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HomeMy WebLinkAboutJ. Hockman, Inc. - 12/31/2021Town of Mansfield Town of Mansfield - Board of Health s Park Row Mansfield, MA 02048 4 Works Installer Application LICENSE NUMBER: APPLICANT: 9 so.v_-- BUSINESS NAME: jr-- y :Z",�C--__ MAIL ADDRESS: /l 5,61 E'z t,� ra & CITY/TOWN: ,-//; z .k:- STATE: ZIP CODE: BUSINESS PHONE: a✓"-/ q d D BUSINESS CELL: �5-,O- 3.P°/- , s4a 6' BUSINESS FAX: '�' 3 S' Y - E-mail: �Hsa r f � yz ce c, 0,.� j Alt E-mail: :EDERAL ID/SS NUMBER: LICENSE HELD: Town Year Licensed ^ �S LICENSE HELD: Town r�—twr`` Year Licensed LICENSE HELD: Town / LI o 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: !O 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 CERTIFICATE OF LIABILITY INSURANCE 6/11/2020 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 pollCy(les) must 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 NAME: Cheryl L. H01113 PHONE (508)295-9500 aC No: (soe1295-9e9e C.L. HOLLIS INSURANCE AIC N0 Etl1 A char llee@insurehollis. com 140 Marion Rd ADDRESS: y _ ^ Y Wareham NA 02571 INSURED J. Hockman, Inc. 11 Sherwood Dr Norfolk MA 02056 THIS IS TO CERTIFY THAT THE POLICIES OF INSIJ ANUr L1Wcv..Lw-,,,..�•.•-�•-•�•-�--•—------- OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE CLAIMS CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID - EXCLUSIONS AND POLICY EFF POLICY POLICY UP LIMITS INSR TYPE OF INSURANCE SUER POLICY NUMBER MMIDD MMIDDIYYYY LTR EACHOCCURRENCERRNT $ 1,000,000 GENERALLIABWTY D ENT D $ 500,000 X COMMERCIAL GENERAL LIABILITY /22/2019 /22/2020 PREMISES Ea aCGlrrenre PREMISES MED UP (Any one person) $ -_ 10,000 A CLAIMS -MADE � OCCUR P681TN 6/22/2020 /22/2021 PERSONAL SADV INJURY $ 1,000,00 X XCU COVERAGE INCLUDED GENERALAGGREGATE $ 2,000,000 X CONTRACTUAL PRODUCTS-COMP/OPAGG $ 2, 000, Ann GEN'LAGGREGATE LIMIT APPLIES PER: $ POLICY X PRO LOG COMBINED SINGLE LIMIT Ea a"Id.nl 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ A ANY AUTO IP6BI7N 6/22/2019 /22/2020 BODILY INJURY (Per accident) $ —_, OWNED X SCHEDULED PROPERTYDAMAGE $ AALL UTOS AUTOS 6/22/2020 /22/2021 NED X X Per accident $ HIREDAUTOS AUTOS medical Expense EACH OCCURRENCE $ 5,000,000 X UMSRELLALIAB X OCCUR 6/22/2019 /22/2020 $ 5, 000,000 AGGREGATE 8 A. EXCESS LIAB CI -AIMS -MADE OP6817N 6/22/2020 /22/2021 DED X RETENTION $ 0, 00 WC STATUS X OTH- A WORKERS COMPENSATION E.L. EACH ACCIDENT $ 1,000,000 AND EMPLOYERS'LIA8ILITY YIN CP6817N 6/26/2011 /26/2020 E.L. DISEASE -FA EMPLOYEE $ 1,000,0 ANY PROPRIETOWPARTNEWEXECUTIVE FN] OFFICERIMEMBER EXCLUDED? NIA 6/26/2020 /26/2021 E.L. DISEASE - POLICY LIMIT $ 1,000,000 (Mmdalmyn'NH) If yse, describe under DESCRIPTION OF OPERATIONS below 6/22/2019 6/22/2020 LEASED/RENTED MAX 200,000 D CONTRACTORS EQUIPMENT BMSE54?2T 6/22/2020 /22/2021 UABILItt...000RENCE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule,"... space is required) _ ..A11-1 r ArI�u TOWN OF MANSFIELD 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 Hollis/CRERYL �W'et ACORD 25 (2010105) © 1988.2010 ACORD CORPORATION. All rights INS025 (201005).01 The ACORD name and loan are realstered marks of ACORD 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. Z � c- 4� =DY Signature of Individual or Corporate Name By. Corporate Officer (Mandatory, if Applicable) DygZ9P/ o *"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\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc < 1 _at_-•, I lie U illilaluillvcoall Of iriussacnitsells Department of IndustrialAccidents Office of Investigations Lafayette 00y Center 2 Avenue de Lafayette, Boston, MA 02111-1750 Ivivlutnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name J HOCKMAN INC Adch-ess: 11 SHERWOOD DRIVE City/State/Zip: NORFOLK,MA 02056 Phone #: 508-384-1400 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑■ I am a employer with 15 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. g, ❑ 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 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]** I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, SEPTIC AND EXCAVATING with no employees. [No workers' comp. insurance req.] 12A Other *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 all employer that is providing workers' compensation insurance for lily employees. Below is the policy infornlatioll. Insurance Company Name: HOLLIS INSURANCE AGENCY Insurer's Address: 140 MARION ROAD City/State/Zip: WAREHAM, MA 02571 Policy # or Self -ins. Lie. # WCP6817N Expiration Date:06122/2021 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 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 thelzai.ns and penalties oflier imy that the information provided above is true and correct. %� %_ ir1 a — _ 11/1/2020 me Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (check one): I.❑BoardofHealth 2.❑Building Department 3.❑City/Town Clerk 4,❑LicensingBaard 50Selectmen's Office 6.❑Other Contact Person: Phone INSURER: NGM INSURANCE 4601 TOUCHTON SUITE 3400 JACKSONVILLE, COMPANY ROAD EAST FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: J HOCKMAN INC C/O C.L. HOLLIS INSURANCE 140 MARION RD WAREHAN MA 02571-1460 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY — INFORMATION PAGE POLICY NO: RENEWAL OF: NCCI Company No: Account No: W1P6817N W1P6817N 16322 CACP6817N AGENCY NAME AND ADDRESS: CL HOLLIS INSURANCE 140 MARION ROAD WAREHAM, MA 02571 AGENCY PHONE NO.: (508) 295-9500 AGENCY NO.: 201423 (See Workers Compensation Location Schedule) ITEM 2, POLICY PERIOD: From: 06-26-2020 To: 06-26-2021 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 1,000,000 each accident Bodily Injury by Disease: $ 1,000,000 policy limit Bodily Injury by Disease: $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: NO, OR, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. l be determined by our Manuals of Rules, Classifications, Rates and ITEM 4. PREMIUM: The premium for this Policy wil Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification SchTotal edule. Minimum Premium: $ 341 Annual Premium: $ Audit Period: ANNUAL Date: 05-18-2020 Countersigned by WC 00 00 01 A Copyright 1987 Naftrol Councll on C="nsa9on ksurance INSURED COPY