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HomeMy WebLinkAboutGuranteed Builders & Developers Inc. - 12/31/202100 00 1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 jj l)__ Disposal Works Installer Application LICENSE NUMBER: 20 APPLICANT: .pJi)riOe-e(rt-I- BUSINESS NAME: c MAIL ADDRESS: si/ 2 Z `t' CITY/TOWN: Ibo a I oA STATE: VY iL ZIP CODE: t S I (o BUSINESS PHONE: 50k'LI7G ' I hCL__ BUSINESS CELL: BUSINESS FAX:�Cj:2 E-mail: MS aCjb,6ViS.00in Alt E-mail: ��m fir L2 hn7 ffla; =EDERAL ID/SS NUMBER: 04_�(a Z L4 1 2 L V LICENSE HELD: Town & V, a _ IYear Licensed LICENSE HELD: Town M �1 I I ��U (Y 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: _ io 1I4; 19ogv 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. ,_n Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)��� 01-,�2b7Lf1;26, "Social Security No. (Voluntanj) 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\Scotes DocumentsFood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts —� Department of Industrial Accidents f� = Office of investigations J_ Lafayette City Center IV 2 Avenue de Lafayette, Boston, MA 02111-1750 ivtvw, mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address; I1} Ja S{-/e& Ci 1114 Phone#: 5og Are yog an employer? Check the appropriate box: Business Type (required): 1. EKI am a employer with C employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Lating 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] 8• ❑ 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 uou-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.aOther YG _i *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. "lf the corporate officers have exempted themselves, but the corporation has other employees, a wofkers' compensation policy is required and such an organization should check box #1. I am art employer that is providing workers' compensation insurance for nny employees. Below is the policy information. Insurance Company Name: Insurer's City/State Policy # or Self -ins. Lie. # 9 c t} 5 (v ,�) Expiration Date: ii ��� � 0 ,-q 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 § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 cw tiU, under the pains and penalties olpenjury that the information provided above is true and correct. Phone#: 5OF—rf7C-- I5JC% O_2 o Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (check one): 1011oard of Health 2.❑ Building Department 50 Selectmen's Office 6. ❑Other Permit/License 3.❑City/Town Clerk 4.❑Licensing Board Contact www. mass.gov/dia Phone ACORO® CERTIFICATE OF LIABILITY INSURANCE 11./- DATE(MMIDDNWY) 3/31/2020 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(les) 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 Marsh &McLennan Agency LLC 100 Front St, Ste 800 CONTACT NAME: Cindy L. Carey PHONE FAX • 508-852-8600 AIc No : 866-795-8016 ADDRESS: cindy.carey@marshmma.com Worcester MA 01608 INSURERS AFFORDING COVERAGE _ NAIC# INSURER A: Graphic Arts Mutual Insurance Company 25984 _ INSURED GUARABUILD3 Guaranteed Builders & Developers, Inc. 14 West Street INSURER B: Utica Mutual Insurance Company 25976 INSURER C: Slarstone S ecialt Insurance Company_ 44776 INSURER D: East Douglas MA 01516 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 618070350 REVISION NUMBER: 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF IMMIDOMWI POLICY EXP IMMGOWYYILIMITS A X I COMMERCIAL GENERAL LIABILITY CPP4051108 4/2/2020 4/2/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE I -XI OCCUR PREMISES Ea omu ante $100,000 MEDEXP(Any onsparson) $5,000 PERSONAL &ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 GEN'L POLICY JET I LOC PRODUCTS-COMP/OPAGG $2.000.000 $ OTHER: A AUTOMOBILE LIABILITY 4051109 4/2/2020 4/2/2021 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ w-. ANY AUTO AAUTOSDONLY X AUTOS SCHEDULED BODILY INJURY (Per accident) S X HIRED X NONCOINEDPROPERTY AUTOS ONLY AUTOS ONLY DAMAGE Per accident $ ._ 5 A X UMBRELLA LIAR X OCCUR CULP4051112 4/2/2020 4/2/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION$1pnPn _ S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN 4045631 4/2/2020 4/2/2021 PEft OTH- X I STATUTE ER E.L. EACH ACCIDENT $1,000.000 ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE -EA EMPLOYEE — $1,000,000 (MandatoryinNH) Ir yes, describe antler E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below C A Excess Liability IM Equipment Floater W73660200ALI CPP4051108 4/2/2020 4/2/2020 4/2/2021 4/2/2021 Ea God Aggre9ale RentedlLeasetl From Others, ACV $3,000,000 $125,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD10i,Additional Remarks Schedale,may be attached If more space is r-q.ftad) The certificate holder is included as an additional insured as respects the general liability, if required by written contract for work performed by the named insured. Town of Mansfield, MA 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD