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Home My WebLink AboutM. Pacella Excavating LLC - 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: MICHAEL PACELLA Doing business as: M. PACELLA EXCAVATING LLC. PO BOX 688 FOXBORO MA 02035 is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or repair individual sewage disposal systems. This permit is granted inconformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 12 FEE : $25.00 BOARD OF HEALTH Dr, Raymond Martin, Chairman Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER 12 APPLICANT: MICHAEL PACELLA BUSINESS NAME: M. PACELLA EXCAVATING LLC. MAIL ADDRESS: PO BOX 688 CITYITOWN: FOXBORO STATE: MA BUSINESS PHONE: (508) 543-1974 BUSINESS FAX: (508) 698-9198 FEDERAL ID/SS NUMBER 26-0074953 LICENSE HELD: Town roXbuo BUSINESS CELL: Town of Mansfield 6 Park Row Mansfield, MA 02048 ZIP CODE 02035 Year Licensed LICENSE HELD: Town WM6 do Year Licensed c22rnC E) LICENSE HELD: Town _�ICt,�, (l k', Year Licensed z0b 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: 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. i ature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) �t-C?07-4Q5,3 ** 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. Tlne Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ICcCk-StC(1trCXtCx i I �' Address: PC)" pcx i'�'`t) City/State/Zip: FurM MA C LC 37 Phone #: Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail IV. lama employer with _ employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inel. 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 by volunteers, 12.0 Other tt Ly r' ak l QtlChl with no employees. [No workers' comp. insurance req.] *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 # I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: C COY i (Y1 S Insurer's City/State/Zip: / Policy # or Self -ins. Lic. #� l fA , � F)2��` u i Expiration Date: �Z �(Ql �� 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 certi under tlae pains ena/ties ofjurytlrat the information provided above is true and correct official use only. Do not write in this area, to be completer/ 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.mass.gov/dia Phone Fm:nee.certificates@hubinternationai.com To:Pacella Certificates of Insurance 08:02 12129108GMT-12 Pg 06-15 n.s....«x. OAAAI MPACELLAEX .. ..,.O......., ACORD. CERTIFICATE OF LIABILITY INSURANCE 12129/0s°"r"' ARODUCER HUB International New England 600 Longwater Drive Norwell, MA 02061 791 792-3200 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. INSURERS AFFORDING COVERAGE NAIC # INSURED M Pacella Excavating LLC P.O. BOX 688 Foxboro, MA 02035-0688 INSURER Acadia Insurance 31325 INSURERB: INSURER C: INBURER D'. NSURER E: GVYCRMvmo 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 POLICY NUMBER POLICY EFFECTIVE D MMIOD POLICY EXPIRATION DATE IDDIYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERALLIA.BILITY CLAIMS MADE OCCUR CPA8153958 10106106 10/06/09 EACH OCCURRENCE $1000,000 DAMAGE TO RENTED MIS $250DDU ,E+oamn:rr MEDEXP(MYone Person) $5000 PERSONAL S ADV INJURY $160D000 GENERAL AGGREGATE s2.000.000 GENT AGGREGATE POLICY LIMIT APPLIES PER: X PRO- LOG JECT PRODUCTS-COMPIOPAGG $2000000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS MAA8153982 10/06/08 10106/09 COMBINED SINGLE LIMIT (Ea accident) $1,ODD,D6D BODILY INJURY (Perpeleon) S X BODILY INJURY (Peramdent) $ X X PROPERTY DAMAGE (Per accident) S GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ A E%CESSIUMBRELLA X LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ CUA02661111 10106/08 10106/09 EACH OCCURRENCE $1 000 000 AGGREGATE $1 00D 000 8 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNERIFXECUPYE OFFICERIMEMBER EXCLUDED9 Ityas, describe under SPECIAL PROVISIONS below WCA815754610 12108108 12/08/09 X WC LIMIT' PER E L. EACH ACCIDENT $500000 ET. DISEASE- EA EMPLOYEE 8599 DDD E.L. DISEASE - POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Town of Mansfield 6 Park Row Mansfield, MA 02048 ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION IEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL —JD— DAYS WRITTEN TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR monm o ACORD Fm:nee.certificates@hubinternational.com To:Pacella Certificates of Insurance 08:02 12129108GMT-12 Pg 07-15 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-S (2001108) 2 of 2 #S2138001M211989