Loading...
HomeMy WebLinkAboutHart Title V Service LLC - 12/31/2021(9O,� Town of 'Mansfield - Board of Health IEP 0 2 2021 By :ea 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application q APPLICANT: BUSINESS NAME: T '� d t V J,f e ca", L t -- MAILADDRESS: y�3� Cj��yw fee. CITYITOWN:} & Wte ,?o STATE: O'Y" ZIP CODE: 03 ✓ �4 6. BUSINESS PHONE. _72 (_'N9 " ') BUSINESS CELL: ^% ii 7" '&F BUSINESS FAX: E-mail: X �( di C ( tL • costa Alt E-mail: ID/SS NUMBER: 6 ` " ( t-i t I LJ -7c) LICENSE HELD: Town _ Year Licensed LICENSE HELD: Town rCn•ATpX-> Year Licensed LICENSE HELD: Town ��—) q q -6 aJ - Year Licensed 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: __V —_ — DATE: _...._� 0 —,91 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 UP1[FfNF�Pw7FgN TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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 fficer (Mandatory, if Applicable) I - CL(( 9(_7C) . "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. CAUsersWeite\Desktop\Scott's Documenls\Food Establishments-Temp\TAX CERTIFICATION FORM.doc g 'h The Comtmutwealth of dlaysachas'etts Department of IndustrialAccidents �4� 4 -a+a I , Office of Investigations S 1 a i Lafayette City Center u-y 2Avenue de Laftrpetle, Morton, MA 02111-17,50 t Immina s.govldio Workers' Compensation Insurance Aliidavit: Builders/Contractors/El lectriciansfPlutnbers Applicant Information 111cau Print l,euilh1v Name L(.b�A(W—'A-Z1Tk'4 U e-rr.IiLe (J-c Address: Cit dStawZi : e Inorl O `(G Phone 0: `7 r � -' Jt rr9f — Y3 . Arc you an onaplayer't Check the appropriate box: Type of project (regodred); I, W I elm it employer avian 4. ❑ I wo a general cohlmctor and I 6. ❑ New cottatruction amphtgea {,hall alttbor par •tana%}. + have hired the ab-contmaans 2. ❑ 1 am it sole Pmprictor at, partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no emplaye s These sub•contnlcton have a. ❑ 1?enlalitinn Work'hIg fur me lit ally capeicily. employees and have workcr%* 4). ❑ tlnllding addition )No workel'.i' comp in-m'amc£ required. comp.insurance.t 5, ❑ We ale a £olpotatkYn and Ics Io.o Electrical repaim of additions �1^^lI •i. L 12111 a ha n 4N9Ber dolag all work oltieets have exerciScal then I Lo Plumbing repairs ataddilkilas myscff. [No workers' canto. right of exemptlom per MOL. 12.❑ Roof repairs insloan£e laatlallr4x9,i t c. 152, k1(a), and wa have no uutployves,[No porkers' 13.K]Otfer_ s5T�4 canto. insurance reouircd.l -Ally ipplicani PW Ot ,k* ixly VI Icmat atlx, rill uuuhc ss xl rl h."nw SllnumaItr,tt sesek4r5 1�nr IlKeci nr Imlu.y raalRlrnatai.m i IIaalm milm xhu.rlhual lido aflldavit In(1xauluk llwc mtd.in;ills even, mid IN%hht lupin!.+.P'dnv:6ary f9agmil'mlit a N%n0-Wilvir indi"ing such �CGnan{:ffi Ir,gowekII45 hax alU51 &l ivml.RiN h'Avs crnlas�}`ccs. If thrsuh-�manuul5 huva�cntYlluy4e*c lCw"y' nwu purvld; dlclt ualrs' 4amlp. pnhcs null:her. lain an engriRrer drat is prmpidbig Ivorkilm' compensaNnn hwerasvefor sir arrairilIreex. ftelaw ilv the policy mrrdjab.vile infnrroallart. lnskoalnca Calripwly Mona M - i Policy orSclf=ins. Llc. P: cv--ptl} ]-es � I i apinitioo Date _73 Y_-o ?.----,— Rib Site Akldtrsv, Ni. - Cit)YSlate;lip: _wor(.Q-, �* CI .44%4 .Attach m copy ofthe workers' compensation policy deciarolloo pngc (show'ing the policy number and expiration date). Failure to secure cavala pe as required andor Section 25A of fY1GL c. 152 can lead to tllc imposifton of crimhtal penahies of a flnet up to $1,500.00 ln0or enle-yaur hn6nisonmont, as Wl as civll penalties in the farm ofo STOP WORK ORDFR and It halo of up to S250.00 a day agshrst the vililator. Ba, advised thin a copy of this statement maly he d`arwaodcd io the. Office of Investig buns of flic VIA lbr Insurance covenige verilicalioo, l eta berehy certify under rbe pains aurl penaffirs of perjar}' lhal ills iuforrnalianlrralJdard abomeLr time marl! correct. Smnatu Date.:. t�"• % � `�"i offlrlal use rude. Do sot wHtu /if this area, to be eampleied by chy or town official City or Town: Permit/License Issuing .A uthorily (check one): 113noord omealth Y❑ Bulldiog department 30Cityf1'owm Clerk 4,017.1eetrical lmspector 5alutnbing Inspector 6.00ther Contact Persan: Phone CERTIFICATE OF LIABILITY INSURANCE DATE (MMANNY Y) 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 pollCy(ies) must 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 