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HomeMy WebLinkAboutJF Moreshead Excavating - 12/31/2021/YK -1 coo® Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfi A 02048 r Disposal Works Installer Application�R LICENSE NUMBER: APPLICANT: CA%i%/, oin%are6�eA�Q BUSINESS NAME: eT F -M oRP.s h! P d MAIL ADDRESS: v a.5'o MA A) jQ1 Ave 34-79 CITY/TOWN: No c1o/J STATE: ff)_ ZIP CODE: D2 7 6 6 BUSINESS PHONE: ?'iN aoo 7&f BUSINESS CELL: So r)r 7,7irN/e1,(/ BUSINESS FAX: E-mail: SMOCCbile aca,joh'nofir1C.eN6,,Aoo.,com Alt E-mail: 'EDERALIDISSNUMBER:a—Q9O6$O(� LICENSE HELD: Town Fokbo(co Year Licensed LICENSE HELD: Town { sio &� Year Licensed 2 o a LICENSE HELD: Town No A-lflcboro Year Licensed 2*�B Please submit a copy of the licenses held along with a contact name and phone number for each town. References will be checked. I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage". I understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31 st yearly. FEE: $ 100.00 SIGNATURE: /��� F DATE: ?_ y y _ D y Please make appropriate changes. Sign, date, and enclose check for$100.00 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. Sign re of Individual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, if Applicable) *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\steite\Desktop\ScotPs Docoments\Food Establishments-Temp\TAX CERTIFICATION FORM.doc ACORO® CERTIFICATE OF LIABILITY INSURANCE p" 2/1612020 ' 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsement(s). PRODUCER NANE CT Mark D. Souza Insurance Connection Agency, Inc. PNONE FAX I: 508-386-2291 A(c No:508-386-2298 P.O. Box 401 Mansfield, MA 02048 EMAIL AOpRE55: PRODUCER INSURE S AFFORDING COVERAGE NAIC0 INSURED INSURER A': Nautilus Insurance Co. INSURER e: Arbella Mutual Insurance. Co. JF Moreshead Excavating, Inc. _ 250 Mansfield Avenue, Unit # 79 Norton, MA 02766 (NsuRERc: Liberty Mutual Insurance. Co. INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 MATH 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 - AODLe BR POLICYNUMBER POLICY EFF IMMIDDYMI POLICY EXP IMMIDDrMY)LIMITS A GENERAL LIABILItt X COMMERCIAL GENERAL ABILITY CLAIMS-MADE FRIOCCUR r i I- NN7200984 12/0912020 1210912021 EACH OCCURRENCE S 1000,000 PREMISES Eaooc:uvence $ inamn- MEDEXP(Anyone non) S 5000 PERSONAL B ADV INJURY $ 1,000000 GENERALAGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- El LOG POLICY M PRODUCTS -COMPIOPAGG $ 2000000 S B AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEOULEDAUTOS HIREDAMOS NON-OWNEDAUTOS - 102009035101 10/1V2020 10/11/2021 COMBINED SINGLE LIMIT (Ea ccide ant) s 1,000,000 BODILY INJURY(Per parson) $ BODILY INJURY(Peracddent) S PROPERTY DAMAGE (Peracolden0 S X S ' S UMBRELLALIAB EXCESS LIAS OCCUR CLAIM&MADE�� - EACH OCCURRENCE S AGGREGATE S DEDUCTIBLE RETENTION $ s S O WORKERS AND EMPLovERs•une COMPENSAVn�tv YIN ANY PROPRIETORIPARTNERAD(ECUTIVE OFFICERIMEMBER EXCLUDED? N❑ Mandatory In NNl f yes, describe under NIA VJC5-31$-820830-101 02l23/2020 02/23/2021 �ORIM T- X 0 E.L. EACH ACCIDENT S 00000 E.L DISEASE -EA EMPLOYE $ 1,000,000 E.L. DISEASE -POLICY LIMIT S r r DESCRIPTION OF OPEMPONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remaft Schedule, if more space Is mqulred) Town of Mansfield 6 Park Row Mansfield, MA 02048 ACORD 25 (2009109) 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- 20g"SPRD CORPORATION. All rights The ACORD name and logo are registered marks of ~1D The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lug www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: _ Kq� C C H E.a rJ �k ea v��.wa=ram Address: --a ,r5-0 /{de 479 Are you an employer? Check the appropriate box: LF I I am a employer with employees (full 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] 1 fa 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 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) S. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 120 Other 1-5)qGp raA va 'Any applicant that checks box H 1 must also fill out the section below showing their workers' compensation policy information. x-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:-1`1j,C0t'RNcf 27-NC-- Insurer's Address: /? t2, & A v 410 City/State/Zip: llianjYr'el�ii4 ��oHF Policy # or Self -ins. Lic. # "J A0 0 99 y Expiration Date: /d.A ci ja-/ 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, tunder the pains a ldd penallies of perjury that the information provided above is true and correct 1f3'i 1� Signature: I]rU�AS6e La / Date: �) / I gI 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: 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 permit/license 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-NIASSAFE Fax # 617-727-7749 www,mass.gov/dia Form Revised 5-26-05