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HomeMy WebLinkAboutW. Walsh Co., Inc. - 12/31/2008COMMONWEALTH OF MASSACHUSETTS TOWN OF MANSFIELD SIX PARK ROW, MANSFIELD, MA 02048 DISPOSAL WORKS INSTALLER'S PERMIT This is to certify that. doing business as: CHRISTOPHER WALSH W. WALSH COMPANY, INC. 32 WALTON STREET ATTLEBORO, MA 02703 is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or repair individual sewage disposal systems. This permit is granted in conformity with state environmental code 310 CMR 15.02(2) and expires December 31, 2008, unless suspended or revoked. License Number: 117 Fee: $25.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 DISPOSAL WORKS INSTALLER APPLICATION LIC: 117 APPLICANT: CHRISTOPHER WALSH BUSINESS NAME: W. WALSH COMPANY, INC. MAIL ADDRESS: 32 WALTON STREET TOWN: ATTLEBORO STATE: MA ZIP CODE: 02703 BUSINESS PHONE: (508) 226-4300 FAX NUMBER: (508) 226-8449 FED ID/SS NO.: 04-2565426 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 31s' yearly Fee: $25.00 SIGNATURE: DATE: 1)1510 7 / Please make appropriate changes. Sign, date and enclose checkfor $25.00 payable to Town of Mansfield Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. R:\HeahbVaae's DocuammsTERMIT APPLICATIONSVNSTALLER$ doc 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. Na (sh (6m �pum�U, IL&L& Signature of Individual or Corpotate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Ide�rtificntion 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. R:\FlealthVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc iLllls The Commonwealth of Massachusetts UlfDepartment 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 Name: 4/ Address: 3z /ltUrU /,¢2eT City/State/Zip: Phone#: /"5M% &6- Are you an employer? Check the appropriate box: Business Type (required): 1 I am a employer with 3 �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. 8. ❑ 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 WE] Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12;�Other t%%t; �* &, a'def02 *Any applicant that checks box # I 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 # I. I ani an employer that is providing workers' compensation iasin•aizce for niiy employees. Below is the policy inforniatioit. Insurance Company Insurer's City/State/Zip: Nor t pur6I Lei (201 Y) '? i —1A pp Policy # or Self -ins. Lie. #_ V < D5 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 cent 1uryder toe pglns and penalties ofperjury that the information provider/ above is trite and correct. Phone #: � ::5L9g' ZZ6 � / 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.inass.gov/dia ACCJR& CERTIFICATE OF LIABILITY INSURANCE 1101 7 YYYV) 08/10107 PRODUCER - STARKWEATHER '& SHEPLEY (MA) 400 Blue Hill Drive Suite188 Westwood, MA 02090-2161 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED W. Walsh Company, Inc. 32 Walton Street Attleboro, MA 02703 - INSURER A: Travelers Insurance Company 25674 INSURER B: INSURERC: NsuRERO: INSURERE: V 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR kDD-L NSR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE MMIDD POLICY EXPIRATION DATE MMIDD LIMITS A GENERAL LIABILITY 106D5309 08113/07 08/13/08 EACHOCCURRENCE $1 00Q 000 T DAMAGE TO RENTED $300000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $5 000 CLAIMS MADE 1 OCCUR PERSONAL &ADV INJURY _ $1.000 000 X PD Ded:2,5Q0 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $2000000 POLICY a PRI-JECT LOG A AUTOMOBILE LIABILITY ANY AUTO 810106D5291 08/13/07 08/13/08 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Par person) $ ALL OWNED AUTOS SCHEDULED AUTOS O O X BODILY INJURY (Per accldenll $ HIRED AUTOS NON-OWNEDAUTOS M U X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY - AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESSMMBRELLALIABILITY 106D5310 08/13/07 08/13/08 EACH OCCURRENCE $6000Q0Q AGGREGATE $6 000.000 X OCCUR CLAIMS MADE $ DEDUCTIBLE $ X RETENTION $ 1 Q 000 WORKERS COMPENSATION AND 106DS276 0$/13/07 Q$/1$/0$ ,. TH- X WC STATU- OER E.L. EACH ACCIDENT $1 000 000 EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 If yes, describe under SPECIAL PROVISIONS below OTHER .. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS *-10 days notice of cancellation for non-payment of premium *" Supplemental Name ** W. Walsh Company, Inc. (See Attached Descriptions) Town Of Mansfield Board Of Health 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'An*_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AftCORD 25 (2001108) 1 Of 3 #M170550 JMR 0 Av Unv uncrurce*r wry rnoo Client#: 34032 7 DATE (MM(DDNYYY) ACORD,M CERTIFICATE OF LIAI7I LIT YTHIS EINSU RAN CERTIFICATE IS ISSUED AS A MATTEROFINFORMAT10DN PRODUCER ONLY AND CONFR 'FCATERS NO RIGHTS UPON THE CERTIFICATE S PRODUCER ATHER & SHEPLEY (MA) HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 400 Blue Hill Drive NAIL # Suite 188 INSURERS AFFORDING COVERAGE 25674 Westwood, MA 02090.2161 INSURER A. Travelers Insurance Company W. Walsh Company, Inc. ,N�Un�,.,.. 32 Walton Street NSURER C: Attleboro, MA 02703 INSURER 0: .SURER E: JVERAGES 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 RESHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT ERMSN XCLUSIONS ANDCONDiMiOSNSOFSUCH-� POLICY EFFPOLICIESAGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM tE IMMIODIYYI a nnn nnD D9_7777:r��FER r..,,._..TR NSftSURANCE08/13/08 08/13109 AY106D5309L GENERAL LIABILITYMADE OCCUR500�, wir eaPl IFS PER: PRU LOC POLICY IA JECT 08113108 08/13/09 COMBINED SINGLE LIMIT $1,000,000 810106D5291 (Ea accitlenq A AUTOMOBILE LIABILITY X ANY AUTO BODILY INJURY (Perperson) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Peraccidenl) $ X HIREDAUTOS X NON -OWNED AUTOS PROPERTY DAMAGE (Per accldenU $ X Drive Other Car AUTO ONLY - EA ACCIDENT $ GARAGE LIABILITY EA ACC OTHER THAN AUTO ONLY: AGG S $ ANY AUTO 08/13109 EACH OCCURRENCE $6 OOO OOP 106D5310 08/13/08 AGGREGATE 36 000 DD A E%CESS/UMBRELLA LIABILITY $ X OCCUR CLAIMS MADE ¢ DEDUCTIBLE 08113/08 108/13/09 IAWORKERS COMPENSATION AND EMPLOYERS' LIABILITY ONECUTIVE FICEWMEMBER EXCLUDED? OTHER DN OF 01 e.. AD Cancellation NOfIOe for Non-payment Of Premium Ur EENDORSEMENT *10 DaysBy SPECIAL PROVISIONS ** Supplemental Name ** W. Walsh Company, Inc. (See Attached Descriptions) Town of Mansfield Board Of Health 6 Park Row Mansfield, MA 02048 GtLLA I I'- - LID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _3D_*. GAYS WRITTEN :ITO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL SE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ACORD 25 (2001108) 1 of 3 #M196D57 SSP © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemenl(s). 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S (2001100) 2 of 3 #M196057