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Home My WebLink AboutPond View Excavation Corp. - 12/31/2021fi,- i j Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 19' Disposal Works Installer Application LICENSE NUMBER: / " ley APPLICANT: K e BUSINESS NAME: MAIL ADDRESS: CITYITOWN: �Y'/�A STATE:Njq-- ZIP CODE: ®a 7�n BUSINESS PHONE:, tOff�_-_, 67_�BUSINESS CELL: BUSINESS FAX: 6 d - E-mail: . exe Alt E-mail: ID/SSNUMBER: LICENSE HELD: Town Year Licensed \`kp? LICENSE HELD: Town `> (_ r�V�_ Year Licensed LICENSE HELD: Town Year Licensed \TA 0 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 at yearly. FEE: $ 100.00 SIGNATI 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. Signature of Individual or Corporate Name 6 �Z- 3K�j S 3) "Social Security No. (Voluntary) or Federal Identification Number YL�J-W�,- By: eolqorate Offi •er Mandatory, ' icable) *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\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ACCWZH CERTIFICATE OF LIABILITY INSURANCE lh DATE tMM/OD YYYY) 11126/2020 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 CROSS INSURANCE INC - RHODE ISLAND 376 NEWPORT AVENUE RUMFORD, RI 029160830 CONTA T PHONE (A/C, No Ea[: AC No: ADDRESS: INSURERM AFFORDING COVERAGE NAIC# INSURER A: Liberty Mutual Fire Insurance 23035 INSURED POND VIEW EXCAVATION CORPORATION INSURERS: --- 50 FRENCH STREET INSURER C: ___ _ INSURER D: REHOBOTH MA 02769 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 58763658 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 ADDL SUBR POLICYNUMBER MWDDPOLICYEFF UP MM/DDYAYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR AMAGE TO RENTED PREM SES Ea occurrence) $ MED FXP (Any one person) $ P __ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ RI- POLICY JECTPRO- LOC PRODUCTS_ COMPIOPAGG $ _ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _LEa accident ___ $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY I NJURY(Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE MNNIA OFFICER/MEMBEREXCLUDED9 WC2-31S-365689-020 4/1/2020 4/1/2021 �/ SPER TATUTE ERH E.L. EACH ACCIDENT --- $500000 E.L. DISEASE - EA EMPLOYEE $ 000 0 (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OFTHE STATE OF MA. This certificate cancels and supersedes all previously issued certificates, only as they relate to workers compensation coverage. 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. AUTHORIZED REPRESENTATIVE Jon Smith ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 58763658 1 1-365689 1 20-21 we I ne271703 1 11/26/2020 3:03:05 M (EST) I Page a or t The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: , ,5-p /— h (11 Sf- City/State/Zip: Yi c,h,9 :Eh /"(V 1)g Phone #: qQl — y3fj 300b Are you an employer? Check the appropriate box: Business Type (required): LJBI 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. g ❑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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box 41 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 #l. I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: P, 0 , 8a 6 I 00 // City/State/Zip: Lin VI ('I C Vl K l % %r% b V 00 Policy # or Self -ins. Lic. # I)-) ( 3 ). '— 3(o ,;—U R2 -L)jj2) Expiration Date: g — Z _ a(9 & 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 of perjury that the information provided above is true and correct. Phone#: zf0/ 4139 34Q� Official use only. Do not write in this area, to be completer) 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 www.mass.gov/dia Phone #: