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Home My WebLink AboutRowean Construction, LLC - 12/31/2021 (2)(0 d Town of Mansfield Town-- of Mansfield ® Board of Health 6 Park Row Mansfield, MA 02048 t D' osal Works Installer Application LICENSE NUMBER: APPLICANT: w BUSINESS NAME: to -j &,-j S i L.L 2 MAIL ADDRESS: CITYITOWN: / V&A e!�l/,--- STATE: / 1q ZIPCODE: 020S-- BUSINESS PHONE: °Tim{' 3 v r— I t) BUSINESS FAX: E-mail: Alt E-mail: BUSINESS CELL: SAS+ row-e- "COnsr@go�.• cvA-1 ID/SS NUMBER: Z 7 — f to o LICENSE HELD: Tnwn V�\ If e 1 f LICENSE HELD: Town 140 (' ic-7-110 n Year Licensed 26 161 LICENSE HELD: Town J "1' 01) IQLlr0 Year Licensed �020 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 /l SIGNATURE: DATE: /Z z 7- I—D Please make appropriate changes. Sign, date, and enclose check for $f00.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 The Commonwealth oj'Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information r� Please Print Legibly Business/Organization Name: \ w €A� �nt S +`riot Tip .) L (. Address: 2_ \ VA S7 . City/State/Zip: /aetF 11C- /VA Phone #: 7 got, 1800 % Are you an employer? Check the appropriate box: Business Type (required): 1. Ei�I am a employer with Z employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eadng 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. [No workers' comp. insurance required] R. ❑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]* 11urance ❑Health Care 4. ❑ We are a non-profit organization, staffed by volmrteers, with no employees. [No workers' comp. insreq.] 12.[`Other &nl "any applicant drat checks box #1 must also till out the section below shoedne their workers' comnensatim nnlicv intM marinn "*If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensadon policy is required and such an organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company ZN `Ar��.Y OF 'i 1 Insurer's Address: (a 0() aN tiW� ti 7 rt,iZr City/State/Zip: A/oR j-eAk 11-/t9, 0 &cA6 / Policy # or Self -ins. Lie. # %-A 0 S (d 8t) (4 O Expiration Date: 1431 Z � 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�rtify, undeVthepgimsyndpenalties ofpeijrtiy that the information provided above is true and correct -'Z 7- Phone M 7 7 t/ " 30ta - 1997 Official 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): t. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone M www.nrass.gov/dia 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 By: Corporate Officer (Mandatonj, if Applicable) 27- iuo2( ,ii "*Social Security No. (Voluntanj) 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:\Uscis\sleite\DesktopVScott's Documents\Food Establishments- Temp\TAX CERTIFICATION EORM.doc ROWECON-01 �►coRo° CERTIFICATE OF LIABILITY INSURANCE CW DSID DATE 8/202YY) 1212812020 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 endorsements . PRODUCER License fF 1780862 HUB International New England 600 Longwater Drive Norwell, MA 02061.9146 CONTACT Michelle Wolf NAME: INC, N , Exq: (508) 888-2183 �A/C, No): Ae&Ess: michelle.wolf@hubinternational.com INSURERS) AFFORDING COVERAGE NAIC N INSURERA: Main Street America Assurance Company 29939 INSURED Rowean Construction LLC 21 Valley Street, Suite 1 Norfolk, MA 02056 INSURER B: State National Insurance Company 12831 INSURER C: INSURER D: INSURER E INSURER F: COVFRAGFR CERTIFICATE NUMBER- 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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 INSD SUER MD POLICY NUMBER POLICY EFF IMMIDDITYYYI POLICY EXP fMM/DDfYT`ff1LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X MPT7383R 4/7/2020 4/712021 DAMAGE TO RENTED PREMISES (Ea ecru once 500,000 $ MED EXP (Any one bersom $ 10,000 PERSONAL a ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT 0 LOC GENERAL AGGREGATE $ 2,600,000 PRODUCTS-COMPIOPAGG $ 2,000,000 $ OTHER: A LIABILITY Ee eBINEDccbd tSINGLE LIMIT $ BODILY INJURY Per person)$ 250,000 ANY AUTO MPT7383R 4/7/2020 4/712021 POMOBILE BODILY INJURY Per accident 500,000 $ OWNED SCHEDULED AUTOS ONLY X AUTOS SSyyNE PPerOacoldeniAMAGE $ 100,000 HIRE'TOS ONLY X AUTOS ONLDY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE LED I I RETENTIONS $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERAN EIMBERIEXCLUDEp, ECUTIVE (Mantlalory in NH) NIA NFA 0868040 12/312020 1213/2021 X I PEAT TE OTH- E.L. EACH ACCIDENT 100,000 $ E.L. DISEASEEAEMPLOYE $ 188'808 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 500,000 $ A Business Owners Poll MPT7383R 4/712020 4/712021 Rental Coverage 100,000 DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Town of Mansfield is included as Additional Insured for General Liability, per the policy provisions if required as such in a written contract with the Named Insured which has been executed prior to a loss/claim. Town of Mansfield 255 Hope Street 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. ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD