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Home My WebLink AboutMiles of Excavating - 12/31/2021OC/ '•p Town 6f Mansfield, Town of Mansfield - Board of Health s Pa M sfi MA 02048 Disposal Works Installer Application tf LICENSE NUMBER:_ H-7 — d_`i��%�e�- APPLICANT: 777tK(,-r'A y BUSINESS NAME: C)F YXr.F} MAIL ADDRESS: CITY/TOWN: 77,��/l J/f%f{/i'� STATE ZIIP,pCOD®� -7E/3__..____ BUSINESS PHONE56 30y f S%0 _ BUSINESS CELL: BUSINESS FAX:D-3S—! E-mail: #q ia u f ail ca-_cJu � epkv, r°—" Alt E-mail: Gr ID/SS NUMBER: lid— LICENSE HELD: Town (��} ti`��r�li Year LicensedUl LICENSE HELD: Town 7 clr U Year Licensed 17?e14 LICENSE HELD: Town Year Licensed -O / 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: _�`� '�/P d - ) --- Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 MILEOFE-01 CWOODS_I_DE CERTIFICATE OF LIABILITY INSURANCE OAT0WYYV) sr24/22anazo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY_ AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCEfagE$ 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()es) 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 License q 1780862 England HUB international New En 9 600 Longwater Drive Norwell, MA 02061-9146 go TEA, CT Michelle Wolf PHONE FAX (PMNE, EX1 : (508 886-2183 lac, No E- AIL . michelle.wolf@hubinternational.com INSURERS AFFORDING COVERAGE NAICa INSURER A: LIbe Mutual 23043 INSURED Miles of Excavating Timothy Konowih dba 242 Park Street Wrentham, MA 02093 INSURERS: Commerce Insurance Company 34754 INSURERC: WeSCO Insurance Com )an 25011 INSURERD -Acadia (Insurance Com an 31325 INSURER E: INSURER F: ___ _ ___ .,.......-... RPVISIr1N NIIMRFR' (;UVERAVL'' V RIIr'1l.NIG 1YViviocrt. '--"-'-^ """-- -- 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 ADDLSUBR SD POLICY NUMBER POLICY EFF 0 212712020 2127)2020 POLICY EXP 212712021 212712021 LIMITS A B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X BKS58621919 BHDLXX EACH OCCURRENCE $ 1,000,000 OAMAGETORENTED 300,000 MED EXP (Any one nemon) 15,000 PERSONAL$ ADV INJURY 1,000,000 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY %cof LOC OTHER: AUTOMOBILE LIABILITY ANYAUTO OWNEE�AUTO9DONLV X AUOpTNNOppSULED X MITTS ONLY X AUTOSWONLY PRODUCTS - COMPIOP AGG 2,000,000 NGLE LIMIT EdOMBINE -SI $ 1,000,000 BODILY INJURY Per eneon)$ BODILY INJURY Per eccltlent $ PPetacd0ent AMAGE $ C D UMBRELLALIAB EXCESS LIAS OCCUR CLAIMS -MADE NIA WWC3427526 CIM5146595 8/23/2020 2127/2020 812312021 212712021 EACH OCCURRENCE $ AGGREGATE PER, E )f ETH- DED RETENTION$ WORKERSCOMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PRROIPREIETORIPARTNEWEXECUTIVE (Mantletory In �iPFij EXCLUDED? ❑N If yes. dascdbe under DYSCRIPTION OF OPERATIONS below Equipment Floater E.L. EACH ACCIDENT 500,000 $ E.L. 015EASE-EA EMPLOYE 500,000 $ E.L. DISEASE -POLICY LIMIT rental 500,000 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedute, may be attached if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) v moo-cv IJ PYV V,...............�.............a The ACORD name and logo are registered 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. �� %2cK.aac.ul. Signature of Individual or Corporate Name o V 3!Y5_V lI:- **Social Security No. (Volunta ) 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:\UseiVs1eite\Desktop\ScoIVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations Lafayette City Center 2Avenve # Lafayette, Boston, MA 02111-1750 www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Miles of Excavating Address:242 Park St. City/State/Zip: Wrentham, Ma 02093 Phone #:508-384-9590 Are you an employer? Check the appropriate box: Business Type (required): 1. ■❑ I am a employer with 4 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership slid have no 7, ❑ Office and/or Sales (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. ❑ Manufacturing no employees. [No workers' comp, insurance required]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance rea.] 12.❑ 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Weseo Insurance Company Insurer's Address:800 Superior Avenue City/State/Zip: Cleveland, OH 44144 Policy # or Self -ins. Lie. 4WWC3427526 Expiration Date:8/23/2021 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, , er the pai penalties ofperjury that the information provided above is true and correct. 508-384-9590 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (check one): 1❑Board of Health 2.0 Building Department 50 Selectmen's Office 6. ❑Other Permit/License # 3.0City/Town Clerk 4.❑Licensing Board Contact www.mass.gov/dia Phone