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HomeMy WebLinkAboutAvac The Commonwealth of Massachusetts Department of Industrial Accidents •14 {{ Office of Investigations !a t = 600 Washington Street ry, Boston, MA 02111 '` }; www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Thomas J. Kennedy Plumbing Address: 1635 Broadway, Suite#2 City/State/Zip: Raynham, MA 02767 Phone#: (508) 824-6556 Are you an employer?Check the appropriate box: Type of project(required): 1.E] I am a employer with 40 4. 0 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingforme in anycapacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.®Other Sheet Metal comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Guardian Insurance Group Policy#or Self-ins.Lic.#: THWC012412 Expiration Date: 11/15/2020 Job Site Address: .-- - City/State/Zip: Yarmouth 02673 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage,verification. I do hereby certify u der the pannd penales,,,of perjury that the information provided above is true and correct. Signature: % Date: 2/27/2020 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 8 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other r Contact Person: Phone#: 0 COMMONWE LTH !:F :.tHUSE S DIVISION OF PROFESSIONAL LICENSURE B I ❑-O SHEET METAL WORKERS ISSUESTHE FOLLOWINGtICCENSE ER UNRESTRICTED 8TSEPHEN M KENN f •I t$ BROADLY` SUITE g " RAYN4IAM,MA 02767 360 0 /2812021 656713 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • CONTROL# J12063257 IMPORTANT If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law.Keep this license on your person or posted as required by law and/or regulations. • COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE BOARD OF • SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS • STEPHEN M KENNEDY THOMAS J KENNEDY PLUMBING AND HVAC IN 250 CAPE HIGHWAY TAUNTON,MA 02718 681 11120/2020 585200 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER £L9ZO WI'HillOW2JVA 1S3M z R E LL I D-LU,9OS W ro, M ' ZCCB-Z9C-�9E0 G J 1311VH 13SNV ZO 1 52 0 g - e r d OCCZO I'HIINOWAId WI'IUOaUIfOWNI Li/IP 'I33UIC WOO Ka 31114'LBWS 1O,VA COL W _ g�� II II II I, SNOI1V2131Td 43SOdOdd 0 U39tlU 8(NJJfIN3315,.. 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M6.1 AP,=„ MN,N,A,T, SSsaoo(Fj RYA COMPLETE +n.ylfN:nMry.run CONSTRICTION DOCUMENTS DATE (MM/DDIYYYY) ACORD' CERTIFICATE OF LIABILITY INSURANCE �.--/ 11/12/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER Phone: (508)824-4051 Fax: (508)822-7654 CONTACT MARIA NAME J R TALLMAN&CO,INC PHONE FAX PO BOX 469/12 COURT STREET lac Nn Fe,. (508)824-4051 c Nol (508)822-7654 TAUNTON MA 02780E-M ADDRESS maria@jrtallman.com INSURER(S)AFFORDING COVERAGE NAIC# Agency Lic#:1780241 INSURER A :ARBELLA INSURANCE GROUP INSURED INSURER B :ARBELLA INSURANCE GROUP THOMAS J.KENNEDY PLUMBING HEATING AND HVAC INC 1635 BROADWAY INSURER C :ARBELLA PROTECTION 41360 SUITE 2 RAYNHAM MA 02767 INSURER D: GUARD INSURANCE GROUP 14702 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 32670 REVISION NUMBER: THIS IS TO CERTIFY THAT 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, E)SCLUSIONS AND CONDITIONS OF SUCH PQLIclES.L MITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POUCY EXP rTR JMsn wvn POLICY NUMBER IMM/DDM/WI IMM/DDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 8500070364 11/15/19 11/15/20 EACH OCCURRENCE $ 1,000,000 X OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES(Ea occurence) $ 100,000 MED.EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ C AUTOMOBILE LIABILITY 1020088059 11/15/19 11/15/20 COMBINED SINGLE LIMIT 1 000,000 (Ea accident) $ + ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (per accident) $ $ B UMBRELLA LAB X OCCUR 462009075601 11/15/19 11/15/20 EACH OCCURRENCE $ 5,000,000 -1 _____ EXCESS LAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X 'RETENTION$ 10,000 $ D WORKERS COMPENSATION THWC012412 11/15/19 11/15/20 STATUTE E PER ERH- AND EMPLOYERS' LIABILITY R ANY PROPRIETOR/PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? "/A E.L.DISEASE-EA EMPLOYEE $(Mandatory In NH) 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Thomas J Kennedy Plumbing Heating and HVAC Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1635 Broadway THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN Suite 2 ACCORDANCE WITH THE POUCY PROVISIONS. Raynham,MA 02767 AUTHORIZED REPRESENTATIVE Attention: /eyerziAt ai1/444,4,4: Gloria A. Hamois ACORD 25(2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD