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Home My WebLink AboutFisk Contracting Co. - 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. JAMES FISK Doing business as: FISK CONTRACTING CO 64 CARPENTER STREET SEEKONK MA 02771 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 December31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 109 FEE : $25.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman LICENSE NUMBER APPLICANT: BUSINESS NAME: MAIL ADDRESS: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application 109 JAMES FISK FISK CONTRACTING CO 64 CARPENTER STREET CITY/TOWN: SEEKONK BUSINESS PHONE: (508) 761-7073 BUSINESS FAX: (508) 761-7073 FEDERAL ID/SS NUMBER 30 0243709 STATE: MA ZIP CODE 02771 BUSINESS CELL: LICENSE HELD: Town' -- LICENSE HELD: Town LICENSE HELD: Town Year Licensed _ ,-Q_)'_ Year Licensed 1 S T' Year Licensed o NOV ?008 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 31st yearly. FEE: $ 25.00 SIGNATURE: s 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. N ure of Individual or rate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** 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 wiviv. ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Phone#: ✓ f _. �-" :� Are iyou an employer? Check the appropriate box: Business Type (required): 1 I I am a employer with 2--= 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. g, ❑ 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 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed b volunteers, j with no employees. [No workers' comp. insurance req.] 12.0 Othe{ % *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 #l. I ant an employer that is providing workers' fA compensation insur nce for iny,employees. Below is the policy information. ✓ y Insurance Company Name:—Y Insurer's Address: City/State/Zip: X'& 9 0VUc./, Policy # or Self -ins. Lic. # lV ,% 1-2 6`0 i 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 Investieations of the DIA for insurance coverage verification. I do 11 under the pains and penalties ofperjury that the information provided above is trite and correct. 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.ivass.gov/dia Phone NSURANCE CDATE (MMIDDIYYYV) ORD,,, CERTIFICATE OF LIABILITY I11/11/2008 PRODUCER (401)431-9200 FAX (401)431-9201 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Troy, Pi res &Allen, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 376 Newport Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 4830 East Providence, RI 02916 INSURERS AFFORDING COVERAGE NAIC# INSURED FISK CONTRACTING INSURER A. National Grange Mutual Ins Co 14788 64 CARPENTER STREET INSURER : Transportation Insurance Co. 20494C SEEKONK, MA 02771 INSURER AIM Mutual Ins Co 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 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. INSft OD' TYPE OF INSURANCE POLICY EFFECTIVE POLICY E%PIRATION LIMITS POLICY NUMBER MPP3122B 05/OS/2008 OS/05/2009 EACHOCCURRENCE DAMAGE TO RENTED MED EXP (Any one person) PERSONAL B ADV INJURY GENERA -AGGREGATE PRODUCTS -COMP/OP AGG 53 9 LIMIT GE ICCIDENT EAACC AGG iICE oTH- VWC6012178( I EB E L EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT AD GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY LA -1CLAIMS MADE OCCUR $ 1,000,000 $ 500,00( $ 10,00( $ 1,000,00 $ 2,000,000 $ 2,000,000 GENE AGGREGATE LIMIT APPLIES PER: PRO- LOG POLICYJECT $ B AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULCHEDUL ED AUTOS HIRED AUTOS NON -OWNED AUTOS $ 2SO,000 X $ SOO, DUO $ 100,000 $ GARAGE LIABILITY ANY AUTO $ $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ $ $ C WORKERS EMPLOYERS' ANY OFFICERIMEMBER If yes, SPECIAL COMPENSATION AND LIABILITY PROPRIETOR)PARTNER/EXECUTIVE EXCLUDED? Aesobe anger PROVISIONS below $ lOO, OOO $ 100,000 $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TOWN OF MANSFIELD BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY C/O BOARD OF HEALTH 6 PARK ROW OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE tAe, %7 /« Lori LaFlamme/LORI �. nnn,. nnoononrin,.l aoaa ACORD 25 (2001108) 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 endorsement(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 25 (2001108)