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HomeMy WebLinkAboutAllied/Republic Waste/Fall River 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Hauler's Permit This is to certify that: PERMIT No: 3 ALLIED WASTE SERVICES OF FALL RIVER REPUBLIC WASTE SERVICES OF FALL RIVER 1080 AIRPORT ROAD FALL RIVER, MA 02720 Town of Mansfield 6 Park Row Mansfield, MA 02048 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: #1247 (90614MA) #1241(89623MA) #3417(90601 MA) #4233(93209MA)) FEE PER TRUCK: $25.00 BOARD OF HEALTH Michae[McCCean, Chairman Town of Mansfield Town of'Mansfzeld -Board of'Health 6 Park Row Mansfield, MA 02048 Hauler's Application V 21201 N PERMIT NUMBER: 3 TOTAL FEE: iu ; , C.,`=(, BUSINESS NAME: REPUBLIC WASTE SERVICES OF FALL RIVE BUSINESS ADDRESS: 1080 AIRPORT ROAD TOWN / STATE I ZIP: FALL RIVER, MA 02720 NAME OF OWNER: ALLIED WASTE SERVICES OF FALL RIVER TELEPHONE NO: (774) 488.3626- t�l CELL NO: (508) 491-8522 FAX NO: (508) 676-1580 E-mail: -SFrTZ2b-tBBONS@REPU 3tICSERVtGES CO- Alt E-mail: FED ID/SS NO: 86-1024452 REGISTRATION NO: #1247 (90614MA) #1241(89623MA) #3417(90601 MA) #4233(93209MA)) NO OF TRUCK(S): 4 FEE PER TRUCK: $25.00 Permit Expires December 31st yearly. SIGNATURE: ry i i_.A\ c1.11 DATE: 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. AA H"�.t �., tiY ¢ - tl c�'t, �r4i Imo'%i i✓` $� ! �. 1 -C i.. Signature C of In4iv ual or Corporate Name ame By: Corporate Officer (Mandatory, ifApplicable) i Z� i "*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. 77ze Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNICit'ING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: ( 4`lC City/State/Zip: Are you an employer? Check the appropriate box: I . ❑ I am a employer with employees (full and/ or part-time).* 2: ❑ lam a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' camp. insurance required] 3.�ff 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, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (irel. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11. ❑ Health Care 12.ffOther j- l 1� a' aj . '� *Any applicant that checks box #1 most also fill out the section below showing theirworkers' compensation policy information. **If the corporate of Seers have exempted themsdVes, but the corporation bas other employees, aworkers' compensation policy is required and such an organization should check box 91. I am an employer that ispr"iding workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: ("'t(• i-'' Frl 1 iL j{ (' j 'Y' 9 i I i I Insurer's Address; � 4-'`t )txJ S € ��.+l' i � City/State/Zip' V 1' I k4/ §d-= if t l "a Y-1 i I K'k-+u Policy # or Self -ins, Lic. #� t-i'� - 1-- i (U t. [ C� � —� 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and�penaltl s fperjury that the information provided above is true and correct _, .A . 9 _i r�Y 1 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 Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone CERTIFICATE OF LIABILITY INSURANCE Page I of 2 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 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 CONTACT NAME: CANNON COCHRAN MANAGEMENT SERVICES, INC. PHONE (AIC No.EXQ: FAX (A/C Nc.EXt): 17015 N. SCOTTSDALE RD. E-MAIL ADDRESS:conificateteam(mccrosi.com SCOTTSDALE, AZ 85255 INSURER(S) AFFORDING COVERAGE NAIC # INSURED REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY PHOENIX, AZ 85054 COVERAGES CERTIFICATE NUMBER: 1229994 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF fMMIDDIYYYY) POLICY EXP fMMIDD1YYYYI LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX—1 OCCUR HDO G27867789 06/30/2017 06/30/2018 EACH OCCURRENCE $ 5,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 5,000,000 MED EXP (Any one person) PERSONAL S ADV INJURY $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 PRODUCTS-COMPIOP AGG $ 5,000,000 POLICY F-1 PROJECT ❑ LOG A UTOMOBILE LIABILITY X ANY AUTO X ALL OWNED SCHEDULED AUTOS AUTOS ISA H0906073A 06/30/2017 06/30/2018 COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 BODILY ]NJDRY(Per person) BODILY INJURY (Per acciden) J( HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) MBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS -MADE DED RETENTION $ B A C ORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY NV PROPRIETOR/P XCLUDEEXECUTIVE FFICERIMEMBER EXCLUDE09 � N/A WLR C64412917-ADS WLR C644129 9 - CAIMA/OR SCF C84412929 - WI WCU C64412899-OH XS 06/30/2017 06/30/2017 OB/3012017 06/30/2017 06/3012018 06/30/2018 06/30/2018 06/3012018— X WC STATU- OTHER TORY LIMITS EL EACH ACCIDENT $ 3,000 000 E.L. DISEASE -EA EMPLOYEE $3,000,000 E.L. DISEASE -POLICY LIMIT $3,000,000 A IMandatary in NH) TNS C49166436-TX NSXS 06/30/2017 06/30/2018 D If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Division Number: 4097 - Named Insured Includes: Allied Waste Services of Massachusetts, LLC - Dba: Allied Waste Services of Fall River- Republic Services of Fall River CERTIFICATE HOLDER CANCELLATION 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 Town Of Mansfield Attn: Board Of Health 6 Park Row �- Mansfield, MA 02048-2433 \. United States ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: ACORD® ADDITIONAL REMARKS SCHEDULE Page 2of2 AGENCY NAMEDINSURED REPUBLIC SERVICES, INC. 18500 N. ALLIED WAY POLICY NUMBER See First Page PHOENIX, AZ 85054 CARRIER NAIC CODE See First Page EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE The following provisions apply when required by written contract. As used below, the term certificate holder also includes any person or organization that the insured has become obligated to include as a result of an executed contract or agreement. GENERAL LIABILITY: Certificate holder is Additional Insured when required by written contract. Coverage is primary and non-contributory when required by written contract. Waiver of Subrogation in favor of the certificate holder is included when required by written contract. AUTO LIABILITY: Certificate holder is Additional Insured when required by written contract. Waiver of Subrogation in favor of the certificate holder is included when required by written contract. WORKERS COMPENSATION AND EMPLOYERS LIABILITY: Waiver of Subrogation in favor of the certificate holder is included when required by written contract where allowed by state law. Stop gap coverage for ND, WA and WY is covered under policy no. WLR C64412917 and stop gap coverage for OH is covered under policy no. WCU C64412899, as noted on page 1 of this certificate. TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY: Republic Services, Inc. and its subsidiaries are registered non -subscribers to the Texas Workers Compensation Act. Republic Services, Inc. has filed an approved Indemnity Plan with the Texas Department of Insurance which offers an alternative in benefits to employees rather than the traditional Workers Compensation Insurance in Texas. The excess policy (#TNS C49166436) shown on this certificate provides excess Indemnity and Employers Liability coverage for the approved Indemnity Plan. Contractual Liability is included in the General Liability and Automobile Liability coverage forms. The General Liability and Automobile Liability policies do not contain endorsements excluding Contractual Liability. Separation of Insured (Cross Liability) coverage is provided to the Additional Insured, when required by written contract, per the Conditions of the Commercial General Liability Coverage form and the Automobile Liability Coverage form. ACORD 101 (2008101) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD