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Home My WebLink AboutAGA Inc. - 12/31/2021v Zell - to Town of Mansfield - Board of Health own of kagsfield 6 al Row seld, MA 02648 Disposal Works Installer Application LICENSE NUMBER: APPLICANT:�In �V X BUSINESS NAME: _k�aA I NC MAIL ADDRESS: 14 10(ieY CITY/TOWN: _i�✓t STATE: rrrg ZIP CODE: Uc�O�a BUSINESS PHONE:33 ._ BUSINESS CELL: BUSINESS FAX: U!_�7—% 1L��U_5(,e E-mail: _L{ a (d ryd �y> 1i eS , cod Alt E-mail: a_4L• 6da ID/SS NUMBER: 0 - ;Q 77 2 Sp 7 LICENSE HELD: Town S4oAbIj+-on Year Licensed _2 02,d LICENSE HELD: Town CUv %vl Year Licensed 20 ZO _ LICENSE HELD: Town Year Licensed 2 0 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: DATE: �d-12.1JZu 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. Signatu5 / dividual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 6q- 0'772?-a7 "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:\UsemWeite\Desktop\Scotts Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: AGA J�_ WC. Address: I-{ pt)r }e r Sure I 2-ND F l City/State/Zip: Mw Phone#: -72/- 76,7..3001 Are you an employer? Check the appropriate box: Business Type (required): 1: 5a 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. (No workers' comp. insurance req.] 121? Other *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 A. I am an employer that is providing workers' compensation insurance for my eniplayees. Below is the policy information. Insurance Company Name: 540r Sa Qln C ry Insurer'sAddress:0?(05S Ae4et rn DrVe City/State/Zip: Cn .44t,.1`:, Ai i 'M I- Oz4 - to.11 Z Policy # or Self -ins. Lic. #\tJC'OfS7 bgbv Expiration Date: Srb12nz1 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 certifv, under the pa&v-pruipenalties ofperyurp that the information provided above is true and correct. Phone#: 7M- 7(o7- &oj Official use only. Do not write in this area, to he completed by city or town officiat. 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: Phone #: www.mass.gov/dia * I N S U R A N C E C O M P A N Y 26255 American Drive Southfield, MI 48034-6112 Mailing Address AGA, INC. 46 PORTER ST FL 2 STOUGHTON MA 02072-2670 Workers Compensation and Employers Liability Insurance Policy WC 0870869 108/06/2A020 WC 0870869 1 Policy Declaration MASON E MASON INSURANCE AGENCY INC. P.O. BOX 750 INTERVAL NH 03845 UNEMPLOYMENT ID# I 245612R# I 0412772807 I 010013D 37 ( CORPORATION# Entity of nsured OtherOther Workplaces Not Shown Above: 2. The Policy Period is from 08/06/2020 to 08/06/2021 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1, 000, 000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1, 000, 000 each employee 021 C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except North Dakota, Ohio, Washington, Wyoming, and states designated in item 3.A. above. D. This policy includes these endorsements and schedules: See attached schedule 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Assessments and Taxes SEE EXTENSION OF INFORMATION PAGE MA $485 If the premium is paid on an installment basis, a $5.00 per payment charge applies. Total Estimated Annual Premium $ Expense Constant $ Minimum Premium $ soo Premium Discount $ - Deposit Premium $ Premium Adjustment Period: Issued Date: 06/09/2020 ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly Authorized Representative 14,142 338 366 14. G27 Issuing Office WC 000001(Ed, 12M) INSURED COPY 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 burn 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-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Fonn Revised 5-26-05