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Home My WebLink AboutFerrara Construction 12/31/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Disposal Works Installer's Permit This is to certify that: BRUNO FERRARA Doing business as: FERRARA CONSTRUCTION 49 LINCOLN STREET 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 the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 25 FEE: $25.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman Town of Mansfield - Board of Health Disposal Works Installer AI LICENSE NUMBER 25 APPLICANT: BRUNO FERRARA BUSINESS NAME: FERRARA CONSTRUCTION MAIL ADDRESS: 49 LINCOLN ST CITY/TOWN: NORTON STATE: MA i BUSINESS PHONE: (508) 285-6330 BUSINESS CELL: BUSINESS FAX: (508) 285-6330 FEDERAL ID/SS NUMBER 04-2963314 Town of Mansfield 6 Park Row Mansfield, MA 02048 FNOV2008 ZIP CODE 02766 LICENSE HELD: Town _ _ _ Year Licensed LICENSEHELD;:Town - b beau icensed LICENSE HELD: Town 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 Satndards for the Subsurface Disposal of Sanitary Sewage". I understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31 st yearly. FEE: $ 25.00 SIGNAT E: 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 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. * Signgfure of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 0q-2-5,331 `1 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf WWiv.mass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1Pe_f v-q rrn C n 5t& C.A: zwn 1 Address: `�� t nGr�`i S�sl—e } City/State/Zip: N prk,r, Are you an employer? Check the appropriate box: 1. �am a employer with `3 employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per a 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.] Phone #: S�)e [_ L -G33z, Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I t.❑ Health Care 12.915ther *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 #1. I ant an employer that is prov(�r�(\ing workers' compensation insurance for my employees. Below is t�olicy information. mN Insurance Company Na e: aAkOrrsf\ M-'Aj lhS Insurer's Address: 5 S LZ�2 S"t �, p �+ City/State/Zip: Policy # or Self -ins. Lic. # R Expiration Date: k - 3 '" i 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 eertif order the pains _aand penalties ofperjury that the information provided above is true and correct. IMFJ c c _A Official use only. Do not write in Ibis area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): t. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia Phone "'NpV�`INSURAN :E COMPANY -55 WEST STA:ET KEENE NEW IAMPSHIRE 03431 INSURED WORK RS COMPENSATION AND EMPLOYERS LI kBILITY INSURANCE POLICY INFORMATION PAGI 1. insured Nan' & Mailing Address: FERRARA ()NSTRUCTION CORP 49 LINCOI NORTON, I J ST k 02766 POLI Y NUMBER: WCK14490 RENE JAL OF: WCK14490 CART ER CODE NCCI: 16322 ACC( JNT NO: CACK14490 FEIN: 042963514 ENTI' I: CORPORATION For other we kpiaces not shown above, see Location Schedule AGENT: RIS STRATEGIES COMPANY NUM ER:200535 AGENT PH NE : 781,986-4400 2, Policy Perio+ "The policy period is from 01/03/2008 To 01/ 5/2009 12:01 a.m.: indard Time. at the insured's mailing address. 3. A. Workers "ompensation Insurance: PART ONE of the policy appl -s to the War -rs Compensation law of the states listed here: MA B. Employf s Liability Insurance PART TWO of the policy applies Ic work in each state listed In Item 3.A. The limits of liabili under PART TWO are: BODILY INJURY BY ACCIDENT 500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $ 500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE 6 500,000 POLICYLIMIT C. Other S tes insurance: PART THREE of the policy applies to th, states, if any, listed here: all states except: WA, W , WY, NI), 014, and star s designated in ITEM 3A of the information page. D. Seethe tiached forms schedule for endorsements and schedu s included on this policy. 4. The prOMIL f for this policy will be determined by our manuals of i les classlfieations, rates and rating plans. All information ctuded on the attached schedule S-64 is subject to ver !cation and change by audit. FEIMUMPFMPOSiTPRI AiUM $ TAL 21\TED ANNUAL STANDARD PREMIUM $ MIM AE USTMENT PERIOD ANI UALDATE OF ISS E 01/10/08� COUNTERSIGNED BY _ _9OR aD REPRESENTATIVE 64-7425 (0-01 WC 00 OC M (STANDARD) "INCLUDES COP RIGHT MATERIAL OF THE NATIONAL COUNCIL ON 1 DMPENSATION INSURANCE USED WITH ITS PERMISSION. 19 I COUNCIL ON COMPENSATION INSURANCE"