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Home My WebLink AboutJ. J. Bosse Construction Co. - 12/31/2021Town of Mansfield I`®wtt of Matisfield - Board of'Health 6 Park Row Mansfield, MA 02048 Disposal Works InstallerApplication LICENSE NUMBER: APPLICANT: c_xme<s 13o5se. BUSINESS NAME: MAIL ADDRESS: CITY/TOWN: < _au STATE:./ y I — ZIP CODE: BUSINESS PHONE:I��__ BUSINESS CELL: BUSINESS FAX: qJ2S -AA? t—/7,�� l3 E-mail: � en1(�"cnw'Cat),c+ Alt E-mail: ID/SS NUMBER: 1 LICENSE HELD: Town Fs S -0r) Year Licensed r90aX) LICENSE HELD: Town A \kpn Year Licensed A nj- (�D LICENSE HELD: Towne �� Year Licensed 0O9 % 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". understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31 st yearly. FEE: $ 100.00 SIGNATI 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. L owl ) c or Corporate Name By: Corporate Officer (Mandatory, i(Applicable) C)9 ;,3oq�i(a "*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\Scott's Docnments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts 1VjDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wives. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: City/State/Zip Eli Are you an employer? Check the appropriate box: Business Type (required): I. EK I am a employer with _ employees (full and/ 5. ❑ Retail orpart-time).* 6.❑RestaurantBar/EatingEstablishment 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. 8• ❑ 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, Other & � '�C'f'b wsi'k'_ with no emplovees. Wo workers' comp. insurance req.l 12.® IL *Any applicant drat cliecks box #1 must also fill cattle 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 mid such an organization should check box 91. lam an employer that is providing workers' coMeitsatien insurance for my employees. I3elmv ilthe polio information. Insurance Company Insurer's City/State Policy # or Self -ins. Lic. # WC 9310_; i I `11Z �) (0 04'0 Expiration Date:WAL000 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Itereby certa , under the p/a/iris aat tL/jLgnat,tieespof perjury that the information pro Vide d%a/b V e is true and correct. Cirznahira• i...11, P �//��/"Jf Duter `^'//�/C7/(..7 IYv Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.nsass.gov/dia To: 1508230773 Page: 3 of 6 2020-12-11 16:31:07 GMT 16178018048 From: William Goodrich A� O CERTIFICATE OF LIABILITY INSURANCE DA72/1112020YY) 1v11nazo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(fes) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of Such endorsement(S). PRODUCER William L. Goodrich Agency, Inc. 424 Adams Street#102 Milton MA 02188 NAME: Donna Benoit Pxc°N Ert (617)69$-5544 P: (617)698.8515 ADOREss: dbenoit@wgoodrichins.com INSURER 8 AFFORDING COVERAGE NAIC 0 O'SURERA: Hanover insurance Company 22292 INSURED J J Bosse Construction Co., Inc. 35 Caroline Road South Easton MA 02376 INSURER B: Allmorloo Financial Bonofit 41840 INSURER C: Liberty Mutual Fire lns:ARWC 16586 INSURER D: INSURER&: INSURER F: Can l THIS IS TO CERTIFY THATTHE 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 jp TYPEOFINSURANCE eD 0 POLICY NUMBER MMIDDIY"V XP MMIODIYYYY LIMITS q XI COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FXJ OCCUR 00/06/2020 06/08/2021 EACHOCCORRENCE $ 1,000,000 PREMISES Eaaccurtence $ 100,000 Ep—ZHN912615209 NED EXP (Anyaria Person $ 10,000 PEBSONALaAOVINJURY $ 1,000,000 GETL AGGREGATE LIMIT APPLIES PER: POLICY jEC too OTHER: GENERALAGGREOATE S 2,000,000 PRODUCTS-COMPIOP AGO $ 2,000,000 Owners Or Lossoos S B AUTOMOBILE LABILITY ANYAUTO OWNEDx SCHEDULED AUTOS ONLY AUTOS HIRED v NON-OWNEO X AUTOSONLY AUTOS ONLY Y Y AWN9107254 06108/2020 06/06/2021 