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Home My WebLink AboutJones Contracting, Inc. - 12/31/2021566- (00,°s %( Town of Mansfield Town ql ManTield - Board ®f health 6 Park Row Manstjoki,_MA 02048 - I /41 Disposal Works Installer Application �y G�. �3- or,,eS s( APPLICANT: Jones (on rc�hnc yn�. / QossaU �. 5onti �t BUSINESSNAME: —Sont.s _E�l- MAILADDRESS: 735 +iasM',�tM Sirc�i' CITYfTOWN: l.jr_gP le STATE: MA ZIP CODE: BUSINESS PHONE: 509 -(v(o8 "D" BUSINESS CELL: BUSINESS FAX: .506 -- (060 - yob 0 0 2-o a I Sob--WoV-'7E360 E-mail: �n-�u LJ ;onGSGoniraciin �nC.com Alt E-mail: k�+h�L JoncS c� Ira nc • ca ERAL ID/SS NUMBER: LICENSE HELD: Town o-k Pa l e Year Licensed LICENSE HELD: Town 0^ Year Licensed LICENSE HELD: Town i,)' I M,hi' Year Licensed a0aI a001 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 SIGNATURE: i DATE: -2o2,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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: --- a(xe.s Cyrci-r&c t-� =nA Address: 173Sya al ! -,rr t-r. City/State/Zip: l,)CLp,.le-' `"A` °Z,0'I Phone#: SDI3 ioi t),JB06 Are you an employer? Check the appropriate box: Business Type (required): I.Er I am a employer with 1 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. [No workers' comp. insurance required] 8• ❑NoH-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 to.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with noemployees. [No workers' comp.insurance req.] 12.nOther E-At:L.iab-J wtr��DP *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation poncy ortormaaon. **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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: C s S t „e ✓Y e1LL - A-r b r, it o- Insurer's Address: t e cKk,r� S-tf`� City/State/Zip: ^-N "v r (5 Policy # or Self -ins. Lic. # 4 a b t o i' 1 a - 1 Expiration Date: 611 / " 3aL 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,%urtf/e pai ,sand p/e`tr�lhes ofperjury that the information provided above is true and correct. Phone#: S06-w,&-/g13Db 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. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: 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. .toncs co, trc.c+ Signature of Individual or Corporate Name By: orporate Officer (Mandatory, if Applicable) 34-aol4S49 "*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:\Usen\s1eite\Desktop\Sco1Vs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 12/31/2020 Commonwealth of Massachusetts Town of Walpole Board of Health PublicSealth Prevent, Pr�mM1[e. Pmreet. Date Issued: December 31, 2020 SIL-20-14 Expires: December 31, 2022 Jones Contracting Inc. 735 Washington Street Walpole, MA 02081 Is herebygranted a septic installer permit to install or repair individual sewage disposal systems This permit is granted in conformity with the Statutes & ordinances relating thereto and expires Licensed Installers: Russell E.Jones jr, Russell E.Jones December 31, 2022 unless sooner suspended or revoked. Health Director: 79t&M,}7aU y �' � Ill NUMBER FEE DWIP21-022 THE COMMONWEALTH OF MASSACHUSETTS $132 TOWN OF WRENTHAM Board of Health This is to certify that Jones Contracting Inc. NAME. 735 Washington Street Walpole, MA 02081 ADDRESS IS HEREBY GRANTED A "DISPOSAL WORKS- INSTALLER'S PERMIT' TO CONSTRUCT, ALTER, INSTALL, or REPAIR, Individual Sewage Disposal Systems This permit is granted in conformity with the State Sanitary Code Title V, Regulation 2.2, and expires December 31, 2021 unless sooner suspended or revoked. November 2, 2020� George Smith _ oa d Dr. Brian Kelly ! of Dr. Peter Roman Health Special Conditions: ACORO® CERTIFICATE OF LIABILITY INSURANCE i`� DATE(MMIDDNYYV) 1 07/21/2021 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(les) 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 NAME: Laura Wiesner C & S Insurance Agency, IRC. PHONEo (508) 339-2951 IF NEXNo (508) 3394811 AIC : (MAXAI 190 Chauncy St ADDRESS: laDra@Candsms.com INSURERIS) AFFORDING COVERAGE NAIC# Mansfield MA 02048 INSURERA: Arbella Protection Insurance Cc 41360 INSURED INSURER B: StarStone Specialty Jones Contracting, Inc. INSURER : The Continental Insurance Company 735 Washington Street INSURER O INSURERS: Walpole MA 02081 INSURER F: COVERAGES CERTIFICATE NUMBER: 2021-2022 Master 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. INSIR LTR TYPE OF INSURANCE ADDL Sp SUER D POLICYNUMBER POLICY MMIDD/YYYY XP MMIDDO/YYW LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OOCCUR EACH OCCURRENCE $ 1,000,000 PREMISESEa occurrence $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 A 8500065867 06/01/2021 06101/2022 GENLAGGREGATE LIMITAPPLIES PER: POLICY ❑X JECTT 7 LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMPIOPAGG $ 2,000,000 $ OTHER: I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ecddenl $ 1,000,000 BODILY INJURY (Par person) $ ANYAUTO A OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED N..OWNED AUTOS ONLY X AUTOS ONLY 1020055801 06/01/2021 06/01/2022 BODILY INJURY (Per acraden0 $ X ERTY Per a0denDAMAGE $ X UMBRELLALIAS X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAR CLAIMS -MADE 4620081921 06/01/2021 06/01/2022 DED I X RETENTION $ 10,000 $ A WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY OFFICEPIMEMBER EXCLUDED? ANY PROPRIETORIPARTNER/EXECUTIVE N (Mandatory In NH) I/ yes, describe under DESCRIPTION OF OPERATIONS below N/A 4220108272-1 06/01/2021 06/01/2022 PER OTH- % STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE EA EMPLOYEE $ 1,000,000 E.L. DISEASE POLICY LIMIT $ 1,000,000 Contractors Pollution Pollution Limit $3,000,000 BIC Leased or Rented Equipment F74489210AEM/6078603974 06/01/2021 06/01/2022 Equipment Limit $400.000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remark,Schedule, may be attached R more spate is required) 2021 Disposal Works Installer Application 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 r Mansfield MA 02048 ;i`a-YL lu'taaZ rtnhle mennmd ACORD 25 (2018103) The ACORD name and logo are registered marks of ACORD