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HomeMy WebLinkAboutFoxborough Construction Co,Inc. - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: DONALD R. TREANNIE, JR. Doing business as: FOXBOROUGH CONSTRUCTION CO., INC. 7 JUDGE BROWN LANE FOXBOROUGH MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 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: 145 FEE : $25.00 BOARD OF HEALTH Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: p T G A T ee�tV UAJ t t \I _ BUSINESS NAME: 1'"Lfi �((3d12GpiX� r Croc�-aoa-lelluj C(j <NC Q n! �✓ MAIL ADDRESS t ! JUrt`G� CITY/TOWN: %%y STATE: ZIP CODE: cIZG3� BUSINESS PHONE:-09--S'13 ` 7V / BUSINESS CELL: BUSINESS FAX: ,�—Jg "- - ! -79 / FEDERAL ID/SS NUMBER: � LICENSE HELD Town f o' X 1q6 t2 po Year Licensed evalz@ wl " W r 5 yt4rZ S LICENSE HELD Town /U0t2 r4l IL! Year Licensed LICENSE HELD Town At-ly6F1, [-0 Year Licensed �1*5 i 'i7('rtC,5 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 31 st yearly FEE: $ 25.00 SIGNATURE: aj�vvr�c'.�' . 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 04/03/2009 FRI 8125 FAX 0002/004 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. Dom*-G ?Z ,(-&LPNIE- VL } 0)x(301Zou N aNs(i1oacoA) Signature of Individual or Corporate Name y: Corporate Officer (Mandatory if pplicable) Fro TC) # o'- l - 32// �G'7 "Social Security No. (Voluntary) or edc>ra! 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. MHealtWane's Documctm\PERIAIT APPLICATIONSVIAX CERTIFICATION FORMdoc 04/03/2009 FRI 8:25 FAX 1&003/004 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.inass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legibly Business/Organization Nanic: { -c OW t-+6— auCT f o nil G ns Arldrpn.c 1 /3 url i G 9CA,-,,_ s I n I City/State/Zip: �\ Orr 0,03 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ 1 am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant(Bar/Eating Establishment 2. ❑ I ant a sole proprietor or partnership and have no 7, ❑ Offico and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. workers' comp, insurance required) S. ❑ Non-profit 3. We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l (4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance requiredl* 4. ❑ We are a non-profit organir�dion, staffed by volunteers, 11.❑ Ilealth Care with no employees. [No workers' comp, insurance req.] 12.❑ Other *Any applicant that checks box 41 must also all out tho sootion below showing theft workers' compensation policy information. *"If the corporate officars have exempted thcrosclvcs, but the corporation has other employees, n workers' compensation policy is required and such an orgunimlion should check box #1 1 ant an employer that is providing workers' componsatum insurance for my employees. Below is the policy information. Insurance Insurer's City/Statemip: Policy # or Self -ins. Lie. # Expiration Attach a copy of the workers' compensation policy declaration page (shelving the policy number and expiration date). failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or ono -year hnprisonmnent, 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 a DTA for insurance coverage verification. ,r 1 do hereby ofperrrrry Official use only. Do not write in fibs area, to be completed by city or town (tficial City or Town: PermittLicense rhove is true ay(f correct. 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 wsvwaniss.gov/din Phone From: Georgia Raman At: Axis East Insurance Services FaXID: Axia Insurance To: Foxboro Construction Company Date: 4/8/2009 08:24 AM Page: 2 of 3 ACORD CERTIFICATE OF LIABILITY INSURANCE OPID GR DAM(MMIDDIYYYY) FOXBO-1 1 04/06/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE AXiA EAST Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 73 Market Place ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SpringfieldMA01103 Phone:413-205-2942 Fax:413-886-0190 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'. Travelers Insurance Co 01899 INSURER B: Associated Employers Foxboro Construction Company 7 Judge Brown Lane Foxboro MA 02035 INSURER 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. LTR NSR TYPE OF INSURANCE POLICYNUMBER DATE (MMIDDIYY) DATE (MM/ODM') LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE E OCCUR TBD 05/13/08 05/13/09 PREMISES (Ea occurencej $ 100000 MED ExR(M, are person) $ 5000 PERSONAL &ADV INJURY $1000000 GENERAL AGGREGATE $ 2000000 GF.N'L AGGREGATE LIMITAPPLIES PER'. PRODUCTS - COMP/OP AGO $2000000 -- --I _ POLICY JEC LOC _ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea ecdtlenp $ ALL OWNED AUTOS SCHEDULED Al1TOS BODILY INJURY (Per person) $ HIREDAUTOS NONOWNED AUTOS BODILYINJURY (Per .O,M.neccidenp $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ OTHER THAN EA ACC $ ANYAIRO $ AUTO ONLY: AGG EXCESSIUMBRELLALIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERIUOR AR ANY PROPRIMB R/PPRTNER/E%ECUTIVE TBD 04/07/09 04/07/10 X TORY LIMITS ER E.L. EACH ACCIDENT $500000 E.L. DISEASE - EA EMPLOYEE $SOOOOO EXCLUDE09 It Y., dRIMEMBER S yes, describe uMer SPECIAL PROVISIONS below EL. DISEASE -POLICY LIMIT $SDD DDD OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *30 Days GL/10 Days WC CERTIFICATE HOLDER CANCELLATION MAO2048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $0 SHALL Town of Mansfield IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER, ITS AGENTS OR 6 Park ROW REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Ken J Hark ACORD 25 (2001108) ©ACORD CORPORATION 1988