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Home My WebLink AboutNorfolk Equipment Services, Inc. - 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 J I This is to certify that: MICHAEL DELELLIS Doing business as: NORFOLK EQUIPMENT SERVICES, INC. P.O. BOX 38 BRIDGEWATER MA 02324 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: 146 FEE : $26.00 BOARD OF HE`A2.T Dr. Raymond Martin, Chairman LICENSE NUMBER: APPLICANT: BUSINESS NAME: MAIL ADDRESS: % a6 00 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Disposal Works Installer Application MiNad 0( �D 14 PO eo-,)� eL�ld1`S__ it eS CITYITOWN: owr��Z �.'l�7/ _ STATE: MA ZIP /C1OGDE: 02 2)24 BUSINESS PHONE: h()Q��)(��( U� t�l�Jl7 BUSINESS CELL: — BUSINESS FAX: E-mail: ��r^1� CPS' �rYfiu� �(�✓� Alt E-mail: ERAL IDISS NUMBER: �� g q 3 � _ q 3413 LICENSE HELD Town _a �� eV l Year Licensed `n' g�q- 1�Dq� LICENSE HELD Town r `�Y O�Q �/�(�1�)�e r Licensed LICENSE HELD Town L MA Year Licensed V CJ I - D i g kl�" MA 2006) 6''Svg- r v 9' S�l B 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 31st yearly. FEE: $ 25.00 SIGNATURE:' DATE: (� - to- 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: N C 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. ❑ 1 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. 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 I0.❑ Manufacturing no employees. [No workers' comp, insurance required]* 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, �qq Other C On Any 12 with no employees. [No workers' comp. insurance req.] X *Any applicant that checks box N I must also fill out the section below showing their workers' compensation policy information. **tribe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box Nl. I am an employer that is providing workers' compenns^ation insurancefor mmy employees. Below is the policy information. Insurance Company Name: r t I �cr �?U (lYa t W V' c�n S l k 6 0Ce_", 1nJ—y Insurer's Address: V 5 V It1V 1 `C) �0D �� City/State/Zip: I awl � �i 1' N J Or � O `� —t U `�f U -I / Policy # or Self -ins. Lic. # WG Con _y 2 7 ZQ Expiration Date: 2-/1 0/ 1 Q 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 of perjury that the information provided above is true and correct. N Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone www,mass.gov/dia ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY COMPANY;RANITE STATE INSURANCE 1 4o-. OLK SERVICES INC AND NORFOLK EQUIPMENT AGENT NUMBER' /1.• a POLICY: NUMBER 013-66-0209-00 ISLE Wc99U I y t VK UA1rLC i c WN1¢1 Member Companies of r 0 BOX 3 American International Group IRIDGEWATER, MA 02324-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 WE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC99DS10 .D# •s, a a• FRANCIS M. WALLEY INS. AGENCY, INC. WORKERS COMPENSATION AND EMPLOYERS PO BOX 469 LIABILITY POLICY INFORMATION PAGE DEDHAM, MA 02027-0469 INSURED IS PREVIOUS POLICY NUMBER RENEWAL 00826 612 ..ORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1, OF THE INFORMATION PAGE - WC990610 REM 2 POLICY PERIOD 12:01 AM, standard threat the Insured's mailing address FROM 02/10/09 TO 02/10/10 ITEM A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work In each state listed In item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 ,000,000 each accident Bodily Injury by Disease $ 1 , 000.000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE - WC990612 ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Number Estimated Total Remuneration ❑ Rate Per $100 OF Re, muneration Estimated Premium X 11 ® Annual 3 Year Annual 3 Year SEE EXTENSION OF ITEM 4, OF THE INFORMATION PAGE - WC7764 TAXES/ASSESSMENTS/SURCHARGES $161 EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE By STATE) 8 MA Fn ,.On MINIMUM PREMIUM Sir,'; MA TOTAL ESTIMATED PREMIUM _ 24,202 If indicated balmy. Interim adjustments of premium shell be made: Semi -Annually Quarterly ❑ Monthly DEPOSIT PREMIUM 02/27/09 ASSIGNED RISK 66 Issue Date Issuing Office 39967 (Rev'd 04/081 Authorized Reoresentetive WC 00 00 of 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) "Ty c� �(- / 106 < a�v 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. loard of Health requires that all sewage system mstaaattous cc An "As -Built' plan designed by the engineer and certification It Title V and local Board of Health Rep must be submitted with each installation. No. i`WIMAN it � ... �; • ,� . �, , Fee $250.00 Ck# 1064 vls Date July 11, 2007 i 1 Y III ! ' is hereby granted permission to install a Septic System on the premises at 18 Comnbs Street, Lakeville, MA 02347 (59-3-17) ` For: Manuel Garcia in accordance with an application on file at this office, Said work must be done in strict conformity with the requirements of the regulations of the Board of Health relating thereto. 1, Board of Health Agent Violation of any gl'the requirements or conditions ivill cause ientnediate revocation `of this permit. Number The Commonwealth of Massachusetts F. 00 2007/52 $100 Town of West Bridgewater This is to Certify that Michael DeLellis Name 55 Ledoewood Drive, Bridgewater, Ma 02324 Address is Hereby Granted A Permit by the West Bridgewater Board Of Health For Disposal Works Installer's to Construct, Alter, Install and or Repair This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires on 31-Dec-07 unless 4-Mav-07 _ Date 4his license shall not be sold, assigned or transferred, It must be posted in a conspicuous place Form # 3 Install and or orrevoked Clerk Board Of Health, Member eoard of Health 6105104 The Commonwealth of Massachusetts Town of Burlington Board of Health i _..nit No. Pee: 1KM 2008 This is to certify that: NAME: NORFOLK SERVICES, INC. STREET: P.O. BOX 38 STATE: BRIDGEWATER, MA 02324 IS HEREBY GRANTED A PERMIT FOR 0 Drain Layer (Drain Layers Manual) Septage Handler (310 CMIZ 15.502(1)) This permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires December 31, 2008 unless suspended or revoked, Board /f1�3 - of 1 Health NUMBER FEE 07-09 THE COMMONWEALTH OF MASSACHUSETTS 200.00 h.o. c Town...... of...._D..g....t....n....................................... � . Board of Health This is to Certify that ... ..._.Norfolk _Equip..........................ent Services Inc. ...... ...__. ....... NAME P.. 0....._Box..._38..r.... Br idgewater.r..._MA......_0.23 2.4..................................................................................... ADDRESS IS HEREBY GRANTED A "DISPOSAL WORKS INSTALLER'S PERMIT" TO CONSTRUCT, ALTER, INSTALL, or REPAIR, Individual Sewage Disposal Systems This permit is granted in conformity with the State Sanitary Code Title V, Regulation 2.2, and expires December 31, 2.0,09..................unless sooner suspended or revoked. March..._1a..r....2009.......... WHITE COPY - Origlnal .......................... -/...,_Lj.C?.`:! ...r.-.`.j'�2�R�� !////...............��...... Board YELLOW COPY - Board of Health .. of PINK COPY -Mailed immediately to Regional Environmental Engineer,.... -....... , --- 7 Health Department of Environmental'.Ei ........................................ ... .... .... ... Protection. FORM 1256 A.M. SULKIN CO. - BOSTON. MA POST OFFICE BOX 38 BRIDGEWATER, MASSACHUSETTS 02324 508.807-1076 OFFICE W W W.NORFOLKSERV ICESINC.COM NORFOLKSERV ICES@GMAIL.COM August 10, 2009 Mr. Scott Leite Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 Dear Mr. Leite: hadmiftsuaAmb Enclosed, please find a completed Disposal Works Installer Application, Workers' Compensation Insurance Affidavit and Signed Certification Clause. I've also included a copy of our Workers' Compensation coverage and copies of Installer licenses from other municipalities. Norfolk Equipment Services, Inc. is planning to install a septic system at 25 Bungay Road, Mansfield, MA following system design approval by your Department. Please don't hesitate to contact me directly at 508-245-3722 if you have any questions or need additional information. I look forward to hearing from you regarding the application's approval. Thank you in advance. Sincerely, JDfV�v Michael J. DeLellis Norfolk Equipment Services, Inc.