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HomeMy WebLinkAboutD. Berndt Sanitation & Excavation - 12/31/2021Town of Town of Mansfield - Board of Health 6 Pak Row Mansfield 77field, MA 02048 Disposal Works Installer LICENSE NUMBER: APPLICANT: c;AMTTATTON & EXCAVATTON MAIL ADDRESS: CITYITOWN: ATTLEBORO STATE: MA ZIP CODE: 02703 BUSINESSPHONE: 508-222-4963 BUSINESSCELL: 508-930-3760 BUSINESS FAX: ri,pR 226-s44R E-mail: D-Rprn(9i-Sanit-atinn@cnmcast.net Alt E-mail: ID/SS NUMBER: 20-4721814 LICENSE HELD: Town ATTr.RBORO Year Licensed LICENSE HELD: Town NORTnN Year Licensed LICENSE HELD: Town prArNV�LLF, Year Licensed 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 SIGNATURE: f 1c DATE: 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 20-4721814 "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:\Usem\sleite\Desktop\ScotPs Docnments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth oj'Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 rvrorv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: D. BERNDT SANITATION & EXCAVATION Address: 120 MELODY DRIVE, City/State/Zip: ATTLEBORO, MA 02703 Phone #: 508-222-4963 Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 2 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 Iron -profit organization, staffed by volunteers, with noemployees. [No workers' comp. insurance req.] I 12.❑X Other SEPTIC SYSTEM INSTALLATION "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 111. I urn an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: r.TBRRTV MUTUAL INSURANCE Insurer's Address: P 0 BOX 188025 City/Slate/Zip: FAIRFIELD OH 45018-80 5 Policy #or Self -ins. Lie. BKW57934030 Expiration Date: 8/1/2021 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 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 hereb certi under 11 a pains nd penallies of perjury that the information providedf above is trite rot? correct. Sianattue. NA 01 Ah .1 Date [ ®1 I d(1 Phone #: 508-222-4963 Official use only. Do nol 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.nmss.gov/dia Phone #: From: Tim Gilmore Fax: 17659074329 To: Fax: (508) 226.5448 Page: 2 of 2 101141202012:06 PM ACIC>R .! CERTIFICATE OF LIABILITY INSURANCE GATE IMMIODIYY V 10114/2020 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 certiNcate 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER coNYAcT NAME; Ann -Marie Kahanowilx NA R S GILMORE INSURANCE AGENCY INC °�gMD E ,508) 699-7511 pE No: ADDRESS: amkehanowilz@rsgilmom.com _ INSURER(S)AFFOROING COVERAGE NAIC0 27 ELM STREET NORTH ATTLEBORO MA 02761 wsuRER A o ACE AMERICAN INSURANCE CO 22667 INSURED INSURER 9: INSURER C: BERNDT DONNA IN6URER0: DBA D BERNDT SANITATION INSURER E: 120 MELODY DRIVE 1 INSURER F: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 584836 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 INDIOATCD. NOTWITI ICTANDIHO ANV nCOUITLEMCNT, Tcnm On CONDITION Or A.PPf CO)ITnACT On OTI icn DOOLIMENT V11TI I nCCnCOT TO WI 11011 TI 110 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. INSLTR TYPE OF INSURANCE O R POLICY NUMBER MhWOONYY MSUOPO O ExP LIMITS CONNERCIALGENERALUABDITY EACH OCCURRENCE $ CLAIMS -MADE a OCCUR PREM SES Ea.mirence $ MED EX (An ono peson) S PERSONAL 9ADV INJURY S N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POI,ICV PE 6 LOC PRODUCTS-COMPiOP AGO S S OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LI Ea eWdent S BODILY INJURY (Per Person) S ANY AUTO ALL OWNED SCHEDULED AUTOS TOS NIA BODILY INJURY (Per acdden0 $ PROP RTY DAMAGE $ NONOWNEO HIRED AUTOS AUTOS F UMBRELLA LIAR OCCUR EACH OCCURRENCE_ S AGGREGATE S ERCESS LIAR CLAIMS -MADE N/A DED I I RETENnON6 S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN FOBXEWTIVE OFCEPIMEMERECLU D?NA Mandatory in NH) SG2U64854P57720 092l2020 0912212021e•EncHAcaDENr X L STATUTE ER EL. DISEASE -EA EMPLOYEE $ 500,000 S 500,000 Use, dsscnbe under DESCRIPTION OF OPERATIONS below E.L, DISEASE -POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional 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 OG B, no authorization is given to pay claims for benefits to employees in stales other than Massachusetts it the Insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy in force on Die date that this certificate was issued (unless the expiration dale on the above policy precedes the Issue date of this ceglDca(a o1 insurance). The status of this coverage can be monitored dally by accessing the Proof of Coverage - Coverage Verification Search tool at vnrpv,mass.gov/lwdlwmkems ompen5ationtinvealigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield Board of Health ACCORDANCE WITH THE POLICY PROVISIONS, 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02046 ,I Dan'"'"-••�•�• iel M. CrgWfey, CPCU, Vice President —Residual Market— WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD From: Tim Gilmore Fax: 17659874329 To: Fax: (508) 226.5448 Page: I of 2 101141202012:05 PM DONN&DO-07 AKAHANOVVITZ DATE 10/141202 yr) � a�a/zozo .4CC7/?L7" CERTIFICATE OF LIABILITY INSURANCE L--'� " 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 10 WANED, sub)aat 116 tha tam%i and asndltlana of tha psllay, aaf1a115 p66alaa nVly eaqulm aft midSritemaht. A staten%lit CII -this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C ACT R.S.GilmoreInsurance L Na, E,h): (608) 699-7611 aJc, No :(608) 696.3697 Risks ; North Attleboro, MA 02760 INSURERIS AFFORDING COVERAGE NAICS INSURER A: West American 4439_3 _ INSURED _ _ INSURER B: INSURER C : Donna & Donald Bemdt 120 Melody Drive Attleboro, MA 02703 INSURER D_____,_ —----"—'— INSURER E: --- INSURERF: COVERAGES CERTIFICATE NLIMRER• RFI/ICIAN KUMASI 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL SUBR pOI.ICY NUMBER POLICY EFF 8/112020 POLICY E%P 8/112021 LIMITS A X COM6ERCIAL GENERAL LIABILITY CLAIM&MADE OCCUR X BKW5793403D EACHOCCURRENCE S 1,000,006 DAMAGES RENTED 100,000 MEO EXP (Anyane erson S 15,000 PERSONAL&ADV INJURY 1000'000 J �T._ GEN'L AGGREGATE LIMIT APPLIES PER: POLICYO Pea F �LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPJOP AGO 2,000,000 A AUTOMOBILE IX LIABILITY ANYAUTO OWNED SCHEDULED 1AUT�OESONLV X AUUpTTryOoSSVW�NN��pp AUTOS ONLY .X AU cs% V SAW57934030 8/1/2020 8/1/2021 COMBINED SINGLE LIMIT 1€a a.:ui2eml I ON 000 BODILY NJURY (Perperspn) BODILY Per eultlent $ qITNyJJUppRY .('A0aacident)AMAGE It UMBRELLA LWB EXCESS UAB Id OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE S DEC) RETENTION E ffl E%L3CC��IENS&TONN Y/N QM�pYPRpOPEIEMTSgOe¢pNpEXCWEIE ECUTNE j—) IMantla{roryPln NN) LJ ify69,Cdescdbeunder DESRIPTION OF OPERATIONS below WA PA E ETMD EL EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES(ACORD 101 Additional Remarks Schedule, maybe attached R more space is re fired) Town of Mansfield is named as an Additional Insured unlier the General Liability when required by written con Tract. CERTIFICATE HOLDER CANCFLI ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield Board of Health 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Mansfield, MA 02048 AUTHORIZED REPRESENYA71VE ACORD 26 (2016/03) e01988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD