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HomeMy WebLinkAboutClaude Dubord & Son, Inc. - 12/31/20213 g3Ll2 BUSINESS NAME: C14 ire, OoLr A l su ,? 3�1- MAIL ADDRESS: TOWN: 45 M ei e NAME OF OWNER: ar ad SCvJry }�' BUSINESS TELEPHONE: EMAIL: \ 1 11 FED ID/SS NO: 61 Z� 0 3 S 3 'Z-- FEE PER TRUCK: $100 STATE: 1tiJ.4 ZIP CODE: 6 Z.3 7- CELL: Jo � yvp 7,?Z( FAX:50y b 17- 3 24/ G r '✓% ALT EMAIL: NUMBER OF TRUCK(S): Truck Registration number: Truck Registration number: Truck Registration number: J `� ✓ Circle one: Circle one: Circle one: epta FOG S FOG eta FOG 5 3 Y 6 ( Lr N 0 2 Truck Registration number: Circle one: Septage FOG Truck Registration number: .............................................................................................................................................................................. Circle one: Septage FOG SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: THURSDAY, NOVEMBER 12, 2020 TIME: 7:OOAM-11:00AM PLACE: GILETTE STADIUM - PARKING LOT P10 PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE ............................................................................................................................................................................... FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 SIGNATURE: DATE: 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 Name By: r ora e O cer (Mandatory, if Applicab e) **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\sleitc\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts txs Department of Industrial Accidents I Congress Street, Suite 100 9i1Boston, MA 02114-2017 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITI'. Applicant Information T Please Print Leaild Name (Business/Organization/Individual) City/State/Zip:- ,t t C Are you an employer? Check the appropriate box; #: 6bL (,57- Z621 LE0 I am a employer with 1employees (full and/or part-thnel- 2.r-1 I am a sole propriaorerparmership and havc no employees working for nee in any capacity, [No workers' comp. insurance required.] 3.L] I am a homeowner doing all work myself [No workers' comp, insurance required.]' 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. twill ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.[] 1 am a general contractor and i have hired die sub -contractors listed on the attached sheet, These sub -contractors have employees and have workers' comp. insurance.I 6.Q We are acculturation and its officers have exercised their right orexemption per MGL C. 152, §1(4), and we have, no employees, [No workers' cmnp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 [] Building addition l LQ Electrical repairs or additions 12, Q Plumbing repairs or additions 13.EJ Roof repairs 14: J] Other S,-,o 3 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this offidnvit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ;Contractors unit check this box must attached an additional street showing the nano of the sub-contructm's and state whether or not those entities have employees. If the sub-conhactms have employees, they must provide their workers' comp, policy number. l am an employer that is providing workers' compensation insurance jar my employees. Below is the policy and Job site information. Insurance CompanyName;_Zn� `B / Policyll or Self -ins. Lie,ff: V`f00 Expiration Dater tYl Z Job Site Address: City/State/Zip: _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violatiotrpunishable by a tine 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverace verification. O(ftcial use onlp. Do not write in this area, to be completer/ by city or town afficial. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone ac®2a CERTIFICATE OF LIABILITY INSURANCE �✓ DATE(MM/DD/YYYY) 05/12/2020 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(s). PRODUCER CONTACT Robert Manahan NAME: E&C Insurance LLC PHONE N Eat . (508) 697-6963 FAX(AleNe : (508) 697-5809 45 Main Street EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICB Bridgewater MA 02324 Sent Insurance Company INSURER ry P Y INSURED INSURER B : Claude Dubord & Son Inc. INSURER C: 45 Mae Avenue INSURER D : INSURER E : Bridgewater MA 02324 INSURER F: COVERAGES CERTIFICATE NUMBER. 2020 COI DCVIQIALt AD oases. 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 AUU1. INSD NUDR MD POLICY NUMBER POLICY EFF MMIDD POLICY EXP MM/DD/YY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR EACH OCCURRENCE $ 1,000,000 PREMISES Ee occurcence I $ 500,000 MED EXP(Any ane Person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 A A0149654003 05/14/2020 05/14/2021 GENTAGGREGATE LIMITAPPLIES PER: POLICY � JEC LOG GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG 2,000,000 $ Employee Benefit $ 1,000,000 OTHER: AUTOMOBILE LIABILITY G©MBINED SdiODEA1MIT Ea accident $ 1,000,000 BODILY INJURY (Par person) $ ANVAUTO A OWNED x SCHEDULED AUTOS ONLY AUTOS A0149654004 05/1412020 05/14/2021 BODILY INJURY (Par accident) $ HIRED v NON -OWNED AUTOS ONLY X AUTOS ONLY X PROPERTY DAMAGE Per accltlent $ $ X UMBRELLA LIAB �/ X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB ICLAIMS-MADE A0149654006 05/14/2020 05/14/2021 AGGREGATE $ 2,000,000 DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICER/MEMBER EXCLUDED? PROPRIETORIPARTNEWEXECUTIVE ❑ N/A A0149654005 05/2512020 05I14I2021 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 600.000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 A Professional Liability A0149654003 05/14/2020 05/14/2021 Each Wrongful Act Aggregate 100,000 200,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached it more apace is required) Town of Mansfield 6 Park Row 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 Mansfield MA 02048 I at" 1. All riahts ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD