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HomeMy WebLinkAboutAdvanced Metals Eng., Inc. - 12/31/2021�aS � 6—dco,`� 3ata Town of Mansfield Town of Mansfield -Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: 2 APPLICANT: BUSINESS NAME: C_ MAIL ADDRESS: 5a ko�`v v CITY/TOWN: p STATE: ' Y & ZIPCODE: ()aog j BUSINESS PHONE: 5 s'(o(o� "" 002 BUSINESS CELL: S UOg_TOO - Z 1O BUSINESS FAX: h�__ g6j4 E-mail: _ OAVMP iG (S PJ(l Ut/'F. o e-+ Alt E-mail: 00. Carr FEDERAL ID/SS NUMBER: LICENSE HELD: Town rc�l.0 IA LICENSE HELD: Town Aw pot LICENSE HELD: Town Year Licensed 00.;1-0 Year Licensed 1-90`310 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 Nam► ' F./H� /�►�'��^ _ SIGNATURE: _ F DATE: 104o'l ?�j 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. W8Vo1(IePA {MQ iiA1S �Vlqln2P(twS Jfv_ 0 Signature of Individual or Cc orate Name **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatony, 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 Documents\rood Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 15a- IZCOLC v City/State/Zip: 631 Phone #: Are ypu an employer? Check the appropriate box: Business Type (required): 1.9 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] $• ❑ 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, I1.❑ Health Care L_ f with no employees. [No workers' comp. insurance req.] 12.QrOther 00 C l� IV n *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 M. I am an employer that is providing,workers' compensation insurance for employees. Below is thepoll(icy information. Insurance Company Name:_ Se,1e_c u(2, 5�-6u_�ox 'e' 0ompun�j Insurer's Address: q ® O City/State/Zip:CtJnAqO�(S ( l Policy # or Self -ins. Lic. # W C 07 c/n�.�� Expiration Date: U I Z] 17— I 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 WORD 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 ofpeijury that the information provided above is hue and correct. 10 12,01 ZO 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.mass.gov/dia A� a CERTIFICATE OF LIABILITY INSURANCE DATE 126/2020 ,O/26/2020 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 poiicy(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 Morse Insurance Agency, Inc. 285 Washington Street North Easton MA 02356 CONTACT Donna Walsh NAME: _ AICNNo Eat): (508) 238-0056 FAX No), (508) 230-8367 ADDRESS: donnawalsh@morseins.com INSURERS) AFFORDING COVERAGE NAIC II INSURER A; Selective Insurance Company of South Carolina 19259 INSURED Advanced Metals Engineering Inc. 52 Production Road Walpole MA 02081 INSURER B INSURER C : INSURER D: INSURER E; INSURER F: rnVPRACFR CERTIFICATE NUMBER. 20-21 REVISION NUMBER: THIS IS TO CERTIFYTHATTHE 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. INSR LTR TYPE OF INSURANCE ADDLISUBR INSO Me POLICYNUMBER POLICY EFF MMIDD/YYYY) POLICY ESP (MMIDDNYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR S2400216 06/21/2020 06/21/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED PREMISES Ea occurrence 100,000 S MED EXP (Any one person) S 15,000 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: x POLICY ❑ JECOT LOC OTHER: GENERALAGGREGATE S 3,000,000 PRODUCTS-COMPIOPAGG S 3,000,000 AUTOMOBILE LIABILITY ANVAUTO OWNED SCHEDULED AUTOSONLY AUTOS HIRED NON -OWNED AUTOSONLY AUTOS ONLY COM6 (Ea acccidentSINGLE LIMIT S BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccidenl s 5 UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE S DEC RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANVPROPRIMBRIPARTNER/EXECUTIVE in NH) EXCLUDED? OFFICERIME(Mandatory (Mandatory in NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below N/A WC9082934 O6/21/2020 O6/21/2021 X STATUTE ER EL EACH ACCIDENT S 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 T�� I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 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 AUTHORIZED REPRESENTATIVEn /� �J Mansfield MA 02048 / / / . - t0., / J /J // ACORD CORPORATION. All rlahts reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD THE Hartford Casualty Insurance Company HARTFORD Date: October 5, 2020 Agency Name: EASTERN INSURANCE GROUP LLC/PHS Agency Code: O8 080624 Advanced Metals Engineering, Inc. 52 Production Road Walpole, MA 02081 Insured/Principal: Advanced Metals Engineering, Inc. Policy/Bond : 08BSBGA0114 Account Narnefflu fiber: Terra: December 31, 2020 - Type: Surety - License & Billing Type/Werra: Annual Transaction Type. Renewal Transaction Effective Date: Limit: $5, 000 December 31, 2021 Permit December 31, 2020 As a convenience, our Bond Sales Team is available to serve you. If you require any assistance, please contact us via phone or email as our Business Insurance Professionals want to help. Simply, call toll free 1-866-268-6404 any weekday from 8 AM ET- 7 PM ET to talk to our Sales Team. You can also email us at BondSales@thehartford.com. This record is a billing record advice only. You will be billed directly by The Hartford within 15 days of the effective date of the bond. Payments can be mailed to: The Hartford P.O. Box 