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Home My WebLink AboutAdvanced Environmental Excavation, Inc. - 12/31/2019ck,mK Town of Mansfield ' Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: BUSINESS NAME: ADVANCED ENVIRONMENTAL EXCAVATION. INC. MAIL ADDRESS: 51 GLEBE STREET CITY/TOWN: TAUNTON STATE: MA ZIP CODE: 02780 BUSINESS PHONE: (508) 880-1920 BUSINESS CELL: (508) 889-4206 BUSINESS FAX: E-mail: INFO@ADVANCEDENVI RONMENT.COM Alt E-mail: JAMES T.BROPHY@AOL.COM ID/SS NUMBER: 04-345-0312 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town Year Licensed Year Licensed Year Licensed Please submit a copy of the licenses held along with a contact name and phone number for each town. References will be checked. 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: 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 1= ADVAENV-01 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOIYYYY) 919121119 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policlea may require an endorsement. A statement on this certificate does not confer d hts to the certificate holder In lieu of such endorsement a . PRODUCER MET-- FBInsure, 128Dean Street Taunton, MA 02780 Nc, EX1: 508 824.8%, No 508 S80-0142 .Info ineure.com _ NORPIRRISI AfFORDING COVERAGE NNO0 Ina Co of Southeast 39926 _NiLuggitA;Selective INSURED INSURER ®;Selective Ina CO Of SC 19259 INSURERC: Advanced Environmental Excavation Inc 51 Glebe St Taunton, MA 02780 SURE D; — INSURER e ; INSURERF: _ COVERAGES ERT FIC TE 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. ILTA NSR TypE pp INSURANCE LOVER pOLICV NUMBER POLICY EFF POL YEXP 0/16/2020 LamaA X CONMERCIALGENERALLIABILRV CLAIM"ADE a OCCUR BlktAdd9Ins 2041114 0115/2019 EACHOCCURRENCE1,OOD,000 OAMAGETORENTED 00,000 X MED EXP one con S 15,000 X BIkt WBIVer PERSONAL &ACV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYO jrg LOC OTHER: GENERAL AGGREGATE 3,900,000 PRODUCTS.COMPIOPAG 3,000,000 B AUTOMOBILElUB0.OY ANY AUTO Try A�� OffOONLY UHOULO AU�� prEO�3 . C AN0"M A 9099032 9/16/2019 8/15/2020 OMBINED,MISINGLELIMIT 1,000,000 E ILYINJURY Par ,MM, S BODILY INJURY Par acchi n X B! 7eYInGE n UMBRELLA LUIB EXCESS Luke HOCCUR CLAIMSMAUE EACH OCCURRENCE AGGREGATE DED RETENTIONS V/ORKERa CONPENBATNIN ANGfiNPLOYERe'L 0. Bp�pp(pARTNERIEXECUTNE YIN ANY PROPRIIET (Ixer' ,fn NN) EXCLUDED? Byyaec dwcdbo under DESCRIPTION OF OPE TONS belo NIA PER OTH- E.L EACH ACCIDENT _ E.L DIS SE -EA EMPLOYE .L. DI-POLICYLM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, AddlUonol Remarks SchedLde, maybe attached If mom apace In mqueed) Septic systems installetionlremovallrepair Contractor. Town of Mansfield Town Hail 8 Park Row .Mensf1el4,.MA_82048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. reserved. 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. ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1V www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legi Business/Organization Name: Aal-4w,, e t%/ CAM, 0ew,vt e° 41 ExL l,-, c. Address: � / K"lt'l f SE Phone #: Z— ., U 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. ❑ 1 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. An workers' comp, insurance required] 8• ❑ Non-profit 3. e are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers'. comp. insurance req.] 12.❑ Other CXr&y,5y l != � *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 #l. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 tine 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 Aereby—c—er—lifA under the painted penalties of perjury 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