates@crossa enc com ADDRESS: 4 Y P. 0. EOX 9830 INSURER 5 AFFORDING COVERAGE NAIC n East Providence RI 02916 INSURER A: Nautilus Ins. CO. INSURED INSURER B: SeleCtiVe Insurance CO Of Southeast 39926 Pond View ExcavationCorp, INSURCRC:Libeurty Mutual Fire Ins Co Foley Excavation Corp. INSURER D: 50 French Street _ INSURER E: Rehoboth MA 02769 1 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 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. ILTR TYPE OF INSURANCE DL9m, POLICYNUMBEft POLICYIFF MMIDDIYYYV POLICY E%P IDVPYY Y LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 3 1,000,000 AM GE O ED PREMISES Ea occunance Is 300,000 A CWMS-MADE OX OCCUR MED EXP LAT/000 Poison) g 15,000 RCP202719310 9/21/2018 9/21/2019 PERSONAL aADV INJURY $ 1,000,000 UMITAPPLIES PER GENERALAGGREGATE $ 3,000,000 GEN'LAGGREGATE POLICY 0 ""JEOT LOC PRODUCTS-COMPIOPAGG It 31000,000 P.11ame LaUll $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s PEws 1 5 1,000,000 BODILY INJURY (Per poison) 5 B ANYAUTO ALL OWNED �. SCHEDULED AUTOS AUTOS A 9091349 $ 20 2010 / / 3 20/2019 / BODILY INJURY Poracadenl ( 1 5 X HIREOAUTOS X NON -OWNED PROPERTY DAMAGE Pe ecudm,I $ AUTOS unimn ed mbodm manims, damt, 3 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CAIMS-MADE AGGREGATE g DED I I RETENTION E $ WORKERS COMPENSATION To ee sent by Carrlar PER O H STATUTE E AND EMPLOYERS' LIABILITY YIN EL EACH ACCIDENT $ 500, 000 ANY PROPRIETOURARTNOVEXECUTIVE D OFFICERIMEMBER EXCLUDED? ❑ NIA "4/1/2019 (MandMory In NHI Wc231S365609 4/1/2018 :'. E.L DISEASE - EA EMPLOYEE $ 500 0 a 0 mi E.L. DISEASE POLICY LIMIT $ 500 000 DESCRIPTION DESCRIPTION OPERATIONS below FO A POLLUTION LIABILITY ECP202719310 9/21/2010 9/21/2019 $1000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IN, Additional Remarks Scimmile, maybe attached It more space Is required) Town of Mansfield 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. REPRESENTATIVE Clemente/KCX ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations a 600 Washington Street Boston, MA 02111 e www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ' / L Please Print Legibly Business/Organization Name: 100n t/iPw &,e a Utz/ion �NQ Address:,SD l=rrn�� Sfreet City/State/Zip:IV pa2'i(v9 Phone #: 50,2- 81— Y 6S` Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 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] 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]* I I.n Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[Other E' CavaZn *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 #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Compar Insurer's Address City/State/Zip: L. 05 -6 h / 1 1%� 6o211lp Policy # or Self -ins. Lic. # /A/r ^ �S' — 3foS& —Oo28 Expiration Date:'%1 _ao� 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 i//Z 4t Dater Phone #: L08— 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: Phone #: www.rnass.gov/ora