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Home My WebLink AboutRepublic Services - 12/31/2021r 3 10-, C0 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row IMans I-e1d,"MA-0204& S / Trash Hauler's Application OCT LULO BUSINESS NAME: BUSINESS TOWN/STATE/ZIP: NAME OF OWNER: TELEPHONE NO: CELL NO: FAX NO: PRIMARYEMAIL:'CCCi.it ALTERNATE EMAIL: FED ID/SS NUMBER:; I ( '` l -c,( l-i, REGISTRATION NO: IC62q(�) O j 61 NO OF TRUCKS: LA FEE PER TRUCK: $75.00 TOTAL FEE TO BE PAID: $ SIGNATURE: 8� 7'0a-, -VI Cb DATE: iJ 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. f Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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\sleile\Desktop\Scotts 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 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢ibly Business/Organization Name: Address: City/State/Zip. k (. t IA V ,j UC't , [ffClWO Phone #: ,' ; ( 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. [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.[4 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 f °� f� SILL` { �� i�Y l 1 t x1.() ( V ( ) � fyy { �(% Insurer's Address: ii iu City/State/Zip: t��t j c� t Policy # or Self -ins. Lie. # O t i', t h IL26 . 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 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 www.mass.gov/dia Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permitllicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-N ASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 COI Issuance Page 1 of 2 ACCMow CERTIFICATE OF LIABILITY INSURANCE Pageiol2 DATEONMMIM22/YYYY) 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 Ileu of such endomement(s). PRODUCER CONTACTNAME: PHONE (A/C NoAxl: I FAXA/C NO.Ext: CANNON COCHRAN MANAGEMENT SERVICES, INC. E-MAIL ADDRIESS;cenificateteamazoemsLosm 17015 N. SCOTTSDALE RD INSURERS AFFORDING COVERAGE NAICN SCOTTSDALE. AZ 85255 INSURER A: ACE Amedcanlnsorance Co. 22667 INSURER e: indemnityinsumnw Co an of NA 43575 INSURED INSURER c: ACE Ft. Unde(wdlera 207M INSURER D: Illinois Union Insurance Company 27W REPUBLIC SERVICES, INC. INSURER E: 18500 N. ALLIED WAY INSURER F: PHOENIX, AZ 85054 COVERAGES CERTIFICATE NUMBER: 1781143 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 INSURANCE ADDL INSD UBR WVD POLICY NUMBER POUCY EFF psWI)DIYYYY) POLICY EXP (NIMDDNYYY) LIMITS A X I COMMERCIALGENERAILLIABILITY CLAIMS -MADE 7X OCCUR HDO G71450892 06/3or=o oeno 021 EACH OCCURRENCE $5,CogOW DAMAGE TO RENTED PREMISES (Ea ocwnence) $50W000 MED EXP (Any one person) PERSONAL&ADV INJURY $61000.000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYPROJECT F-1LOC OTHER: GENERAL AGGREGATE $5,a0gDo0 PRODUCTSCOMP/OPAGG $5,onottoo q AUTOMOBILE LIABILITY X ANY AUTO X OVINED AUTOS ffX SCHEDULED ONLY AUTOS 1( HIREDAUTOS X AUTOSONLY NON -OWNED ONLY ❑ ISA H25305425 o6mr2o20 o6130R021 COMBINED SINGLE LIMIT (EeaodtlmU ES,000,000 BODILY INJURY(Perperson) BODILY INJURY (Per acddmq PROPERTY DAMAGE (Per accident) MBRELLA UAB OCCUR XCESS Lips CLAIMS -MADE DED RETENTION$ EACH OCCLRRENCE AGGREGATE S A C A D NORKERS COMPENSATION YIN ND EMPLOYERS' LIABILITY NY PROPRIETORPARTNERIEYECUTIVE N FFIDER/MEMBEft EXCLUDEDa Mmtlataryln NNt I(yes, describe under DESCRIPTION OF OPERATIONS below N/A W'LR C67458424 ADS WLR C6745M82 AZ/CAIMA/OR SCF 067458461 - W WCU C67456503-OH XS TNS C66948560-TX NSXS 0SM0Q020 OB/30rz020 OI3/30rz020 otv or2020 0613o2020 OB/30rz021 06/302021 OSM1221 08130rz021 08/302021 X PER L_JOTHER STATUTE E.L. EAC ACCIDENT E3000000 E.L. DISEASE -EA EMPLOYEE E 3,000,000 E.L. DISEASE -POLICY LIMIT 3000000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Division Number: 4097- Named Insured Includes: Allied Waste Services of Massachusetts, LLC- Dina: Allied Waste Services of Fall River// Republic Services of Fall River CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Mansfield AUTHORIZED REPRESENTATIVE AM: Board Of Health Sign 6 Park Raw Mansfield, MA 02048-2433 United States DownioadIMNCYK11LIMMER ID: LOC #: https:Hsecure.smartcompliance.co/WebForms/External/coi.aspx?htm=1 &btdown=l &doci... 10/14/2020 COI Issuance Page 2 of 2 ADDITIONAL REMARKS SCHEDULE Page 2 of POLICYNUMBER See First ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE NAMED INSURED REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY PHOENIX, AZ 85054 CERTIFICATE NUMBER: 1781143 The following provisions apply when required by whiten contract. As used below, the term certificate holder also Includes any person or organization that the Insured has become obligated to Include as a result of an executed contract or agreement. GENERAL LIABILITY: Certificate holder Is Additional Insured Including on -going and completed operations when required by written contract. Coverage Is primary and non-contributory when required by written contract. Waiver of Subrogation in favor of the certificate holder is Included when required by written contract. AUTO LIABILITY: Certificate holder Is Additional Insured when required by written contract. Coverage Is primary and non-contributory when required by written Contract. Waiver of Subrogation in favor of the certificate holder is Included when required by written Contract. WORKERS COMPENSATION AND EMPLOYERS LIABILITY: Waiver of Subrogation in favor of the certificate holder Is Included when required by written contractwhere allowed by state law. Slop gap Coverage for NO, WA and WY Is Covered under policy no. WLR C67458424 and slop gap Coverage for OH is Covered under policy no. WCU C67458503, as noted on page 1 of this certificate. TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY: Insured Is a registered non -subscriber to the Texas Workers Compensation Act. Insured has filed an approved Indemnity Plan with the Texas Department of Insurance which offers an alternative in benefits to employees ralherthan the traditional Workers Compensation Insurance in Texas. The excess policy (#TNS C66948560) shown on this certificate provides excess Indemnity and Employers Liability Coverage for the approved Indemnity Plan. Contractual Liability Is Included in the General Liability and Automobile Liability Coverage forms. The General Liability and Automobile Liability policies do not contain endorsements excluding Contractual Liability. Separation of Insured (Cross Liability) Coverage is provided to the Additional Insured, when required by written Contract, per the Conditions of the Commercial General Liability Coverage form and the Automobile Liability Coverage fonn. ACORD 101(2UN101) The ACORD name and logo are registered mart of ACORD Download COI in PDF format 01988-2010 ACORD CORPORATION. All rights reserved. https:Hsecure.smartcompliance.co/WebFormslExtemalleoi.aspx?htm=1 &btdown=l &doci... 10/ 14/2020