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HomeMy WebLinkAboutGracewood Development Corp. - 12/31/2021�-�L-1 ^ ( 0 0, Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application APPLICANT BUSINESS 1 zz MAILADDRES�S: ` X ry CITY/TOWN: "�\ ��� STATEPA ZIPCODE: ()ZOq3 BUSINESS PHONE: �� 5� �� Z BUSINESSCELL: BUSINESS FAX: 11 E-mail: C,a'fCiwtiXu�OuG �vl �e�,Cu� Alt E-mail: EDERAL ID/SS NUMBER: 0 '� 3 Z 2 ZJ LICENSE HELD: Town �CaN �t�, A Year Licensed LICENSE HELD: Town AT-\, lq tl�"�-A Year Licensed yr LICENSE HELD: Town { " ""� `t j& Year Licensed )L�c 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 far $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 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. r' ltl 1,=> yrcts Signature of Indi 'du or Corporate Name By: Corporate Of 'cer andaton/, if Applicable) "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. CAUsers\s(eite\Desktop\ScotPs DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: City/State/Zip: M M-A —Phone #: '11 -I J 1 p 19 t 2— drelyou an employer? Check the appropriate box: 1. I am a employer with 2-- 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.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I LE] Health Care(( L� 12.❑ Other \SJ 1 d r borJ '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 #1. I am an employer that is provid�n workers' compeysatiRn insurptice for My employees. Bglow is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration Date: 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 Investigatiana.of the DIA for insurance coverage verification. I do -)kA S ofperjury that the information Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 0 labolr is true and correct. 12 L,t 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 www.mass.gov/dia Phone GRACE-1 ,4co CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODmYY( 01/11/2021 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 508-528-3310 Keefe Insurance Agency 51 West Central Street Franklin, MA 02038 Robert F. Keras CONTACT Robert F. Keras NAME: Mn.528-3310 F^X 508-528-3687 ac, NExt : AIc, No E-MAIL ADDRESS, INSURERS AFFORDING COVERAGE MR;0 INSURER A: Travelers Ins. CO. 12637 j (iraCeWOod Development Corp. Timothy Jones P.O. Box 934 Wrentham, MA 02093 INSURER B INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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. INSR T TYPE OF INSURANCE OOL D SUER POLICY NUMBER POLICY EFF POLICY EXP M D LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR 6803795N506 04/08/2020 04/08/202, EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED 300�000 MEO EXP (Any one Parson $ 5,000 PERSONAL &ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F]jEg 0 LOG OTHER: GENERAL AGGREGATE 21000,000 PRODUCTS-COMPIOPAGG S 2,000,000 A AUTOMOBILE LIABILITY ANY AUTO X OWNED SCHEDULED AUTOS ONLY AUTOS WWNN X ALTOS ONLY X ANUOVa N DY BAON486095 05/25/2020 05/25/2021 EOMBC ria SaLLINGLE LIMIT $ 11000,000 BODILY INJURY PerPerson) S BODILY INJURY Per acddent $ PROPERTY AMAGE Per PERTYl UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE DIED I I RETENTION$ A WORKERS COMPENSATIONOTH- ANDEMPLOYERS'LIASILITY YIN OFFICEWMEMBER EXCLUDEDT ECUTIVE ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 6HUB5B28590819 04/05/2020 04/0512021 E.L. EACH ACCIDENT 100,000 E.L.DISEASE-EA EMPLOYE tOO,000 $ E.L. DISEASE- POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) r i:PTIPWATP Hnl nFR CANCFI.I. ATION MANSF10 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health Fax:508-261-7343 6 Park Row AUTHORIZED REPRESENTATIVE Robert F. Keras Mansfield, MA 02048 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD