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HomeMy WebLinkAboutAllied Waste Services of Fall River - 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: 3 This is to certify that: ALLIED WASTE SERVICES OF FALL RIVER ALLIED WASTE SERVICES OF FALL RIVER 1080 AIRPORT ROAD FALL RIVER, MA 02720 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: #4815 69852 #3411-38207 #1285 68694 #1255 51061 FEE PER TRUCK: $50.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman w`�p9Nct rye ... Town of Mansfield - Board of Health Qq�EP A S A Hauler's Application Town of Mansfield 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 3 TOTAL FEE: $200.00 BUSINESS NAME: ALLIED WASTE SERVICES OF FALL RIVER BUSINESS ADDRESS 1080 AIRPORT ROAD TOWN / STATE / ZIP: FALL RIVER, MA 02720 NAME OF OWNER: ALLIED WASTE SERVICES OF FALL RIVER TELEPHONE No: (508) 676-1091 CELL No: FAX No: (508) 646-1862 FED ID/SS No: 86-1024452 REGISTRATION No: I,g cl r3111 L� "128568694 #125551061 No OF TRUCK(S): 4 FEE PER TRUCK: $50.00 Permit Expires December 31st yearly. SIGNATURE: _ _ DATE: ✓�i Please make appropriad 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 (Manda 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 U11. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: City/State/Zip: � A K--&Q , U� 41)OPhone bt: 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. ❑ 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. [No workers' comp. insurance required] 8• ❑ Non-profit 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]* 4. ❑ We are anon -profit organization, staffed by volunteers, 11.❑ Health CareC} j with no emnlovees. [No workers' coma. insurance real Ii.Uf Otherl G( A A *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 #1. Iota an employer that is provid#W,lvorkers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip . q Policy # or Self -ins. Lic. # � � 1 `"Ipb� 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 tine 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 s ofperjury that the information provided 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 Person: Phone www.mass.gov/dia ACORP. CERTIFICATE ATE OF LIABILITY INSURANCE page 1 of 3 1 10/30/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: American Home Assurance Company 19380-005 (Named load. Cont. Below) 18500 North Allied Way INSURERS: Illinois National Ina. Co. 23817-002 -- INSURERC: Ina. Co. Of the State of PA _- 19429-000 Phoenix, AS 85054 INSURERD: New Hampshire Insurance Company 23841-001 NSURERE: 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. INSR LTR OD' NSR TYPEOFINSURANCE POLICY NUMBER POLICYEFFECTIVE DATE IMWDOMI POLICVEXPIRATION DATE MM D LIMITS A GENERALU BILITY GLIS95716 1/1/2008 1/1/2009 EACHOCCURRENCE $ 2, 500.000 DAMAGET pFITTED PREMISESEsoxurwI_ _ $ 100 000 X COMMERCIALGENERALLIABILITY CLAIMSMADE 10 OCCUR EXP Anyone person) $ _MEO PERSONAL& ADV INJURY _ $ 2.500. 000 GENERALAGGREGATE $ 10 000 000 LIMIT APPLIESPER: PRODUCTS -COMPIOPAGG $ 5,000,000 GEN'LAGGREGATE POLICY jET LOC A A AUTOMOBILE X_ LIABILITY ANYAUTO CA1607261 CA1607262 1/1/2008 l/l/2008 1/1/2009 1/l/2009 COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 BODILYINJURY (Per person) $ A ALLOWNEDAUTOS SCHEDULEDAUTOS CA1607263 1/1/2008 l/1/2009 BODILYINJURV (Peraroden0 $ HIREDAUTOS NON-OWNEDAUTOS PROPERTY DAMAGE (Peramidenl) $ GARAGE LIABILITY AUTOONLY-EAACCIDENT $ OTHERTHAN EAACC $ ANYAUTO $ AUTOONLV: qGG E%CESSNMBRELLALIABILITY EACHOCCURRENCE $ AGGREGATE $ OCCUR CLAIMSMADE $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC5145026 l/1/2008 1/1/2009 TT X TORYSTLIM ATIU- OER E.L. EACH ACCIDENT --- $ 1,000,000 A ANY PROPRIETOWPARTNERIEXECUTIVE WC5145027 1/1/2008 1/1/2009 E.L. DISEASE -EA EMPLOYEE $ 1 000,,000 B A OFFICEWMEMBER EXCLUDED? Ifyyes, naibeunder SPECIAL PROVISIONS below WC5145029 WC5145022 1/1/2008 iLilaue 1/1/2009 14142009 E.L. DISEASE -POLICY LIMIT $ I.Q00,000 C OTHER WC5145025 1 1 2008 1 1 2009 C Workers Compensation WC5145023 l/1/2008 1/1/2009 $1,000,000 Each Accident D WC5145024 l/1/2008 l/1/2009 $1,000,000 Disease Policy Limit S1,000,000 Limit Each Employee DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS DIV # 097 - Named Insured Includes Allied Waste Services of Massachusetts, LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DD SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Town of Mansfield Attn: Board of Health REPRESENTATIVES. 6 Park Row T RIZE REPRESE NE Mansfield, MA 02048 ACORD 25(2001108) Coll:2523778 Tpl:748386 Ce :11572113 ©ACORD CORPORATION 1988 WI111S CERTIFICATE DATE OF LIABILITY INSURANCE page 2 of 3 1 3.0/30/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Sox 305191 Nashville, RN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURER A: American Home Assurance Company 19380-005 (Named load. Cont. Helow) 18500 North Allied Way INSURERS: Illinois National Ins. Co. 23817-002 INSURERC: Ins. Co. of the State of PA 19429-000 Phoenix, AZ 85054 INSURERD: New Hampshire Insurance Company 23841-001 NSURERE: Employers Liability (Stop Gap) coverage for Monopolistic States is included. Additional Workers Compensation Policy: Insurance Company New Hampshire Insurance Company Limits: $1,000,000 Each Accident $1,000,000 Disease - Policy Limit $1,000,000 Disease - Limit Each Employee Policy # Eff./Exp. Dates WC5145028 01/01/08-01/01/09 C011:2723'/'/tl '1'p1:74H3H6 Cert:11572113 AC �? ,,N CERTIFICATE OF LIABILITY INSURANCEPage 1 of 3 10/30/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. 26 Century Blvd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, ALTER THE COVERAGE AFFORDED BY THE EXTEND OR POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: American Home Assurance Company 19380-005 (Named Insd. Cont. Below) 18500 North Allied Way INSURERS: Illinois National Ins. Co. 23817-002 INSURERC: Ins. Co. of the State of PA 19429-000 Phoenix, AZ 85054 INSURERD: New Hampshire Insurance Company 23841-001 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. INSR L DD' TYPEOFINSURANCE POLICY NUMBEfl POLICY EFFECTIVE O E MM DD POLICY EXPIRATION DATE DD Y LIMITS A GENERAL LIABILITY GL1595716 1/1/2008 1/1/2009 EACHOCCURRENCE $ 2,500,000 PREMISES Gas once $ 100,000 X COMMERCIAL GENERAL LIABILITY CLAIMSMADE I -XI OCCUR MED EXP(Any one person) $ PERSONAL& ADV INJURY $ 2,500,000 GENERAL AGGREGATE $ 10,000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 5,000,000 POLICY jE0 LOC A A AUTOMOBILE LIABILITY ANY AUTO CA1607261 CA1607262 1/l/2008 1/1/2008 l/l/2009 1/1/2009 COMBINED SINGLE LIMIT (Ea accident) $ 5 000,000 r X BODILY INJURY (Perperson) $ A ALLOWNEDAUTOS SCHEDULEDAUTOS CA1607263 l/1/2008 1/1/2009 BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY . EAACCIDENT $ OTHERTHAN EAACC $ ANYAUTO $ AUTOONLY: AGO EXCESS/UMBRELLA LIABILITY EACHOCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE WC5145026 WC5145027 1/l/2008 1/1/2008 1/1/2009 1/l/2009 X TOCY LAMITS OT EN E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE. EA EMPLOYEE $ 1 000 000 B OFFICER/MEMBER EXCLUDED? WC5145029 1/1/2008 1/l/2009 E.L. DISEASE - POLICY LIMIT $ 1,000,000 A If yes, describe under SPECIAL PROVISIONS below IWC5145022 111112008 1 1 2009 C OTHER WC5145025 1/1/2008 1/1/2009 C Workers Compensation WC5145023 1/l/2008 l/1/2009 $1,000,000 Each Accident D WC5145024 1/1/2008 1/1/2009 $1,000,000 Disease Policy Limit 1 000 000 Limit Each Employee DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS DIV # 097 - Named Insured Includes Allied Waste SerViCe6 of Massachusetts, LLC CERTIFICATE HOLDER CANCELLATION statutory NoeLca roc Noa-eaymaat SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Town of Mansfield Attn; Board OE Health REPRESENTATIVES. PRESE7foVE 6 Park ROW Mansfield, MA 02048 ACORD25(2001/08) Coll:2523778 Tp1:748386 Cei:V-.11572113 v © ACORD CORPORATION 1988 DATE Willis CERTIFICATE OF LIABILITY INSURANCEPage 2 of 3 10/30/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. 25 Century Blvd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURER A: American Home Assurance Company 19380-005 (Named Iced. Cont. Below) 18500 North Allied Way INSURERB: Illinois National Ins. Co. 23817-002 INSURER C: Ina. Co. of the State of PA 19429-000 Phoenix, AZ 85054 INSURERD: New Hampshire Insurance Company 23841-001 INSURER E: Employers Liability (Stop Gap) coverage for Monopolistic States is included. Additional Workers Compensation Policy: Insurance Company NEW Hampshire Insurance Company Limits: $1,000,000 Each Accident $1,000,000 Disease - Policy Limit $1,000,000 Disease - Limit Each Employee Policy # Eff./Exp. Dates WC5145028 01/01/08-01/01/09 Rn1.e74RAR9 Carte1.1.572113 ACOR DATE TM CERTIFICATE OF LIABILITY INSURANCEpage I of 3 12/17/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis HRH HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: Zurich American Insurance Company 16535-007 (Named Insd. Cont. Below) 18500 North Allied Way INSURERB:American Zurich Insurance Company 40142-001 INSURERC: Phoenix, AZ 85054 INSURERD: 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSfl LTR hDD'L NSR TVpE OFINSURANCE POLICY NUMBER POLICVEFFECTIVE E MWDDfYYI POLICY EXPIRATION DA E MWDD V LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE 7OCCUR GLO594527700 1/1/2009 6/30/2009 EACHOCCURRENCE $ 3,000,000 PREMISESOEaoccureno. $ 100 000 MED EXP(Any one person) $ PERSONAL& ADV INJURY $ 3 QQQ 000 GENERAL AGGREGATE $ 5.000.000 GEN'L AGGREGATE LIMITAPPLIES PER: X1 POLICY PEO LOC PRODUCTS COMP/OPAGG $ 51000,000 A AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIREDAUTOS NON-OWNEDAUTOS BAP594527600 l/1/2009 6/30/2009 COMBINED SINGLE LIMIT (Eaaccident) $ 5,000,000 X BODILY INJURY (Perperson) $ BODILY INJURY (Peraccident) $ PROPERTYDAMAGE (Peraccident) $ GARAGELIABILITY ANVAUTO AUTO ONLY -EA ACCIDENT $ OTHERTHAN EAACC AUTOONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACHOCCURRENCE $ AGGREGATE $ $ $ B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITV ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, IALP be antler SPECIAL PROVISIONS below WC594527300 WC594527400 l/l/2009 1/1/2009 6/30/2009 6/30/2009 X I TOCVLMAU- OTH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE-POLICV LIMIT $ 1 QQQ QQQ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS DIV # 717 - Named Insured Includes Allied Waste Services of Massachusetts, LLC .................. ____.... CERTIFICATE HOLDER CANCELLATION statutory Notice For non-Faymont SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR field Meld Town of Mans 808Yd of Health REPRESENTATIVES. PFIESEtttOVE Six Park ROW Mansfield, MA 02048 ACORD 25(2001/08) Coll:2565317 Tpl:864625 Cebr„ 11802238 v ©ACORD CORPORATION 1988 w'VI11IS CERTIFICATE OF LIABILITY INSURANCE page 2 of 3 12/1DATE 7/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS MATTER OF INFORMATION UPON THE CERTIFICATE Willis NAN HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURER& Zurich American Insurance Company 16535-007 (Named Insd. Cont. Below) 18500 North Allied Way INSURERB: American Zurich Insurance Company 40142-001 INSURERO: Phoenix, AZ 85054 INSURERD: INSURER E: Employers Liability (Stop Gap) coverage for Monopolistic States is included. Allied Waste North America, Inc. and it's subsidiaries are registered non -subscribers to the Texas Workers Compensation Act. An approved Indemnity Plan has been filed with the Texas Department of Insurance therefore they are not required to carry Workers' Compensation insurance in Texas. A certificate referencing the Texas Excess Employers Indemnity policy can be provided upon request. The policy provides both Employers Liability and Excess coverage for the approved Indemnity plan. Cert:11802238 AJ10RDTe CERTIFICATE DATE OF LIABILITY INSURANCE page 1 of 3 12/18/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willie HRH HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: Zurich American Insurance Company 16535-007 (Named Insd. Cont. Below) 18500 North Allied Way INSURERS: American Zurich Insurance Company 40142-001 INSURERC: Phoenix, AZ 85054 INSURERD: 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. INSR LT ADD- NS TYPE OF INSURANCE POLICYNUMBEfl POLICYEFFECTIVE TE M DD Y POUCYEXPIRATION DATE M DD Y LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE1XI OCCUR GLOS94527700 1/1/2009 6/30/2009 EACHOCCURRENCE $ 3 000 000 DAMAGE TO RENTED PREMISES Eaoccurence $ 100,000 MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ 3.000.000 GENERALAGGREGATE $ 5,000,000 GENIAGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT OC PRODUCTS-COMP/OP AGO $ 5,000,000 A AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS BAPS94527600 l/l/2009 6/30/2009 COMBINED SINGLE LIMIT (Eaaccident) $ 51000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE (Per accident) $ GARAGE LIABIUrY ANYAUTO AUTO ONLY -EAACCIDENT $ OTHERTHAN EAACC AUTOONLY: AGO $ $ EXCESS/UMBR ELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACHOCCURRENCE $ AGGREGATE $ $ $ B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describeunder SPECIAL PROVISIONS below WC594527300 WC594527400 l/1/2009 l/l/2009 6/30/2009 6/30/2009 X I TOCVLIMITS OEH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 11000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHIC LES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS DIV # 097 - Named Insured Includes Allied Waste Services of Massachusetts, LLC CERTIFICATE HOLDER CANCELLATION stat,.t,„ xeti— eor SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 Town of Mansfield IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Attn: Board of Health REPRESENTATIVES. T flIZE EPRESE VE 6 Park ROW Mansfield, MA 02048 ACORD 25(2001/08) Coll:2566847 Tpl:864540 Ceke.11851658 OACORD CORPORATION 1988 DATE Willis CERTIFICATE OF LIABILITY INSURANCE page 2 of 3 12/18/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS MATTER OF INFORMATION UPON THE CERTIFICATE Willis HRH 26 Century Blvd. HOLDER. THIS CERTIFICATE DOES ALTER THE COVERAGE AFFORDED NOT AMEND, BY THE EXTEND OR POLICIES BELOW. P. O. Box 305191 Nashville, IN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied waste North America, Inc. INSURERA: Zurich American Insurance Company 16535-007 (Named Ined. Cont. Below) 18500 North Allied Way INSURERB:American Zurich Insurance Company 40142-001 INSURER C: Phoenix, AS 85054 INSURERD: INSURER E: JC MCIY 1/�YCV INL YItV V101 V IVO Employers Liability (Stop Gap) coverage for Monopolistic States is included. Allied Waste North America, Inc. and it's subsidiaries are registered non -subscribers to the Texas Workers Compensation Act. An approved Indemnity Plan has been filed with the Texas Department of Insurance therefore they are not required to carry Workers' Compensation insurance in Texas. A certificate referencing the Texas Excess Employers Indemnity policy can be provided upon request. The policy provides both Employers Liability and Excess coverage for the approved Indemnity plan. :2566847 Tnl:864540 Cert:11851658 Page 3 of 3 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the cerlificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORN 25(20n1/nRl Cn1.1.e2566R47 Tnl-R6454n ACORD. CERTIFICATE OF LIABILITY INSURANCE page 1 of 3 12/17/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS MATTER OF INFORMATION UPON THE CERTIFICATE Willie HRH 26 Century Blvd. HOLDER. THIS CERTIFICATE DOES ALTER THE COVERAGE AFFORDED NOT AMEND, EXTEND OR BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: Zurich American Insurance Company 16535-007 (Named Ined. Cont. Below) 18500 North Allied Way INSURERB:American Zurich Insurance Company 40142-001 INSURERC: Phoenix, AZ 85054 INSURER D: 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WISH R NOWIL N FI TYPEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE E DO POLICY EXPIRATION DATE M 00 LIMITS A GENERAL LIABILITY GLO594527700 1/1/2009 6/30/2009 EACH OCCURRENCE $ 3,000,000 X COMMERCIAL GENERAL LIABILITY PREM SETo e.. urene. $ 100,000 CLAIMS MADE OOCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ 3 000 000 GENERALAGGREGATE $ 5,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $ 51000,000 X I POLICY 7 PRO- LOC A AUTOMOBILE LIABILITY ANYAUTO BAP594527600 l/1/2009 6/30/2009 COMBINED SINGLE LIMIT (Eaacciden0 $ 5,000,000 X BODILY INJURY (Perperson) $ ALL OWNED AUTOS SCHEDULEDAUTOS BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Peraccident) $ GARAGE LIABILITY AUTO ONLY -EAACCIDENT $ OTHERTHAN EAACC $ ANVAUTO $ AUTOONLY: AGO EXCESSIUMBRELLA LIABILITY EACHOCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ B * WORKERS COMPENSATION AND LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE WC594527300 WC594527400 1/1/2009 l/1/2009 6/30/2009 6/30/2009 X TWO ITATU- TRI- CRY TORYL E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 OFFICER/MEMBER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIM IT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS DIV # 717 - Neared Insured Includes Allied Waste Services of Massachusetts, LLC CERTIFICATE HOLDER CANCELLATION Statutory Notice nor Non-payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Town of Mansfield Board of Health REPRESENTATIVES. T RI2E EPRESE VE Six Park Row Mansfield, MA 02048 ACORD 25(2001/08) Coll:2566124 Tpl:864625 CeE—V.11813012 L1 0 ACORD CORPORATION 1988 Willis CERTIFICATE OF LIABILITY INSURANCE page 2 of 3 12/17/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS MATTER OF INFORMATION UPON THE CERTIFICATE Willis ERR 26 Century Blvd. HOLDER. THIS CERTIFICATE DOES ALTER THE COVERAGE AFFORDED NOT AMEND, EXTEND OR BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Allied Waste North America, Inc. INSURERA: Zurich American Insurance Company 16535-007 (Named Iced. Cont. Below) 18500 North Allied Way INSURERS: American Zurich Insurance Company 40142-001 INSURERC: Phoenix, AS 85054 INSURERD: INSURER E: Employers Liability (Stop Gap) coverage for Monopolistic States is included. Allied Waste North America, Inc. and it's subsidiaries are registered non -subscribers to the Texas Workers Compensation Act. An approved Indemnity Plan has been filed with the Texas Department of Insurance therefore they are not required to carry Workers' Compensation insurance in Texas. A certificate referencing the Texas Excess Employers Indemnity policy can be provided upon request. The policy provides both Employers Liability and Excess coverage for the approved Indemnity plan. Col1:2566124 Tp1:864625 Cert:II8131012 Page 3 of 3 19TOTMEMTH If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD25(2001/08) Co11:2566124 Tp1:864625 Cert:11813012 AC®R" CERTIFICATE OF i`� LIABILITY INSURANCE Dare (MMIDDmvY) 5/17/2009 PRODUCER Phone: 818-662-4200 Fax: 877-297-9262 BB&T - Knight Insurance Services 535 North Brand Blvd., 10th Floor THIS CERTIFICATE IS ISSUED AS A MATTER ONLY AND CONFERS NO RIGHTS UPON HOLDER. THIS CERTIFICATE DOES NOT AMEND, ALTER THE COVERAGE AFFORDED BY THE OF INFORMATION THE CERTIFICATE EXTEND OR POLICIES BELOW. Lic# 0619252 Glendale CA 91203 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:ZURICH AMERICAN INS CO 16535 717 Allied Waste Services of Central Indiana 15469 STATE ROAD 17 CULVER IN 46511 INSURER B: AMERICAN ZURICH INS CO 40142 INSURER C:AMERICAN GUARANTEE & LIAB INS 26247 INSURER D: 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. INSR DD'L POLICY NUMBER DALECMMDDCTIYY POLICY EXPIRATION LIMITS A GENERAL LIABILITY GL0370304202 6/30/2009 6/30/2010 EACH OCCURRENCE $5 000 000 DAMAGX PREMIETORENTED PREMISES RENT occurrence) $ 5 OOO OOO COMMERCIAL GENERAL LIABILITY MED EXP(My one person) $ CLAIMS MADE aOCCUR PERSONAL S ADV INJURY $S 000 000 GENERAL AGGREGATE $ 5 000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $5 000 000 POLICY PRO X LOG A AUTOMOBILE LIABILITY ANY AUTO BAP370304302 6/30/2009 6/30/2010 COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 X BODILY INJURY (Per person) $ All OW NED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS NON-OWNEDAUTOS X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN EA ACC $ ANYAUTO $ AUTO ONLY: AGG C EXCESS UMBRELLA LIABILITY AUCS94569901 6/30/2009 6/30/2010 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ S OOO 000 X1 OCCUR D CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ B A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICEWMEMBER EXCLUDED? � (Mandatory in NH) WC370304002 WC370304102 EWS594527801 6/30/2009 6/30/2009 6/30/2009 6/30/2010 G/30/2010 6/3O/2OlO WCSTATU- OTH- X I E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE -EA EMPLOYE $ 1 OOO OOO E.L. DISEASE - POLICY LIMIT $1 000 000 SPECIAL PROVISIONS below PE,de SPRO S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Employers Liability (Stop Gap) coverage for Monopolistic States is included. CFRTIFICATF Hill nFR CANCELLATION in ilav (`a n r ollafinn fnr Mnn-PaV Pnt __-----._-.-_--_— SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE Town of Mansfield Board of Health CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Six Park Row SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Mansfield MA 02048 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE itl.M ^(i ACORD 25 (2009101) © 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a� " CERTIFICATE OF LIABILITY INSURANCE Y) 5/17/200rc9 PRODUCER Phone: 818-662-4200 Fax: 877-297-9262 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BB&T - Knight Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 535 North Brand Blvd., 10th Floor HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lic# 0619252 Glendale CA 91203 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:ZURICH AMERICAN INS CO IG535 097 Allied Waste Services of Fall River INSURER B:AMERI CAN ZURICH INS CO 40142 1080 AIRPORT RD FALL RIVER MA 02720 INSURER C:AMERI CAN GUARANTEE & LIAB INS 26247 INSURER D: 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. INSR LTR DD'L F NSURANCE POLICYNUMBER OATECMMFFFECTIVE PPOLIICYEXPPIIRATION LIMITS A GENERALLIABIUTY GL0370304202 6/30/2009 6/30/2010 EACH OCCURRENCE $5 000 QQQ DAMAGE ( RENTED PREMISESTo REITurrence)$5 QQ QQQ 000, X COMMERCIAL GENERAL LIABILITY CLAIMS MADE 10 OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $5 QQQ 000 GENERAL AGGREGATE $ 5 QQQ 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $S 000 000 POLICY PRO-jFQT X LOC A AUTOMOBILE LIABILITY ANYAUTO 13AP370304302 6/30/2009 6/30/2010 COMBINED SINGLE LIMIT (Ea accident $ 5,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNEDAUTOS X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN EAACC $ ANYAUTO $ AUTO ONLY: AGG C EXCESS I UMBRELLA LIABILITY AUCS94S69901 6/30/2009 6/30/2010 EACH OCCURRENCE $5 QQQ QQQ OCCUR CLAIMS MADE X AGGREGATE $ 5 QQQ 000 $ DEDUCTIBLE I $ RETENTION $ B A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED'! � (Mandatory In NH) WC370304002 WC370304102 EWSS94527801 6/30/2009 6/30/2009 6/ 30/2009 6/30/2010 6/30/2010 6/30/2010 WC STATU OTH- XFIT E.L. EACH ACCIDENT $1 000 000 E.L. DISEASE - EA EMPLOYEE $1 QQQ QQQ If yes, describe under SPECIAL PROVISIONS belm E.L. DISEASE -POLICY LIMIT $1 QQQ QQQ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS mployers Liability (Stop Gap) coverage for Monopolistic States is included. CERTIFICATE HOLDER CANCELLATION10 Day Cancellation for Non -Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE Town of Mansfield Attn: Board Of Health CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 6 Park. Row SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Mansfield MA 02048 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE,tNXV ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A�R" CERTIFICATE OF LIABILITY INSURANCE 2009 ' 5�17 PRODUCER Phone; 818-662-4200 Fax: 877-297-9262 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BB&T - Knight Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 535 North Brand Blvd., 10th Floor HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lic# 0619252 Glendale CA 91203 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:ZURICH AMERICAN INS CO 16535 717 Allied Waste Services of Central Indiana 15469 STATE ROAD 17 INSURER B: AMERICAN ZURICH INS CO 40142 INSURER C:AMERI CAN GUARANTEE & LIAB INS 26247 CULVER IN 46511 INSURER D: 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. INSR LTR DD'L D E E POLICY NUMBER POLICY EFF D M DDECTIVE POLICY EXPIRATION DATE fMM1DDAivyyI LIMITS A GENERAL LIABILITY GLO370304202 6/30/2009 6/30/2010 EACH OCCURRENCE $5 QQQ 000 $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $ 510001000 CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL B ADV INJURY $5,000,000 GENERAL AGGREGATE 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGGQQ QQQ1-1 POLICYPROjECT X LOCA AUTOMOBILE LIABILITY ANYAUTO BAP370304302 6/30/2009 6/30/2010 COMBINED SINGLE LIMITX (Ea accident) r$5 QQ, QQQALL INJURY (Per person) OWNED AUTOSBODILY SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG C EXCESS UMBRELLA LIABILITY AUC594569901 6/30/2009 6/30/2010 EACH OCCURRENCE $5 QQQ 000 X OCCUR 11 CLAIMS MADE AGGREGATE $51000,000 $ DEDUCTIBLE $ RETENTION $ B A A WORKERS COMPENSATION AND EMPLOYERS'LIABILITV YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) WC370304002 WC370304102 EWSS94527801 6/30/2009 / /ZOO9 6/30/2009 6/30/2009 6/30j2U10 6/30/2010 6/30/2010 WC SLIM OTH- XER E.L. EACH ACCIDENT $1 000 000 E.L. DISEASE - EA EMPLOYEE $1 000 000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $1 QQQ 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Employers Liability (Stop Gap) coverage for Monopolistic States is included. CERTIFICATE HOLDER CANCELLATIONIO Day Cancellation for Non-Pavfnent SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE To THE Town Of Mansfield Board Of Health CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 511 Park ROW SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Mansfield MA 02048 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009101) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD