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Home My WebLink AboutRodenhiser Excavating - 12/31/2021Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: APPLICANT:IV BUSINESS NAME: 6 M j"" MAIL ADDRESS: 4(�„� ['°.,,` �G_`�K- --,o CITYITOWN: }ssUllos_ '> STATE: _ ZIP CODE: illmansm iq 0 2CIZl Row - eld, MA 02048 BUSINESS PHONE: , . L 2!)- C I 953 BUSINESS CELL: (}''5 Uri Q _( BUSINESS FAX: G �}Z_-V!°�� E-mail:dt0te_� c�y,0_l'1�4SC.d,q��' Alt E-mail: E�� 'lNQ, --r t' IDISS NUMBER: B 3' ( Q L)"�-- LICENSE HELD: Town 1' L _i: Year Licensed LICENSE HELD: Town t' A \ \-G s- ,A_ Year Licensed LICENSE HELD: Town Q °U, _Lyn,_ Year Licensed 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: DATE: Lo 19 1 2- fit t 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. ,ZI_ oL47 Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0L131 -4- u) (i a: -- *"Social Security No. (Voluntary) 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:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TA%CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealbly Name (Business/Organization/Individual): S Address: -4- aA 4LL UF - City/State/Zip: �� _I �Phone #:�' Are you an employer? Check the appropriate box: Type of project (required): Ll am a employer with 10 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).' have hired the sub -contractors 2. El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity, employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. (No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13 ther_l! AC comn. insurance required.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. k g Insurance Company Name m k i MY l �V\ rm ! , "� 6 kr\k_ Q Policy # or Self -ins, Lie. #: ) C, o 2 (!gq Z � Expiration Date: 1 ,i U 2-- Job Site Address: =6, e (6 it• City/State/Zip: 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 fire, 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 pigs and penalties of perjury that the information provided above is true and correct. 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone ACORL® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD Y Y) 06/08/2021 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 CONTACT Melissa NAME: Pflug Mackintire Insurance Agency PAC HONENo Ext: (508) 366-6161 FAX _ E-MAIL Melissap@mackintire.com ADDRESS: 11 West Main St INSURER(S) AFFORDING COVERAGE RAID Westborough MA 01581 INSURERA: Ohio Security Insurance Company 24082 INSURED INSURER B: Commerce Insurance Company 34754 INSURER C: Ohio Casualty Insurance Company 24074 Rodenhiser Excavating, Inc. INSURER D: WR Berkley Corporate Group 98 70 Bartzak Dr. INSURER E: _ 1 INSURER F: Holliston MA 01746 COVERAGES CERTIFICATE NUMBER: 20-21 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 RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 rypE OF INSURANCE ADDLSUBR INSD MD POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDDNWY LIMITS X COMMERCULGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CI-AIMS-MADE� OCCUR DAMAGF TO RENTED PREMISES Ea occurrenrs $ 300,000 MED EXP(Any.m,mramd $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 A BKS56029939 07/01/2020 07/01/2021 GENTAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY [g jEGT LOC PRODUCTS - COMPIOPAGG $ 2,000,000 Employment Practices $ 1,000,000 OTHER: AUTOMOBILE LIABILITY SOMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANVAUTO B OWNED M SCHEDULED AUTOS ONLY AUTOS XHIRED NON -OWNED AUTOS ONLY AUTOS ONLY BHXMVB 07/01/2020 07/01/2021 BODILY INJURY(P.,..Idan1) $ PROPERTY DAMAGE Peraccidenl $ PIP -Basic $ 8,000 X UMBRELLALIAB �/ X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 A EXCESS LIAS CLAIMS -MADE US056029939 07/01/2020 07/01/2021 X DEB RETENTION $ 10,000 $ C WORKERS COMPENSATIONPER EMPLOYERS' LIABILITY YIN N CUTIVE ANY PROPRIETOR EXCLUDED' (MandatoryIn NH) EXCLUDED? El (Mandatory In NH) NIA XW056029939 07/01/2020 07/01/2021 X STATUTE ER IAND EL, EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below Each Occurrence $600,000 D Leased/Rented Equipment CIM5109533 07/01/2020 07/01/2021 DED $2,500 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101,Additianal Remarks Schedule, may be attached If more space Is required) C.FRTIFIr.ATF HOI nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048— @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Disposal Works Installer's Application & Permit The undersigned hereby applies for a DISPOSAL WORKS INSTALLER'S PERMIT to construct, alter, install, or repair subsurface sewage disposal systems and /or the components of, required by the provisions of the State Environmental Code, Title 5, and the rules and regulations of the Holliston Board of Health. NAME OF FIRM OR CORPORATION Any and all telephone numbers must be provided for normal and after business hours for the Holliston Board of Health or its Agent to contact the authorized installer. EMAiL ADDRESS I hereby certify that I have RECEIVED, READ AND FULLY UNDERSTAND the subsurface sewage disposal system requirements of the Holliston Board of Health, and the State Environmental Code, Title 5, and that I agree to comply with such regulations as existing or may from time to time be amended, and that I am familiar with the construction practices and inspection requirements. PERMIT # .1 FEE PAID: DATE REM: = C, J APPROVED BY: DATE: 1=' ZO I' This permit expires on December 31 of the calendar year granted. Any installer new to Holliston must include three (3) letters of reference from area towns. Renewa1fee$l00ifbyJanuary3ie. Newapplicatlunfee$250. �^ List any I/A certifications and attach copy: U J h 5 _, EAS11 BOARD of HEALTH TOWN HALL, 703 WASHING ON STREET, ET, HOLLI FAxTON. MASS CHUSETTS 01746-2168 TELWebsite: www.townofholllston.us Z:Wpps, Per6u, Rep., Fo"n aepao a Wrhalellera.AWp_PermilAm TnWN OF WESTON Board of Health Tel; 781-786-5030 I I Town House Road Fax: 781-786-5039 P.O. Box 378 Weston, MA 02493 Permit Number: SIL-2021-002 wEsTON. I NCDHPC TDD This is to certify that William Rodenhiser Rodenhiser Excavating Inc. 70 Bartzak Drive Holliston, MA 01746 IS GRANTED A LICENSE TO INSTALL AND REPAIR SEWAGE DISPOSAL SYSTEMS IN THE TOWN OF WESTON Date of Application January 2021 This license is granted in conformity with the Statutes and Ordinances relating thereto and expires December 31, 2021 This license may be suspended or revoked for negligent workmanship or failure to install systems in compliance with Title V and local regulations. A minimum twenty-four hour notice is required for all inspection requests. Wendy Diotalevi, R.S. Public Health Director