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HomeMy WebLinkAboutAbove Grade Excavation - 12/31/2019m SEp i 0 2019 Town of Mansfield Town of Mansfield - Boar of Health 6 Park Row Mansfield, MA 02048 Nt 4 FpA8 APt5, ' Disposal Works Installer Application LICENSE NUMBER: APPLICANT: 06'N0I,L _r n U BUSINESS NAME: I! OV E Qn®E MAIL ADDRESS: 33 _S ff`­' ^ 5 N, Ii DA�- CITYITOWN: Iy v A7ri e&o u STATE: eM fi ZIP CODE: 6,� 7G o BUSINESS PHONE: 30ls — D- I -I BUSINESS CELL: BUSINESS FAX: E-mail: 6&vC (APP(E.kI0 Aui, cum'+ Alt E-mail: IDiSS NUMBER: t6— -1 ( ft p try I LICENSE HELD: Town AJ Ortl w(,aa v Year Licensed t2no LICENSE HELD: Town Year Licensed 9616 LICENSE HELD: Town I-vc5rnan; 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 SIGNATURE: DATE: 'S -) 0 1 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. 00 C_ `p<,r0 Signature of Individual or Corporate Name "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:\Usecs\sleite\Desktop\Scoffs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ©V E O c ed c Cl1- ce lL n vn Address: 33 S)nrn5 /Frl/ ®^, City/State/Zip: N, 1)tf) -e&aku ;0)fi o,) 760 Phone #: .S-bi - - fd a- / rfr/ Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail _ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 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. g• ❑ 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 I 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Cate 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] I 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: b M Insurer's Address: Sf/ rth;� City/State/Zip: fit, A I! n S t '�n Policy # or Self -ins. Lic. # Av& C106 - 76 ' '10" 4 -,)(, i S (- Expiration Date: a® -do er©a C2 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 a 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 -rand penalties ofperjury that the information provided above is true and correct. 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 P -1 m 4C"'RL7 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 08/20/19 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 5 Man Mar Drive Plainville, MA 02762 CONTACT NAME: Rene AraujO PHONE _a.7096Durcan-Cuddy acEN. .699.7007 c No): . EMAIL" raraudurcan-cudd .com ADDRESS: J, @ Y INSURERS) AFFORDING COVERAGE NAIC 1/ INSURERA: Travelers Casualty & Surety INSURED INSURER B : Associated Industries Of MA Mu INSURER C: Commerce Dominic Tedino _ INSURER D: dba Above Grade Excavation 33 Spring hill Drive North Attleboro, MA 02760 INSURERE: INSURER F : COVERAGES rrRTIFICATF hIIIMRER- 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 INSD D POLICY NUMBER POLICY EXP MMIDD/VYYYX LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR y y 6803GB37960 rMMiDDrtM 09/18/19 EACH OCCURRENCE $ 1,000,000 D OR D PREMISES Ea occurrence $ 300,000 MED EXP An one erson $ 5,00A PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY [:] PRO- JECT F_�LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 $ Q AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY RSJ898 06106119 06/06120 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 150,000 BODILY INJURY (Per accident) $ 300,000 PROPERTY DAMAGE Per accident $ 100,000 $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEC) I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVEY/N OFFICER/MEMBER EXCLUDED? y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA AWC-400.7034006.2016A 02/20/19 02120120.:. X STATUTE OERH E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE- EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 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. ri ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD All rights reserved.