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HomeMy WebLinkAboutAll Seasons Septic, Inc. - 12/31/202100 Town of Mansfield Town of Mansfield - Board of Health 6 Pam Row' M sfield, MA'02048 0 ~` Disposal Worlrs Installer Application f` LICENSE NUMBER:._,f/� J31, _._. APPLICANT: BUSINESS NAME: MAIL ADDRESS: CITY/TOWN: __Aff Seaow dW-- 2ii0 Cushing St., U#i STATE: ZIP CODE: BUSINESS PHONE: BUSINESS CELL: BUSINESS FAX:J E-mail: (�/1p 12 cam_ hOd .9,4r Alt E-mail: 'EDERAL ID/SS NUMBER: LICENSE HELD: Town a�_, A, Year Licensed 7.07JO LICENSE HELD: Town s�-Nct121.Or, LICENSE HELD: Town 'P 1�� Year Licensed ZO7 Year Licensed -2,6�vo 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: DATE: dq) )'v� Please make appropriate changes. Sign, date, andlenclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwianmss govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ALL SEASONS SEPTIC SERVICE, INC. Address: 200 CUSHING ST., U#7 City/State/Zip: STOUGHTON, MA 02072 Phone #: 866-822-6846 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 4 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2. ❑ 1 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have ]0.❑ 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.j 121Other *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 #1. Iam an employer that isprovidiiig workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: TRAVELER'S INDEMITY CO Insurer's Address: ONE TOWER SQUARE City/State/Zip: HARTFORD, CT 06183 Policy # or Self -ins. Lie. # UB-BP210683 Expiration Date: 04/14/21 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certW, /mde/tlre pains and penalties ofperjury 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 A O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDANW) 1o/zs/zozo 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 Malcolm & Parsons Insurance Agency 713 Washington Street P.O. Box 627 Stoughton MA 02072 CONTACT Jaime Gonsalves NAME: IHONr o Eai : (781) 344-3200 1 ac No): (781) 344.1425 E-MAIL jll@malcolmandparsons.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL R INSURERA: Ohio Security Insurance Company INSURED All Seasons Septic Service Inc 200 Cushing Street Suite 7 Stoughton MA 02072 INSURERS: Travelers Casualty Ins Co 19046 INSURER c: Travelers Indemnity Cc 25658 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: Master 6141213 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. ILTR TYPE OFINSURANCE INSD WVD POLICY NUMBER MMIDD MM/0WEXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 CLAIMS -MADE FX—I OCCUR DAMAGEIORLNItU PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 15,000 A BKS(21) 60955059 02/12/2020 02/12/2021 PERSONAL SADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2.000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 i� POLICY ❑ PR LOO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (Per accident) $ B OWNED X BCHEDULED AUTOS ONLY AUTOS X HIRED I X NON-OWNED AUTOS ONLY BA-6P002260 02/12/2020 02/12/2021 PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN CUTIVE a ANY PERIMEMOREXCL EXCLUDED? (MandatoryIn NH) EXCLUDED4 (Mantlatory in NH) N/A UB-8P210683 04/14/2020 04/14/2021 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E,L, DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS bale. Per Act $100,000 A Contractors Errors &Omissions BKS(21) 60955059 02/12/2020 02/12/2021 Aggregate $100,000 Deductible $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Septic System Services Insured's Copy Evidence of Insurance 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 ©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. By: CorpoWte Officer (Mb,Zidato# 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