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HomeMy WebLinkAboutWarchal Excavation - 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: DENNIS WARCHAL WARCHAL EXCAVATION 366 RESERVOIR ST NORTON, MA 02766 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: 88 Fee: $25.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman LIC: 88 TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 DISPOSAL WORKS INSTALLER APPLICATION 17�1►1i:1I.y57:13OVIAR I BUSINESS NAME: WARCHAL EXCAVATION MAIL ADDRESS: 366 RESERVOIR ST TOWN: NORTON STATE: MA ZIP CODE: 02766 BUSINESS PHONE: (508) 285-4671 FED ID/SS NO (508) 285-4671 011-54-8930 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: $25.00 SIGNATURE: DATE: € J 2ox)- 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 U1eftLVnne's DocunientsNERMIT APPUCATIONSVNSTALLERSAm 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, if 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. R:\HmIthVan&s DocumentsWERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization City/State/Zip: Phone 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. E04am 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, § I (4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.aOthe r L 1 with no employees. [No workers' comp. insurance req.] -UX *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 #l. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: 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(utcertify, r}9ai([dper+ y{thepains ai(n�'d pe(/n1,l tie �erjt(ry that the information provr`irteldFp (a(bovr%e is true q)and frcorrect . Ci��nfi.rn• PlV �I 1. J 1.I'll at U ( 1� Vim/ ) not,... V Y (\ 4 06 Official use only. Do not write in this area, to he 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 ACORD,M CERTIFICATE OF LIABILITY INSURANCE DAll/8/O/y7YY) PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Barrows Insurance Agency, Inc. ONLYAND CONFERS NO RIGHTS UPON THECERTIFICATE 215 North Main Street HOLDER. THIS CERTIFICATEDOES NOT AMEND, EXTEND OR Mansfield, MA 02048 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA OneBeacon Insurance Co Dennis Warchal d/b/a INSURERS: Commerce Insurance Warchal Excavation 366 Reservoir Street INSURER C: Norton, MA 02766 INSURER D: INSURER E: COVERAGES 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 RESPECTTO 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 ADD-L E POLICYNUMBER PDOUEYEFFBCCTIVE o LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAMS MODEOCCUR FB 1U12965 4 25 07 / / 4 25 08 / / EACH OCCURRENCE $ 1,000,000 ETOTRERTE PREMISES Eaoccurence $ 300,000 MED EXP(Anyone person) $ 51000 PERSONAL S ADV INJURY $ 11000 000 GENERALAGGREGATE $ 2 000 000 GENTAGGREGATE LIMIT APPLIES PER: PRO POLICY PRO- LOC PRODUCTS-COMPIOPAGG $ 2,000,000 B AUTOMOBILE LIABILITY ANYAUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIRED AUTOS NON-OWNEDAUTOS LP5292 4/25/07 4/25/08 COMBINED SINGLE LIMIT (�-cid-I) $ BODILY INJURY (Per person) $ 50,000 X BODILY INJURY (Per accident) $ 3.00,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY ANVAUTO AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC AUTOONLY: AGG $ $ E%CESSIUM BRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ WORKER S COMPENSAT ION AND EMPLOYERS' LIABILITY MY PROPR IETOR/PPRTNER/IXECUTISE OFFICERMEMBEREXCLUDED7 I(yYss descfbeunder SPECIALPROVISIONSbebw WCVSTATU- LIMBS OTE TOR $ — $ $ E.L. EACH ACCIDENT E.L. DISEASE. EAEMPLOVEE E.L. DISEASE POLICY LIMB OTHER DESCRIPTION OF OPERATIONS I LOCA71ONS IVEH CLES I EXCLUSIONS ADDED BY END CRSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER W ILL ENDEAVOR TO MAIL 10 DAYSWRITTEN Town of Mansfield NOTIC ETD THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TOD OSO SHALL 6 Park Row IMPOSENO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Mansfield, MA 02048 REPRESENTATIVES. AUTHO D REPRESENTATIVE NU G ACORD 25 (2001108) y© ACORD CORPORATION 1988