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HomeMy WebLinkAboutBP Trucking, Inc. - 12/31/202144 q4- -).s - 76r0-= V" n a gl. r tl ld Board ASK °f w Trash Hauler's Application BUSINESS NAME: 9 BUSINESS ADDRESS:--? n c) 'k :2 r TOWN / STATE / ZIP: AS F-1 i A rli -/-) In A NAME OF OWNER: ray �)✓=A (7 L �� TELEPHONE NO: - Lik- ? s /_ /dC e-;� CELL NO: % 7 V• i j- FAX NO: R- Ss'.Sf i / L- _� PRIMARY EMAIL: a LP s Cd h �Ilp�e , C� L)m FED ID/SS NUMBER: REGISTRATION NO: NO OF TRUCK(S: / FEE PER TRUCK: $75.00 TOTAL FEE TO BE PAID: $ / Town of M sfisId fi Row . Mr MA 02048 "-'' e� t ✓� SIGNATURE: xG D DATE: 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 Individual or Corporate 40ame By: Co orates fficer ( audatory 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\sleite\Desklop\Scotts Docnments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE02/27/2018 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 I RDED (S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must 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 endorsemen s . PRODUCER THE GETCHELL COMPANIES INC P O BOX 844 STOW MA 01775 CO TACT NAME: Christina Dennehy PNONE . 978 697.7773 FAX AIC o E-MAIL ADORES Chdsttha@gelCAefiCOm anies.com INSURER S AFFORDING COVERAGE INSURERA: TRAVELERS INDEMNITY CO OF AMERICA NAIC# 25666 INSURED B P TRUCKING INC INSURERS: INSURERC: INSURERD: PO BOX 386 INSURER E ASHLAND MA 01721 1 INSURER F: ncrrorwr" UHHOCrt: 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 CONTRACTOR 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. ILTR TYPE OF INSURANCE ADD ]SUBR POLICYNUMBER MM/DDY EFF MMIDDYA'l YY LIMITS COMMERCIALGENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACH OCCURRENCE $ E PREM SES ESoccuarrence $ $ MEDEXP(Anyone arson) N/A PERSONAL& ACV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY❑JECTPRO- LOC GENERALAGGREGATE $ GEN'L PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT Ea accMen $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTO8 NOWOWNED AUTOS N/A BODILY INJURY (Per person) $ BODILY INJURY(Peraccidenl) $ PROPERTY DAMAGE Per accident $ T_ UMBRELLALIAB EXCESS LIAR H OCCUR CLAIMS -MADE N/A EACHOCCURRENCE $ AGGREGATE $ LIED I I RETENTION$ WORKERSCOMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNERJEXECUTIVE OFFICERIMEMBEREXCLUDEDT NIA (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below _ X STATUTE ERH $ A NIA N/A 6HUB5046P65218 02/07/2018 02/07/2019 E.L. EACH ACCIDENT $ 1,OOD,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1 $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonal Remarks Schedule, maybe attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was Issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage Can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.govflwd/workers-compensation/Investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Chicago IL 60642 Daniel M. Cr�oJey, CPCU Vice President— Residual Market— WCRIBMA ©1988.2014 ACORD CORPORATION. All rights resen At UKu 2D (2014/0) The ACORD name and logo are registered marks of ACORD iZsl The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ulr� mvty.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lelzibly Business/Organization Name: B—P Trucking, Inc. Address: 47-65 Nickerson Road P.O. Box City/State/Zip: Ashland, MA 01721 Are you an employer? Check the appropriate box: 1.® I am a employer with g0 employees (fill 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.] Phone#: 508-231-1000 ITIM131 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 l l.❑ Health Care 12.�] Other Solid Waste "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 run an employer that is providing tvorlrers' compensation insurance for my eaployees. Below is the policy information. Insurance Company Name: The Travelers Idemnity Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. # 6RUB5046P65220 Expiration Date: 2/07/2021 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 MOL a 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 c ify, under the pAitis and pAialties 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 Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person Phone www.mass.gov/dia