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Home My WebLink AboutStephen & Paull Contractors, 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: PETER DISISTO doing business as: STEPHEN ANDO PAULL CONTRACTORS, INC. 95 TURNPIKE STREET WEST BRIDGEWATER, MA 02379 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: 139 Fee: $25.00 00-IRRE LOIN 61—IM N"m Dr. Raymond Martin, Chairman TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 DISPOSAL WORKS INSTALLER APPLICATION LIC: {{ P ( APPLICANT: Cc 4 c , f.0;`11 / BUSINESS NAME: '? MAIL ADDRESS: TOWN: C ' a .. STATE: &; ZIP CODE:,, > f BUSINESS PHONE: FAX NUMBER:' FED ID/SS NO.: LICENSE HELD: Town LICENSE HELD: Town 411C,, t k flo , LICENSE HELD: Town Year licensed Year licensed l 5 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 3 1 " yearly Fee: $. SIGNA' 1._ " 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 U eallh'Jane's DoctinlenlsNERMIT APPLICATIONS\BLANK INSTALLERS.doe 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 ice, C, t ( ; 14 i *"Social Security No. (Voluntary) or Federal Identification Number I 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. RMenithUane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name. C c-, Address: ` 1 > it G W City/State/Zip: t xJ-�t 'i� I lkk t c i Phone #: 2 'C� Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 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] 3• ❑Nom-profit 3We are a corporation and its officers have exercised 9. ❑ Entertainment ii their right of exemption per c. 152, § 1(4), and we have 10. ❑ 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. ther t., < • t , z *Any applicant that checks box # t must also fill out the section below shoving 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: t rr✓ an C c+ 5 ivg k--- v,:" t t Insurer's City/State/Zip: Policy # or Self -ins. Lic. # UJ & �A �[ i z Expiration Date: 1 I a t V'L cY>e 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification. I do hereby eertiify,,under the pains an penalties ofperjury that the information providejdp( abovee( tis true and correct. F's � `t0' Sa b ?. 2 Z 31,-, Official use only. Do not write in this area, to be completed by chy or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia APR.24'200E 09:03 6177739920 TONRY #604C. P-'))110)2 Ales-MM. CERTIFICATE OF LIABILITY INSURANCE DATE (MMmo/YYYYI PRooucEp (617)773-9200 FAX (617)773-9920 04/24/2oo8 'Albert J. . TOnry & Co. , Inc, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 300 Congress Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Quincy, MA 02169 ALTERTHECOVERACEAFFORDEDBYTHEPOLICIESBELOW. INSURERS gFFORDINO COVERAGE - HSURED Stephen Ando Pau Contractors, Tm^ ----- Northeast Reclaimation Corp. 95 Turnpike Street West Bridgewater, MA 02379 THE POLIGIES OF INSURANCE LISTED BELOW 1 ANY REQUIREMENT, TERM OR CONDITION OF I MAY PERTAIN, THE INSURANCE AFFORDED BY POLICIES, AGGREGATE LIMITS SHOWN MAY HP rvOR DD• TYPE OT INSURANCE TOENERALL'ASS BILITYX COMMERCIALGENELICLAIMS MADE C GEN-L AGGREGATF LrAUTOD IIMMAPPLIES PER. X JECp LOCIABILITYD AUTOSA DAUTOBOBD AUTO: ANY AUTO EXCESSfUMBRELLq LIABILITY X OCCUR CLAIMS MADE, C OEOUCTIBLE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY g ANY PROPRIETORfPARTNERJEXECUTNE OFFICERfMEMBER EXCLVDE09 D IContr'actor'S Equipment Various 5 usual to a site and road contractor Town of Mansfield, MA. 6 Park Row LMansfield, MA 02048 RD 26(2 FAX: (5p$)5 INSURER MAY SUCH EACH OCCURRENCE E °DAMA SE„�r0— RENTED —_ S MED FXP(AAyp %parson) PERSONAL &ADV INJVRY $ 00ERALAGORCGATE $ PRODUCTS• COMPrOP AGO $ �OepEI�E�OBINGLELIMIT $ BODILY INJURY {perOeaYltljRY $ PROPERTY DAMAGE (PWRa 07n4) $ AUTO ONLY - EA ACCIDENT --- g OTHERTHAN UAAOC I5 AUTO ONLY: AGG s FAVVIULNi 1 $ S \SE. EA EMPLOYEE 9 5 k$C-POLICYLIMIT $ 5 ised / Rented $250,( Scheduled Equipment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTIDB TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OACORD CORPORATION 1988 Town of Mansfieldop SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER- No:2 No.-2 Dept Board of Health To the Departmental Officer making the Payment Receipt of $ for the period 1/0/1900 Collections as per schedule of this date, filed In my office Treasurer