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Home My WebLink AboutDick Morse Excavating, Inc. - 12/31/2021#/ 6}3I Town of Mansfield - Board of Health I Disposal Works Installer Application LICENSE NUMBER: 17 APPLICANT: Dick Morse Town 6 Parl BUSINESS NAME: Dick Morse Excavating, Inc. MAIL ADDRESS: 351 Mountain Street CITY/TOWN: Sharon STATE: MA ZIP CODE: 02067 BUSINESS PHONE: 78.1-784-3136 BUSINESS CELL: BUSINESS FAX: 781-784-2288 E-mail: Alt E-mail: dickmorseexcavating@gmail.com ID/SS NUMBER: 04-3515477 LICENSE HELD: Town of Sharon LICENSE HELD: Town of Foxborough LICENSE HELD: Town of Stoughton Year Licensed 1985 Year Licensed 1978 Year Licensed 1987 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: 0,4 DATE: o\ -a (DOD-0 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. Dick Morse Excavatina, Inc. �`"'t Signature of Individual or Corporate Name Fed. I.D. 04-3515477 "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:\Usecs\sleite\Desklop\Scotrs Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth ol/Wassachusetts Department of Industrial Accidents Office q/1noestigations 600 Washington Street Boston, MA 02111 k1ri mi,minass.govIdia Workers, Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: niece Morse Excavating, Inc. Address: 351 Mountain Street City/State/Zip: Sharon, MA 02067 Are you an employer? Check the appropriate box: 1.H I am a employer with 4 employees (full and/ or part-time).'' 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] • ••v ••�•r^•••••^ ••••• ��> ova xi umst also ntl out Inc Section below showin tl Phone #: 781-784-.3136 Business Type (required): S. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (tact. real estate, auto, etc.) 8. ElNon-profit 9. El Entertainment 10.0 Manufacturing 11.❑ Health Care 12.9 Other Installer Disposal Works y 1Cu .. , uwuipcnsauon policy rotor nelion. w*Ir 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 flL I ant an employer that is providing workers' compensation insznnnce for znjt employees. Below is the policy information. Insurance Company Name: See Attached Insurer's City/State/Zip: Policy # or Self -ins. Lie. # Expiration 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 WORI{ 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,,/ uun�n//,d,er the ains and penalties Ofpezyaty that the information provided above is true and correct. Sienatnre. aw xlilvtn, I 1 781-784-3136 QVicial use Only. Do not write in this laCa, to be completed by cult or town official. City or Town: Issuing Authority (circle one): I. Board of Health 2. Building Department 6. other Contact Permit/License # 3. City/Town Cleric 4. Licensing Board 5. Selectmen's office www.mass.gov/dia Phone #: A CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 4/1/2020 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 1- 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 Eastern Insurance Group LLC 233 West Central St CONTACT Select Department _ NAME: _ - _ PHONE (800)333-7239 FAX 'l83-5B6-8244 AplO.J1a,�+OL_— _ LA/�NOP E-MAIL seleotwork@easterninsurance. core ADDgass: .- .._. INSUflER(S) AFFORDING COVERAGE __ NAIC p INSURERA:T av Ind of CT _, 25682 Natick MA 01760 INSURED Dick Morse Excavating, Inc. D.M. Equipment Inc. INSURER e:Travelers CBS & Surety of IL __ 19046__ INSURER C:Travelers Prop & Casualty Amer _ 25679- INSURER D:Wesco._Insurance Co ___ -_ 25011 INSURERE:_ __. 351 Mountain Street INSURER F: Sharon MA 02067 COVERAGESTHIS LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IS TO CERTIFY THAT THE POLICIES OF INSURANCE REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DDLB BF POLICY EFF POLICY EXP ar TYPE OPINSURANCE O D POLICY NUMBER M1IMIDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGETO RENTED $ 300, 000 A CLAIMS -MADE ❑X OCCUR PREMISES (Ea occurrerce -MEDEXP(Anyone _ 6006671P535 4/3/2020 4/3/2021 parson) $ 5, 000 PERSONAL 8 AOV INJURY $ 1, 000, 000 GENERAL AGGREGATE $ 2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: ___. - X ECT �� LOG 0 j PRODUCTS-COMPIOP AGG $ 2, 000, 000 ' POLICY AIOI $ OTHER: COMB NED SINGLE LIMIT $ 1, 000, 000 AUTOMOBILE LIABILITY _ BODILY INJURY (Par person) $ BODILY B ANY AUTO ALL OWNED X SCHEDULED BAOM703722 4/3/2020 4/3/2021 aODILY INJURY (Per acciden0 $ AUTOS AUTOS NONAUTOS PROPERTYDAMAGE $ X HIRED AUTOS X Ler_accltlen0-_ XNUCL $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 000 AGGREGATE __1,000 $ 1 000 000 EXCESSi CLAIMSMADE $ CUP6613P565 4/3/2020 9/3/2021 EO RETENTION XTATUTE ERHPLOYERS' fl5 COM11PENSATION E.L. EACH ACCIDENT $ 500 000 LAmLITV yIryOPRIETOR'PA9TNERIEXECUTIVE TC! NIA RIMEMBER EXCLUOE07 5/27/2020 5/2T/2021 E.L. DISEASE -EA EMPLOYE $ 500e oryln NH)MC3411467 scribe under E.L. DISEASE -POLICY IIMR $ 500 000 IPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addllional Remarks Schedule, may be allached if more space is required) SEPTIC TANK INSTALLATION/SERVICE/REPAIR Town of Mansfield Building Dept 6 Park Row Mansfield, MA 02048 ACORD 25 (2014101) INS025 (M1401) 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 Koegel/JBARRE no 19RR-2n14 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD