The URL can be used to link to this page

Home My WebLink AboutKenny Jones Corp. - 12/31/2021LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: 36 V, Iowa ofMansfield m Board of Health Disposal Works Installer Application J _ /0o 0C? Town of I'ansfield 6 Park Row Mansfield, MA 02048 CITY/TOWN: AC 1 tw v STATE: 4— ZIP CODE: O7il ) BUSINESS PHONE: 6_09 95jd r15) _ BUSINESS CELL: L(. BUSINESS FAX: 6D SA E-mail: KL'-hntfQ?_eonnit,Jb5�JPrsr�.Cz>r� Alt E-mail: a rYo Lie Ag_can(Af4--iy °' IDtSS NUMBER: LICENSE HELD: Town Uly LII/C. Year Licensed Aiodd LICENSE HELD: Town es o lam- Year Licensed mj) LICENSE HELD: Town � f Year Licensed [7 22d 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: + f DATE:dm 0 �dl � 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 KENNJON-01 AKAHANOWITZ 1 ,AcoR® CERTIFICATE OF LIABILITY INSURANCE L.�./ DATE 1212900A/2020 12129 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 endorsement(s). PRODUCER R. S. Gilmore Insurance Nor27 rtth Atlm tleboro, MA 02760 NONEACT (AI°cN o, Ext; (508) 699-7511 FAX No):(508) 695-3597 Wfiss: INSURER S AFFORDING COVERAGE NAIC It INSURER A:Arbella Indemnity 10017 INSURED INSURER B: SafetyIndemnityIns. Co. 33618 _ INSURER c: Contlnentallndemnit COm an Kenny Jones Corp __- INSURER D: 2092 Main St Walpole, MA 02081 INSURER E: _ INSURER F: !`OVERAGES r PRTIFlr`ATF NIIMRFR• 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 TYPE Of INSURANCE AODL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS�MADE F V 1 OCCUR 3500054554 4/1/2020 4/1/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED SES Ea occ ante $ 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL SADVINJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEa LOC OTHER: GENERALAGGREGATE $_ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED TTNOS AIUIRRTEEOSONLV X AUUp030 X AUTOS ONLY X AUTNLB 2436062 4/1/2020 4/1/2021 NED COM BI ididou SINGLE LIMIT $ 1,000,999 BODILY INJURY Per arson $ BODILY INJURY Per accident _ $ Pe0PEN DAMAGE $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACHOCCURRENCE $ ._ AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY OFFICEWMEIMBOER E%CWDED ECUTIVE YIN (Mantlalory In NH) —J Ii yes, describe under DESCRIPTION OF OPERATIONS below NIA 376465500101 6/3/2020 6/3/2021 PER OTH- E.L. EACH ACCIDENT 500,000 $ E.L. DISEASE -FA EMPLOYE 5U9,U6D E.L. DISEASE - POLICY LIMIT _ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. maybe attached If more space is required) r:FRTIFIr.ATF Hint nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwramassgov/dia Workers' Compensation Insurance Affidavit: General I .aulicant Information Business/Organization Name:, City/State/Zip: UJQ,_ j Rp jPhone #: , j .-_I_. ) Are you an employer? Check the appropriate box: Business Type (regair d): 1. I am a employer with J ., employees (full and/ 5. Retail or part-time).* 6. ❑ Restaurant/Bar/E ling Establishment 2. ❑ I am a sole proprietor or partnership and haven° 7. ❑ Office and/or Sal s (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.Q Manufacturing no employees. [No workers' comp. insurance required]* 4: n ❑ We are a non-profit organization, staffed by voluteers, 1117 Health Care // with no employees. No workers' comp, insurance req.] 12.4 Other � G � �LX C � lid �l 6r1 'Any applicanttbat checks box #1 must also fill out Ibesection below showing their workers' oorepensmion policy ipformatilm **If the corporate offioers 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 providing workers' compensation imurdwee, for my employees. Below is thepolicy information. Insurance Insurer's City/state/Zip: C It) � 5 v Policy # or Self. -ins. Lie. # ��' (o y la 35 G o (C71 Expiration Date: 0(o,l /)a va 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 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 I do hereby eerdfy, of perjury that the information provided above is true and correct Official use only. Do not write In this area, to be completed by city or town of, trial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityrrown Clerk 4, Licensing Board 5. Selectmen's Office 6.Other Contact Person! Phone #: www.mass,gov/dia 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 Individual or otpoi'ate Naine By: Corporate Officer (Mandatory, i Applicable) l La o� *Social Security 6. (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 Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc