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Home My WebLink AboutRibeiro Enterprises - 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: DYLAN RIBEIRO Doing business as: RIBEIRO ENTERPRISES P.O. BOX 455 NORTON MA 02766 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: 33 FEE $100.00 BOARD OF HEALTH NichaeCHeaCey, Chairman V The Commonwcglth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: lL,4zt.a C�fz^fz^'Sezt1 e Address: [ kr''1wsl"-/*i-� 4x— City/State/Zip: 0Y761 Phone#: '3`1--)'/93 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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, 1 ��P7/c �C/21r with no employees. [No workers' comp. insurance req.] 12.® Other Gts *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomration. **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 am an employer that is providygg workers' Insurance Company Name:)%;n,,epj Insurer's Address: i"LD L%Ji City/State/Zip: my employees. Below is the policy information. Policy # or Self -ins. Lic. # l✓ Expiration Date: / 1 &° r� / 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 pena tes ofperjury that the information provided above is true and correct. Signature: Zvv Date: / D /1 % Ilk Phone #: S a 3 4 -7 - IJ-63 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.mass.gov/dia 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. �' L/ Ind y/t 'iG/t�/uSCSt -47 Signature of Individual or Corporate Name By: Corpor Officer (Mandatonj, if Applicable) i",_ *"Social Security No. (Voluntanj) 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:\Usem\sleite\Desktop\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc acoiro® CERTIFICATE OF ILrilABILITY INSURANCE DATEIMMIDDIYYYY) 1 10/24/2018 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(ies) 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 Partners Insurance Group, LLC 560 Wilbur Avenue Swansea MA 02777 CONTACT NAME; Marla ArfUda PHONE FAX c o .508-491-317fi AIf C, No1: 508-491-3108 AIL ADDRESS: MArfuda artnersinsgrpilc,com INSURERIS AFFORDING COVERAGE NAIC0 INSURER A: NGM Insurance Company 14788 INSURED RIBEI-2 Rlbelr0 Enterprises. Inc. Dylan J. Ribeiro INSURER B: INSURER C: _ INSURER D : _ P.O. Box 455 Norton MA02766 INSURER E; _ INSURER F : COVERAGES CERTIFICATE NUMBER: 458865972 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 rypE OF INSURANCE AT6L SJOB POLICY NUMBER POLICY EFF MMIDDIYYI'Y POLICY EXP MMIDDAYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE EX ]OCCUR MPT2783C 10142018 101412019 EACH OCCURRENCE $1,000,Wfr DAMAGE TO RENTED PREMISES Ea occurregcel_ __ $500,000 MED EXP(Anyone person) $10,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMITJECT APPLIESPER: X POLICY PRO- LOC PRODUCTS-COMP/OP AGE $2,000,000 $ A AUTOMOBILE _ LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON-OWNED HIRAUTOS MIT27830 t0/42018 10/4/2019 COMBINED SINGLE LIMIT Ea a.Ident 5 BODILY INJURY (Per person) $500,000 BODILY INJURY(Peraccident) $1,000,000 PROPERTY AMAGE rrrociorm _ $ - $ _.-__ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE NUT2783C 10/4201B 10/4/2019 EACH OCCURRENCE $1,00(T000 AGGREGATE $1,0WD00 DED I X RETENTION$10000 I $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICERIMEMBEER EXCLUDED?ECUTIVE (Mandatory In NH) If yes, describe under DE SCRIPTION OF OPERATIONS below NIA WCT2783C 11/10/2018 '11/102019<': WC STATU- OTH- TOBYLIMITS E E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $600,000 E.L. DISEASE -POLICY LIMIT $600,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if 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. AUTHORIZED REPRESENTATIVE All riahts reserved. ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: Hr/ SI Uk11 rill»[Nt1�Y� BUSINESS NAME: MAIL ADDRESS: CITYITOWN: , L�,Awt lrze-r 191 1t1dMyaA1 U s'r Town of Mansfield 6 Park Row Mansfield, MA 02048 STATE: _IYW ZIP CODE: a`�-766 BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX: E-mail: 11�1". CA. Alt E-mail: ID/SS NUMBER: U 4 — LICENSE HELD: Town Year Licensed LICENSE HELD: Town //�H4w Year Licensed LICENSE HELD: Town % 45� `^� Year Licensed io f U f� 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: 6/11 Ac 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