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HomeMy WebLinkAboutCase Disposal LLC -12/31/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Hauler's Permit PERMIT No: 6 This is to certify that: JOHN E. CASE III CASE DISPOSAL, LLC 1320 SOUTH WASHINGTON STREET NORTH ATTLEBORO, MA 02760 is hereby granted a permit for a HAULER. This permit is granted in conformity with the Statues and Ordinances relating thereto, and expires December 31, 2009 unless suspended or revoked. REGISTRATION No: J93177 FEE PER TRUCK: $50.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman gC�NC7 !Y N Town of Mansfield - Board of Health 0 Hauler's Application BUSINESS NAME: BUSINESS ADDRESS TOWN I STATE / ZIP: NAME OF OWNER: TELEPHONE No: CELL No: FAX No: FED ID/SS No: REGISTRATION No: No OF TRUCK(S): FEE PER TRUCK: 0 !r� aa pp0 T I 6 Park Row Mansfield, MA 02048 RECEIVED OCT 2 3 2000 PERMIT NUMBER: 6 TOTAL FEE: $50.00 CASE DISPOSAL, LLC 1320 SOUTH WASHINGTON STREET NORTH ATTLEBORO, MA 02760 JOHN E. CASE III (508)695-1461 (508) 699-7050 57-1164480 J93177 1 $50.00 Permit Expires December 31st yearly. SIGNATURE: a ? �i % DATE: 10127/DO CA- S.e 171 Xeo&A t_ rRLC- Please make ppropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. Signature of Individual or/ Corporate Name (Mandatory) Corporate Officer �,CRse 3yI/ {�PGS+ (Mandatory, if applicable) V9`=% S?- 114 (Ino ** Social Security Numb r (Voluntary) or Federal Identification Number * This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name: CASe �ts oSA LLL Address:/3ao S;� 1_, LJA&l t.+j�n/ lei" Phone #: 6�6$ 62b' —/yG / Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (met. 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 10.❑ 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.X Other /jrw/�%?e+G%7� XS it*i -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 Iti. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Insurer's City/State/Zip: _ A L't'MM 1 Mh (1 g?) d Yz- 80-tro 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 ceftify, yyder the pains and p�yalties ofperitay that the information provided above is true and correct use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License z7 108 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 Person: Phone #: www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE OPID PS DATE(MMMDNYYY) JECAS-1 10/24/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 50 Prospect Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waltham MA 02453 Phone:781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAICN INSURED INSURER A: Hanover Insurance Co. 22292 J.E. Case, Inc. INSURER S. Guard Insurance Company 31470 Case Materials, inc. Case Disposal, LLC _ INsuRERc INSURER D: 1320 S. Washington St North Attleboro MA 02760 INSURER E: COVERAGES 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. IUTR NSRE TYPE OF INSURANCE POLICY NUMBER DATE IMM/DDM') DATE (MMIDDNY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE NIOCCUR LDN8403189 10/01/08 10/01/09 EACH OCCURRENCE $1,000,000 PREMISES(Ee occurence) $250,000 MED EXP (My one person) $ 5,000 PERSONAL If ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X jET LOC PRODUCTS - COMP/OP ASS $2,000,000 Emp Ben. 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS NON -OWNED AUTOS AM148417388 10/01/0 10 /O1/09 COMBINED SINGLE LIMIT (Ea accidenp 81, 000, 000 BODILY INJURY (Parperson) $ X X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC AUTO ONLY. ASS $ $ A EXCESS/UMBRELLA LIABILITY X I OCCUR �CIAIMSMADE DEDUCTIBLE RETENTION $ UHN8442373 10/01/08 10/01/09 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 $ $ $ B WORKERS COMPENSATIO14 AND EMPLOYERSLIABILITY ANY PROPRIETORAPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? f yes, describe under SPECIAL PROVISIONS below �e.WC910306 10/01/08 10/01/09 X TORY LIMITS ER E.L.EACHACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 11,009,999 E.L. DISEASE -POLICY LIMIT $1,000,000 ,000,000 A OTHER Equipment Floater ELHNS442503 10/01/08 10/01/09 Comp/Coll $2,5000 Rent/Leas $3,115,300 DESCRIPTION OF OPERATIONS I LOCATIONS ( VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION MANSMA— SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Town of Mansfield NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Board of Health 6 Park Row IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Mansfield, MA 02048 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE r ACORD 25 (2001108) % © ACORD CORPORATION 1988 Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Hauler's Permit PERMIT No: 7 This is to certify that JOHN E. CASE III CASE DISPOSAL, LLC (ROLL OFF PERMIT) 1320 SOUTH WASHINGTON STREET NORTH ATTLEBORO, MA 02760 is hereby granted a permit fora HAULER. This permit is granted in conformity with the Statues and Ordinances relating thereto, and expires December 31, 2009 unless suspended or revoked. REGISTRATION No: J93177 FEE PER TRUCK: $60.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman Town of Mansfield - Board of Health ti t p�JfUM AOste4')� �j. Hauler's Application Town of Mansfield 6 Park Row Mansfield, MA 02048 OCT, 2 8 Z008 PERMIT NUMBER: 7 TOTAL FEE: $50.00 BUSINESS NAME: CASE DISPOSAL, LLC (ROLL OFF PERMIT) BUSINESS ADDRESS 1320 SOUTH WASHINGTON STREET TOWN I STATE I ZIP: NORTH ATTLEBORO, MA 02760 NAME OF OWNER: JOHN E. CASE III TELEPHONE No: (508) 695-1461 CELL No: FAX No: (508) 699-7050 FED IDISS No: 57-1164480 REGISTRATION No: J93177 No OF TRUCK(S): 1 FEE PER TRUCK: $50.00 Permit Expires December 31st yearly. SIGNATURE:' C' _ _ DATE: C4 t o 01 SPw A L t_ L. C Please make a propriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. J.E. CASE9 INC. 1320 SOUTH WASHINGTON STREET NORTH ATTii EBORO, MA 02760 (508) 695-1-161 - FAX (508) 699-7050 December 11, 2008 Town of Mansfield Board of Health Six Park Row Mansfield, Ma 02048 To Whom It May Concern: Enclosed, please find a copy of the Cormnercial Driver's License for John E. Case III. We are also including 3 insurance certificates with Certificate Holders: Town of Mansfield Board of Health Mansfield, MA 02048 Town of Mansfield Engineering Dept. Attn: Diane Six Park Row Mansfield, Ma 02048 Town of Mansfield Water & Sewer Dept. 6 Park Row Mansfield, Ma 02048 Sincerely, _> E.Case III (Poresident COMMERCI, NUMBER SJ8243667 up DOD 07.15-2012 07-15 1952 CLASS NEST HGT SEX 'F AM &0I M CASE t I' JOHN E III 32 NEWPORT AVE s �' ATTLEBORO, MA. 02703-4435 ,. 0]i61952_e SE y, h a fi �SS 1� NA m COMMONWEALTH OF MASSACHUSETTS COMMERCIAL DRIVER'S LICENSE #14446756 ACORD, CERTIFICATE OF LIABILITY INSURANCE OP ID PS DATE(MM/DD/YYYY) JECAS-1 1 10/07/08 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:781-647-3670JINSU"RERE: URERS AFFORDING COVERAGE NAIC# INSURED over Insurance Co. 22292 rd Insurance Company 31470 J.E. Case, all,Inc. Case Materials, Inc. 1320 S. Washington St North Attleboro MA 02760 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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. F INSURANCE POLICY NUMBER LTR NSRFAGGREGATE DATE (MM/DD/Y1)E PDATE MM/DD/YY)N LIMITS ITY EACH OCCURRENCE $ 1,000,000 A X AL GENERAL LIABILITY LDN8403189 10/01/08 10/01/09 PREMISES(Eaoccurence) $250,000 MADE � OCCUR MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1, OOO , OOO GENERAL AGGREGATE $2, 000, 000 LIMITAPPLIESPER: PRODUCTS-COMP/OP AGO $2,000000 JECTP'O_ Loc Emp Ben. 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A ANY AUTO AMN8417388 10/01/08 10/01/09 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS accident) (Per accitlenQ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTOONLY-EAACCIDENT $ ANYAUTO OTHEEAACC $ AUTO ONLY AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $S,000, QQQ A X OCCUR �CLAIMSMADE UHN8442373 10/01/08 10/01/09 AGGREGATE $5,000,QQQ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND X TWU LIMITS ER B ANPLOYERIETOR/LITY JEWC910306 ANY PROPRIETOR/PARTNER/EXECUTIVE 10/01/08 10/01/09 E.L. EACH ACCIDENT $1 000 000 , , OFFICER/MEMBER EXCLUDED? - E.L. DISEASE- EA EMPLOYEE$ 1,000,000 If yes, describe under E.L. DISEASE -POLICY LIMIT 1 $1 000,000 SPECIAL PROVISIONS below OTHER A Equipment Floater RHN8442503 10/01/08 10/01/09 Comp/Coll $2,5000 Rent/Leas $3 115,300 RE: Drainlayers License, Sewer Design and Construction Regulations Town of Mansfield is named as Additional Insured only ATIMA with regards to general liability. CERTIFICATE HOLDER CANCELLATION MANSMA6 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Town of Mansfield NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Board of Health IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Mansfield MA 02048 ._REPRESENTATIVES. it A -2 - CORPORATION 1 C RD JECACERTIFICATE ®F LIABILITY INSURANCE OPIDS-1 PS DATE (MM/10/07/ 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:781-647-36704INSURER S AFFORDING COVERAGE NAIC# INSURED Hanover Insurance Co. 22292 Guard Insurance Company 31470 J.E. Case, , Inc. Case Materials, Inc. 1320 S. Washington St North Attleboro MA 02760 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. T LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY FF IVE POLI PIRATIODATE(MWDD/YY) I DATE(MM/DD/VYI LIMITS LIABILITY EACH OCCURRENCE $1, 000,000 MERCIAL GENERAL LIABILITY LDN8403189 10/01/08 10/O1/09 PREMISETEITI S (Eaoccvrence) $250,000 CLAIMB MADE � OCCUR VIED EXP (Any one person) s5,000 PERSONALBADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GREGATE LIMITAPPLIES PER PRODUCTS-COMP/OP AGG $2, 000, 000 CY X jECOT LOC Emp Ben. 1,000, 000 ILE LIABILITY JC AMN8417388 10/01/08 10/01/09 COMBINED SINGLE LIMIQ00 (Ea accident) QQQUTO /WNED AUTOS BODILY INJURYEf DULED AUTOS (Per person)AUTOS BODILY INJURYWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident)) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $S, QQQ, QQQ A X OCCUR �CLAIMSMADE UHN8442373 10/01/08 10/01/09 AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND X TORV LIMITS ER B EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE LTEWC910306 10 /01 /OS 10/01/09 E.L. EACH ACCIDENT $1, 00O, OOQ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EAEMPLOYEE$1 QQQ 000 If yes, describe antler / / SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $1, QQQ, QQQ OTHER A Equipment Floater RHNS442503 10/01/08 1 10/01/09 Comp/Coll $2,5000 ITown of Mansfield is named as Additioinal Insured only as their interest may appear. Town of Mansfield Engineering Dept Attn: Diane Six Park Row Mansfield, MA 02048 MANSMA4 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO 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 SO SHALL IMPOSE NO OBLIGATION LIABILITY OF ANY i UPON THE INSURER, ITS AGENTS OR ACORo. CERTIFICATE OF LIABILITY INSURANCE OP ID PS DATE(MMIDDIYYYY) JECAS-1 10/07 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern - States .Insurance _ ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 50 Prospect Street 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: Hanover Insurance Co. 22292 INSURERS: Guard Insurance Company 31470 Case, Inc. INSURER C: CasJ.Ee Case Materials, Inc. 1320 S. Washington St INSURER D' North Attleboro MA 02760 INSURER E: - COVERAGES 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. INSURANCE POLICY NUMBER DATE (MM%DOm E PDATEOLIC (MX RATION N LIMITS LTR NSRrGENERALLIABILITY TY CURRENCE $1,000,OOQ A L GENERAL LIABILITY LDN8403189 10/01/08 10/01/09S(Eaoccorence) $250rON MADE X❑ OCCUR (Any one person) $ 5,000 LBADV INJURY$1,000,000 %Emp AGGREGATEE LIMIT APPLIES PER: S-COMP/OP AGOJECOT LOC en . 1,000,000 AUTOMOBILE LIABILITY A ANY AUTO AMN8417388 CO accident) 10/01/08 10/01/09 (EaCOMBINED SINGLE LIMIT $1 r000 r00 Q ALL OWNED AUTOS URY X SCHEDULED AUTOS $ X HIRED AUTOS EBODILY URY$ X NQN-OWNED AUTOS Q —�— PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $5,000,000 A X OCCUR �CLAIMSMADE UHN8442373 10/01/08 10/01/09 AGGREGATE $5,000,000 $ DEDUCTIBLE IS RETENTION $ $ WORKERS COMPENSATION AND X TO LOSTIMITS ER B EMPLOYERS'LIABILITV ANYPROPRIETOR/PARTNER/EXECUTIVE JEWC910306 10/01/08 /OB 10/01/09 E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED9 EL.DISEASE -EAEMPLOYEE $ 1,000,000 S yECIAL PRO under E.L. DISEASE -POLICY LIMIT- $1000000 SPECIAL PROVISIONS below A Equipment Floater RHNS442503 10/01/08 10/01/09 Comp/Coll $2,5000 Rent/Leas $3,115,300 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Town of Mansfield is named as Additioinal Insured only as their interest may appear. CERTIFICATE HOLDER CANCELLATION MANSr.j.jA- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Town of Mansfield NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Water & Sewer Dept 6 Park Row �+IMPOSE NO OBLIGATION 11 LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR _ Mansfield, MA 02048 REPRESENTATIVES.: 1' 25 (2001/08)