Loading...
HomeMy WebLinkAboutMiles of Excavating - 12/31/2020Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 1, 4 2019 Septage/FOG Haulers Application DATE: ---- LICENSE NUMBER: BUSINESS NAME: / iltF5 OF ZKCAUFI-TlAt)ly MAIL ADDRESS: vQVA 1:�Ak?K Sy TOWN: W4eUT/f� STATE:1444- ZIP CODE: U NAME OF OWNER: r 7ry14--1-1Y BUSINESS TELEPHONE5-0S-ys7y-qs- jv CELL: 9',t ,7;. & - S--) FAX: 5D EMAIL: /(,ti ALT EMAIL: y� FED ID/SS NO: (_)q NUMBER OF TRUCK(S): 1 -3yt)g K( 1 FEE PER TRUCK: 4 loo Truck Registration number: /(�% c'J_ Circle one: Septa a FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG 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:OOAM 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. 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 Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. - SIGNATUR DATE: ' MILEOFE-01 CWOODSIDE CERTIFICATE OF LIABILITY INSURANCE DATE F 8/126!22612019 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 poliay(les) 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 endorsements . PRODUCER License # 1760862 c ncT Michelle Wolf HUB International Now England 600 Lon water Drive Norwell, MA 02061-9146 A/c No EA: 508 888-2183 A No; E A L s• michelle.wolf@hubinternational.com INSURERISI AFFORDING COVERAGE NAIC# 2127/2019 INSURERA: Liberty Mutual EACH OCCURRENCE S 1,000,000 INSURED INSURER B:Commerce Insurance Company 34754 INSURERC: Wesco Insurance Company 25011 Mlles of Excavating Timothy Konowltx dba 242 Park Street Wrentham, MA 02093 INSURERD: INSURER E: INSURER F S COVERArFA CFRTIRIPATF NI IMRPP- RR1IIgInN NI IMROC. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR POLICY PERIOD INDICATED. NOTVVITHSTANDING 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. I aR TYPE OF INSURANCE AOOL au BR POLICY NUMBER FOLIOY EFP POLIOY"Pubun OMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR X BK868621919 2127/2019 212712020 EACH OCCURRENCE S 1,000,000 OAMAGETO R ANTED oal s 300,000 MED EXP An one arson $ 15'000 PERSONA BAUV IN URY $ 1,000,000 OEN'L AGGREGA ELIMITAPPLIES PER: POLICV P LOC OTHER: GENERAL AG GRE GATE $ 2,000;000 PRODUCTS-COMPlop GG $ 2,000,000 S B AUTOMOBILE X LIABILITY ANY AUTO AUgTEO�S ONLY X AUpTOSWwULNNED❑p AUTOS ONLY X AUTOOIf V SHDLXX 2127/2019 212712020 COMBINIFe ED SINGLE LIMIT $ BODIL INJURY Per ersan S BODILY INJURY Peraccideni S 1,000,000 feLeCdJ.Yl AMAGE s 11000'000 $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE DEC RETENTION S S C WORKERS ND EMPLOYERS LIF IB COMPENSATION ANYPROPRIETORIPARTNER/EXECUnVE YIN QQ��FICcEPpIMEEM�ER EXCLUDED? TY Imantlel so 'b Irvae deacdbe under Md DESGRI TIO OPOPERATIO below N/A WWC3366078 812312019 8123/2020 PER X OTH- E.L. EACH ACCIDENT S 50O,ODO E.L. DISEASE -EA EMPLOYE S 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ADDED 101, Additional ROMOWS Schedule, may be attached If mom space Is required) Town of Mansfield Board of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ht.Umu AD (ZUT a/U3J ©1966-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Intlustrial Accidents I I 1 Congress Street, Suite 100 Boston, MA 02114-2017 wipw.mnss gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE RILED WITH THE PERMITTING AUTHORITY. Business/Organization City/State/Zip: Are ou an employer? Check the appropriate box: 1. 1 am a employer with �—employees (full and/ fff orpart-Hmo).* 2.11 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required) 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Business Type (required): 5. ❑ Retail 6. ❑Reslaurant/Bar/Eating Establishment 7. ❑ office and/or Sales (incl. real estate, auto, etc.) 8. [] Non-profit 9. ® Entertainment 1011 Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box NI inial also fill out the section belowshowing their workers' compensation policy information. "IfIlia corporate officers have exampled lhemselvas, butthocorporation has other employees, a workers' compensation policy is reguhed and suoh an organization should cheek box If 1. 1 (11tt all errg)loyer that is provldlrrg tpor/ref s' comp _ensadon Insurancefor gly einp/oyees. Below is tkepoliey Information. Insurance Company Insurer's City/State 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 1 do hereby Offictal rose only. Do not sprite In tbls area, to be completed by city or town official. City or Town: Permit/License M10 ami collect. Issuing Authority (circle one): 1, Board of Health 2. Building Department 3. Chy/Town Cleric 4, Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone 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. - al�� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) _-gf kl �i —: --- *"Social Security No. (Voluntary) of r 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\Scotfs Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc