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HomeMy WebLinkAboutWind River Environmental - 12/31/2019 (3)Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: NICHOLAS GENESEO Doing business as: WIND RIVER ENVIRONMENTAL 46 LIZOTTE DRIVE MARLBORO MA 01762 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: 13 FEE $100.00 BOARD OF HEALTH NichaeCHeaCey, Chairman 1 w DEC 14 2019 s Town of Mansfield - Board of Health 02048 Disposal Works Installer Application LICENSE NUMBER:, .L-1399 ,— APPLICANT: _.ir L�.O,_ BUSINESS NAME: MAIL ADDRESS: CITYITOWN: j. .:T.. ,. STATE: BUSINESS PHONE: glin -1/92-Ma BUSINESS BUSINESS FAX: .1-7A 56va- 7�5 E-mail: nef1tSP!7CaU� Alt E-mail, Wr��w�c1n+;.jc.�• Cb•r-• �EDERAL ID(SS NUMBER: d!" l — IHO( 7(Q "7 -7 LICENSE HELD: Town a- ZIPCODE: CELL: 9-73 —�' — (-0L,2&— _ Year Licensed LICENSE HELD: Town MC•t S(Jefa{ Year Licensed O''k2%�v` LICENSE HELD: Town _. lAn M Year Licensed la5 I have read 310 CMR 15AO, 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 FEE: $100.00 SIGNATURE: 4 DATE: I Please make appropriate chang Malt to: Board of Health, Town c !a, and enclose check for $f00:00 payable to Town of Manslleld. Six Park Row, Mansfield, MA 02048 � ± § ± ® » / C« \ \t . .1 , k to s % m % P � © © § .IN .<\. \ ( \ «? .� .. �....2..�.j.. ^ � . 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 Jndividual or Corporate Name 01-1 -341`�707"I **Social Security No. (Voluntary) or Federal Identification Number By: CoOeOfflcerMandatonf, 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 wider the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\DesktoplScotrs Dmuments\Food Esmbtlshments- Temp\TAX CERTiFICATION FORMA= The Cotinnotnvealth of Massachusetts Department of Industri4l Accidents Office of Investigations e 1 Congress Street, Stike 100 Boston, MA 02114-2017 tvtvita mrrss,gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information +' - ( Please Print Legibly Business/Organizat f2ion Name: l &Q �L c01�av n�z✓� ___ _ Address: (P -%70iA r— -. -- ----- Phone M AreeXou an employer? Check the appropriate box: Business Type (required): I A) I am a employer with —106 employees (full and/ 5. ❑ Retail ( or part-time).* 6. ❑ RestourantiBar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no g ❑ Office and/or Sales (root, 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. ❑ Bntertairlolent their right of exemption per c. 152, ys 1(4), and we have ME] Manufacturing no employees. [No workers' comp. insurance required]** I LHealth Care ❑ - 4. ❑ We are a non-profit organization, staffed by vol , umtaers c.j�- with no employees. [No workers' comp. insurance req.] 121DOtherC'v' *Ay applicant that checks box HI must also fill out the section below shaving their workers' compensation pelicy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is n:quired and such an organ ration should check box It I. !nun nhr autpioyer iltrrt is providing tvnrkers' coatpensnliar insru•mhcafnr my employees. Beloly is file police h1formation, Insurance Company Name:__�,_c,�,�-1,,�_'Sr e„ter, car• pj cu,��.r �__ Insurer's City/State Policy # or Self -ins. Lic. H�_Q.�QQQ..�es { 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 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 imprisomnent, 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 cergy, under the of perjure that the Information provided above is trite and correct. Official use only. Do not unite In this area, to be completed by city or town offtcMt City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. CityPlbwn Clerk 4. Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone AC40JZH CERTIFICATE OF LIABILITY INSURANCE 16*� 6/30/2019 DATE(MMIDDI(YYY) 1 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#01`15767 725 S. Figueroa Street, 35th flISM Los Angeles CA 90017 CONTACT NAME: _ PHONE ;FAX Nis Exti, AIC No:. E-MAIL ADDRESS: 213-689-0065 INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: Evanston Insurance Com an _ 35378 INSURED Wind River Environmental, LLC 1448815 46 Lizotte Dr. wsuRER 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 : 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 R TYPE OF INSURANCE ADDL D SUBS MD POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDDA'YYYI LIMITS p X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE I —XI OCCUR N N 10000905i2181 6/30/2018 6/30/2019 EACH OCCURRENCE $ 1i00'0Q00__-__ DAMAGETOREN TEU— PREMISES rE,, occurrent $ 100,000 MED EXP (Anyone person) $ 5 000 PERSONAL &ADV INJURY $ 1000000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L POLICYa JE� LOG PRODUCTS - COMP/OP AGO $2000000 $ OTHER D D AUTOMOBILE LIABILITY X ANYAUTO N N 1000198837181 ((MA))(AOS) 1000198836181 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 (Peracckkmn _ PROPERTY DAMAGE Pereccident $ XgXXXXg $ XXXXXXX OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY _ s XXXXXXX X Comp/Coll D IX Various UMBRELLA LIAR OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX EXCESS LIAB CLAIMS -MADE DED RETENTION$ I $ XXXXXXX D WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICEWMEMBEREXCLUDED? rN (Mandatory in NH) NIA N 1000003291 6/30/2018 6/30/2019 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 1 000 E.L. DISEASE - EA EMPLOYEE $ 1000 o00If yes, describe uner DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 A XS Auto Liab N N MKLV5EUL101095 6/30/2018 6/30/2019 Limit:$3,000,000 A XS General Liab MKLV5EULI01095. 6/30/2018 6/30/2019 Limit: $4,000,000 B 2nd XS Layer ELD30000710700 6/30/2018 6/30/2019 Limit: $5M xs $5M C 3rd X 100030507901 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 # MKLV5EUL 10 1095) include $3,000,000 excess the primary Auto Liability and $4,000,000 excess the primary General Liability and Employers Liability. Evidence of Insurance IQ 15473701 C/o Wind River Environmental, LLC 46 Lizotte Dr. Marlborough MA 01752 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Oi[-f:TaYIiS6tidKi1:7i7�T�l 73�7:7e�11 [gI�_11�tCIiiFAA ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD