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HomeMy WebLinkAboutRibeiro Enterprises, Inc. - 12/31/2021NAME OF OWNER: 12yt,qk, 1� � �J f l l U BUSINESS TELEPHONE: rj'O �° )*s 5 4 % CELL: �O Y 3 % f�( 7j FAX: EMAIL: dliq 1ri6e,jr-oe /�y/�G/Ia0. com FED ID/SS NO: OV p) 7 aPO ALT EMAIL: FEE PER TRUCK: $100 u NUMBER OF TRUCK(S): Truck Registration number: / Circle one: epta FOG Truck Registration number: Circle one: Up age FOG Truck Registration number: Circle one: Septage FOG 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. TRUCKSINSPECTIONS: DATE: THURSDAY, NOVEMBER 12, 2020 TIME: 7:OOAM-11:OOAM 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: 133 City/State/Zip: Sef bI C 6 Phone #: SW ;Z *-� 5W 7 Pp Are y an employer? Check the appropriate box: Business Type (required): 1.I�J r am a employer with y employees (full and/ 5. Retail or part-time).* 6. ❑ Restauram/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales (met. 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]* I .❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. Other *Any applicant that checks box #1 most 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 Insurer's Address: City/State/Zip: iL✓np? PA 41,lf 6A7 2 J Policy # or Self --ins. Lic. # ;V G 7�� ? y5c Expiration Date: 1lw/a21 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, undet.�ains anoenalties of perjury that the information provided above is true and correct. 70 Phone #: .2-t3 ell 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 A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDYYYY) 11/16/2020 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(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 Partners Insurance Group, LLC 560 Wilbur Avenue Swansea MA 02777 CONTACT Maria Arruda PHONE FnX ac No Ext: 508-491-3176 INC.No:508-491-3108 ADDRESS; MArruda@ParInerS;InscGrpLLC.com INSURERS AFFORDING NAICN _COVERAGE INSURER A: NGM Insurance Company 14788 INSURED RIBEI-2 INSURERS: Main Street America Assurance Company 29939 Ribeiro Enterprises Inc. Dylan J. Ribeiro -- INSURERC: --- P.O. Box455 INSURERD: INSURER E: Norton MA 02766 INSURER F: CGVFRAGFB CERTIFICATE NUMBER: 659309817 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 rypE OF INSURANCE ADDL SUBft POLICYNUMSER MM%UD EFF MMIPO"ODY�p LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y Y MPT2783C 10/412020 10/4/2021 EACHOCCURRENCE $1,000,000 DAMAGETORENTED PREMSES(Ea occunence $500,000 MED EXP (Any one pesos) $10.000 PERSONAL& ACV INJURY $1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY 0 JECOT LOG OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG 1 $2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY MIT2783C 10/4/2020 10/4/2021 COMBINED SINGLE LIMIT Ea accident $ _ BODILY INJURY (Per person) $500,000 BODILY INJURY (Per accident) $1,000.000 PROPERTY DAMAGE Pera¢ident $500,000 A X UMBRELLAUAB EXCESS LIAB X OCCUR CLAIMSWADE N N CUT2783C 10/4/2020 10/4/2021 EACH OCCURRENCE $1,000,000 AGGREGATE $1.000,000 _ DED I X RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN ANYPROPRIEfOR/PARTNERIEXECUTIVE Y OFFICERIMEMBEREXCLUDED4 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA N WCT2783C 11/10/2020 11/10/2021 PER OTH- STATUTE L ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE -POLICY LIMIT $500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remar s Schedule, maybe aHached if more space is required) 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 6 Park Row AUTHORIZED REPRESENTATIVE SZ-A— Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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: Corp ate 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\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc