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HomeMy WebLinkAboutBrunelle Contracting LLC - 12/31/202144 D,-�-t `i( (dQ "'o Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: _Z_� I To of Mansfield 6 P, rk ow Mansfield, MA 02048 j, APPLICANT: '8111 er-ae ._ ✓(?IF/ — ---- — ---- BUSINESS NAME:ji((i'oULG MAIL ADDRESS: �LNo CITYITOWN: ���`_JGG(� STATE: ZIP CODE: Dd y BUSINESS PHONE: _0y-33_�_—_lt/0 BUSINESS CELL: BUSINESS FAX: �5io6 1�9�c 99 E-mail: 81LLAD_ Alt E-mail: AL ID/SS NUMBER: LICENSE HELD: Town Year Licensed LICENSE HELD: Town LICENSE HELD: Town Year Licensed 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 31 st yearly. FEE: $ 100.00 SIGNATURE: V DATE: / '2— 2-9 _. 2-02 v 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ruass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: .5'o ✓l9✓�l'CE ST City/State/Zip: R/ evl/tO 400OY6 Phone #: -5-0 6 --ysy 9 5�6 Ire you Pln employer? Check the appropriate box: Business Type (required): I am a employer with Z employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restamant/Bar/Eating Establishment !. ❑ I am a sole proprietor m partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in ally capacity. [No workers' crimp. insurance required] 8. ❑ Non-profit I. ❑ 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]* 1 L❑ Health Care 1. ❑ We are a non-profit organization, staffed by volwateers, with no employees. [No workers' comp. insurance req.] 12.0 Other �:C/i-Utlri t�tJiAd)47L my applicant that checks box #1 nntsI also till out the section below showing their workers' compensation policy infiamation. If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compeusatiou policy is required and such an canization should check box #l. ran an employer that is providing workers' compensation insurance far my employees. Below is the policy information. Lsurance Company Name: 4 4i E/ - d�(A e_&y x1 1� k tle y LL e isurer's Address: I t2( / 6Lyal/l S % �� ♦7d ity/State/Zip: /A a e ' S eou !�'%✓f ��(� Airy Hot' Self -ins. Lie. H U'l l' / o,, = Expiration Date:�� ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of it tie 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 'up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification, do hereby certify,, u�nd�er� thee�pains and penahies of perjury that the information provided above is true and correct. iignatmc /y,"v/.•*'-`CJ 1l-✓�/nitd A — Date: %Z—?o- 2-,:)'7-e2 3--q el - -5-6 3 5- QJlicial 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mass.govhlia Phone 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 Naive 2d- y 72_6 *"Social Security No. (Voluntary) or Federal Identification Nuinber 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. Q\Usus\sleite\Desktop\Scotts DocumentsWood EstabHshnaulls-Temp\TAX CERTIFICATION PORM.doc A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/14/2020 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 Marsh & McLennan Agency LLC - New England 100 Front St, Ste 800 Worcester MA 01608 CONTACT NAME: K IS Morrissey PNNE' FAX AIC Ne Exit:888-850-9400 ac Nn : 866-795-8016 E-MAIL MMA.NewEn Iand.CLines marshmacom INSURERS AFFORDING COVERAGE NAIL R INSVRERA: Selective Insurance Company Of America 12572 INSURED BRUNECONTR INSURER B: Brunelle Contracting Company, LLC R 50 Maple Street INSURER C__ Mansfield MA 02048 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1876367657 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. INSRPOLICY ft I TYPE OF INSURANCE INSO SWVD UER POLICYNUMBER EFF MMIDDIYAN POLICY EXP MM/ DIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY S2021887 7/27/2020 7/27/2021 EACH OCCURRENCE $1,000,000 _ CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence $ 500,000_ MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3.000,000 POLICY ] ECT PRO- � LOC PRODUCTS-COMP/OPAGG $3,000,000 $ OTHER: A AUTOMOBILE LIABILITY _. A9098706 7/27/2020 7/27/2021 COMBINED SINGLE LIMIT ,(Ea accident) $ 1,000,000 BODILY INJURY (Par person) $ ANY AUTO OWNED F I SCHEDULED AUTOS ONLY AUTOSBOOILV ......._____..._....._.-._...__._......_._..____ INJURY (Per acdtlonl) $ PROPETYDAMAGE Per accitlenl $ XHIRED NON -OWNED AUTOS ONLYAUTOS ONLY n A X UMBRELLALIAB X OCCUR S2021887 7/27/2020 7/27/2021 EACH OCCURRENCE $ 3,000,OD0 AGGREGATE $ 3.000,000 EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANYPROPRIETORPARTNEWEXECUTIVE WC9024934 3/19/2020 3/19/2021 7-7—PER TUTE EORH ""-_ E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDED? N NIA E.L. DISEASE - EA EMPLOYEE — $1,000,000 (MandatoryinNH) I(yes, descdbe under DESCRIPTION OF OPERATIONS helow E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Town of Mansfield Board of Health 6 Park Row Manfield MA 02048 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 ACORD 25 (2016/03) © 1988-2015 ACORD The ACORD name and logo are registered marks of ACORD reserved.