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HomeMy WebLinkAboutL & L Heating - 12/31/2021 **4-534j 100'°' Town of Mansfield - Board of Health Disposal Works Installer Application r.1r; LICENSE NUMBER: APPLICANT: !J /t BUSINESS NAME: 2 "F L l MAIL ADDRESS: CITY/TOWN: 7 STATE: ZIP CODE: 6 Z BUSINESS PHONE: 0- ° q 1 II SS / - 6 0 °/—' BUSINESS CELL: "S '" 1_1 le — BUSINESS FAX: E-mail: Alt E-mail: ERAL ID/SS NUMBER: LICENSE HELD: Town Year Licensed LICENSE HELD: Town k i � � ,J-U v� Year Licensed LICENSE HELD: Town Year Licensed Ze, 7 �� z� y� 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: 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. i ature o , dividual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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 ly \ 1/1G Vf IYl UJJrIL./LUJCLLJ 3Lu Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses nnlicant Information Please Business/Organization Name: t ll r ei,�- jl i Address: 10 / 7 d t 1-t City/State/Zip: 4f—d— Phone #1 % Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with _` 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. [No workers' comp. insurance required] g• 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, r with no employees. [No workers' comp. insurance req.] 12.❑'6ther *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 providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: & ( Ala& rt C „ 1, ) "'t L�& Insurer's Address: 3 City/State/Zip: l' Policy # or Self -ins. Lic. #- �L r } y7 c/ Expiration Date: 7 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 hereby certify, under the pains and penalties ofperjury that the information provided a/bPve is true and correct Shmature: J Date: qC, 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 Person: Phone AC6Ro® CERTIFICATE OF LIABILITY INSURANCE `,...� DATE IMMIDDrYYYY) 10/28/2020 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(ies) 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 CONTACT NAME: Isabel Carreiro HW LAPOINTE JR INSURANCE AGENCY INC PHONE (508) 678-8341 aC No: E-MAIL ADDRESSlearreiro@lapointeins.com : icarreiro la omteins.com INSURER S)AFFORDING COVERAGE NAICN 10 North Main Street 1st Floor INSURER A: ACE AMERICAN INSURANCE CO 22667 Fall River MA 02720 INSURED INSURERS: INSU RER C: LOGAN RAYMOND INSURER D: DBA L & L PLUMBING & HEATING INSURER E: 1011 HILLSIDE AVE INSURER F: ATTLEBORO MA 02703 COVERAGES CERTIFICATE NUMBER: 589874 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 TR rypE OF INSURANCE ADDLRm SUBD NUMBER POLIPOLICY MMu�YEFF NOLICYIYVIY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 11 OCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLI ES PER: GENERALAGGREGATE $ POLICY ❑ JECT � LOG PRODUCTS-COMPIOPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIREDAUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR M CLAIS-MADE N/A DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY OFFlC RNEMSER EXCLUDED?ANYPROPRIETORIPARTNEIVEX NIA (Mandatory In NH) NIA NIA 6S62UB4579P92020 03/24/2020 03/24/2021 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Addifonal Remarks Schedule, maybe attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the 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 date 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 www.mass.gov/lwdfworkers-wmpensationlinvestigations/. Sole proprietor has not elected coverage. 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. 6 Park Row AUTHORIZED REPRESENTATIVE �"'0 Mansfield MA 02048 Daniel M. C*Jey, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD RAYMLOG-01 ICARREIRO ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE 1128/2020 10@8/2020 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(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 CONTACT NAME: PHONE (A/C, Na, EXq: (508) 678.8341 lac, Ne):(508) 678.0438 H W Lapointe Jr Ins Agency, Inc 10 North Main Street Suite 1 Fall River, MA 02720 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: Travelers Casualty Insurance Co of America 19046 INSURED INSURER B : INSURER C : Raymond Logan DBA L & L Plumbing & Heating INSURER D: 1011 Hillside Ave Attleboro, MA 02703 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LTR rypE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDDlYYYY POLICY EXP WW MMIDDI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X 6804A644596 812312020 8123/2021 EACH OCCURRENCE $ 500,000 DAMAGE TORENNT ante $ 300,000 MED EXP (Any one personj $ 6,000 PERSONAL B ADV INJURY $ 500,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY T LOC OTHER: GENERAL AGGREGATE $ 1,000,000 PRODUCTS-COMPIOPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS Eo AUTOS ONLY AUTOSONLV COMBINED ISINGLE LIMITIre $ BODILY INJURY lParperson) $ BODILY INJURY Per accident $ PPerr aWdent MADE Per $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERMIEMBER EXCLUDED?ECUTIVE ❑ (Mandatory in NH) Ifyes6 ES6descbe antler DRIPTION OF OPERATIONS below NIA STRTUTE ERH E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE $ EL. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED /REPRESENTATIVE ACORD 25 (2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield - Board of Health LICENSE NUMBER: APPLICANT: (IL c, BUSINESS NAME: Disposal Works Installer Application t s Mansfield ahsfld, MA1029$,8 4/20 f MAIL ADDRESS: 1 Z %�I f / I 1 � S !`�}Z 7� V ) CITY/TOWN: �x �� � STATE: 1 ZIP CODE: BUSINESS PHONE: � U �—) J P— i� 4 % BUSINESS CELL��O '1 V )/ — / 9 " t BUSINESS FAX: E-mail: Alt E-mail: 4W ERAL IDISS NUMBER: 7 (/4/ ­ LICENSE HELD: Town V7r,)ii Year Licensed 0— -� 7 C � —w ,f LICENSE HELD: Town �`� Year Licensed oz- ` /1C V'-fP LICENSE HELD: Town 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: �'�/� 2. 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. �s f�. re iviXa or Corporate Name **Social Security No. (Voluntan/) or Federal Identification Number By: Corporate Officer (Mandatonj, if Applicable) *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\ScoWs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization /Name:_ Address- City/State/Zip: Phone #: Are yoy an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 2� 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. 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, 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 an employer that is providing/workers' con nation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 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 Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and pemdti"perjury that the information provided allove is true and correct. /{ r/ i L_ �. Sienature: s��-�� ��/ Date: / �` 1 !� Official use only. Do not write in this area, to be completed by city or town offfciaL 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 Person: Phone #: www.mass.gov/dia ACJ�RY CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DIYYYYI 10/28/2020 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 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 HW LAPOINTE JR INSURANCE AGENCY INC CON A IT NAME: Isabel Carreiro P"CN o Es (508) 678-8341 INC No: E-MAIL carre iiro la olnteins.com ADDRESS: Q P INSURERS AFFORDING COVERAGE - NAIC # 10 North Main Street 1st Floor INSURERA: ACE AMERICAN INSURANCE CO 22667 Fall River MA 02720 INSURED INSURER B : ' INSURERC: LOGAN RAYMOND INSURER D: DBA L & L PLUMBING & HEATING INSURERS: 1011 HILLSIDE AVE INSURERF: ATTLEBORO MA 02703 rM%IRPAGFS CFRTIFICATF NIIMRER: rAcA74 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 LTR TYPEOFINSURANCE ADO S BR POLICYNUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE PREMISES Es occunence $ MEb EXP (Any one person) $ PERSONAL B ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY ❑ PRO-JECT ❑ LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS NON -OWNED HIREDAUTOS AUTOS N/A PROPERTY DAMAGE Per acGtlent $ $ UMBRELLAUAS OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION$ $ A WORKERSCOMPENSATION AND EMPLOYERS' LIASIUTY YIN OFFIC RIM MBERPEXCLUDED ANYPROPRIETORAARTNER/EXECUTIVE NIA (Mandatory in NH) NIA NIA 6S62UB4579P92020 03/24/2020 OWN/2021 �/ X STATUTE EOR" E.L. EACH ACCIDENT $ 500,000 E.L, DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached Borore apace is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the 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 date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verifcalion Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. 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. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M.Crcyoy, CPCU, Vice President —Residual Market— WCRIBMA 9)1988.2014 ACORD COKPOKA I IUN. AO rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD RAYMLOG-01 ICARREIRO i l kl.. O CERTIFICATE OF LIABILITY INSURANCE � ��- DATE 81202 YY) 10/2812020 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 H W Lapointe Jr Ins Agency, Inc 10 North Main Street Suite 1 Fall River, MA 02720 Cp TACT NAME: ja�NN , Eat): (508) 678.8347 FwA''o, Nol:(508) 678-0438 E-MAILE s: INSURER(Sl AFFORDING COVERAGE NAIC p INSURER A: Travelers Casualty Insurance Co of America 19046 INSURED INSURER a : INSURER C : Raymond Logan DBA L & L Plumbing & Heating INSURER D: 1011 Hillside Ave Attleboro, MA 02703 INSURER E INSURER F: rvorrorATE NUMBER RFVISION NUMBER: y "'-- 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. MSR LTRTYPE A X OF INSURANCE COMMERCIAL GENERAL LIABILITY ADDL p SUER yyyp POLICY NUMBER POLICYEFF r DNMUDDIYYYYI POUCYEXP LIMITS EACH OCCURRENCE $ 500,000 culMs-MADE X occuR X 6804A644596 8/23/2020 812312021 DAMAGETORENTED PRE a occu e 300,000 $ MED EXP (Any one persor $ 5,000 PERSONAL &ADV INJURY 500,000 GENT X AGGREGATE LIMIT APPLIES PER: POLICY1:1 jEa LOC GENERALAGGREGATE $ 1,000,000 PRODUCTS-COMP/OPAGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY E,,e deDSiNGLE LIMIT $ BODILY INJURY Par p.rs.ril $ ANY AUTO BOOqDILY INJURY Per accitlant b OWNEDSCHEDULED AUTOS AUTOS OS HIRED NONAWNEO AUTOS ONLY AUTOS ONLYY POrawtlenl AMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTIONS AND EMPLOYERSELIPB ILOITNY YIN ANY PROPRIETORIPARTNERIEXECUTIVE STATU OERH E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYE $ OFHCE�iIMEMSER EXCLUOEpy ❑ (Mantle oM in NNN) NIA E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is requiredl 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. W/U' of 4.1 "-- ACORD 26(2016103) W lubu-ZU'lo AUUMU VVRrul AI IVIV. N11 rRJIRb iCacnvuu. The ACORD name and logo are registered marks of ACORD