anHnrsu,ase,.er�r PRODUCER -- METROWEST INSURANCE AGENCY B HIGHLLEDHART ND AVENUE INSURERS AFFORDING COVERAGE NAIC# 7 MA 02484 INsuRERA: ACE AMERICAN INSURANCE CO 22687 INSURED TITLE V SERVICES LLC INSURER 0; INSURER C: INSURER D: MEADOW STREETINSURERE: RO MA 02346 INSURERS: COVERAGES nbbne,nwrc• THIS --" TO CERTIFY THAT THE POLICIES OF INSURANCE `• "��V45 LISTED BELOW HAVE REVISION NUMBER: INDICATED. A: NOTWITHSTANDING ANY REQUIREMENT, BEEN TERM OR CONDITION OF ANY ISSUED TO CONTRACT THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED By THE OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN POLICIES REDUCED BY DESCRIBED PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TERMS, T8 TYPE OF INSURANCE A00 9 BR POLICYNUMBER MPOLICY EF on MIMMERCI POLICYMMIDE%P D/YYYY LIMITS COAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACHOCCVRRENE 8 OR TE PREMISES Bea rre ce " S MEDEXP(Any oneparson) § NIA PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMITAPPUES PER; GENERALAGGREGATE $ POLICY ❑PRO• ❑ JECT LOC PRODUCTS •COMP/OP AGO § OTHER: BINDLE T a AUTOMOBILE LIABILITY ANY AUTO Eaaccl a $ BODILY INJURY IPer person) $ ALL OS AUTOS NUT03ULE0 NON -OWNED NIA BODILY INJURY (Per acGdenU § HIREDAUTOS AUTOS PPar a� a DAMAGE $ $ UMBRELLA LIAR OCCUR EXCESS LIpB CLAIMS•MADE NIA EACHOCCURRENCE $ AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ �/ AND EMPLOYERS' LIABILITY YIN X STATUTE ER"- A ANYOFFICEWMEMa REXCLU ED7 ECUTIVE NIA N/A N/A E.L. EACH ACCIDENT s 1.000,000 (Mandatory In NH) 6S62UB1K72069220 11/27/2020 11/27/2021 It ee, descuiheunfer E.L. DISEASE -EA EMPLOYEE $ 1.000.000 DESCRIPTION OF OPERATIONS below E,L. DISEASE -POLICY LIMIT $ 1,000.000 N/A DESCRIPTION OFOPERATIONSI LOCATIONS I VEHICLES (ACORD 101, Additional Remarks schedule, may he attached It more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization la given to pay claims for benefits to employees in states other than Massachusetts If the Insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was Issued (unless the expiration date on the above policy precedes the Issue dale of this Certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage • Coverage Verification Search 1001 at WWW.Mass.90V/IwdAworkers•compensationlinvestigations/. CERTIFICATE HOLDER ............ _._.. Town of Mansfield 6 Park Row Marshfield ACORD 25 (2014101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, CPCU, Vice President — Residual Market— WCRIBMA 01988.2014 AC The ACORD name and logo are registered marks of ACORD MA 02048 I Daniel M. H�KL/ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YVYY) 3/9/2021 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 endorsements). PRODUCER ACT CONTNAME Metro West Insurance Agency 648 Highland Avenue PHONE (A/c, No, Ell): (781) 444-6790 ja/c, No):(781) 444-3318 Needham, MA 02494 a MA ass, info G@neinsure.com _ INSURERS AFFORDING COVERAGE NAIC H wsuRERA:Merchantsinsurance Grou 23329 — _ __ INSURED INSURER e: Ed Hart Title V Services, LLC INSURER C 75 Rocky Meadow Street Middleboro, MA 02346 INSURER D: - ---- INSURERE: _ _._— __. INSURER F --' - "' '�^' ^"'•"""`• KC V ISIUN 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 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 ADDL IN SUER D - POLICY NUMBER MPOLIICCY EFF 3/9/2021 POLICfYYYYI CY EXP NyYyj LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR CMP9165929 3/9/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED EMI S Eat 100,000 $ 6,000 MED EXP (Any one oersonl PERSONAL1,ADVINJURY $ 1,0J009 "- GENT AGGREGATE LIMIT APPLIES PER: X POLICY[ JECOT LOC OTHER: GENERAL AGGREGATE $ 2,0 PRODUCTS - COMP/OP AGO $ 2,0 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY Per arson $ OWNED SCHEDULED AUTOS ONLY AUTOS p AOTOS ONLY AUTNOS ON€LY BODILY INJURY Per accident $ fRerOPERT nl DAMAGE $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE - $- DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICER/MEMBER/EXCLUDED?ECUTIVE E J (Mantletory In NH) N/A ST TUTE RRH $ E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ UFS, de scribe under DE SCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE 1401 nFu _...__.. __._. Town of Mansfield 6 Park Row 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. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988.2016 ACORD CORPORATION. All rights reserved.