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Home My WebLink AboutLewicki & Sons Excavating, Inc. - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: CAROL LEWICKI Doing business as: LEWICKI & SONS EXCAVATING, INC. 15 WILMARTH LANE PLAINVILLE MA 02762 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 SPATE ENVIRONMENTAL CODE. 310 CMR 15.02(2) and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 82 FEE: $25.00 BOARD OF HEALTH 'Pf�, ✓ br� Dr. Raymond Martin, Chair an LICENSE NUMBER APPLICANT: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application 82 CAROL LEWICKI BUSINESS NAME: LEWICKI & SONS EXCAVATING, INC. MAIL ADDRESS: 15 WILMARTH LANE CITY/TOWN: PLAINVILLE BUSINESS PHONE: (508) 695-0122 BUSINESS FAX: (508) 695-6991 FEDERAL IDISS NUMBER 04-3424537 STATE: MA ZIP CODE 02762 BUSINESS CELL: LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town L�✓%r��1��_ Year Licensed ,AW_7_ — �< Year LicensedA� Year Licensed �:,?00 7 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: DATE: /,�'//.-0 y _. 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) 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 a 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: ems: Address: City/State/Zip:Z,'/� Phone #: ea' Are you an employer? Check the appropriate box: Business Type (required): 1. H' I am a employer with 5_ employees (full and/ 5. ❑ Retail orpart-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. [No workers' comp. insurance required] 8. ❑Nor -profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have WE Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care rance with no employees. [No workers' comp. insureq.] 12.0 Other *Any applicant that checks box 01 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. Iarn an employer t/rat isproviding workers' compgisation insurance for my employees. Below is the policy information. Insurance Company Name: e d' Insurer's Address: 1,,y 4— oor [ /( 2 Z (n City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: _�'" /" 0 ry 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 and penalties ofperjury that the information provided above is true and correct Phone #' 5F5K 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 Phone Contact www.mass.gov/ciia ACORD CERTIFICATE OF LIABILITY INSURANCE OPT, P LEWIC-1 DATEIMM/DONM) 12/11/08 PRODUCER - Eastern States Insurance Agency, Inc. 50 Prospect Street THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waltham MA 02453 Phone:781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance Company 31325 INSURER B'. Haaem'a inauvnw cowpany 217$4 INSURER Lewic$i & Sons Excavating, Inc 1S Wilmarth Lane Plainville MA 02762 INSURER D: rrelawencS 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 MY 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. TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDM•jDATE (MMIDD IO LIMITS LIABILITY MERCIALGENERALLIMILITY CLAIMS MADE � OCCUR CPA0066680-17 03/01/08 03/01/09 EACH OCCURRENCE $1,000,000 PREMISES(Eaooaxence $ 250,000 VIED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 GREGATE LIMIT APPLIES PER' ICY JECT LOC 1-1 PRODUCTS-COMP/OP AGO $2,000,000 EmpBen. 1 mil BILE LIABILITY ALTO OWNED AUTOS EDULED AUTOS FA�OS DALITOS -OWNED AUTOS MAAO09125S-12 03/01/08 03/01/09 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per attltlent) $ GARAGE LIABILITY ANY AUTO ALTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGO $ $ EXCESS/UMBRELLA LIABIUR OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILRY ANY PROPRIETOR/PARTNERIFXECUTIVE QFFICERIMEMSER EXCLUDED? If yes, describe uMer SPECIAL PROVISIONS below WCA0066676-15 03/01/08 03/01/09 X TORYLIMITS I ER E.L. EACH ACCIDENT $500000 E.L. DISEASE - EA EMPLOYEE $500000 EL DISEASE -POLICY LIMIT $500000 A OTHER Equipment Floater CPA0066680-16 03/01/08 03/01/09 Limit: See Below Ded: $1,000 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Town of Mansfield is named as Additional Insured only ATIMA. YGR III"IF.IIIG RVVVGI\ —••• ••"�' MARS 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $0 SHALL Town of Mansfield IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Mansfield MA 02048 REPRESENTATIVES. AUTH.O�RIZE�D,R..E�PRESENTATIVE