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Home My WebLink AboutJ. F. McNamara & Sons, Inc. 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 This is to certify that: Board of Health Hauler's Permit PERMIT No: 8 JAMES F. MCNAMARA J. F. MCNAMARA & SONS, CORP. 161 MORTON STREET, P.O. BOX 6 STOUGHTON, MA 02072 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: J68799 P73189 FEE PER TRUCK: $25.00 BOARD OF HEALTH .Michaet`AcCkan, Chairman '4- ri Town of Mansfield - Board of Health Hauler's Application Town of Mansfield 6 Park Row Mansfield, MA 02048 NOV 0 2 2017 .. Fd 6 PERMIT NUMBER: 8 TOTAL FEE: BUSINESS NAME: J. F. MCNAMARA & SONS, CORP. BUSINESS ADDRESS: 161 MORTON STREET, P.O. BOX 6 TOWN I STATE -/ZIP: STOUGHTON, MA 02072 . NAMIt OF OWNER: JAMES F. MCNAMARA TELEPHONE NO: (781) 344-9682 CELL NO: ` &,t Soy-elt_0-Ji/l'17 FAX NO: (781) 341-2787 E-mail: rA I ChAt-( �� rn(,V1GCW1.CtN . C01"I Alt E-mail: FED ID/SS NO: REGISTRATION NO: NO OF TRUCK(S): FEE PER TRUCK: 04-24444302 ._-PJo8341 J68799 P 131 d q 2 $26.00 Permit Expires December 31styearly. SIGNATURE: �/� ��(F�Q � LATE: Ibld 7117 Please make appropriate changes. Sign, date and enclose check 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 Corporate Name By: Corporate Officer (Mandatory, i(Applicable) "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. Fool) W®9 (Rev. December 2011) Department of the Tressoy Internal Revenue Service Request for Taxpayer I Give Form to the Identification Number and Certification requester. Do not send to the IRS. name, Check appropriate box for led, at tax cl 'imalion: ❑ IndividuaVsols proprietor LYC Corporation ❑ S Corporation p ❑ Partnership ❑ TmsVeslelo L] limited tiabilily company. Enter the tax classification C-C corp oration, potation, S_S corporation, P=patlnershlp)► ess (number, street, and apt. Enter your TIN In the appropriate box. The TIN provided must match the name given cn the "Name" line to avoid backup withholding. For Individuals, this is your soc!al security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see Flow to get a TIN on page 3. Note. If (he acccut, j in more than one name, see the chart on page 4 for guidelines on whose number to enter. Under penalties of I certify that: name The number shown on this form is my correct taxpayer identification number (or I am walling for a number to be Issued to me), and I 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 4RS) Ghat f am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no ioncor subject to backup withholding, and 3. 1 am a .'.S. citizen or other U.S. person (defined below). Certificapon Instructions. You must cross out Item 2 above if you have been notified by the IRS that you am currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest pal.;, acquisiticr• ^r abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments cuter than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on oaue 4. Signature of U.S. Person► General Instructions Section rnferencoc are to the Internal Revenue Code unless otherwise noted. Purpose W Form A person who is required to file all information return with the IRS must obtain your correct taxpayer idactfication number (TIN) to report, for example, income paid to you, real estate transactions, mortgage Interest you paid, acquisition or abandonment of secured property, cancellation of debt, er contributions you made to an IRA. Use Fonu W-9 only if you are a U.S. person (including a resident alien), to p,.wide your correct TIN to the person requesting it (the requesle,),and, when applicable, to: 1. Cerhfy that the TIN you are giving Is correct (or you are walling for a number lobe issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption i,c1l backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business Is not subject to the withholding tax on foreign partners' share of 1>T► 10/.�'7// Note. If a requester gives you a form other than Fenn W-9 to request your TIN, you must use the requester's form if It is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An Individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined In Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of Income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, If you are a U.S, person that is a partner In a partnership conducting a trade or business in the United Slates, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231x Form tit/-9 (Rev. 12-2011) 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 Legibly Business/Organization.Nalne: m sloe mG't,gc, i Sort'S 1 _(�o,_ Phone #: Are yop an employer? Check the appropriate box: Business Type (required): 1. D I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or, partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for e in any capacity. . $ ❑Non-profit [No workers' comp. insurance required] 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 by 11.❑ Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.] 1211 Other *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 isproviidi.ng workers'—ctonipensation insurance for my employees. Below is the policy information. Insurance Company Name: l 1-l.t &A A • l:VV ix 1rx Vhf 1z (' B e r k S In i Q e l �Gt�-Vt(9 i,t1fl � O nAh[ lij ) Insurer's Address:_ City/State/Zip: 0 Policy # or Self ins. Lic. W G 10 b I Expiration Date: d 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 the 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 ofperjury that the information provided above is true and correct. 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 www.mass.gov/dia MCNAM-2 OP ID: SH 4ta R CERTIFICATE OF LIAB'IL'ITY INSURANCE `—� D09127/2017ATE Y) 09127/2017 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(les) 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 Ileu of such endorsement(s). PRODUCER Rodman Insurance Agg. A ency, Inc. 145 Rosemary St., Bld Needham, MA 02494.3238 Jim Stoller NAME: T Jim Stoller PAIC HO�No ea 781-247-7B00 FANo: 781.444-0090 ENTAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC B INSURERA:Guard Insurance INSURED JF McNamara & Sons Corp INSURER S:COmmerCeInsuranceCOmpany 34754 PO BOX 6 Stoughton, MA 02072 INSURERC:Atain Specialty Insurance INsuRERD: Evanston Insurance Co INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. NREqXCLUSIONS ILT TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYV EFF MMILDIDIYYYY LIMITS C TCOMMERCIAL GENERAL LIABILITY CLAIMSMADE OCCUR CIP333105 09/06/2017 09/0612018 EACH OCCURRENCE $ 1,000,006 TED PREMISES Eaolcowence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER POLICY a JEC � LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS-COMPIOP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS X X NON OWNED HIRED AUTOS AUTOS 16MMBCMWYD 09/17/2017 09/1712018 COMBINED SINGLE LIMIT Ea accident $ 1,000,006 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ D X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE XOBW7297517 I 09/06/2017 09/06/2018 EACH OCCURRENCE $ 3,000,00 AGGREGATE $ 3,000,000 DIED I I RETENTION$ I I$ A WORKERS COMPENSATION ANDEMPLOVERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Lela,, NIA R2WC700321 02120/2017 02/2012018='EL. E H- X STATUTE ER EACH ACCIDENT $ 500,00 EL DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE- POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IB1, Additional Remarks Schedule, maybe attached If more space is required) CERTIFICATE HOLDER CANCELLATION MANSFIE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE 226&�2 ACORD 25 (2014/01) OO 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD