The URL can be used to link to this page

Home My WebLink AboutM&R Excavating LLC - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Board of Health Disposal Works Installer's Permit This is to certify that: BRENO CHAVES Doing business as: M&R LANDSCAPINGIEXCAVATION 1614 SOMERSET AVENUE TAUNTON MA 02780 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 SLATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 144 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 Disposal Works Installer Application LICENSE NUMBER: APPLICANT: _53tlJC� C'l✓c�S BUSINESS NAME: +/ fC AfbuD� nvc C u MAIL ADDRESS: ` _ __ _ CITYITOWN:STATE: A ZIP CODE: 0_?� BUSINESS PHONE: BUSINESS CELL: S�S7`7 d _ BUSINESS FAX: 5p -J_ FEDERAL ID/SS NUMBER: _Qtf_ j 0 ' 6- 0 LICENSE HELD Town ZaaLfro/J _ LICENSE HELD Town _r7Gk_) Year Licensed ,- O60 ' 10D 0 � l `00 Sob-L�N�!aa2 x 3 Year LicensedvO� _. LICENSE HELD Town _ /�J/��4EI'5c>✓ZC Year Licensed c>g � qq6 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: 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 aNcR 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 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Z?4& ZAVt)5(21tRiibC_ Address: City/State/Zip: 0--2 2&0 Phone #: 5Zk - &t V 5 2--a % Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.X 1 am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (me], real estate, auto, etc.) employees working for me in any capacity. g, ❑ 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.❑ Other with no employees. [No workers' comp. inswance req.] •Any applicant that checks box ff 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 boxHl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ` W,� r //A&ZT1-D/L 6 Address: Policy # or Self -ins. Lic. Expiration 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 thtpains and penalties ofperjury that the information provided above is true and correct. o phnnr U. -6v&- 9,;) q,5 / 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 Phone www,mass.gowma RightFax N2-1 4/1/2009 6:12:48 AM PAGE 1/002 Fax Server FAX To: CHAVES BRENO Company: Fax: 5082617425 Phone: From: Gupta,Mukesh Kumar Fax: Phone: E-mail: NOTES: Certificate of Insurance 0468M79A-08 - 1 1 /8/2008 77iis communication, including attachments, is confidential, may be subject to legal privileges, and is intended for the sole use of the addressee. Any use, duplication, disclosure or dissemination of this communication, other than by the addressee, is prohibited. If you have received this communication in error, please notify the sender immediately and delete o- destroy this communication and all copies Date and time of transmission: Wednesday. April 01, 2009 6:12:24 AM Number of pages including this cover sheet: 02 RightFax N2-1 4/1/2009 6:12:48 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 04-01-09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ALLAN M WALKER & CO HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 120 HIGH ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 1057 COMPANIES AFFORDING COVERAGE TAUNTON, MA 02780 COMPANY 22LTT A HARTPORD GROUP INSURED COMPANY B CHAVES BRENO DBA M & R LANDSCAPING COMPANY 1614 SOMERSET AVE C TAUNTON, MA 02780 COMPANY D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEC, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM\DD\YY) DATE LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL PRODUCTS-COMP/OP AGO. $ CLAIMS MADE OCCUR. PERSONAL && ADV. INJURY $ OWNER'S && CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ MED. EXPENSE (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY (Par Person) $ SCHEDULEAUTOS BODILY INJURY (Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON -OWNED AUTOS GARAGE LIABILITY ANYAUTOS AUTOONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-046BM79A-08 11-08-08 it-08-09 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 500,000 PARTNERS/EXECUTIVE INCL DISEASE -POLICY LIMIT $ 500,000 OFFICERSARE: X EXCL DISEASE - EACH EMPLOYEE $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERYCOMPENSATION POLICY DOSS NOT PROVIDE COV13RAOE FOR CHAVES UPEND. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF MANSFIELD EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT 6 PARK ROW FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25.5 (3/93) Ramani Ayer