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Home My WebLink AboutJames F. McNamara & Sons, Corp. 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: 8 This is to certify that JAMES F. MCNAMARA J. F. MCNAMARA & SONS, CORP. 161 MORTON STREET, P.O. BOX 6 STOUGHTON, MA 02072 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: N22834, 846146 FEE PER TRUCK: $50.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman 02/26/2009 THU 11:40 FAX 0002/005 Town of Mansfield -Board of Health s ask Row nsfleia Mansfield, MA 02048 Raider's Application PERMIT NUMBER: TOTAL FEE:,oC�, BUSINESS NAME: BUSINESS ADDRESS: �. � S� iO �vx h TOWN/STATEIZIP: �� L�fp� 41%L 0,967--4 NAME OF OWNER: Taelus TELEPHONE NO: %(��y(f— CELL NO: N 1 A FAX NO: % e / ` .}(41 - 0 FEDIDISSNO: 0 tl — o?(/L/L/ 30� REGISTRATION NO: N ;2,'2 e??'' /) NO OF TRUCK(S): (A) FEE PER TRUCK: $50.00 Permit Expires December 31st yearly. SIGNATURE: w''"`"`"'h�L- DATE: G� Please make appropriate 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, 02/26/2009 THU 11:61 FAX 4003/005 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. (/� w2� c ✓ � vet �-u�_ * Si nature of Individual or Corporate Name (Mandatory) LMe5 llcN'a#Il g 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. 02/26/2009 THU 11:41 FAX U004/005 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant )(Information Please Print L er-ribly Business/Organization Name: (P IVt Qmcm `4 SGY)c� PA'A'D, Address: y Arc you an employer? Check the appropriate box: 1. ( l am a employer with employees (full and/ I or part-time). * 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §t (4), and we have no employees, [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' camp. insurance rogj Business Type (required): S. [] Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.0 Other 'Any applionnl (bat shooks box el must also fill out the section below showing their workers' compensation policy informution. **If the corporate officers have exempted thomsoNos, but the corporation has other employees, a workers' compensation policy is rcauimd and such an orSanimtion should check box xi. r am an employer that is propldfng workers' compensart^ a Insurance for my emptoyees. Below ds iha policy information. Insurance Company Nat Insurer's Address:_ _t City/State/Zip; _ Policy # or Self -ins. Lic. Attach a copy or the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e, 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 maybe forwarded to the Office of investigations of the DIA for insuranco coverage verification. and penalties ofperjury that rite Phone#: is true and correct. Officfrrl use only. Do not write fit this area, to be completed by city or town ofjidat City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, Cityrrown Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mass.gov/dia From:S. Hale FaxID:781-444-0090 Rodman Date:2/26/2009 12:58 PM Page: 2 of 2 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID SH DATE(MMIDOM'YY) Rodman Insurance Agency, Inc. 145 Rosemary St., Bldg. A Needham MA 02494-3238 Phone:781-247-7800 Fax:781-444-0090 J F McNamara & Sons Corp PO Box 6 Stoughton MA 02072 ALTER THE COVERAGE AFFORDED BY INSURERS AFFORDING COVERAGE INSURER A'. Apostle, Protection Insurance INSURER B'. Commerce insurance Coal INSURER C: Nautilus INSURER D. INSURER E. NAIC # 347S4 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 NSRC( TYPE OF INSURANCE POLICY NUMBER DATE(MM/OD/YY) DATE(MWODM/l LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 C X COMMERCIAL GENERAL LIABILITY NC709873 09/06/08 09/06/09 TAMACEARPREMISES (Eaoccwence) $SODDD CLAIMG MPDE OCCUR MED EAR (My one person) $5000 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEHL AGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP/OP AGG $2000000 Poucv PECT Loc BI/PD Ded 1000 AUTOMOBILE LIABILITY B MY AUTO BBVZJP 09/17/08 09/17/09 COMBINED SINGLE LIMIT (Ea accident) $ 1000000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULEDAUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON -OWNED AUTOS (Peracoidenl) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EAACCIDEM $ ANY AIJTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TORY LIMITS ER A ANY PROPRETOR/PARTNERIEXECUTIVE TBI 02/04/09 02/04/10 E.L. EACHACCIDENT $500000 EXCLUDED? OFFIIt EL. DISEASE - EA EMPLOYEE $500000 dR/Mbe and yes describe Under FL DISEASE -POLICY LIMIT $ 5D0000 S SPECIAL PROVISIONS Oelmv OTHER DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER Town of Mansfield 6 Park Row Mansfield MA 02048 CANCELLATION MANSFIE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.