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Home My WebLink AboutTNT Development Corp. - 12/31/2009This is to certify that: Doing business as: Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Dasposal Works Installer's Permit TIMOTHY BOBOLA TNT DEVELOPMENT CORP. PO BOX 64 FRANKLIN MA 02038 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: 64 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 64 APPLICANT: TIMOTHY BOBOLA BUSINESS NAME: TNT DEVELOPMENT CORP. MAIL ADDRESS: PO BOX 64 CITY/TOWN: FRANKLIN BUSINESS PHONE: (508) 520-9500 BUSINESS FAX: (508) 541-8118 FEDERAL ID/SS NUMBER 04-344-8066 LICENSE HELD: Town LICENSE HELD: Town LICENSE HELD: Town STATE: MA ZIP CODE 02038 BUSINESS CELL: STEVE (508) 341-3297 Year Licensed Year Licensed Year Licensed 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: 2 14A) ,� DATE: 10`� 0u( w 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. \ N7 �eU,O -q 44 * Signature of Individual or Corporate Name (Mandatory) S fi By: Cc e fficer (M�gda ry, 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 oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Nam( Address: \ ' O(> . City/State/Zip: "TN DN6 Phone 5; VA S 1 0 A Are you an employer? Check the appropriate box: Business Type (required): 1 X 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. 8• ❑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 WE Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12 ,0Other *Any applicant that checks box #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 box #l. Ian( an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: S� i AIo• Qe Ce_t'-ik,(.t Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: 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 ciertiq, under the pains and penalties ofperjury that the information provided above is true and correct. 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 www.mass.gov/dia Phone 10:50 OCT 31, 2008 ID: WILLIAM PALUMBO AGY FAX NO: 359-2114 023504 PAGE: 2/3 ACORD,,, CERTIFICATE OF LIABILITY INSURANCE ID 31/2008 PRODUCER (508) 359-4151 FAX: (508) 359-2114 William Palumbo Insurance Agency, Inc. 4 West Mill Street P.O. Box 250 Medfield MA 02052-0250 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 NAIL0 INSURED Tnt Development Corp Tim Bobola P.O. Box 64 Franklin MA 02038 INSURER A:MWCARP INSURER 8: INSURER C: INSURER D: INSURER E: 'OVERAGES 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 IAHICH 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. AS EGATE LI ITS SHO YHA BEEN REDUCED B PAID CLAIMS. INSR ADO'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE GATE M/ODIYV POLICY EXPIRATION DATE MMDNY LIMITS GENERAL UI COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑OCCUR EACH OCCURRENCE DAMAGE TO RENTED PREMISES Ee ocalnerwe $ MED EXP 0,Yana parson)S PERSONAL 8 Al2V INJURY GENERAL AGGREGATE 3 GENT AGGREGATE POLICY LIMIT APPLIES PER: - JEPRCOi LOG PRODUCTS - COMP/OP AGG S AUTOMOBILE LIABILITY ANYAUTO ALLOMEDAUTOS SCHEDULEDAUTOS HIREDAUTOS NON-ONNED AUTOS COMBINED SINGLE LIMIT (Ea awdeM) S BODILY INJURY (Perpomm) 3 BODILY INJURY (Perswdert) 3 PROPERTY DAMAGE (Perawderl) 3 GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT 3 OTHER THAN EA ACC AUTO ONLY: AGO S A EXCESS/UMBRELLA LIABILITY OCCUR CLAIMSMADE DEDUCTIBLE RETENTION WORKERS COMPENSATIONANO EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? Ifyes,desaibewder SPECIAL PROVISIONS below WC1315367108018 5/30/2008 5/30/2009 EACH CCURRENC AGGREGATE S E 3 WC STATU- OTH- IMFP Is E.L. CNT EACH AC 500,000 -IDEEMPLO L DISE SOD, OOO E.L. DISEASE - POLICY LIMB $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Town of Mansfield 6 Park Road Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WLL ENDEAVOR TO MAIL 10 DAYS wRiTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 30 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE AUTHORIZED REPRESENTATIVE Tina Hayes/THAYGS----�i��= — I _- ® ACORD CORPORATION 1988 ACORD 25 (2001/08) Pene al? INS0T5 rmnm nn