HomeMy WebLinkAboutRalph Excavating - 12/31/2021-10
Town
Town of Mansfield - Board of Health 6 Parl
MA 02048
Disposal Works Installer Application (
LICENSE NUMBER:
APPLICANT:
BUSINESS W
o
MAIL ADDRESS: Lo_)
CITYITOWN: t �°? STATE:" _ ZIP CODE: (!M L-0
BUSINESS PHONE: ti C BUSINESS CELL: `_~ t°" L'i l_
BUSINESS FAX:�4`
E-mail: Z(jaT\C6C,
Alt E-mail:
ID/SS NUMBER: ! S3 0A l } 'L
LICENSE HELD: Town '\k) Year Licensed n
LICENSE HELD: Town t `! Year Licensed t ��%Lj
;�
LICENSE HELD: Town ' e iCgj . is � t . Year Licensed C ry r LL
l 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:. �,j� z" J
DATE: P' 017 - Z&CD
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
L-Eo
**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\Sco(Vs Docwnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offtce oflnvestigations
600 Washington Street
Boston, JUA 02111
tvlwrv.rnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
City/State/Zip:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (fidl and/
pr`part-time).*-._-...
2.0`r I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, yti' 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp_ insurance req.]
Phone #:
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.❑Other f,gst�tiA,�'�
'fury applicant that checks box #1 must also Fill out the section below showing their workers' compensation policy infomtattott.
a `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 arts an employer that is providing ivorkers' contpensationtinsurance, for nql employees. Below is file policy information.
Insurance Company
hrsurer's Address:��
e rr1 -�
City/State/Zip: � i A a' i aY` 1t� 1 'So (.> \
Policy # or Self -ins. Lic.
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 herchy cedifp, under the pains atidpena/ties ofpeijuiy that the inJbrttratiori provicled above is true and correct.
e J Date
Sitmature a f
r>I... oN. \`, Co � t—e iC _
Official use only. Do not write in this area, to be completed hp 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 #•
ITEM
1. Tt%lnsuiet Dana Ralph FEO4:**� I)JV
DBA:
Mailing address: 110 Holmes Road
North Altiehoro, MA 02760
Legal Entity TYPe� Individual
Other workplaces not shown above: address.
020 to 04/2212021 12:0 a' to m. the Workers thedard time at Insureds
Law oft e
2- The policy Period Is from 04__-f z212 .--- Rol-wY applies
3. A. Workers compensationlnsuranoW=Part One.
states listed here: MA to work in each state listed in item 3A-
B- EmPloYers' Uability Insurance: Pad Two at the Policy applies100,000 each acdident
Thelimi[s of liability Bodily Injury under Part Two are: godly Injury by Accident $ � Policy limit
ury by 0`45ase $
� each employee
Bodily injury by Disease $
�---
20 03 O6 B
C- Other States Insurance: Coverage Replaced by Endorsement WC
nd5chedules: SEE SCHEDULE
D: This Policy includes these Endorsements aPlans.
premium for this policy will be determined by our Manuals of Ruleauditssth alions. Rates and Rating
d. The pr - uired below is subject to verification and change by
All information req ..m uacls Rates
Esdmeted
Estimated Per FIFO Annual
Code Of Premium
No. Told Annual Ren m a'on
Remuneration --
INTRA 000318765
INTER
Minimum Premium $500
GOV 16306
OV
STATE ASS
MA
This policy, including all endorsements, is hereby countersigned by
Service Office:
54 Third Avenue
Burlington MA 01803
Total Estimated Annual Premium
Is
Depoat Prernlurn
State AssessmentsiSurcharges
$4,722.00 x 3.5100%
c_14� r - 7�—.iG—
03/1212020
ale —
_-._. AuMaiagr eignsium
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WC 00 00 01 A (741)
lnstudes coWtrhtd msI&d8l ar tha Nedanai Coundl an Gamrrensseon insurenca.
used Wlnf es P*M( tan -
Willis Mackinnon Ins Alloy Inc
5 Man Mar Drive
Plainville, MA 02762