COAIBINdEO SINGLE LIMIT Ea acrin $ BODILY INJURY (Per patron) s 1,000,000 BODILY INJURY IPerauldoi) s PROPER O?MAGE Per accMe t g IDGid UMBRELLA LIAO EXCESS LIAR OCCUR CLAtrASA1ADE EACH OCCURRENCE $ AGGREGATE $ DEG I I REfENi10N $ $ C WORKERS COMPENSATON AND EMPLOYERS' UABILITY YIN MY FFICERIMEMSER EXCLUDEIDD?ECUTNE ❑ (Mandatory In NH) It Sae. Iler00be Under DESCRIPTION OF OPERATIONS baba NIA Provided by carrier 6TATUTE ERH E L. EACH ACCIDENT $ EA. DISEASE - EA EMPLOYEE $ E.L. DISEASE POLICY LIMIT 8 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addifbnal Remnrka Wu dub, may be attached if more apace is required) Town of Mansfield and any other parties required by specific written contract are added as an additional insured with respect to the automobile liability Insurance on a primary and non-contributory basis. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Six Park Row — AUTHORREDREPRESENTATVE Mansfield MA 02048 p +7L[.• 1BBB-2U ACORD 26 (2016103) The ACORD name and logo are registered marks or ACORD NuN. An rigors To: 1508230773 Page: 4 of 5 2020-12-11 16:31:07 GMT 16178018048 From: William Goodrich ACORp" CERTIFICATE OF LIABILITY INSURANCE DATE (MM Donvrr) 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) 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 endorsemenl(s). PRODUCER COMEACT Donna Benoit PNONE 617)698.5544 o: WILLIAM L GOODRICH INSURANCE AGENCY INC _ExIAD aooRlEss: dbenait@wiGodrichins.com _ INSURER(S) AFFORDING COVERAGE NAIC 4 424 ADAMS ST INSURERA: LIBERTY MUTUAL FIRE INS CO _ „23035_ MILTON MA 02186 _ INSURED INSURER B: INSURER C: J J BOSSE CONSTRUCTION CO INC INSURER D : INSURER E: 35 CAROLINE ROAD INSURER F: SOUTH EASTON MA 02375 COVERAGES CFRTIFICATF NUMBER: R043R7 REVISION NUMBER: THIS IS '1'0 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, I18R TYPEOF04SURANCE AmDLS BR POLICY NUMBER IMOLODY/YYYFVI IXPI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS -MADE n OCCUR PREMISESIE _ MEDEXP (Anyone Arson) S PERSONAL A AOV INJURY S N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRODUCTS CQb1PlOP AGG 5 POLICY n P . � LOC OTHER: S AUTOMOBILE LIABILITY QUMBINED SI ULE MIT a a.d.ri S BODILY INJURY (Per person) S ANYAUTO BODILY INJURY (Par accidanp 6 ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOS NIJq PROPERTY DA 4AGE P racade^`' g S UMBRELLALIAB OCCUR EACH OCCURRENCE S AGGREGATE S EXCESSUAS CLNMSWADE N/A DED I I RETENTIONS 5 A WORKERS COMPENSATION AND EMPLOYERSLIABILITY YIN ANYPROPRICTORrPARTNCRICXECUTIVC OrrICRIMEMBEREXCLUDED9 NIA (Mentlalory k, NIT) NIA WA WC231 S317826040 04l05/2020 04105l2021 X I STATUTE I I EORTH_ E.L. EACH ACCIDENT S 100,000 E.L. DISEASE EMPLOYEE 3 100,000 El DISEASE -POLICY LIMIT --- 8 500,000 11V856IepolnbeanUer DESCRIPTION OF OPERATIONS bel. N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE6 (ACORD 901 Adtlilimwl flemar Ns Solletlule, maybe olluahed if more eyeuo ix regpire:e Workers' Compensallon benefits wlil be paid to Massachusetts employees Only. Pursuant to Endorsement WC 20 03 OB B, no authorization is given to pay claims for benefits to employees In states other than Massachusetts Hthe Insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue data of this Certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at wm,nlass.govllwd/workers.compensation/Investigations/. e unr nee CANCEL I_ATION CIEr19 ,Vllr�r,V�r��.� --' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield SIX Park ROW AUTHORVEDREPRESENTATIVE Mansfield MA 02048 Daniel M.. Crq vBy, CPCU, Vice President -Residual Market- WCRIBMA ACORD 26 (2014101) CU 19OU-2014 ACOKD GUKNUKAI ION. All rights The ACORD name and logo are registered marks of ACORD