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Home My WebLink AboutSoares Pumping, Inc. - 12/31/2019u 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: ROBERT SOARES, JR Doing business as: SCARES PUMPING, INC. 195 THRASHER STREET TAUNTON MA 02780 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: 38 FEE $100.00 BOARD OF HEALTH MlchaeCHeaCey, Chairman Y_ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: Iz BUSINESS NAME: SOCA(,e5 MAIL ADDRESS: i GI S T�I f Gt5 CITY/TOWN: -&J✓l4y o STATE: 11A ✓k _ ZIP CODE:...Oa BUSINESS PHONE: S� �' �a fI O Lr�� BUSINESS CELL: BUSINESS FAX: E-mail: _560Q5 Q$OcreShuv✓lRC0ri — o Alt E-mail: ID/SS NUMBER: 0 q - 314 Lp,59/ (0 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed 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: DATE: 16 --02 q, - 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 By: Corporate Officer (Mandatory, if Applicable) 014-3N"913(_.., *"Social Security No. (Volanitary) 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. CAUsers\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc \ 11.G I VI1111. V1f IV 04C41f! Vf lIIWUJW4iLNp CLW Department oflndustrial Accidents Office oflnvestigations 600 Washington Street s~ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information C Please Print Legibly Business/Organization Name: J('jC,( e M ✓t TnC. Address: lis 7hrc-,her 54Cee_T City/State/Zip:7e,0040", IM A 03�`6D Phone #: SdFr- �aU- dy<6-'7 Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with /0 employees (full and/ 5. ❑ Retail or part-time).* 6.❑RestaurantBar/EatingEstablishment 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. S. ❑ 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 I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other *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 ain an employer that is providing workers' compensation insurance for iuy employees. Below is the policy information. Insurance Company Name: S 4 C, (- T ✓) � 0(-G ✓) LQ Insurer's Address: 30(3 M i I I i Kerr f3 upp. r City/State/Zip: 1'Gc�l 2 (Ve (, rA V, o 0-7 a s Policy # or Self -ins. Lie. # b 1i - 314 &-�113 �> 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 tinder 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 cet tijy, underribe pains i na penalties ofpeijmy that the information provided above is true and correct Phone #: .S O `6' ga U- b N Ojjicial 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia SOARPUM-01 PAMARAI 1 ,a►coRO° CERTIFICATE OF LIABILITY INSURANCE D0111512019Y) 0111512019 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 suchooendorsement(s). PRODUCER License $ 1780862 NAMEACT Diane Carvalho PHONE FAX INC, No, Ext : (AIC, No): HUB International New England 222 Milliken Boulevard Fall River, MA 02721 an A'E : diane.Carvalh0@hubinternatlOnal.Com INSURENSf AFFORDING COVERAGE NAIC W _ INSURER A: Selective _ INSURED INSURER B: INSURERC: Soares Pumping, Inc INSURER D: 195 Thrasher Street Taunton, MA 02780 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. INSR TYPE OF INSURANCE ADDL SUER tvvn POLICY NUMBER POLICYEFF POLIICOY EXP IYVVYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR ' EACH OCCURRENCE $ DAMAGE TO RENTED -PREMISES-sotto ence $ GEN'L MED EXP (AnY one person) $ PERSONAL& ADV INJURY b _ AGGREGATE LIMIT APPLIES PER: POLICY El z8f 11 LOG OTHER: GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG S S AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSWN AUT OS ONLY AUTOS ONLY EOMei den SINGLE LIMIT $ BODILYINJURY Per erson b BODILY INJURY Peraocidenl $ PPe�acurlen DAMAGE S UMBRELLA LIAB E%CESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE AGGREGATE $ DED I RETENTIONS $ A WORKERS COMPENSATION ANOEMPLOYERS'LIABILITV OFFICEOPh1EETTgOE�RR�IE%CIUDRIEED? ECUTIVE Y� (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS be. NIA WC90B0203 01123/2014 0112312020' PEROTH- E.L.EAGH ACCIDENT 500,000 $ E.L. DISEASE - FA EMPLOYE 500,000 b E.L. DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES IACORD 101, Additional Remarks Schedule, may be attached if more space Is required) rcoTlnrAre HOLDER CAMr F:I I ATIfTN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD