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Home My WebLink AboutSoares Sanitation Pumping - 12/31/2020Town of Mansfield - Board of Health OV 1 1 2G19 17o q Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: BUSINESS NAME: Scares &Y%1' 0hon 'Pump' 01 MAIL ADDRESS: oi$rj Thr*3VVY S+ TOWN:1&0n+b 1 STATE: Mk NAME OF OWNER: QObey f Soares BUSINESS TELEPHON05016 SO $310 CELL: LICENSE NUMBER: ZIP CODE: 021t® FAX: rJ' O $ 22 4 414 IA EMAIL: ; QIQS®3O0.Y'eS?UMplrgj. COM ALTEMAIL: JeS51CQ(@'soarespgj pin9.cALien FED ID/SS NO: O%+ -Q941141 2 NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: SM6561%% Circle one: FOG Truck Registration number: 5Mi'�S45 Circle one: Wepage FOG Truck Registration number: Circle one: FOG Truck Registration number:.? Circle one: Truck Registration number: Circle one: Septage FOG ................................. SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:00AM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. X I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of nsfield. Mail to ,'Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: IO jasj 19 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. Joys CAOA Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, 0,+-aAt+ 1102. "Social Security No. (Voluntary) or Federal Identification Number *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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information1 Please Print Legibly Business/Organization Name: SSa acvfs r i4ccha ► R r"Einq SnC ass T rocs 6A r Shreeir City/State/Zip7T;A„Tan, M A 0 a $O Phone #: 502224 $3'10 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]* 1 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, QC ha�u (2 r with no employees. [No workers' comp. insurance req.] 12.�Other *Any applicant that checks box #1 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. I am an employer that is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Insurer's Address: n3 t' Q6 T` 041( r%gdo r% WaH S U l }e 200 City/State/Zip: l .,�C,1A0++e , Ne aga-i� Policy # or Self -ins. Lic. # L l 9 az I ul 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 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 INA fW insurance c* age verification V 7 do hereby cTrnI he rns an `enalties oj'perju,Arthat the information provided above is true and correct. Snature r' Date: a Phone #: 508 a-4- $310 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: www.mass.gowma Phone #: 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 burn 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 arm Revised 5-26-05 SOARSAN-02 PAMARAI .�CORO" CERTIFICATE OF LIABILITY INSURANCE D10/2812019ATE Y) 10/2812019 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, pollcy(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 License # 1780862 CONTACT Megan Bodyul HUB International New England 222 Milliken Boulevard Fall River, MA 02721 PHONE (AIC, FAX -- No, Ext): (508) 235.2231 IANC, Nal: ADDR . s: megan.bodyul@hubinternational.com _ INSURERS AFFORDING COVERAGE NAIC # 1/1/2019 INSURER A: Selective Insurance Company of South Carolina 19259 EACH OCCURRENCE $ 1'000'000 INSURED INSURER B: Selective of the Southeast 39926 _ INSURER C:Ironshore Specialty Company_ _. 25445 Soares Sanitation Pumping, Inc. INSURER D: 285 Thrasher Street Taunton, MA 02780 INSURER E INSURER F MED EXP An one erson $ 16'000 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 LTR TYPE OF INSURANCE AOpL INSD SUBR Me POLICY NUMBER POLICY EFF D POLICY EXP MDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 52190987 1/1/2019 1/1/2020 EACH OCCURRENCE $ 1'000'000 DAMAGE TO RENTED 500,000 PREMISES fE�q�e encs $ MED EXP An one erson $ 16'000 PERSONAL &ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECOT LOC GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGO $ 3'000'000 $ OTHER: A AUTOMOBILE _ LIABILITY COMBINED SINGLE LIMIT 1,000,000 Eaac ichnt $ ANY AUTO _ A9100369 111/2019 1/1/2020 BODILY INJURY Pet arson $ BODILY INJURY Per accident $ 1,000,000''' AUTOS ONLY X AUTOSSULED X — Peri aeiltlen DAMAGE $ __— AUTOS ONLY X AUTOS UR $ A X UMBRELLA LIAB X OCCUR - EACH OCCURRENCE $ 3'000'000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE 52190987 1/1/2019 1/1/2020 DED RETENTION$ $ 3,000,000 B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR(PARTNER)EXECUTIVE Y� (Mandatory In NH) EXCLUDEDP N /A WC9081074 6/1912019 6/1912020 X STATUTE ERH E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 800,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 500,000 C Pollution / Environm 002617503 1/1/2019 1/1/2020 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Board of Health 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) @ 1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Christopher George From: Jessica Alberg <jessica@soarespumping.com> Sent: Tuesday, December 3, 2019 11:03 AM To: Health Hello Chris, We currently don't have any customers on a schedule for Fats, Oils, & Grease in the Town of Mansfield. Please let me know if you have questions. Thank you Jessica Soares Sanitation Pumping Inc. 285 Thrasher Street Taunton, MA 02780 Tel: 508-824-8370 Fax: 508-824-9429