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HomeMy WebLinkAboutPlainville Pump & Excavating, Inc. - 12/31/20216 _4�'�0 �7 _� d©,— Town of Mansfield - Board of Health Tpwrk afield 8 Park R Mansfield, "20, i• �, { Disposal Works Installer Application c 7— LICENSE NUMBER: APPLICANT: SOSeP r i I lPl i'e BUSINESS NAME: Vid1l(( A MAIL ADDRESS: 18 CITYITOWN: -PIQ.111V I I I e STATE: HA ZIP CODE: 02762— BUSINESS PHONE: 508- CAS-q_L5(p BUSINESS CELL: BUSINESS FAX: 5[)3—(oQ5— 4y33 E-mail: Sb_e_p_ V i ALP_-PU_n<t'p-corn AR E-mall: 'I n QD @ -Pla" rtu I I I& i O Ind ID/SS NUMBER: D4-281(1130 SOO-72_6-%5Co LICENSE HELD: Town NOr h A41 e_bOrro Year Licensed 202-0 LICENSE HELD: Town r xb0ro Year Licensed 2.020 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 31st yearly. FEE: $ 100.00 r SIGNATURE: DATE: f U 141 - Zo'z,) 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. re of Indivi al o r e 04-281 y 130 **Social Security No. (Voluntary) or Federal Identification Number - ose_ph V 6646 V P 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:\Userntsleite\Desktop\ScotPs Doe ments\Food Establishments- Temp\TAX CERTIFICATION FORMAac s vee a.vvveuwre rveuecvi Vj 1rLuaowe.rsuuecw UlfDepartment of Industrial Aeeidents 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 N Address: 100 (V 1 � Il e �A 1}- On (o 2- Phone #: S OF3 ^ (C S`q I Sip Are you an employer? Check the appropriate box: Business Type (required): 1. Uf- I am a employer with I 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. [No workers' comp. insurance required] S• 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 req.] 1 12.0 Other E *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informwon. **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 pro viding workers' compensation insurance for lily employees. Below is the policy infra-nratioti. Insurance Company Name: AC Q (� I) _Xi'1 S U VQA1CPCZ) rn pa4 tN Insurer's Address: 2Q O ))QQQ 1(j J Lt.l V'1 W City/State/Zip: M(> L 1 bnML�h 11-4 V_} F) i l J L Policy # or Self -ins. Lic. # we Ki 538 I S7Cn — I i Expiration 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, tinder the pains and penal/ties ofperjury that tiret. information provided above is true and correct Phone #: S�g�(eQs^q I Ci(n Official use only. Do trot 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 #: www.mass.gov/dia WC 00 00 01 A 07 11 Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 it � • a �. � � _. • � LIABILITY INSURANCE POLICY RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5381876 - 11 Previous Policy No.: 5381876-10 1. Name Insured and Address Agency Name and Address 07231 Plainville Pump & Excavating, Inc. (781) 642-9000 77 School Street Eastern States Insurance Agency, Inc Plainville, MA 02762 50 Prospect Street Waltham, MA 02154 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 042814130 Risk ID No.: Bureau File No.: 000041122 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 01/25/2020 to 01/26/2021 12:01 AM Standard Time at the insured's mailing address. COVERAGE 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA, RI B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 01 A 07 11 Includes copyrighted material of The National Council on Compensation Page 1 of 6 Insurance, with their permission.