HomeMy WebLinkAboutDepco Enterprises Inc. - 12/31/2021LICENSE NUMBER:
APPLICANT:
Town of Mansfield - Board of Health
Disposal Works Installer Application
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Town of Mansfield
6 Park R'+D+ry
Mansfte"'Al2,048
BUSINESS NAME: �w✓�.�+ Tam, __
MAIL ADDRESS:
W 2
CITY/TOWN: r�it@lxiv STATE: Lug ZIP CODE: , 270'3
BUSINESS PHONE: $a9•-d9S'-iS-Do BUSINESS CELL: _!�V 6 -.S-0 7-79 -72
BUSINESS FAX:
E-mail: rick E dPwc-em-f, Cary
Alt E-mail:
ID/SS NUMBER: 20 yor' 62
LICENSE HELD: Town Nl 44 &&- "^v Year Licensed 1'98s-- e &4-,
LICENSE HELD: Town /got v Year Licensed
LICENSE HELD: Town p (,/�I Ik Year Licensed
/ ler - "
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:
2
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 of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
20 y66G 33
**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\Scou's 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
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: Oelz�Q
Address: Glo �-> a 2-
City/State/Zip: kA#" /,U4' ? Phone #: Sy 9- -o 9-- ?V 72
Are you an employer? Check the appropriate box:
Business Type (required):
1. O I am a employer with 3 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 (met. real estate, auto, etc.)
employees working for me in any capacity.
S. ❑ 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
I0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.EpOther i laa t°�^
with no employees. [No workers' comp. insurance req.]
I 'o
*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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: 14u^ IT-e"e /sloe % II W"^'+ sr-.
Insurer's Address: 1/66/ AcG'Ie� iU
City/State/Zip:
N81/6
Policy # or Self -ins. Lic. If lucv G'3 4039?41 Expiration Date: _9/t2121
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 paitiUiid petialties�of perjury that the information provided above is true and correct.
0
Phone#: ZoP-Sag',>97?
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
NP 121443644
Wesco Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY
INSURANCE POLICY
Ncci Code: 26135
Insured:
Depco Enterprises Inc.
60 Holman Street, #2
Attleboro, MA 02703
Other workplaces not shown above:
None
Producer:
AmTrust North America, Inc.
c/o Mackinaw Underwriters, Inc
It801 Grand River Rd.
Brighton, MI 48116
WC990001 B
1 of 5
INFORMATION PAGE
Policy Number: WWC3457930
_Individual _Partnership
X Corporation
Federal Tax ID: 204066233
Risk Id:
Renewal of: WWC3403974
2. The policy period is from 3/17/2020 to 3/17/2021 12:01 a.m. 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: Massachusetts
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$100,000 each accident $500,000 policy limit $100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and State(s) Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
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.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
STATE ASSESSMENT
TOTAL ESTIMATED COST
Minimum Premium
Deposit Premium
Issue Date: 1/27/2020 Countersigned by:
Authorized Representative
6,925
229
7,154
479
7,154
0