660916 Dallas, TM 75266-0916 Copydght © 2017 by The Hadford. Classification: Internally Controlled. All fights reserved. No part of this document may be used, reproduced, published or posted without the permission of The Hemordi Continuation Certificate The Hartford Insurance Group Surety - License & Permit The Hartford Casualty Insurance Company, (hereinafter called the Company) hereby continues in force its Bond No. 08BSBGA0114 inthesum of Five Thousand ($5,000.00) Dollars onbehalfof Advanced Metals Engineering, Inc. 52 Production Road, Walpole, MA 02081 infavorof Town of Walpole, Water & Sewer Dept. for the (extended) term beginning on December 31, 2020 and ending on December 31, 2021 subject to all the covenants and conditions of said Bond, said Bond and this and all continuations thereof being one continuous contract. This Continuation is executed upon the express condition that the Company's liability under said Bond and this and all continuations thereof shall not be cumulative and shall in no event exceed the sum of Five Thousand ($5,000.00) Dollars. IN WITNESS THEREOF, the Company has caused this instrument to be signed by its officers proper for the purpose and its corporate seal to be hereto affixed on October 5, 2020. LM Anem Hartford Casualty Insurance Company Direct Inquiries/Claims to: THE HARTFORD BOND, T-11 POWER OF ATTORTNTEY One Hartford Plaza Hartford, Connecticut 06155 Bond.Clai msCrdthehartf ord.com call..888-266-3488 or fax: 860-757-5836 KNOW ALL PERSONS BY THESE PRESENTS THAT: Agency Name: EASTERN INSURANCE GROUP LLC/PHS Agency Code: 08-080624 Hartford Fire Insurance Company, a corporation duly organized under the laws of the State of Connecticut Hartford Casualty Insurance Company, a corporation duly organized under the laws of the State of Indiana Hartford Accident and Indemnity Company, a corporation duly organized under the laws of the State of Connecticut Hartford Underwriters Insurance Company, a corporation duly organized under the laws of the State of Connecticut Twin City Fire Insurance Company, a corporation duly organized under the laws of the State of Indiana Hartford Insurance Company of Illinois, a corporation duly organized under the laws of the State of Illinois Hartford Insurance Company of the Midwest, a corporation duly organized under the laws of the State of Indiana Hartford insurance Company of the Southeast, a corporation duly organized under the laws of the State of Florida having their home office in Hartford, Connecticut (hereinafter collectively referred to as the "Companies") do hereby make, constitute and appoint Joelle L LaPierre of Lake Mary, Florida, its true and lawful Attorney -in -Fact, to sign its name as surety(ies) only as delineated above by , and to execute, seal and acknowledge the following bond, undertaking, contract or written instrument: Bond No. 08BSBGA0114 Naming Advanced Metals Engineering, Inc. as Principal, and Town of Walpole, Water & Sewer Dept. as Obligee, in the amount of See Bond Form(s) on behalf of Company in its business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. In Witness Whereof, and as authorized by a Resolution of the Board of Directors of the Companies on May 23, 2016 the Companies have caused these presents to be signed by its Assistant Vice President and its corporate seals to be hereto affixed, duly attested by its Assistant Secretary. Further, pursuant to Resolution of the Board of Directors of the Companies, the Companies hereby unambiguously affirm that they are and will be bound by any mechanically applied signatures applied to this Power of Attorney. Shelby Wiggins, Assistant Secretary STATE OF FLORIDA ss. Lake Mary COUNTY OF SEMINOLE �®rae0slnro> }'�vsivacw[°s�anena'ar € 3�_*'lNro_a�loa�ew•�p-'o,`��:t6"as ot >1',nWwUM907 141 gyyS.;W oFrt a 9"v,&,�W2. Joelle L. LaPierre, Assistant Vice President On this 13th day of February, 2020, before me personally came Joelle LaPierre, to me known, who being by me duly sworn, did depose and say: that (s)he resides in Seminole County, State of Florida; that (s)he is the Assistant Vice President of the Companies, the corporations described in and which executed the above instrument; that (s)he knows the seals of the said corporations; that the seals affixed to the said instrument are such corporate seals; that they were so affixed by authority of the Boards of Directors of said corporations and that (s)he signed his/her name thereto by like authority. .f •,q , .•pV•' Jessica Noelle Ciccone My Commission #FF029702 Expires June 20, 2021m I, the undersigned, Assistant Vice President of the Companies, DO HEREBY CERTIFY that the above and foregoing is a true and correct copy of the Power of Attorney executed by said Companies, which is still in full force effective as of October s. 2020. Signed and sealed in Lake Marv. Florida. ptlY In4iq� f///��////���'''',•q �u� f\er xr `xlFr ♦. P y^�>fi iron`�`% r� �0! itV % 11 g a see :g t �/070! r 1019 3i o }1 , ,q\ 0.yan Jdia :.•!tl Y ''sf a l� nc. 3 a .* ��' .h �'°% Keith D. Dozols, Assistant Vice President