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Home My WebLink AboutWaste Management 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health. Hauler's Permit This is to certify that: PERMIT No: 4 WASTE MANAGEMENT OF MA, INC. WASTE MANAGEMENT OF MA, INC. 100 HILL STREET NORTON, MA 02766 is hereby granted a permit for a HAULER. This permit is granted in conformity with the Statue and Ordinances relating thereto, and expires December 31, 2018 unless suspended or revoked REGISTRATION No: R46519; R46452; R88466 R87560; 74670-RO; 89615-RO FEE PER TRUCK: $25.00 BOARD OF HEALTH Nichae(McCCean, Chairman O`jaR.IP'r v ti Town of Mansfield - Board of Health NlIn ASR 4�y``�pkyl�I Hailer's Application DEC 0 5 2017 Town of Mansfield 6 Park Row , Mansfield, WA 02048 PERMIT NUMBER: 4 TOTAL FEE: BUSINESS NAME: WASTE MANAGEMENT OF MA, INC. BUSINESS ADDRESS: 100 HILL STREET TOWN I STATE / ZIP: NORTON. MA 02766 NAME OF OWNER: WASTE MANAGEMENT OF MA, INC. TELEPHONE NO: (508) 622-6111 CELL NO: (508) 989-3454 FAX NO: (866) 373-4079 E-mail: JCEDERQU@WM.COM Alt E-mail: FED ID/SS NO: 04-2535063 )ey(oysa -7Y67a-1eL REGISTRATION NO: *R46519; JUS461�,R88466+R87560; NO OF TRUCK(S): 6 FEE PER TRUCK: $25.00 Permit Expires December 31st yearly. SIGNATURE: DATE: pleas m, aka propriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of -lealt , own 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 Name > By: Cdrporate Officer (Mandatory, if Applicable) C�53 i7K)62 "*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. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street y` Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: City/State/Zip:��; � , AM �? r'%�-4- Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. N' I am a employer with /G'G r 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• ❑ 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]** I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.30ther *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 #l. I am an employer that is provAding workers' compensation insurance for my employe, Below is the policy information. Insurance Company Nan Insurer's City/State/Zip: % Policy # or Self -ins. Lic. # i ilLd S��l /G�% cl()7 Expiration Date: / 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, under the pains and penalties of perjury that the information provided above is true and correct. Offecial 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD V) I/v2018 10/24/2017 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 endorsemenl(s). PRODUCER LOCKTON COMPANIES CONTACT 5847 SAN FELIPE, SUITE 320 PHONE FA% AIA✓_No: HOUSTON TX 77057 E-MAIL 866-260-3538 ADDRESS: INSURER(5) AFFORDING COVERAGE NAICN INSURER A: ACE American Insurance Company 22667 INSURED WASTE MANAGEMENT HOLDINGS, INC. & ALL AFFILIATE INSURER B:Indemnity Insurance Co of North America _.._ _ 43575 1300299 RELATED & SUBSIDIARY COMPANIES INCLUDING: INSURER c_ ACE Property &Casualty Insurance Co 20699 INSURER D: ACE Fire Underwriters Insurance Company 20702 WASTE MANAGEMENT -NEW ENGLAND MARKET AREA 26 PATRIOTS PLACE, SUITE 300 INSURER E: FOXBOROUGH MA 02035 INSURER F: COVERAGES MAWRSTBO CERTIFICATE NUMBER: I S017R7i REVISION NUMBER: XXXXXXX 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 SUER POLICY NUMBER POLICYEFF WWDDYEXP MMIDDIYYYY MMIDDIYYYY LIMITS A X__ COMMERCIAL GENERAL LIABILITY Y Y HDO G27860825 I/I/2017 I/I/2018 EACH OCCURRENCE $ 50 00000 DAMAGE RENTED PREMISES Ea occunence $ 5,000,000 CLAIMS -MADE OCCUR X MET EXP (Anyone person). $ XXXXXXX XCU INCLUDED ( „ISO FORM_CG00010413 PERSONAL&ADV INJURY s 5 000 000 X GEN'L AGGREGATE LIMIT APPLIES PER: ( GENERALAGGREGATE $ 6000000 PL�AJIE�Lee POLICY jECT I- PRODUCTS cower AGO $ 6 000a000 OTHER: $ A AUTOMOBILE LIABILITY y y MMT H09052884 1/1/2011 1/1/2011 COMBINED SINGLE LIMIT (E -acc dem) $ _ 1 000 000 X ANY AUTO BODILY INJURY (Per person) $ XXXXXXX BODILY INJURY IPerealden0 $ X OWNED SCHEDULED AUTOS ONLY AUTOS-.,..._XXXXXXX X HIRED X NON0WNEO PROPERTY DAMAGE Peraxidenl $ xxX .�. . AUTOS ONLY AUTOS ONLY It XXXXXXX X MCS-90 C X UMBRELLA LIAB X I OCCUR Y Y XOOG27929242002 1/1/2017 I/I/2018 EACH OCCURRENCE $ 15000000 AGGREGATE $ 15 000 000 EXCESS LIAB CLAIMS MADE OEO RETENTION$ $ XXXXXXX B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Y WLR C49106944(AOS) 1/1/2017 1/1/2018 ' PER OTH- `X STATUTE _. ___-_ER__ A D ANY PROPRIETOIUPARTNER�EXEGUTIVE F NIA WLR C49106907(AZ,CA,&MA) SCF C49106981(WIT 1/1/2017 1/1/2018 I/1/2017 1/1/2018 E.L.EACH ACCIDENT $3000000 --- EL DISEASE-, EA EMPLOYEE $ 30000O0 OFFICERIMEMBER EXCLUDED? (MyandataryinNH) DE SCc-scribe under RIPTION OF OPERATIONS below EL.DISEASE -POLICY LIMIT $ 3000000 A EXCESSAUTO Y Y XSA 1109/11172 I/l/2017 1/1/2018 COMBINED SINGLE LIMIT LIABILITY $9,000,000 (EACH ACCIDENT) OF DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additions$ Remarks Schedule, may be aHached If more space is required) BLANKET OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EXCEPT FOR WORKERS' COMP/EL) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION 15013823 TOWN OF MANSFIELD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BOARD OF HEALTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 PARK ROW ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD MA 02048 AUTHORIZED REPRESENTATIVE 91988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD