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HomeMy WebLinkAboutWind River Environmental - 12/31/2019 (2)Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: MICHAEL DECOSTA, JR. Doing business as: WIND RIVER ENVIRONMENTAL 46 LIZOTTE DRIVE MARLBOROUGH MA 01752 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: 47 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman Town of Mansfield Town of Mansfield - Board of Health s Park Row Mansfield. MA 02048 Disposal Works Installer LICENSE NUMBER:: APPLICANT: ----- BUSINESS NA MAIL ADORES CITY/TOWN: BUSINESS PH BUSINESS FA E -ma Alt E• FEDERAL ID/SS NUMBER: LICENSE HELD! Town Year Licensed UCENSEHELD: TownfV I� _;tFid Year Licensed OeC2 i 2S LICENSE HELD: Town Year Licensed 1 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: ��•r� M_S� DATE: Please make appropriate changes. Sign, date and enclose check for S100.00payable to Town of Mansfield. Mall 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. W1n t XPi` E, v ( Signature of Individual or Corporate Name C%i-3gg7&7_7 `�Sociat Security No. (VoIuntm y) 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. CAUsersWeite\Desktop\ScotPs Doeuments\Food astablishments- Temp\TAX cERTtFICATION FORM -due The C'ornntonwealth of Massachusetts Department of IndustrirtlAccideuts Office of In vestigations I Congress Street, Suite 100 Boston, MA 02 114-2 01 7 mtvly, nutss.govklia Workers' Compensation Insurance Affidavit: General Businesses AbDlicant Information S' Please Print Legibly Business/Organization Address: /q (-e L-lzcr� 2 Mee oil an employer?Check the nppropriate bux: I I am a employer with `1 Ob employees (ftill and/ or part-time).* 2. ❑ l 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, stuffed by volunteers, with no employees. [No workers' oomp. insurance req.] Phone #: Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) & ❑ Non-profit 9. ❑ Entertainment l0.❑ Manufacturing 1Lk❑� Health Care *Any appticantlhal cheeks box ill mustalso fill out the section below showing their workers' compensation policy information. s*IP the corporate officers have exempted themselves, bill the corporation his other ianployees, a workers' compensation policy is required and such an organization shroud check box # I. I aiu all employer drift Is providing tvorkersr' compensation lasurvmcefor ray employees. Below is the policy information, Insurance Company NameLP,-Jf-�='Sh ¢,�,r, �r Insurer's City/State Policy 9 or Self -ins. Lie. H\_Q(�Q.Q.' � et 1 Expiration Date:. i.1 �0 �_..._ 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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. mnlpenahies of perjury that the Intlorinadon provided above is true and correct. Official use only. Do not Ivrite Ar Ods area, to Ge cnrnpleterl Uy city or totvrl official. City or Town: Permit/License Issuing Authority (circle rote): 1. Board of Health 2, Building Department 3. City(rowu Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone ,I , AcoRo® CERTIFICATE QF'LIABILITY INSURANCE I`,/ 6/30/2019 DATE (MMIDD WY ) 7/2/2018 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 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 Lockton Insurance Brokers,LLC CA License #0F1 5767 725 S. Figueroa Street, 35th fl. Los Angeles CA 90017 NAME CT PHONE ExtiA/C No: E-MAIL ADDRESS: TMERCIAL GENERAL LIABILITY CLAIMS -MADE [R] OCCUR N 213-689-0065 INSURERS AFFORDING COVERAGE NAICN INSURER A: Evanston Insurance Company EACH OCCURRENCE $ 1,000,000 _ PREMBESOEaoccu ante $ 100,000 INSURED Wind River Environmental, LLC 1448815 46 Lizohe Dr. -35378 INSURER B: Endurance American Specialty Insurance Co. 41718 INSURER C: Liberty Surplus Insurance Corporation 10725 INSURER D: Starr Indemnity & Liability Company 38318 Marlborough MA 01752 INSURER E PERSONAL &ADV INJURY $ 1,000,000 INSURER F: COVERAGES WINRI01 CERTIFICATE NUMBER: 15473701 REVISION NUMBER: XXXXXXX 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 TYPE OF INSURANCE ADDL D SUBR POLICY NUMBER POLICY EFF MWDONYYY POLICY EXP MMIDDlYYYY _ LIMITS D TMERCIAL GENERAL LIABILITY CLAIMS -MADE [R] OCCUR N N 1000090512181 6/30/2018 6/30/2019 EACH OCCURRENCE $ 1,000,000 _ PREMBESOEaoccu ante $ 100,000 MED EXP (My one person) $5000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE LOCLOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER D D AUTOMOBILE LIABILITY X ANYAUTO N N 1000198837181 (MA) 1000198836181 (AOS) 6/30/2018 6/30/2018 6/30/2019 6/30/2019 COMBINED SINGLE LIMIT Ea accident)$ 2,000,000 BODILY INJURY (Per person) $ XXXXXXX BODILY INJURY (Per accident) $ . _ XXXXXXX FIIROPERTYDAMAGE $XXXXXXX Per a"Idenl OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON-OWNEO AUTOS ONLY AUTOS ONLY _ $XXXXXXX X Comp/Coll D IX Various UMBRELLA LIAR El OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX___ AGGREGATE $ XXXXXXX EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ XXXXXXX D WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N/A N 1000003291 6/30/201$ 6/30/2019 X I STATUTE ERH E.L. EACH ACCIDENT $ 1.000.000 E.L. DISEASE - EA EMPLOYEE $ 1.000,000 E.L. DISEASE -POLICY LIMIT 1 $ 1.000.000 If yes, describe under OE SCRIPTION OF OPERATIONSbelo. A N N MKLV5EUL101095 6/30/2018 6/30/2019 Limit: $3,000,000 A XS General Liab MKLVSEUL101095. 6/30/2018 6/30/2019 Limit: $4,000,000 B �XSAutoLlab 2nd XS Layer ELD30000710700 6/30/2018 6/30/2019 Limit: $5M xs $5M C 3rd X 100030507901 1 6/30/2018 6/30/2019 Limit:$6M xs$10M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Excess Liability limits for Evanston Insurance Company (Policy # MKLVSEUL101095) include $3,000,000 excess the primary Auto Liability and $4,000,000 excess the primary General Liability and Employers Liability. Evidence of Insurance CERTIFICATE HOLDER CANCELLATION 15473701 C/o Wind River Environmental, LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 46 LIZOtte Dr. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Marlborough MA 01752 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR 7 ©1988-2019 ACGIRD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD