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Home My WebLink AboutRalph Excavating - 12/31/2019Commonwealth 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: DANA A. RALPH Doing business as: RALPH EXCAVATING 110 HOLMES ROAD NORTH ATTLEBORO MA 02760 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: 32 FEE $100.00 BOARD OF HEALTH NichaeCHeaCey, Chairman 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 wz "Social Security No. (Voluntanj) or Federal Identification Number By: Corporate Officer (Mandatonj, if Applicable) *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:\Usem\sleite\Desktop\Scott'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 Ulf www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: 7 ' - of Address: �A3 City/State/Zip: Phone #:a 61.� C \� Are you an employer? Check the appropriate box: Business Type (required): 1.EEr'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. 8• ❑ Non-profit [No workers' comp. insurance required] 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, 12.❑ Other urance with no employees. (No workers' comp. insreq.] *Any applicant that checks box SI 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 k 1. I am an employer that is providing workers' compgnsation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: t G ._ L[ 0 10 City/State/Zip: \ dl 6 T\ - c 3 C'A 16L ,j" C: Y'g 1'Cl } , Policy # or Self -ins. Lie. # t rVQ A 0(' C 1 11 ' � � ' Expiration Date: ` �� t�l 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 of perjury that the information provided above is true and correct. i �'1 Signature: `,.,�.-,^ _ Date: t-i Of 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.mass.gov/dia A� H CERTIFICATE OF LIABILITY INSURANCE DATE11/09M8 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 endorsement(s). PRODUCER CONTACT NAME: Rene Araujo _ __ Willis -MacKinnon HONE Ext: 608.699.7007 plc No: 608.809-6334 5 Man Mar Drive 608.699-7007 noOREss: rarauJo@durcan-cuddy.com INSURERS) AFFORDING COVERAGE NAICN Plainville, MA 02762 INSURER A: Travelers INSURED INSURER a: AIM INSURER C: Charter Oak (Travelers) ::-Dana Ralph 110 Holmes road North Attleboro, MA 02760 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYYI IMMIDDIYYYYlLIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1_x_1 OCCUR y y 1660204P1952 02127/18 02127119 EACH OCCURRENCE $ 1,000,000 PREMISES(Ed occunens $ 100,000 MED EXP (My one pemord $ 6,000 PERSONAL B ADV INJURY $ 1,0003000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECT LOG OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,0003000 $ Q. AUTOMOBILE LIABILITY ANY AUTO OWNED A X SCHEDULED AUTOS ONLY UTOS HIRED NON OWNED AUTOS ONLY X AUTOS ONLY Y Y BA970K476A 09111/18 09/11/19 Ed acccideDI—SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ 260,000 !� BODILY INJURY (Per accident)$ 500,000 PROPERTY DAMAGE Per accident $ UMBRELLA LAG EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED] n❑ (Mandatory In NH) Use, describe under DESCRIPTION OF OPERATIONS he. NIA VWC6007138012011 04122l18 04122/19 PER OR"' X STATUTE Eft E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Jdoucette@mansfieldma.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED J ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: kAG by, 03110 APPLICANT: 1- 1MU1*19,1L MAILADDRESS: CITYITOWN: i l p) _� % STATE V'VI_ / — ZIP CODE 0 160, _ BUSINESSPHONE:`�bj �}$Z BUSINESS CELL: BUSINESS FAX: E-mail: dVl(tkCA Alt E-mail: IDISS NUMBER: LICENSE HELD: Town E _I� Year Licensed '-'fib SO' A� LICENSE HELD: Town Year Licensed LICENSE HELD: Townt i1��K' 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 31 st yearly. FEE: $ 100.00 SIGNATURE: DATE: 6(J ( 1 - i s l 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