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HomeMy WebLinkAboutJ. Mariano Construction Inc. - 12/31/2020Town of Town of Mansfield - Board ofHealth 6 Parka Disposal Works Installer Application Joseph Mariano APPLICANT: J. Mariano Construction Inc. BUSINESS NAME: MAILADDRESS: 104 Bittersweet Drive CITY/TOWN: Seekonk STATE: MA ZIP CODE: 02771 BUSINESS PHONE: 401-556-4998 BUSINESS CELL: BUSINESS FAX: E-mail: Mark4O26@gmail.com Alt E-mail: FEDERAL ID/SS NUMBER: _ 01! ' "07' �v 401-556-4998 LICENSE HELD: Town Seekonk Year Licensed 2020-2021 LICENSE HELD: Town Rehoboth Year Licensed 2020-2021 LICENSE HELD: Town Swansea Year Licensed 2020-2021 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: 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 Jf Individual or Corporate Name -bf -n �7 8 l "Social Security No. (Voluntary) or Federal Identification Number 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. Ct\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts U11Department 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: J. Mariano Construction Address: 104 Bittersweet Drive City/State/Zip: Seekonk MA 02771 Phone #: 401-556-4998 Are you an employer? Check the appropriate box: Business Type (required): 1.0 1 am a employer with 1 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. 8. ❑ Non-profit 3.❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, § 1(4), and we have 10.❑ Manufacturing 4.❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by I LE] Health Care volunteers, with no employees. [No workers' comp. insurance req.] 12.❑✓ Other Construction _ *Any applicant that checks box # I 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 #l. I am an employer that is providing worlrers' compensation insurance for niy employees. Below is the policy information. Insurance Company Name: HW. Lapointe Insurance Insurer's Address: 177 Pleasant Street City/State/Zip: Fall River, MA 02723 Policy 9 or Self -ins. Lic. 9 0615N79A Expiration Date: 06/11/2021 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 hereby certify{ under the(i[tins and penalties of perjury 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 www.mass.gov/dia eflnar_IMI �:tlly-lr i o Al ORO —, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDN"Y) 6/21/2020 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 c TACT Karen A. Martin H W Lapointe Jr Ins Agency, Inc P O Box 4099 Fall River, MA 02723 PHONE FAX AIC No, Ett: (508) 678-8341 212 AIC, Na):(508) 678-0436 E'MDAIL , „ kmartin@lapointeins.com lapointeins.com INSURERS AFFORDING COVERAGE NAICH INSURER A: United Specialty Insurance Company _ INSURED INSURERB:Zurlch American Insurance Company INSURER C: J Mariano Construction Inc INSURER D: 104 Bittersweet Drive Seekonk, MA 02771.1102 INSURER E: --"— INSURER F: COVERAGES CERTIFICATE NIIMRFR- RFVISInld 1,1111MRFR• 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. INSR L TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF y POLICY EXP I)D LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_X] OCCUR DCG07005-02 6/7/2020 6/7/2021 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTEDQcua... PREM15ES Ira or $ 100,00 MED EXP (Any oneperson) $ 5,00 PERSONAL B ADV INJURY $ 1,000,00 GENT AGGREGATE LIMITAPPLIES PER: POLICY DPEoCT F]LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGO S 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS EE AI/TO& ONLY AUTOS OONNL� COMBINdED SINGLE LIMIT $ BODILY INJURY Per arson $ BODILY INJURY Per accident 5 Perr.ccid.rtOAMAGE _ $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ Ll AGGREGATE $ DED I I RETENTION$ $ 8 WORKERS AND EMPLOYERS' LIABIILIITY v/N ANY PERIM TORIPXCLUDEIEXECUTIVE gFFICERIMEMgEq EXCLUDED? Y (Mandatory In NH) it yes, describe under DESCRIPTION OF OPERATIONS below N/A 0615N79A 6/11/2020 6/11/2021 �( PER OTH- LUTE ER E.L. EACHACCIDENT — S 500,00 E.L. DISEASE - EA EMPLOYEE $ 600,00 E.L. DISEASE -POLICY LIMIT 500,00 $ DESCRIPTION OF OPERATIONS I LOCATIONS /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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Q. rXRAb_;L ACORD 25 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD