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HomeMy WebLinkAboutPaul Colantuoni Bros. Corp. - 12/31/2020I -ft- <60 51�7-/0o0 0 1 Town of Mansfield Town of Mansfield - Board of Health 6 Parr ow Mans��i,r1N� 03948 Disposal Works Installer Application LICENSE NUMBER: 12 (2018) APPLICANT: Paul COlantuonl BUSINESS NAME: Colantuonl Bros. Corp. MAIL ADDRESS: 77 Davis Ave CITYITOWN: Norwood STATE: MA ZIP CODE: 02062 BUSINESS PHONE: 781-255-1001 BUSINESS CELL: BUSINESS FAX: 781-255-1009 E-mail: stacey@colantuonibros.com l_ltiriir"I IDISS NUMBER: 04-3181739 LICENSE HELD: Town Taunton LICENSE HELD: Town Dedham LICENSE HELD: Town Brookline 617-799-0401 Year Licensed 2006 Year Licensed 2008 Year Licensed 2010 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: i 11 f, ) U •) o, 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. f t.klu-4w Phi Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 04-3181739 "*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\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.moss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly t � Business/Organization Name. v) 6 i � u, [, I ry; Lf-, Address: 11 [ ivl;t'> kfti City/State/Zip: `s` tv 5 �� i i�. t Phone # 11 Zvi! Ar�e{�ou an employer? Check the appropriate box: Business Type (required): 1. �l 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. teal estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We 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.n Other Eh V-) *Any applicant that checks box #1 must also rill 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 insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: tul i Policy # or Self -ins. Lie. # Gu it i 4C - C7Zi' 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 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 and penalties ofperjury that the information provided above is true and correct. Phone#: 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 4� �® CERTIFICATE OF LIABILITY INSURANCE DATE/2MIDDtY 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 Marsh & McLennan Agency LLC 100 Front St, Ste 800 Worcester MA 01608 CONTACT CindyCareyFAx PHONE o E : 508-595-7934 Alc Na:866-795-8016 aooalESS: Cind .care marshmma.com INSURERS AFFORDING COVERAGE NAIC r{ INSURER A: Hanover Insurance Com an 22292 _ INSURED COLANBROSI Colantuoni Bros. Corp. 77 Davis Avenue INSURER B: Massachusetts Bay Insurance CompanV 22306 INSURER C INSURER D: Norwood MA 02062 IN9URERE: _ IN URER F: COVERAGES CERTIFICATE NUMBER: 1297092362 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 TYPE OF INSURANCEINSD ADDL SUER Won POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MMIDD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR ZDNA397323 8/20/2019 8/20/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $700,000 MED EXP(My one person) $10,000 PERSONAL& ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY [X I JEo LOG OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG $2,000,000 $ B AUTO MOBILE LIABILITY ANYAUTO OWNED X SCHEDULED AUTOS ONLY AUTOS "REO X NON -OWNED AUTOS ONLY AUTOS ONLY ADNA317515 8/20/2019 8/20/2020 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Par person) $ BODILY INJURY Per accident ( ) $ X PROPERTY DAMAGE Per accident $ _ $ A X UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE UHNA397329 8/20/2019 8/20/2020 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED I X I RETENTION$ h $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED'! � (Mandatory in NH) It yes, tlescri5e under DESCRIPTIONOFOPERATIONSbelow NIA WHNA713149 8/20/2019 8/20/2020 X STATUTE EORH EL EACH ACCIDENT $500,000 E.L. DISEASE -EA EMPLOYEE $500,000 - E.L. DISEASE -POLICY LIMIT $500,000 A Equipment Floater IHND715314 11/15/2018 8/20/2020 Remedy Leasetl From Others, ACV $160,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Job: Disposal Works Installers License The Town of Mansfield is included as an additional insured asrespects General Liability, if required by written contract, for work performed by named insured. Town of Mansfield Board of Health 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. ©1988.2015 ACORD reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD .,aHinover Insurance Croup_ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 02 WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WHN-A713149-03 CARRIER CODE NO 13933 Policy Number Policy Period Coverage is Provided in the Agency Code From To WHN-A713149-04 08/20/2019 08/20/2020 THE HANOVER INSURANCE COMPANY 3202122 ITEM 1. Named Insured and Address Agent Telephone: 508-852-8500 COLANTUONIBROS CORP MARSH & MCLENNAN AGENCY 77 DAVIS AVE LLC NORWOOD, MA 02062 100 FRONT ST, 8TH FLOOR WORCESTER, MA 01608 Federal ID No. 043181739 Bureau File No. 000D96629 SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 08/20/19 TO 08/20/20 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. -----'------------------------------------------------------'------- ------------- ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- MA,RI. -------------------------------------------------------------------- B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT 0500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE S500,000'POLICY LIMIT -------------------------------------------------------------------- C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. -------------------------------------------------------------------- D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ---------------------------------------------------------------------------------- ITEM 4, THE PREMIUM FOR THIS POLICY WILL BE DETERMINE➢ BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. --------------------------------------------------------------------------- CLASSIFICATION OF OPERATIONS I EST f ANNUAL I PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS I I 24,235 PREMIUM DISCOUNT MINIMUM PREMIUM $750 EXPENSE CONSTANT PREMIUM FOR TERRORISM TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM ALL OTHER STATE TAXES AND ASSESSMENTS TOTAL STATE TAXES AND ASSESSMENTS TOTALESTANNUALPREMIUMINCLUDING ALLTAXESANDASSESSMENTS ------ -- - - - - - -- THIS DAY OF BRANCH OFFICE:100 NORTH PARKWAY 479- 338 $179 $24,273 $24,273 0672 0672 024,945 ------------- AUTHORIZED REPRESENTATIVE WORCESTER MA 01605 Form 331-0226(9-03) WCO000018 Date Issued: 08 23/2019 ORIGINAUINSURED Payment Type: ELECTRONIC EXCHANGE 000,er GROUP NAME: TARGET GROUP NUMBER: ZBG