Loading...
HomeMy WebLinkAboutWaste Management of MA, Inc. - 12/31/2021BUSINESS NAME: BUSINESS AD TOWN / STAT / Zy Sn -� 3 NAME OF OWNS-R -4, IHI��1©1 - M Towo of Ma uqfield o Board ®fIt Health Trash Hauler °N A plpiinsap ou r TELEPHONE NO: �ok �y6 CELL NO: FAX NO: PRIMARY EMAIL: ALTERNATE EMAIL: FED ID/SS NUMBER: I. . wQ/ Town of Man Id: 6 Park Row ' =' Mansfield, MA 02048 REGISTRATION Na IVV6 7Z s NO OF TRUCKS: i7(oaD- FEE PER TRUCK: $75.00 TOTAL FEE TO BE PAID: $ Il SIGNATURE: DATE: // /7 Z Please make appropriate changes. Sign, date and enclose check 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. Signature of or Corporate Name a �1- IDS 3 �06� **Social Security No. (Voluntary) or Federal Identification Number (Mandatory, if Applicable) unkq "'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 Establishments- Temp\TAX CERTIFICA PION FORbEdoc The Commonwealth of Massachusetts ii,�� t l [ ��, jd Department of Intlustrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE PILED WITH THE PERMITTING AUTHORITY. Dnlicant Information PI Bus iness/Organization City/State/Zip: i�%i�//?il : l��f�J� '.�%GAG' Phone#: )6j c ��->) �' ,�-) Are you an employer? Check the appropriate box: Business Type (required): Lp 1 am a employer with ! Cf% 7 employees (frill 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/of Sales (ael. real 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 1 l.❑ Health Care with no employees. (No workers' comp. insurance req.j 12.0 *Any applicant that checks box ttl most also fill out the section below showing their workers' compensation policy information. i/ **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 tltttt is providitr,gworkers' coitipensntion insurance for by employees. Below is the policy information. Insurance Company Name: 141 )( l // l , / /'I `,lI d cf: l(l ( Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. &, L>�i 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, nod�e"r the pains emit penalties of peijrtry that the information provided above is true andcorrect. Signature: M Date' V_.2-61' Phone Official use only. Do not write in this area, to be completed by city or town official. City or Town: DENNIS Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Kristen Keller, Health Director www Phone #: (508)-760-6158 ACORO' CERTIFICATE OF LIABILITY INSURANCE 14� 1/U2021 DATE(MWDDIYVYY) 1 12/6/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER LOCKTON COMPANIES 3657 BRIARPARK DRIVE, SUITE 700 HOUSTON TX 77042 866-260-3538 CONTACT W.%, Et): I W No); .MAIL D ESS: AFFORDINGINSURERISI INSURER A: ACE American Insurance Company 22667 INSURED WASTE MANAGEMENT HOLDINGS, INC. & ALL AFFILIATED, 1300299 RELATED& SUBSIDIARY COMPANIES INCLUDING: WASTE MANAGEMENT - NEW ENGLAND MARKET AREA 26 PATRIOTS PLACE, SUITE 300 FOXBOROUGH MA 02035 INSURER B: Indemnity Insurance Co of North America 43575 INSURER C: ACE Fire UndenvriterslnSUmnceCompany 20702 INSURER p,ACE Property & Casually insurance Co 20699 E COVFRAGFS MAWESTRn CERTIFICATE NUMBER: 10632621 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 LTR TYPE OF INSURANCE ANSD DL SVIVD URR POLICY NUMBER P LICV EFF I/l/2020 POLICY E%P 1/1/2021 LIMITS A X COMMERCIAL GENERAL LIABILITY y y HDOG71237345 EACH OCCURRENCE ,5000000 CLAIMS -MADE Fx] OCCUR DAMAGE PREMISES TO RENTED Ea occure ce 5,000,000 X MEDEXPAn one erson XXXXXXX XCII INCLUDED X ISO FORM C000n10413 PERSONAL &ADV INJURY $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $6000000 POLICY��E0 �LOC PRODUCTS -COMP/OPAGG$6000000 $ OTHER: A AUTOMOBILE LIABILITY y Y MMTH25290008 I/l/2020 I/l/2021 COMBINED SINGLE LIMITa accident) $ 1,000,000 X BODILY INJURY (Per person) $ XX}{XXxx ANY AUTO X AUTOSONLY SCHEDULED AUTO BODILY INJURY (Per accident $ XXXXXXX X PP Oa d ADAMAGE $ XXXXXXX AUTOS ONLY X AUTOS ONLY }( $ XXXXXXX MCS-90 D X UMBRELLALIA6 X OCCUR Y Y XOO G27929242 005 I/l/2020 I/l/2021 EACH OCCURRENCE $ 15000000 AGGREGATE IS 15,000,000 EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ XXXXXXX B '4 C WORKERS COMPENSATION WORKERS COMP NSATI- N AND ANYEMPLOYE PARTNEIUE%ECUTIVE YIN OFFICERNEMSEREXCLUDE07 NN/A (Myandatoryln Nn) Y WLR C66043058 ADS) WLR C66043D1D AZ CA&M SCFC66043095( 0 I/l/2020 I/t/2020 I/l/2020 I/1/2021 1/1/2D21 1/1/2021 PER OTH- X sTATuTE E ELEACH ACCIDENT $3000000 E.L. DISEASE - EA EMPLOYEE 3000000 DESCRIPTION OF OPERATIONSWe El. DISEASE - POLICY LIMIT 3000000 A EXCESS AUTO LIABILITY Y Y XSA H25289961 I/l/2020 I/l/2021 COMBINED SINGLE LIMIT $9,000,000 (EACH ACCIDENT) DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) BLANKET WAIVER OF SUBROGATION IS GRANTED W FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT RE URdED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EX FOR WORKERS' COMP/EL) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. 10632623 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 CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD