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HomeMy WebLinkAbout2022-23 The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS Number: BOHHM-17-4359-05 Issue Date: 7/1/2022 Mailing Address: Location Address: FULLER ELECTRIC COMPANY 126 MID-TECH DR WEST YARMOUTH. MA 02673 126A MID-TECH DRIVE WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022-2023 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires June 30, 2023 unless sooner suspended or revoked and is not transferable. Conditions Yarmouth Board of Health Hazardous Materials Regulation, Section 12A: Must report any spills over one gallon in size to the Health and Fire departments. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman Of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy,M ,R . CHO/James G. Gardiner Health Director/Assistant Health Director Av rl Et LICENSE we Oth+ , v`. ', ,, FEE: $150.00 �' JUN 13 2022 TOWN OF YARMOUTH BOARD OF HEALTH "N • 2022/2023 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS sltTsk-I DEPT. LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY JUNE 30,2022 PLEASE COMPLETE ALL QUESTIONS NAME OF BUSINESS Fu.1 'C I&4rte. epMpod) y BUSINESS TEL. # 5ag-`11c-Co"O BUSINESS ADDRESS IN YARMOUTH IAt,A Micrrez_G-.1)►' West yarmotAk m A 02613 MAILING ADDRESS (� akme EMAIL ADDRESS Oc-y(Ce QJ,IN,rc,dec-ric. MANAGER/CONTACT PERSON Wax M t s,L 1 I CS111 S "Si 124 OME TEL. # -Ip 54-- L3 OWNER NAME L rice.. I(Yla ?n eYne\( HOME TEL.# 56!) - 3(01 (qj$, HOME ADDRESS I D CI"f O Id Sta cr, exi,4-e(Nrt�1 e CORPORATION NAME(IF APPLICABLE) TEL. # CORPORATION ADDRESS Sane) 'C.,,_ Q S o ho V� MAILING ADDRESS TAX ID(FEIN OR SSN) Ott aax231,01 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S)AND FEE(S)ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. -Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes no n/a Under Chapter 152,Sec.25C,subsection 6,the Town of Yarmouth is required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certification of Workers Compensation insurance. As part of renewal or issuance of your permits,you must complete the enclosed Workers Compensation Affidavit. If not applicable,please explain: REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED Y N ALL SAFETY DATA SHEETS ON FILE Y N ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION / NEW APPLICATION APPLICANT'S SIGNATURE DATE 1 ,g ,per _. The Commonwealth of Massachusetts / =W = L Department of Industrial Accidents + .r' 4 l 1 4-, Sri il L 1 Congress Street, Suite 100 HEAL L. " rr:: TN dER e�r�=f;�= Boston, MA 02114-2017 r ;. �•'• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): IRA, U&( C I e-t_A-r i c.., C CI\, Y\y Address:1 g 6 A rr ,a { City/State/Zip: f r U 3 c � D�V YYlll u- � 1 � Phone #: ,6 --/1 S---Gu ?IT; Are y u an employer?Check the appropriate box: Type of project(required): 1. I am a employer with tAi employees(full and/or part-time).* 7. ❑New construction 2.E I am a sole proprietor or partnership and have no employees working for me in g 8. Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself t 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.21 Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'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: A°Aid 1 a In 4...4(Of C r 0..k m`alAy Policy#or Self-ins. Lic.#: VI C IN L c t j 14 -(j Expiration Date: ? ) j3 1;3 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tlzes and penalties of perjury that the information provided above is true and correct. Signature: . 6-/ (a - • Date: Phone#: `�i).3--1 C-bt l`-3 C 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. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACCP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.../- 09/16/2021 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 have ADDITIONAL INSURED provisions or 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 • - �p�+ • • - • endorsement(s). W PRODUCER r m d CONTACT Martha Kenney,CISR Dowling&O'Neil Insurance Agency PHONE/C (800)640-1620 FAX JUN 13 2022 (A .No.Extr. (A/C,No): 973 lyannough Road ADDRESS: mkenney@doins.com INSURERS)AFFORDING COVERAGE NAIC# Hyannis HEALIIM IDS . INSURER A: Tri-State Insurance Co.of Minnesota 31003 INSURED Acadia Insurance Company31325 INSURER B: FULLER ELECTRIC COMPANY,INC. INSURER C: 126A MID TECH DR INSURER D: INSURER E: W YARMOUTH MA 02673-2560 INSURER F: COVERAGES CERTIFICATE NUMBER: CL219281613 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDD/YYYI) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE1O RENiEL) CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 10,000 A ADV5450504-11 09/22/2021 09/22/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JECOT X LOC PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ 1,000,000 - (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OUTOS WNEDONLY AUTOS X SCHEDULED ADA5450538-11 09/22/2021 09/22/2022 BODILY INJURY(Per accident) $ A XHIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accident) $ X UMBRELLA LIARH OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS UAB CLAIMS MADE ADV5450504-11 09/22/2021 09/22/2022 AGGREGATE $ 5,000,000 DED >41 RETENTION$ 0 $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIEBEREX LUDEDXECUTIVE N N/A WCA5450514-11 09/22/2021 09/22/2022 E.L.EACH ACCIDENT $ 500,000 -OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth;Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 *e... l s ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `..---- 09/26/2022 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 have ADDITIONAL INSURED provisions or 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 NAME:CONTACT Martha Kenney,CISR Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road E-MAIL mkenney@hilbgroup.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Tri-State Insurance Co.of Minnesota 31003 INSURED INSURER B: Acadia Insurance Company 31325 FULLER ELECTRIC COMPANY,INC. INSURER C: 126A MID TECH DR INSURER D INSURER E: W YARMOUTH MA 02673-2560 INSURER F: COVERAGES CERTIFICATE NUMBER: . 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUUL SUHk EFF LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD POLICY POLICY EXP ( ) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A ADV5450504-12 09/22/2022 09/22/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE 2,000,000 POLICY X PROT X LOC 0000PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED ADA5450538-12 09/22/2022 09/22/2023 BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS X HIRED ..se NON-OWNED PROPERTY DAMAGE AUTOS ONLY /• AUTOS ONLY (Per accident) $ $ 100,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE ADV5450504-12 09/22/2022 09/22/2023 AGGREGATE $ 5,000,000 DED X RETENTION $ 0 $ WORKERS COMPENSATION XI STATUTE I I EORH AND EMPLOYERS'LIABILITY Y I N BANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA WCA5450514-12 09/22/2022 09/22/2023 (Mandatory in NH) F tOIERg5E E- MP_O,,EE_-y 500_000 -- _. ?f yes,deecribe'n c- - '— DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of in_surance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. - SEP 2 8 2022 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth;Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE . �._ South Yarmouth MA 02664 — -- _� CO 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AR o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/27/2023 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 have ADDITIONAL INSURED provisions or 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 CONTACT Martha Kenney,CISR NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX (A/C.No,Ext): (A/C,No): dba Dowling&O'Neil E-MAIL mkenney@hilbgroup.com ADDRESS: 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURERA: Tri-State Insurance Co of Minnesota 31003 INSURED INSURER B: Acadia Insurance Company 31325 FULLER ELECTRIC COMPANY,INC. INSURER C: 126A MID TECH DR INSURER D: INSURER E: W YARMOUTH MA 02673-2560 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2391113097 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES._ ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUtiR -- - - - - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RETE CLAIMS-MADE X OCCUR PREMISESO(Ea occur ence) $ 300,000 MED EXP(Any one person) $ 10,000 A ADV5450504-13 09/22/2023 09/22/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY JECT PRO X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILYINJURY(Perperson) $ A OWNED *s/ SCHEDULED ADA5450538-13 09/22/2023 09/22/2024 BODILY INJURY(Per accident) $ AUTOS ONLY /", AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X, OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE ADV5450504-13 09/22/2023 09/22/2024 AGGREGATE $ 5,000,000 DED X RETENTION $ 0 WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N 500 000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A WCA5450514-13 09/22/2023 09/22/2024 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Ce shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. _ OCT 0 2 2023 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth;Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 s --s I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD