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Home My WebLink AboutDown to Earth Construction - 12/31/2021LICENSE NUMBER: APPLICANT: t n i Disposal Works Installer Application 5,�,/, yy �1 VI �1 Town off`► .fielder •.6 Park Rows s I�I "sfield, MA 0i648 BUSINESS NAME: MAIL ADDRESS: f -7 CITYITOWN: lV o f � STATE: ZIP CODE: G Z l G G BUSINESS PHONE: ��'� ' Z 7 1 1 BUSINESS CELL: Z 7 j 1 BUSINESS FAX: 60 E-mail: �• S �T� ✓✓ ✓ , r_ v Alt E-mail: -EDERAL ID/SS NUMBER: C j G <' LAe-14-- LICENSE HELD: Town Fo $ bury Year Licensed 7—UZ & LICENSE HELD: Town li� e=.11,u P3 v V k Year Licensed zbecl LICENSE HELD: Town _t t> t �.L >^ 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 31 st 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 of Individu 1- Corporate Name "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. C:\Userskleite\Desklop\Scotl's Documenls\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Commonwealth of Massachusetts City of Attleboro Health Department 7/15/2020 This is to Certify that: Down To Earth Construction Robert Silva 102 West Main St. Norton MA 02766 Is hereby granted a Title V Septic Permit for. 110-2020 This Permit is granted in conformity with the State Sanitary Code Title V, regulation 2.2 and expires March 31, 2021 unless sooner suspended or revoked. Alan D. Perry Health Agent t Permit Number: 120-72 Fee: $100.00 The Commonwealth of Massachusetts Town of Rehoboth Board of Health This is to certify that: Robert Silva Doing Business As: Septic Preservation Services Mailing Address: Same Located at: 102 West Mani St, Norton, MA 02766 IS HEREBY GRANTED A PERMIT TO PERFORM TITLE V SERVICES WITHIN THE TOWN OF RE, HOBOTH AS SYSTEM INSTALLER This permit is granted in confornrity with the State Environmental Code (Title V) and the Rehoboth Board of Health Rules and Regulations, and expires December 31, 2020 unless sooner suspended revoked. Rachel Smith, Chairman Tony Gaucher, Vice Chairman Theresa Moitozo, Clerk Mark Hass, Member Issued: June 23,2020 George Kellum IV, Member t _ ( Commonwealth of Massachusetts Division of Professional Licensure Hoisting Engineer Restricted to: HE -IC -Telescoping Booms wio Cables HE-2A-Excavators DIG SAFE Call Center: (888) 344-7233 In case of accident call: 60 Contact opsi 617)727-3200 or visitWWW.massgovidpl/opsi The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: lC Address: L{{ C//y' c ��i�,- City/State/Zip: , �-. -. 1 /1 a LC, 7 7�, 6- Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. O'� I am a employer with 4)— 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] g ❑ 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.] 12. L�her Gun r ✓ z p *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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. ', Insurance Company Name: �—�.,�� ; ��'.-fir r�ti�.,��a t-- f �'15 r .ter h L 1 "r, r-�,-, � ,.__ Insurer's City/State/Zip: ,_ I Policy # or Self -ins. Lic. # bli,/G . Z, — 3 Z 9 `j -- Gb t e) 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 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 thSpains and penalties ofperjury that the information provided above is true and correct. Phone ff: Da not write. ju.f is ywq._tn hv. romn_t_e_te_ d hv_ city or town of Trial_ fly or Town: Permit/License # mi ag Authority (circle one): brrard of Aealth 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Other pbmm www.mass.gov/dia 5EPTPRE-U7 JDACOSTA TE D 11/30/2020/D0/ 11/30 At CERTIFICATE OF LIABILITY INSURANCE 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 endorsements . PRODUCER Carey, Richmond & Viking Insurance Two Corporate Place Middletown, RI 02842 CONTACT NAME: PHONE FAX A/C, No, Ext): (401) 683.3900 A/C, No): (401) 683-7329 EMAIL S: info@crvinsurance.com INSURERS AFFORDING COVERAGE _ NAIC# INSURER A: Ohio Casualty Insurance Company, Member of Liberty Mutual Grnu 24074 INSURED Envirocheck Inc DBA Septic Preservation Services,DBA All Clear Septic And Wasterwater INSURERS: Liberty Mutual Fire Insurance Com an 23035 INSURER C:Nautilus Insurance Company Earth Construction DBA 38 Harold Sweet Drive INSURER D Attleboro, MA 02703 INSURER E: -- INSURERF: COVERAGES CFRTIFIr.ATF NIIMRFR• RGtnRlf1m Mt lmga R. 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 SUBJECTTOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L TYPE OF ADDL g0 SUER POLICY NUMBER POLICY EFF POLICYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR 13KO(21)58427282 3122/2020 3122/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 1001000 MEDEXP An one amen $ 15,000 PERSONAL&ADV INJURY 11,0001,000 GEN'L _ AGGREGATE LIMIT APPLIES PER: POLICY mLOC OTHER: GENERAL AGGREGATE 2,00000 $ 0 PRODUCTS 0, 2000 A AUTOMOBILE LIABILITY ANY AUTO AUTOS ONLY X AUUaTTqOSULED AUTOS ONLY X AUT030NLD BAO(21)58427282 3122/2020 3122/2021 COMBINED SINGLE LIMIT BODILY INJURY Per arson BODILY INJURY Per accident X ROPE.% nt AMAGE P4,000,000 A X UMBRELLA LIAS EXCESS LIAR X OCCUR CLAIMS -MADE USO(21)58427282 3/22/2020 3/22/2021 EACH OCCURRENCE AGGREGATE DED X RETENTION$ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINWC2-31S-617244.020 ANY PRRRO//PRiETOR/PARTNER/EXECUTIVE If rs alny.NH) EXCLUDED? If yes, descdbe under DESCRIPTION OF OPERATIONS below N/A 9/8/2020 91812021 PER OTH- STATUTE Ea E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 11000/000 E.L. DISEASE -POLICY LIMIT 1,000,000 C Pollution Liability CCP2029376-11 6/2612020 6/26/2021 Pollution Liability 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 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 N r t AOUKU 25 (2UIU/U3) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD