Loading...
HomeMy WebLinkAboutTMG Carpentry - 12/31/2021Town of Mansfield - Board of / wn of Mansfield Park w ansf' 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: OM BUSINESS NAME: MAIL ADDRESS: ©r CITY/TOWN: 'V Dt'+,1 STATE: MA ZIP CODE: -0 -Z7l6,;, L BUSINESS PHONE: 0 BUSINESS CELL: S�D R V )V - BUSINESS FAX: E-mail: I Chn I�_ Alt E-mail: ID/SS NUMBER: LICENSE HELD: Town Wvr 01 ____ __._ Year Licensed Z O 1 __,z 0_4 LICENSE HELD: Town tM A*&V_ Year Licensed 201 LICENSE HELD: Town Year Licensed 2t0_/ 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 FEE: $ 100. SIGNATURE: DATE: 9 tz� I /2-I 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 Cdr orate Name "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:\Useis\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc jne uommonwealtn ojmassacnusetts 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 Legibly Business/Organization Name: Address: City/State/Zip: A(6r 6,^ I/A 0-OU' Phone #: :!Pt- IdQ- 2-7F-1 Are you an employer? Check the appropriate box: Business Type (required): 1.01-1 am a employer with _ employees (full and/ 5. n 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. ❑ 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]* 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care ®• with no employees. [No workers' comp. insurance req.] 12.6ther t0-- ]�:u& Ur *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **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: S `1 !` ._(,� ZS v f A -A C 2 Insurer's City/State/Zip: Policy # or Self -ins. Lie. # j/h L 0 ? 70 I10 —1 Expiration Date: /,2- V'12-� 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 vlo or. Be advised that a copy of this statement may be forwarded to the Office of of the DIA Kr insurande 2&craee verification. I do hereby ce�yritlder the ins fdndpenalties ofperjury that the information provided above is true and correct Phone #: Z-�/Ao. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Z 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of IndusMal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia TMGCARP-01 CCORTA A CERTIFICATE OF LIABILITY INSURANCE DATE 6/16/202115/2021 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 Armfield, Harrison $ Thomas, LLC 458 South Ave. Whitman, MA 02382 CONTACT NAME: ac°ONe o,E.t: (781) 4475531 aC,Ne:(781) 447-7230 _— noualEss• certificates@ahtins.com INSURERS AFFORDING COVERAGE NAICA INSURERA:Main Street America Assurance 29939 INSURED INSURER B:NGMInsurance Company_-14788 INSURERC: Star Insurance Company 18023 TMG Carpentry Inc. INSURER D : 46 Barrows St Norton, MA 02766 --- INSURER E : INSURER I: _ COVERAGES CERTIFICATE NUMBER: RFVICinN NHMRFR- 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 INSO SUER POLICY NUMBER POLICVEFF POLICYEXP 2/1712022 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMSMADE [-j] OCCUR MPT7998Z 211712021 EACH OCCURRENCE $ 1,000,000 DAMAGE S RENTED $ 500,000 -PREMMED EXP (Any oneperson) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ wT LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPIOP AGG L210101000 B AUTOMOBILE LIABILITY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS A��OS ONLY X AUTOS ONLY MIT7998Z 2117/2021 2/17/2022 EOMBINEDISINGLE LIMIT $ 1,000,000 BODILY INJURY Per Person IxANY BODILY INJURY Per accident $ PeFaiGde^t AMAGE $ B X UMBRELLALIAH EXCESS LIAB X OCCUR CLAIMS -MADE 1 CUT7998Z 1 2117/2021 211712022 EACH OCCURRENCE $ 1,000,000 AGGREGATE 1,000,000 DED I X I RETENTION$ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINS ONFFICEROIMEMBERwEXCLUOE�?ECUTIVE a (Mandatary In Nil) If yes, desedbe under DESCRIPTION OF OPERATIONS below NIA WC0870107 112412021 1124/2022 X PER OTH- U E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE FA EMPLOYE 500,000 E.L. DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Romans Schedule, may be attached if more space is required) Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACVKU ZO (ZUIOIU3) V 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD