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Home My WebLink AboutChris Hartley - 12/31/20210 /0�4 1 od -- LICENSE NUMBER: APPLICANT: BUSINESS NAME: Town of Mansfield - Board of Health Disposal Works Installer Application 1Yl 6_4 f twR �r MAIL ADDRESS: v l Q 11 a 7 CITY/TOWN: V)c Town of Mansfield 6 Park Row Mansl7eld, MA 02048 STATE: r I i A ZIP CODE: �'� �41 BUSINESS PHONE: 60y W -b2 I BUSINESS CELL: 50�- RA, 63.�'- BUSINESS FAX: E-mail: O�Cira ill ��oxsyn2V-CpQLA C�o„Ctm Alt E-mail: ID/SS NUMBER: M b()� LICENSE HELD: Town nn ('t, c` ,, j LICENSE HELD: Town LICENSE HELD: Town Year Licensed Bl8 �D covrl,r Year Licensed 2boK �b W Vr&-r-i Year licensed X I `6 �b bi V ✓ r)i 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 31 st yearly. FEE: $ 100.00 SIGNATURE: ( �� DATE: I - I S - 2 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 nattieboro.com 19 Landau Road THE COMMONWEALTH OF MASSACHUSETTS Town of North Attleborough, MA, Board of Health DISPOSAL WORKS INSTALLER LICENSE Fee: $100 IV PublicHealth 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 This Is an e-permit. To learn more, scan this barcode or visit northattleboroughma.viewpointcloud.com/#lrecords/52559 The Commonwealth of Massachusetts Board of Health of the Town of Norfolk DISPOSAL WORKS INSTALLER LICENSE License No. SI18-000013 This is to certify that (Individual installer's name) Chris Hartley (business name) H & M Excavating Inc. of (address) 19 Landeau Road. Plainville. MA Fee $150.00 December 02, 2020 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 Board of Health OFFICE OF BOARD OF WATER & SEWERAGE MEDFIELD, MA 02052 508-906-3004 APPLICATION FOR LICENSE TO INSTALL WATER & SEWERAGE $100 FEE ^ CASH OR CHECK MADE OUT T( TOWN OF MEDFIELD The undersigned hereby applies for a license to install, alter or repair water and/( required by the provisions of the Medfield Water and Sewerage Board, Medfield Plumbing Code. �n/� / JArt' IM Y' ,I 40I)A1i,M IVI p�MT9TT� DEC 0 2 2020 Name of Person 'r firm makin, ppinlan ( C' N (L I n V o I (L Address 'Soy wq - U -, Telephone Number where you can be contacted by the Water and Sewerage Board A license will be granted subiect 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 "Jackals 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 - 13 - A) 100,01 Farm W-9 (Rev. October 2018) ospedmem of the Treasury Intemel Revenue service Request for Taxpayer identification Number and Certification ►Go to instructions and the latest information. Give Form to the requester. Do not send to the IRS. HBrM Excavatin , fnc. - 2 Business name/disreganled angry name, k different from above 3 Check eppropdme hox for federal tax classification of the person whose name is entered an Tins 1. Check onhy one of theFd to kles `notenUi�dua�s; seemfollowing seven boxes. s on page 3):Q✓ S Corporation ❑ Partnership ❑ Tnaftill ate ❑ C Corporation proprietor orsingle-member yee cads (k ny)Individuatsole LLC the single -member owner. Do not checn ❑Limited liability company. Entertha tax classification (C=C corporation, S=S corpomtbn, P=Parnership)Note: tram FATCA reporting�+LLC Check the appropriate box In the line above far the tax classificaton of tithe LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC isny)V: member LLCthIs u adie g dediromttt ownearde fromcheck the eppmpdate box for ral he�a't clsassifi lion oflts owwner. m„xa,rexims•aau�sxe ur•USJ So ❑Other (sae instructions)► Requester's name and add— Vtionap See instmctions. vl 8 Address (number, street, and apt. or suite no.) 19 Landau Road e City, state, and ZIP code Plainville, MA 02762 7 Ust account numbers) here wpWI VID Enter your TIN In the appropriate box. The TIN provided must match the name given on Tine i to avo _ m -FT withholding. For individuals, this is generally your social security number (SS M• Howavar, for a resident alien, sole proprietor, or disregarded entity, seethe instructions for Part I, later. For other entities, it is your employer identification number (EIN). if you do not have a number, see How to get a or TIN, later. Employer idemificarkm number NNote: If u berthe account Is in more Give the Requester to guidelines n one , sea ths whose) n Instructions enter. a 1. Also see What Name and 8 1- 2 7 4 4 6 0 8 Under penalties of perjury, I certify that: 1. The number shown an this forth is my correct taxpayer Identification number (or I am waiting for a 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 an subject to backup withholding as a result of a failure t report all interest or dividends, or (0) 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 code(s) entered on thie form (d any) indicating that I am exempt from FATCA reporting is correct Certification instructions. You must crass out item 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 � yourtax oreturn. bt, contributions to an ndividuatem 2 l retirement tnot apply. snngem ntr(IRA) and generally, payments st paid. acquisition or abandonment of secured property,t� other than interest and dividends, you are not required / sign the certification, but you must provide your correct TIN. See the Instructions for Part 11, later. Signature of U.S. person► 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, such�rneggiisslation enacted after they were published, g www.1m.gov/FomW9. of Form An Individual or entity (Form W-9 requester) who is required to Ole 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 (ITN), adoption taxpayer Identification number (ATIN), or employer identification number (EIamount eporttart bleanlinan noorrmatination return return. Examplespaid of information ou, or other returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) Date 1, 1'd ,><-' 5t I • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form f o99-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099.E (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 parry network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1 o98-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. ter with a 77N, you might be subject to backup u do not raturn F holding. See Whanni W-9 to the t Is backup withholding, later. Form W-9 (Rev. 10-2018) Cat. No. 10231X The Commonwealth ofMassaehusetts Department of industrial Accidents t I Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia �y Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH TBE PERiViI'1 MG AUTHORITY. PI Business/Organization Name: H&M Excavating Inc. Address: 19 Landau Road City/State/Zip: Plainville, MA 02762 Are you an employer? Check the appropriate box: I. Q✓ I am a employer with 2 employees (full and/ or part-time).* 2. ❑ I 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 c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]' 4. F1 We are a non-profit organization, staffed by volunteers, I es INTO workers' comp. insurance req.] Phone #: 508-699-0218 Business Type (required): 5. ❑ Retail 6. QRestaurait/Bar/EatingEstablishment 7. 0 Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.[] Health Care 12.91 Other Excavation wool no crop eye *Any applicant that checks box # i must also fill out the section below showing their wcompensation policy information. **Ifthe 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' compensntfon Tnsurancefor my employees. Below }s !Ae polrcy rnformaov 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 J212022 Policy # or Self --ins. e # R2WC201541 Expiration Date: an., 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 e.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, under the that the o e#: 508-699-0218 official use only. Do not write In this area, to be completed by city or town ofeial City or Town: Permit/License above is true and carrell Issuing Authority (circle one): ityfTown Clerk 4. Licensing Board 5. Selectmen's Office 1. Board of Health 2. Building Department 3. C 6.Other Contact Phone #: R R&X/Berkshiire Hathaway +•`' Insurance GUARDCompanies Worker' er s Comaensation and EmplOYpr's LiabiliYy Folic AmGUARD Insurance Company A Stock Co Policy Number R2WC201541 Renewal of R2WC139947 NCCI No.[21873] Policy Information Page (AR) jNamed 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: MAELLIIO Insured is Corporation [21 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: 1,000,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 [41 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 --- Total Estimated Policy Premium $$ $9,203 00 Total Surcharges/Assessments $,,,, nn Page Information Page WC 000001A MGA : new�4u�341 Date :12/08/2020 MANOTE Issuing Officer P.O. 8eX AHr 39 Public Square, Wilkes-Barre, PA 18703-0020 * www.guard.com