HomeMy WebLinkAboutDavid Towle & Sons Excavating - 12/31/2019Town of Mansfield - Board of Health
Disposal Works Installer Application
LICENSE NUMBER: '` ! r
APPLICANT: bra V 11 C 1 ,40
BUSINESS NAME: _ VI I /31J t, L U"S E�
o
SEP 25
Town of Mansfield
6 Par -Row
Mansfield, MA 02048
MAIL ADDRESS: 14), 1 tol)�x 14 i I I , R oa i
CITY/TOWN: l (A 4Y 1 ICU tt STATE: V-r ZIP CODE: U 2O `if
BUSINESS PHONE: �T " 3_53 N A BUSINESS CELL: `T �° ' 0 ► tr0�
BUSINESS FAX: Yl
E-mail: II �Urll rah � ho
Alt E-mail:
ID/SS NUMBER: Q,: P Sy— p 41
LICENSE HELD: Town ru l aP)-1) 9I �' /'jt l
LICENSE HELD: Town I D RW J � U l � A_
LICENSE HELD: Town f 1AkA y i I I L
Year Licensed SSW
Year Licensed C9 00 O
Year Licensed J v + L4
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: jXj
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.
L'4
Signa ure of Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
b�q _n IScf 1
**Social Security No. (Voluntary) 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.
C:\Users\sleite\Desktop\Scott's Documents\Food Establisbments-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Addre.gs: hl , ViAiqe
City/State/Zip: t C U I) Jt' )aj) d P-1
Are you an employer? Check the appropriate box:
L[&I am a employer with 9 employees (full and/
or 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 employees. [No workers' comp. insurance req.]
*Any
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
1 L❑ Health Care
12.❑ Other
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organivation should check box #t.
am an employer that is providing workers' compensation insurance for, my employees. Below isAke policy information.
Insurance Com
Insurer's Addr,
City/State/Zip:
N
/Y L
Policy # or Self -ins. Lie. # �)ocloo llo q Expiration Date: ° br oLoo—C)
Attach a copy of the workers' compensation policy declaration page (showing the policy number Ad expi •ation 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 eert fy„ alkler Jhe paoy and 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
C. VKc,htln.-, F
µi Mutual Insurance Co.
Date: May 20, 2019
Policy Number: 0000061473
Policy Information Page
1
Account Holder: David L Towle Agent Name: Karen L Worcester -Wood
Address: David L Towle & Sons Excavating Agent Address: 3 Putnam Pike
42 Tower Hill Road Route 44
Cumberland, RI 02864-1508 Chepachet, RI 02814-2226
Phone: (401)949-5551
Agent Number: 01356
NCCI Carrier Code: 30325
Named Insured: David L Towle Dec Type: Renewal Group Affiliation:
Endorsement Reason
Transaction Date: 05/20/2019
Policy Number
Endorsement Effective
Date
Endorsement Expiration Date
Account Number
0000061473
1 07 09 2019
1 07 09 2020
1 20493039
2
Policy Period
From
I To
07/09/2019
I 07/09/2020
12:01 a.m. standard time at address of named insured
3
A. Workers' Compensation Insurance: Part one applies to the Workers' Compensation law of Rhode Island.
B. Employers' Liability Insurance: Part two applies to work in Rhode Island. The limits of our liability are:
BODILY IN URY BY ACCIDENT
$500,000
EACH ACCIDENT
II
BODILY INJURY BY DISEASE
$500,000
POLICY LIMIT
I
BODILY INJURY BY DISEASE
$500,000
EACH EMPLOYEE
IC. Endorsements & Schedules: I
Endorsement
Endorsement
Endorsement
Endorsement
BE_00_00_01 - WC and
BE_00_00_01A -
BE 00 00 40 - OFAC Trade
BE_00_00_50 -Audit Non
Employers Liability Policy
Cancellation Endorsement
Sanctions Notice and
Compliance Charge
Endorsement
Endorsement
This is not an Invoice
Insured
The Beacon Mutual Insurance Company
One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com
Underwriting: 401.825.2667 1 Toll Free: 1.888.886.4450
BE00 00 14 V9 _
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