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HomeMy WebLinkAboutR. Moreshead Excavating - 12/31/20190 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: RYAN MORESHEAD Doing business as: R. MORESHEAD EXCAVATING 46 RYDER CIRCLE 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: 28 FEE $100.00 BOARD OF HEALTH 9blichaet'Heacey, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: 13Can rtj _ BUSINESS NAME: I NI 0r-c S k a _ EX ck va41 �t MAIL ADDRESS: CITY/TOWN: I/ nr'��1 ifUJ0'r0 STATE: Mfk ZIP CODE: O27�✓N7 _ BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX: E-mail: f'v u� S ,C,,J r4� u �• Alt E-mail: FEDERAL ID/SS NUMBER: ( 5 6 7 V` 7 LICENSE HELD: Town fox6Gr-0 Year Licensed :1z 01 LICENSE HELD: Town Year Licensed 0-0/ � LICENSE HELD: Town yl,c, v S C 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 SIGNATI. DATE: 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 f lodividual or Corporate Name 0� � (D-7 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth 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: KM Address: 16 �,i4r Gr'G'e- f `F Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ r part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no emDlovees. [No workers' coma. insurance rea.l C Phone #: - ( , 1 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ IjealthCare 12. Other *Any applicant that checks box #1 must also till 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: JS le C h V C r z, Insurer's Address: P (%r 13 o)G 11 oy City/State/Zip: I `✓ rh �+ c� r l` - t7 el r Policy # or Self -ins. Lie. # 5 _,I l i C>3 q D Expiration Date: /% 1 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. In l Y � 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.mms.gov/dia E (MMIDDtYYYY) AG ® CERTIFICATE OF LIABILITY INSURANCE DAT1/11/2019 ,�- 1/11/2019 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(sl. PRODUCER uuniwci NAME: CROSS INSURANCE INC - RHODE ISLAND PHONE 401-431-9200 AC N Ext: PO BOX 4830 E-MAIL RUMFORD RI 02916-0830 INSURERA: SELECTIVE INS CO OF THE SOUTHEAST 39926 INSURED INSURER B : INSURER C: RYAN MORESHEAD 46 RYDER CIRCLE INSURER D: INSURER E NORTH ATTLEBORO MA 02760 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. ILTR TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDOYYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OoccuR X S 2110340 4/28/2018 4/28/2019 EACHOCCURRENCE $ 1,000,000 D AGETORENTED PREMISES [Ea occurrence 5 $ 00,000 MED EXP(Any one person) $ 15,000 A PERSONAL 6 ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 3,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY ] JECT LOC PRODUCTS, COMP/OP AGO $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accimma $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY ( Per accident) () $itl HIRED AUTOS NON OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Peracdmmt _ $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE _ $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEWMEMBER EXCLUDED? NIA STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE- POLICY LIMIT - $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Certificate of Liability Insurance was created by Selective on behalf of the agent. Town of Mansfield is included as additional insured with respect to General Liability as required by written contract or agreement. Town of Mansfield 6 Park Row SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield MA 02048 AUTHORIZED REPRESENTATIVE R.d c u14.� ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD25 (2016/03) The ACORD name and logo are registered marks of ACORD r Bank k Pk9f TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: BOARD IF HEALTH = SEPTIC Date: 1.11-2019 Schedule: JH'1111, From Whom Account Number Amount RYAN MORESHEAD PERC 160 OLD ELM STREET 01512,445006,. $ 150.00 RYAN MORESHEAD 56 KERRY DRIVE $ 76.00 OWED ON SEPTIC INSTALLATION Cash $ 226.00 Checks $ Total $ 225.00 Online or Wire Receipt $ TOTAL: $ 22500 Mansfield, MA -11-2019 To The Officer Making the Payments: The above is a detailed list of moneys collected b me, amountingin the a re ate to: $225.00 forthe Brio% ending - 1-11-2019 which I have paid to the Town Treasurer whose receipt I hold therefo . ". - Em to ee or Dept Head