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Home My WebLink AboutK&V Construction - 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: VERNON FERREIRA K&V CONSTRUCTION 27 NORTH MAIN STREET CARVER, MA 02330 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: 138 Fee: $25.00 4 Dr. Raymond Martin, Chairman TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 DISPOSAL WORKS INSTALLER APPLICATION LIC: APPLICANT: f e�-t �yy BUSINESS NAME: 'K'VV MAIL ADDRESS: Z:'l 1,j TOWN: 0ft-QV tf STATE: (n Y' ZIP CODE: BUSINESS PHONE: FAX NUMBER: FED ID/SS NO.: LICENSE HELD: Town C:,I9i uc-". Year licensed ZoO-Z LICENSE HELD: Town Ap t�(-Ak LICENSE HELD: Town Year licensed 2.60-7 Year licensed 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 315` yearly Fee: $25.00 SIGNATURE: DATE: Please make appropriate changes. Sign, date and enclose check for $25.00 payable to Town of Mansfield Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. R UlenithVnne's Documen(APERMIT APPLICATIONSTLANK INSTALLERS dw 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. _4L� - Signature of In> iclual or Corporate Name 030 �g s6QS "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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:\Health'Jane's DocwnentAPERMIT APPLICATIONS\TAX CERTIFICATION PORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street e Boston, MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: KAAJ Oa ,.gd',rly[,hov-1 Address: - L-L w Yn #T t# J 4A- y City/State/Zip: L[ �4 ICE l 6 tq Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail o art -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 10.0 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.] 12.0 Other *Any applicant that checks box kl 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 q 1. mn art employer that is providing worlrers' conipensatimt insurance for my employees. Below is the policy information. Insurance Company Names(2`1.�FPeC- �sln%n �in,S Insurer's Address: ` City/State/Zip: k Lev S +C----) rl on 4 e-1 S et A Policy # or Self -ins. Lic. # Expiration 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. Phone #: /— &6 % i\ CP lco — g Zo (J 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.mass.gov/dia 02/11/2008 23:17 FAX N I I PRODUCER (781)585-2522 FAX: (781)585-9415 1HIS LICKrrr'iumI1 la 1... ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Clippership Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Dox 112 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Kingston MA 02364 INSURERS AFFORDING COVERAGE NAIL# INSURED INBURERANautiluS Insurance Vernon Ferreira, DHA: K and V Construction INSURER B; 27 N Main St INSURERC; INSURER D; Carver MA 02-930 INSURERE; 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, LIMITSkTE H INOR ADD`L TYPE OFINSURANCE POLICY NUMBER POLICY EJMWbCTIVE GATE MM/DONY POLICY DATSjM IDDIY I DATE MM/DDIYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR NC704699 1/10/2008 1/18/2009 8,- 3DD, 0D0 DAMAGETO RENTED 9 50,000 MEp a arson p 10,000 PERSONAL ADVINJIIRY a 300,000 GE ATE B 600,()00 PRODUCTS, COMPIOP O p 600 ODO GEN1 AGGREGATE LIMIT APPLIES PER X POLICY PR AUTOMOBILE LIABILITY ANY AVID ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accldeN) a BODILY INJURY (Par person) p BODILY INJURY (Peradcldent) p PROPERTY DAMAGE (Per accident) e GARAGE LIABILITY ANY AUTO AUTO ONLY -EA ACCIDENT 8 OTHERTHAN AUTO ONLY: AGO EXCESSIUMBRELLA UASILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIVOMPARTNERUXECUTIVE OFFICERIMEMBER EXCLUDED? It yea,dev bounder PECIAL PROVI EACH QQr,(JRRVNrp AGGREGATE B T - OTR• A HACCOENT 9 -" E.L DISEASE -EA EMPLOY E.L.DISEASE-POLICY LIMI OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNERICLESIEXCLU$IONS ADDEO BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLOEH. (508) 261-7425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Mansfield Town. Hall EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Six Park Row 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Mansfield, MA 0204 B FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESEN E ACORD 25 (2001108) INS025 (Dlospae Peep 1 &2