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Home My WebLink AboutJ.E. Case, Inc. - 12/31/2009This is to certify that: Doing business as: Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit JOHN E. CASE III J.E. CASE, INC. 1320 SOUTH WASHINGTON ST. NORTH ATTLEBORO MA 02760 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: 26 FEE: $25.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 RE CE Disposal Works Installer Application OCT 2 4 2000 LICENSE NUMBER 26 APPLICANT: JOHN E. CASE III BUSINESS NAME: J.E. CASE, INC. MAIL ADDRESS: 1320 SOUTH WASHINGTON ST. CITY/TOWN: NORTH ATTLEBORO STATE: MA ZIP CODE 02760 BUSINESS PHONE: (508) 695-1461 BUSINESS CELL: BUSINESS FAX: (508) 699-7050 FEDERAL ID/SS NUMBER 04-2477486 LICENSE HELD: Town _ _ Year Licensed 2 0 2008 LICENSE HELD: Town _ _ Year Licensed BY LICENSE HELD: Town Year Licensed 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: C cs ol-fn � , CA.Se ('2c��r ate" 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. * Signature of Individual or Corporate Name (Mandatory) . orporate Officer CYHZ Cafe --JJT R(j t� DL — (Mandatory, if applicable) -OY - ay M ** Social ec�y 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 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeilily Business/Organization Name: c-3 i (f t f / Ie Z-�ryc Address 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. ❑ 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. 8. Non-profit 3. ❑ [No workers' comp. insurance required] 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 by volunteers, 12.0 Other with no employees. [No workers' comp, insurance req.] *Any applicant that checks box 41 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 kl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip Policy # or Self -ins. Lic. # TE W C. 9 L o $ O% Expiration Date: / o� `( 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 certify, under the pains mtd penallldems Ilfperjury that the information provided above is true and correct. Cianntnre• — C� LP � //U/� _.. Date: /V //�,�j g 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 Person: Phone www.mass.gov/dia From: Peggy A. Stevenson At: Eastern States insurance Agency, Inc. FaXID: To: J.E. Case, Inc. Data: 1024200E 01:25 PM Page: 2 Acow, CERTIFICATE OF LIABILITY INSURANCE OPID PSI DATE IIAMIDDA599T JECAS-I 10/24/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 50 Prospect Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waltham MA 02453 Phone:781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAIC'U INSURED INSURER A: Hanover Insurance Co. 22292 J.E. Case, Inc. INSURER B. Guard Insurance Company 31470 Case Materials, Inc. Case Disposal, LLC INSURER C. 1320 S. Washington St INSURER D. North Attleboro MA 02760 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTNRIISTANDIPIG ANYREQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY EE 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 LISR TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDAT) DATE IMM/DOM'I LIMBS GENERAL LIABILITY EACH OCCURRENCE 0 A X COMMERCIAL GENERAL LIABILITY LD148403189 10/01/08 10/01/09 DAN PREMISES IEa oaurence) CLAIMS MADE OCCUR MED EXP IAny one Person) PERSONAL2PDV INJURY 0 aO GENERAL AGGREGATE GEHL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG POLICY' X JECT LOC Emp Ben. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT gl, OOO, OOD A MY Auro A1II48417388 10/01/08 10/01/09 IEa accidenp ALL OWNED AUTOS 60DILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS IParattidenp PROPERTY DP.MP.G E $ IF., accidenl) GARAGE LIABILITY AUTO ONLY -E4 ACCIDENT $ ANY AUTO OTHER THAN EAP.CC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILIY EACH OCCURRENCE $5,000, OOO A X OCCUR CLAIMS MADE UHN8442373 10/01/08 10/01/09 AGGREGATE $5,600,000 a DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X 6S TORY LIMITS ER B EMPLDYERS'LIABILRY JEWC910306 10/01/08 10/01/09 E.L.EACH ACCIDENT $1,000 000 ANY PROPRIETORIPARTNERIEXECU TIVE I OFFICERNEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE $1, 000, 000 If,, describe under SPECIAL PROVISIONS below EL DISEP.BE-POLICYLIAT $1,000, 000 OTHER A Equipment Floater RHN8442503 10/01/08 10/01/09 comp/Coll $2,5000 Rent/Leas $3,115,300 Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 CANCELLATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAPS WRITTEN NOTICE TO THE CERTIFICATE HOLDER TIAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE 1,10 OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. r