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HomeMy WebLinkAboutSite & Septic Corp. 12/31/2021-J I q -4- (� _1 00, 0 U Town of Mansfield Town of Mansfield - Board ofHealth 6 Park Row Me7P, AMA 02048 `> # Disposal Works installer Application APPLICANT: F�4)0h BUSINESS NAME: MAILADDRESS: jl-n S S1+0ez7t_ CODE: 02 O 17 BUSINESS PHONE: M 27 8'0 61 � BUSINESS CELL: BUSINESS FAX: E-mail: Alt E-mail: S 40 Gh d E� �n,a,').GoV)-, IDISS NUMBER: i,/Z ` 2 —s 2 1 q3 LICENSE HELD: Town Oar/ onj Year Licensed 2C>ZC> LICENSE HELD: Town Rcd (is �on Year Licensed `- 0 2 c�) V LICENSE HELD: Town TLe,.IIihc bC,ol Year Licensed 2-cv20 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 31st yearly. FEE: $100.00 Che&k 4t SIGNATURE: DATE: 7> IV12 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 Town of Mansfield 6 Park Isom, Mansfield, Massachusetts 02048 Health Department Amy Donovan -Palmer, MPH, RS Health Agent New Onsite Disposal Works Installer: Please submit the following documents and payment to the Health Department. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. • Disposal Works Installer Permit Application (Attached) • Tax Certification Form (Attached) • Workers' Compensation Insurance Affidavit: General Business. (Attached) • Workers' Compensation policy declaration page. The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address. The current Mansfield BOH fee is $100. Also attached to this application are relevant forms to be used: • Application for a Disposal System Construction Permit • Soil Suitability Assessment for On -site Sewage Disposal Please contact the Health Department if we can be of any additional assistance. Sincerely, wwv �alw.r�ax t Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 • Fax (508)261-7425 • Email adpalmer@mansfieldma.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: t o a7,:4 EE� tc CcrD Address: Il Phone #: 7 ?q - Z a - Cal V9 Are you an employer? Check the appropriate box: Business Type (required): L © 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]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[fl Other C S�n.cF v *My applicant that checks box kl 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, aworkers' 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: t/1Gt k,nq \-e— 7S a Cn V Insurer's Address: l� cdes+ _-,IC_," City/State/Zip: ( jes3k �o me S k ✓A Jt C I !fa Policy # or Self -ins. Lie. 9 0 C- i%tx-2 ' % O 3S i 5 %— 2o204� Expiration Date: 9 �� 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 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mms.gov/dia 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 2- 25 q 21 q� "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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\sleite\Desktop\Scott's DocumentsTood Establishments- Temp\TAX CER11FICA ON FORM.doc ACCORV CERTIFICATE OF LIABILITY INSURANCE DATE (MM DDrvYYY) 03/03/2021 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 CONTACT Tracey Maffei NAME: Mackinfire Insurance Agency PHONE (508) 366-6161 FAX /C No : Ext: AID. 11 West Main St E-MAIL Tmceym@mackinfire.com ar-Tmceym@mackintire.com ADDRESS: INSURERS) AFFORDING COVERAGE NAIC9 Westborough MA 01581 INSURERA: Main Street America Group 311 INSURED INSURERS: NGM Insurance Company 14788 Site and Septic Corp INSURER C: The Workers' Compensation Rating & Inspection Bureau 1179 South Main SL INSURER D: INSURER E: Bellingham MA 02019 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSD We POUCYNUMBER POUCYEFF MM/DD POLICY EXP MmIDD LIMITS X COMMERCIALGENERALLIABILITY CLAIMS -MADE 19 OCCUR EACH OCCURRENCE $ 1,000,000 DA AGETO RENTED PREMISES Ea ocwrrence 500,000 $ MEDEXP(Anyaneperson) _ $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 A MPP8230D 09/16/2020 09/16/2021 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY ❑ JEQ El LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS- COMPlOP AGG 2,000,000 $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acddent $ 1,000,000 BODILYINJURY(Perperson) _ $ ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS M2P8230D 10118/2020 10/18/2021 BODILY INJURY (Per accidenp $ PROPERTY DAMAGE Peraccident $ HIRED NON-0ANED AUTOS ONLY AUTOS ONLY Undminsured motorist BI s 100,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION $ $ C WORKERS COMPENSATION EMPLOYERS' LIABILITY Y ANY PROPRIETORIPARTNERIEXECIDIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, descdUe under DESCRIPTION OF OPERATIONS helm NIA AWC-400-7035737-2020A 0911612020 0911612021 PER FOR STATUTE ER EL EACHACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 EL.DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Addmonal Remad¢ Soh&lule, may W aaached ff mom space is mquinM) Town of Mansfield is listed as additional insured with respect to general liability per writtne contract or agreement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA 02048 r� V 1888-2U15 ACUHU CORPOKATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD