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HomeMy WebLinkAboutPeter DeGirolamo & Sons, Inc. - 12/31/2021Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: 1 O APPLICANT: JOSEPH DeGIROLAMO BUSINESS NAME: PETER DeGIROLAMO & SONS INC MAIL ADDRESS: 77 EAST BELCH ER RD CITY/TOWN: FOXBORO STATE: MA BUSINESS PHONE: 508-543-7228 BUSINESS CELL: BUSINESS FAX: 508-543-9212 E-mail: joe.degirolamo@verizon.net AltE-mail: deb.choiniere1@verizon.net ID/SS NUMBER: 04-2498634 LICENSE HELD: Town MANSFIELD LICENSE HELD: Town SHARON LICENSE HELD: Town FOXBORO Town of Mansflaid 6 Park Row Mansfield, A 11;m 8 " ZIP CODE: 02035 508-962-1344 Year Licensed 2010-2020+ Year Licensed 2019, 2020 Year Licensed 2019 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: y 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. PETER DeGIROLAMO & SONS INC s- Signature of Individual or Corporate Name Corporat fficer (Mandatory, if Applicable) 04-2498634 '"'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:\Usem\sleite\Desktop\Scott's Doe ments\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents 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: PETER DeGIROLAMO & SONS INC Address: 77 EAST BELCHER RD City/State/Zip: FOXBORO, MA 02035 Phone #: 508-543-7228 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 15 employees (full and/ 5. ❑ Retail or pact -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 3. ❑ [No workers' comp, insurance required] 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]* 1111 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 #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 41. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: MARSH & MCLENNAN AGENCY Insurer's Address: 100 FRONT ST. SUITE City/State/Zip: WORCESTER, MA 01608 Policy # or Self -ins. Lic. # WCC-500-5012531-2020A Expiration Date: 10/11/2021 Attach a copy of the workers' compensation policy declaration page (sbowing 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, undgr fhe pght awl penalties ofperjury that the information provided above Is true and correct Offrcial 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 Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC-50 1-5012531-2020A PRIOR NO. WCC-50 1-5012531-2019A ITEM 1. The Insured: Peter DeGirolamo & Sons Inc DBA: Mailing address: 77 E Belcher Road FEIN: **-***8635 Foxboro, MA 02035-0000 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 10/11/2020 to 10/11/2021 12:01 a.m. standard time at the insured's mailing address. 3. 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: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No, Total Annual Of Annual Remuneration Remuneration Premium INTRA 000137395 INTER SEE CLASS CODE SCHEDU E Minimum Premium $575 Total Estimated Annual Premium $23,886 GOV GOV Deposit Premium $6,175 STATE CLASS —WA 6217 State Assessments/Surcharges $23,107.00 x 3.5100% $811 This policy, including all endorsements, is hereby countersigned bye_ 09/10/2020 Authorized Signature Date Service Office: 54 Third Avenue Burlington MA 01803 WC 00 00 01 A (7-11) Marsh & McLennan Agency LLC 100 Front Street Suite 800 Worcester, MA 01608 Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. Ac �® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 Marsh &McLennan Agency LLC -New England 100 Front Street, Ste 800 Worcester MA 01608 CONTACT NAME:PHONE FAX c e E 888-860-940o A c No: 866-795-8016 ADDRESS: MMA.NewEngland.CLines@rnarshmc.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: Massachusetts Bay Insurance Company 22306 INSURED PETERDEGIR1 INSURER B: Allmerica Financial Benefit Insurance 41840 Peter DeGirolamo & Sons, Inc. 77 E. Belcher Road msURERC : Hanover Insurance Company_____ _ 22292 INSURER D: Associated Industries of MA Mut Ins Cc 33758 Foxboro MA 02035 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1955873089 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 TYPE OF INSURANCE AODL SUER POLICY NUMBER POLICY EFF MMIDUYYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY ZDNH070619 10/11/2020 10/11/2021 EACHOCCURRENCE $1,000,000 CLAIMS -MADE 1 571 1 OCCUR PAMAGE TO REM SES Ea ocounence)_ $100,000 _ MED FXP (Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY[fl jE� LOC PRODUCTS - COMP/OP AGG $2,000,000 OTHER: $ e AUTOMOBILE LIABILITY AWNH070686 10/11/2020 10/11/2021 COMBINED SINGLE LIMIT Ea accident $1,00D,0o0 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY G X UMBRELLA LIAB IX OCCUR UHNH070620 10/11/2020 10/11/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 EXCESS LIAB CLAIMS -MADE DED TX7 RETENTION _ $ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE F_N] OFFICER/MEMBEREXCLUDED4 NIA 5012531 10/11/2020 10/11/2021 X P R OTH- __ STATUTE. ER E.LEACHACCIDENT $1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if more space is required) Disposal Works Installer Permit CERTIFICATE HOLDER CANCELLATION 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 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD