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Home My WebLink AboutAttleboro Hauling - 12/31/2008This is to certify that: TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 HAULER'S PERMIT ATTLEBORO HAULING 205 O'NEIL BOULEVARD ATTLEBORO, MA 02703 is hereby granted a permit for a HAULER. This permit is granted inconformity with the Statues and Ordinances relating thereto, and expires December 31, 2008, unless suspended or revoked. Fee per Truck: $50 Registration No: 102949/71706; 02950/71705; 506816/L91401; 208616/L91404 Permit No.: 4 BOARD OF HEALTH l Dr. Raymond Martin, Chairman BUSINESS NAME: BUSINESS ADDRESS TOWN & ZIP: NAME OF OWNER: TELEPHONE NO: FAX NO: REG. NO.: FED ID/SS NO.: PERMIT NO:4 TOWN OF MANSFIELD BOARD OF HEALTH SIX PARK ROW, MANSFIELD 02048 HAULER'S APPLICATION Attleboro Hauling 205 O'Neil Boulevard Attleboro, MA 02703 Waste Management of Attleboro 508-226-1585 36-3668109 FEE PER TRUCK. $50. 00 �oJ -10 ) rwal bI LWY01 Permit Expires December 3151 yearly. SIGNATURE: DATE:�— Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. R Vical@Vane's Docuinellls@ER ll'APPLICATIONS\HAULER'Sdoc TAX CERTIFICATION FORM 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. LL uo�:� — Signature of Individual or Corporate Name Dq—),�; -�>' G)ie3 "Social Security No. (Voluntary) or Federal Identification Number ,Iaj) " By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. RMeallhVane's Documents\PERMIT APPLICATIONSUAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �)t{gk M�+kyFirl Address: (7 Nz 13L iJV-,., Phone #: SU'b • 172-2 •.561 4, 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 (incl. 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed byurance volunteers, /Wks \ with no employees. [No workers' comp. insreq.] 12.[ia'6ther S £� 1 r_, 1 *Any applicant that checks box RI 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 H 1. I out an employer that is providing workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: L oc L'-i-s.,, +Ci Insurer's City/State/Zip: L r, Policy # or Self -ins. Lie. # AbV c.1 t 34-,- •7-4-, 1- Expiration 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% rderAnre p s andpenalties of perjury that fire information provided above is true and correct. fo4�Harp• tTh)A"lam JA Official use only. Do not write in this area, to be completed by city or town offrcial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass,gov/dia Form Revised 5-26-05 CERTIFICATE OF INSURANCE Date: 12/28120078/2007 PRODUCER LOCXl00 Companies. 6B47 San Felipe, Suitee 320 Houston, TX 77057 066.260.3538 (Phone) 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 INSURED: Waste Management Holdings, Inc. & All Affiliated, Related a Subsidiary Companies including: Waste Management, inc. 1001 Fannin, Suite4000 Houston, Texas 77002 Insurer A: ACE American Insurance Company Insurer B: Indemnity Insurance Company of North America v p Y Insurer C: _ 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 BE EXHAUSTED BY PAID CLAIMS. INTR TYPE OF INSURANCE POLICY NUMBER EFFECTIVEDATE EXPIRATION DATE LIMITS _ — 'A GENERAL LIABILITY HDO G23736767 - 1/10)08 1/1/2009 EACH OCCURRENCE $ 5,000.000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE MYONEPIRE) $ 6,000,000 X OCCURRENCE MED EXP(PER PERSON) ' X X xCU mCWDED ISO FORMCGo0C11zoa PERSONAL & ADV INJURY $ 5,000,000 GENERAL AGGREGATE $ 6,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS/COMP. OP. AGO $ 6,000.000 X PROJECT of LOCATION _ AUTOMOBILE LIABILITY ISA H08240395 1/1/2008 1/1/2009 COMBINED SINGLE LIMIT_ $ 1,000,000 A X ANYAVTO `Au -(EnCN ACCIDENT) X OWNEDAU`Tos X HIRED AUTOS X X NON-OWNEDAUTOS MCS-90 A EXCESS AUTO LIABILITY XSA H08240231 1/1/2008 1/1/2009 COMBINED SINGLE LIMIT EACH ACCIDENT $ 9,000,000 EXCESS LIABILITYIUMBRELLA XOOG23889389 1/1/2008 1/1/2009 EACH OCCURRENCE $ 16.000,000 A X I OCCURRENCE CLAIMS MADE AGGREGATE $ 15,000,000 g WORKERS'COMPENSATION and EMPLOYERS LIABILITY WLR C43997646 (AOS) WLR C43997609(CA) SCF C43997567 (WI) 1/1/2008 1/1/2008 1/1/2008 1/l/2009 1/1/2009 1/1/2009ELDISEASE-POLICYLIMIT WORKERS'COMPENSATION STATUTORY EL EACH ACCIDENT $ 3,000,000 A EL DISEASE -EA EMPLOYEE $ 31000,000 p $ 3,000,000 REMARKS: DESCRIPTION OF OPERATIONS/LOGATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT PROVISIONS: CHECK BOX LAN®BKET WAIVER OF SURROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER ON ALL POLICIES WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT WHERE PERMISSIBLE BY LAW. ® CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED (EXCEPT FOR WORKERS' COMP/EL) WHERE AND TO THE EXTENT REQUIRED eY WRITTEN CONTRACT. CERTIFICATE HOLDER: CANCELLATION: "For Informational Purposes Only" 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 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. -EXCEPT 10 DAYS NOTICE FOR NON-PAYMENT. AUTHORIZED REPRESENTATIVE: