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Home My WebLink AboutPermit document 4/17/26 THE COMMONWEALTH OF MASSACHUSETTS Registration valid for individual use only before the Office of Consumer Affairs&Business Regulation expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE:Individual 1 Federal Street-Suite 720 Registration Expiration Boston,MA 02110 214559 01/14/2027 JESSE BRANTH JESSE BRANTH ;=.'- r NSr,., )\ • 26 COREY ST APT 2 EVERETT,MA 02149 Undersecretary Not valid without signature 2/10/25, 3:49 PM Details .Y Licensee Details 11 Demographic Information i. i' Full Name: JESSE F BRANTH _.______�__ ti: Owner Name: License Address Information ity: Everett _____1 tate: MA pcode: 02149 r untry United States J License Information 'License No: CS-121091 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: issue Date: 2/4/2025 Expiration Date: 2/23/2028 License Status: Active Today's Date: 2/10/2025 Secondary License Type: Doing Business As: Status Change Reason: License Issuance Prerequisite Information i No Pre = e uisite Information 4 .k 42 No Available Documents a fc The Commonwealth of Massachusetts Department of Industrial Accidents 0X, 'QC- 9 ,--- _ Office of Investigations `) Lafayette City Center / 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): K 1G SC` n.U t C ET S / A C- Address: 1610 W O k.0 CS 7E- , R/J 3,3 L/A City/State/Zip: F 'grAllJGH414( 1'WM --(fit-() Phone #: (5o500 66 3 - U> ( G Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. 7-4 Remodeling2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3.❑ I am a homeowner doing all work 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' 13.0 Other 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: H eik( -TAG e I NSt)Q*rJC_c Policy#or Self-ins. Lic. #: 5 G GL 3 S G QO l 6-8 Expiration Date: O G/o3 /'az 2-4 Job Site Address: 15 5 PO T 2-3 / W C ST YA ovuou Tr-/ City/State/Zip: l'iM_ 6 4 3 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 under the pains and penalties of perjury that the information provided above is true and correct Signature:f ),,, 6 1^-1_ Date: C I/15/ z Phone#: ( c ) (G6 3 - ?,8 16 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): l❑Board of Health 2❑Building Department 3EICity/Town Clerk 4.❑Electrical Inspector 5Ek'lumbing Inennrtnr I ll lilt hnr ACc RL CERTIFICATE OF LIABILITY INSURANCE DAT4/08,2D/YYYY) 04/OB!2C26 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 NAME- Emily S Jones-Heritage Insurance PHONE HERITAGE INSURANCEA Lo.Ext): (248)434-5508(305)735-0441 (A/c,No): (202)599-9675 E-M5 CONCOURSE PARKWAY ADDRESS: insurance.eua@gmail.com ATLANTA, GA 30328 _-_ INSURER(S)AFFORDING COVERAGE NAIC# I INSURER A: Heritage Insurance 98305 INSURED INSURER B: Heritage Insurance 5474 RDC SERVICES INC INSURER C: 1610 WORCESTER RD APT 334A FRAMINGHAM, MA 01702 USA INSURER D: INSURER E: 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 TYPE OF INSURANCE ADOL SUBRI POLICYPOLICY EFF POLICY EXP LIMITS LTRINSD VD' POCY NUMBER (MM/DD/YYYY)I(MM/DD/YYYY) x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED $ 100,000 PREMISES(Ea occurrence) MED EXP(Any one person) $ 5,000 -—- 56GL3SC60168 A 06/03/2026 06/03/2027 PERSONAL 8 ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1.000.000 POLICY X JECTPRO- POLICY LOC PRODUCTS-COMP/OP AGG $ 1,000.000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _(Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED -- AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLALIAB OCCUR EACH OCCURRENCE EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X STATUTE PER ,! OTTH- I ER AND EMPLOYERS'LIABILITY YIN1,000.000 ANYPROPRIETOR/PARTNER/EXECUTIVE 92WC0781U056 03/06/2026 03/06/2027 E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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) RESIDER I IAL AND COMMERCIAL HOME IMPROVEMENT SERVICES OWNED BY RODRIGO OUT RA CORDEIRO. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BLUE LOBSTER INN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 759 ROUTE 28 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE • in,1cIRR-209R Aron-C:ORPCIRATION- All rinhtc rpcervpri. EPARTME OF T S INTERNALNREVENUEESERVICERY CINCINNATI OH 45999-0023 Date of this notice: 07-26- Employer Identification Numb 38-4276229 000433.346534.306306.27261 1 MB 0.561 693 ihhli4AIVIIIIMPIIII01404111111'hlul ,1VIn.lNli Form: SS-4 Number of this notice: CP 5 For assistance you may call RDC SERVICES INC 1622 WORCESTER RD APT 610E 1 800 829 4933 FRAMINGHAM MA 01702 IF YOU WRITE, ATTACH THE STUB OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER ink you for applying for an Employer Identification Number (EIN). We assigned y V 38-4276229. This EIN will identify your entity, accounts, tax returns, and cuments, even if you have no employees. Please keep this notice in your germane! cords. xpayers request an EIN for their business. Some taxpayers receive CP575 notices en another person has stolen their identity and are opening a business using the: formation. If you did not apply for this EIN, please visit, www.irs.gov/ nnotrequested. en filing tax documents, making payments, or replying to any related correspondei is very important that you use your EIN and complete name and address exactly a: own above. Any variation may cause a delay in processing, result in incorrect formation in your account, or even cause you to be assigned more than one EIN. e information is not correct as shown above, please make the correction using thi Cached tear-off stub and return it to us. sed on the information received from you or your representative, you must file t' llowing forms by the dates shown. Form 1120 04/15/2024 you have questions about the forms or the due dates shown, you can call us at t one number or write to us at the address shown at the top of this notice. If yo td help in determining your annual accounting period (tax year), see Publication Accounting Periods and Methods. assigned you a tax classification (corporation, partnership, etc.) based on ormation obtained from you or your representative. It is not a legal determina your tax classification and is not binding of the IRS. If you want a legal ermination of your tax classification, you may request a private letter ruling m the IRS under the guidelines in Revenue Procedure 2020-1, 2020-1 I.R.B. 1 (or erseding Revenue Procedure for the year at issue). Note: Certain tax ssification elections can be requested by filing Form 8832, Entity Classificatj :tion. See Form 8832 and its instructions for additional information. Y TOWN OF YARMOUTH . dl 4,0\ _Y : k Office of the BuildingCommissioner tsi - "• 1146 Route 28, South Yarmouth, MA 02664 ` :° RATED 1�t 508-398-2231 ext. 1260 Fax 508-398-0836 DEMOLITION DEBRIS DISPOSAL APPLICATION Pursuant to M.G.L. c.40 §54 and 780 CMR Section 105.3. 1 tt4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at. Je ? DES YL1Z ,4U1 � £ G1 � Work Address S�? Is to be disposed of at the following location: 2�� vJ r� 1+9IC PA.-, 1 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §15UA. 09 /5W4 . Signature of Applicant Date .Z.,bC. - / 3 r__ Permit No.