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Home My WebLink AboutH & M Excavating - 12/31/2021E LICENSE NUMBER: APPLICANT: BUSINESS NAME: *OW4 00 Town of Mansfield - Board of Health Disposal Works Installer Application ry) & MUO V-)G. MAIL ADDRESS: I � v l L Q 1,J 0, 0 (Da-C CITYROWN: TlQ u� IItILn STATE: i A BUSINESS PHONE: 5� 6' �-C2 t BUSINESS CELL: Town of Mansfield 6 Park Row Mansfield, MA 02048 ZIP CODE: N -1 b o- _ JD `6 StA , 63:2- BUSINESS FAX: E-mail: O c ill `�0.v �VYI f l i�110�(y�, LC✓n s Alt E-mail: ID/SS NUMBER: <6I ' ), q `4 Lot) LICENSE HELD: Town LICENSE HELD: Town n, LICENSE HELD: Town / �I�\�-' ' 04 Year Licensed _Big IIP LOVrLrj4 0 I Year Licensed 9b u U)V'Q ti-/ Year Licensed 10 i i U L) V �f✓ij Please submit a copy of the licenses held along with a contact name and phone number for each town. References will be checked. 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 14, SIGNATURE: 4,A DATE: / - f � -)- 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 Chris Hartley H&M Excavating, Inc. Permit No. DW-20-22 Town of North Attleborough, MA Board of Health 43 South Washington St. North Attleborough, MA 02760 608-699-0103 nattleboro.com 19 Landau Road THE COMMONWEALTH OF MASSACHUSETTS Town of North Attleborough, MA, Board of Health DISPOSAL WORKS INSTALLER LICENSE Fee: $100 IV Public Health Prevent. Promote. Protect. Issue Date: October 19, 2020 This permit is issued in conformity with the authority granted to the Board of Health, by Chapter 111, Section 31A, of the Massachusetts General Laws, and amendments, and is subject to the provisions of the Town of North Attleborough, MA Ordinances, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health. Chris Hartley H&M Excavating, Inc. Whose place of business is: 19 Landau Road Type of business and any restrictions: DISPOSAL WORKS To Install Disposal Works in: Town of North Attleborough, MA, Massachusetts Permit Expires: October 31, 2021 Thls Is an e-permit. To learn more, scan this barcode or visit northattleboroughma.viewpointcloud.wnJ#/records/52559 fl. �o�;oL9st; 52� '7-7q 7 The Commonwealth of Massachusetts Fee $150.00 Board of Health of the Town of Norfolk DISPOSAL WORKS INSTALLER LICENSE License No. SI18-000013 December 02, 2020 This is to certify that (Individual installer's name) ChrisHartley (business name) H & M Excavating Inc. of (address) 19 Landeau Road Plainville MA Is hereby granted a "DISPOSAL WORKS INSTALLER PERMIT' to install individual subsurface sewage disposal systems in a manner to be in accordance with the approved Engineer Disposal plan, Title V and all applicable local regulations. License Expires: 12/31/2021 r Board of Health OFFICE OF �a BOARD OF WATER & SEWERAGE I U) f Mu MEDFIELD, MA 02052 11111 Ou' 0 2 Zug 508-906-3004 APPLICATION FOR LICENSE TO INSTALL WATER & SEWERAGE $100 FEE — CASH OR CHECK MADE OUT TC TOWN OF MEDFIELD The undersigned hereby applies for a license to install, alter or repair water and/r required by the provisions of the Medfield Water and Sewerage Board, Medfield Plumbing Code. d �, Name of Person or Irm aking app ication l j�� 1,) .� ( 9- 1 I. !1 A (1 i i C' ' a i n v .i i �. � f U J -V -- Address Telephone Number where you can be contacted by the Water and Sewerage A license will be granted subject to the following conditions: 1. Two Municipal references relative to prior sewer installations will be supplied. 2. A copy of your current Certificate of Liability Insurance will be supplied. 3. No work will be started on a particular installation until the homeowner or their agent has received and paid for . a sewer installation/inspection permit form the Water and Sewerage Board. 4. Whenever any excavation is contemplated, the applicant shall be required to notify DIGSAFE before starting excavation on any private or public property as per State and Town laws and a "Jackie's Law" application will be paid for and submitted. 5. 24 hour notice will be given to the Water and Sewerage Board prior to inspection. 6. Work must comply with the regulations of the Water & Sewerage Board regarding pipes, Jointing, backfilling, bends, cleanouts, etc. 7. Upon completion of a particular installation, an AS BUILT PLAN shall be submitted to the Water & Sewerage Board showing location, appropriate ground and pipe grades, depths and method of connection of said sewer and sufficient, permanent ties to allow future location of points of connection, bends, cleanouts, etc. I hereby certify that I have read and fully understand the requirements of the Medfield Water and Sewerage Board and that I agree to comply with such regulations as existing or may from time to time be amended and, that i understand that this license does not include sewer connections to any interceptors. Failure to follow any regulation to the satisfaction of the Water and Sewerage Board will be cause for revocation of license. Applicant Date I I - [3 1�)I) i)C6 (� A 100,U0 The Commonwealth of Massachusetts t r Department of lndustrialAceidents - 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwftcmassgov/dia F4 Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMrrMG AUTHORM' p! A iicant Information Business/Organization Name: H&M Excavating Inc. AAA..... 19 Landau Road - City/State/zip: Plainville, MA 02762 Are you an employer? Cheek the appropriate box: 1. Q I am a employer with 2 employees (full and/ or part-time).* 2. ElI 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 e. 152, §I (4), and we have no employees. [No workers' comp. insurance required]' 4. Fj We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] phone #: 508-699-0218 Business Type (required): 5. ❑ Retail 6, QRestaurant/Bar/HatingEstablishment 7. n Office and/or Sales (inct. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing i ID Health Care 12.E Other Excavation 'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation loamy mm mauoo. *.If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organktation should check box 41. I am an employer that is providing workers' compensation insurancefar my employees. Below rs the polrcy informalhm Insurance Company Name: Guard Insurance Companies Insurer's Address: P.O. Box A-H, 16 S. River Street City/state/Zip: Wilkes-Barre, PA 08703-0020 policy # or Self -ins. # R2WC201541 Expiration Date: Jan.21, 2D22 Attach a copy of thee 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 cerdfy, the one #: 508-699-0218 offmial use only. Do not write in this area, to be completed by city OF town ofchd above is true and correct City orTown: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk d. Licensing Board 5. Selectmen's Office 6.Other Phone #: Contact person, A ♦��%Berkshire Hathaway �`� Insurance t`GUARDComparees Workers Comaensation and Employer's 'ability POIIC AmGUIARD Insurance Company A Stock Co Policy Number R2WC201541 Renewal of R2WC139947 NCCI No. [21873] Policy information Page (AR) Named Insured and Mailing Address H&M EXCAVATING INC 19 Landau Rd Plainville, MA 02762 Federal Employer's ID XX-XXX4608 Risk ID Number 1079541 Agency EDWARD A. ELLIS INSURANCE AGENCY, INC, 182 W. Central St Suite 302 Natick, MA 01760 Agency Code: MAELL110 Insured is Corporation [2] policy Period From January 21, 2021 to January 21, 2022, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: S,000,tl00 Bodily Injury by Accident - each accident $1,000,000 Bodily Injury by Disease - each employee $1,000,000 Bodily Injury by Disease - policy limit C. Refer to Residual Market Limited Other States Insurance Endorsement- WC200306B D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) -- Total Estimated Policy Premium $3,203 � $97 DO Total Surcharges/Assessments y �An nn Page - 1 - Information Page WC 000001A MGA : RZWw 4ul"4 Date :12/0812020 MANOTE Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guar .com Form ■■M9 (Rev. October 201 B) Depedment of the Treasury Interest Revenue Service an Request for Taxpayer I Give Form to the identification Number and Certification s�ai thDo riot ► Go to on instructions and the latest information. FGh��ksppmpfiate ppropriate box for federal tax classification of the person whose name is entered an Tine i. Check only oneofthe certain e tiies, nnoot Individuals; see seven boxes. instructions on page 3): C Corporation S Corporation ❑ Partnership ❑ Trusus"fate duaVsole proprietoror Exempt payee code Many) m.member LLC ed Ilebility company. Enter the tau classification (C--C corporation,S=Scogwretion, P=Partnership): Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting H the LLC is classined as a single -member LLC that is disregarded from the owner unless the owner of the LLCiscode (If any) a Eer LLC that is not disregarded from the owner for U.S. federal tax Purposes. Otherwise.asingle-member LLC that regarded from the owner should check the appropriate box for the tax classification of its owner. kanw�nsaamnmes,wreaau�sea meus.l Enter your TIN in the appropriate X. The T7N provided must match the name given on line i to avo _ m _ backup withholding. for individuals, this is generally your social security number (SSN)However, for a resident alien, sole proprietor, or disregarded entity sae the instructions for Part 1, later. For other FT entities, It is your employer identification number (EIN). if you do not have a number, see How to get a or TIN, later. Employer tdemlaoatton number Note: If the account Give the Is in more thn for on ens a on whosee see the Instructions number to for line 1. Also see What Name and 8 1— F21 7 4 4 f 61 0 8 Under penalties of perjury, I certify that 1. The number shown on this form is my correct taxpayer identification number (or I am wailing for s number to be issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (defined below); and A. The FATCA codes) entered on this form Of any) Indicating that I am exempt from FATCA reporting is correct cerrmcetlan Instructions. you must cross out Hem 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does net apply. For mortgage Interest paid. acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required 1 sign the certification, but you must provide your correct TIN. Sae the instructions for Part II, later. slgn I Signature of Here u.s.permaw General Instructions i Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its Instructions,su yFhaas legislation enacted after they were published, g u90 Purpose of Form An Individual or entity (Forth W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), individual taxpayer Identification number (ITIN), adoption taxpayer Identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Forth 1099-INT Qnterest earned or paid) Cat. No. 10231X Date► I -d )-- -/-/ — • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-13(stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest),1098-E (student loan interest), tOgo-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What Is backup withholding, later. Form W-9 (Rev.10-2018)