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Home My WebLink AboutDrain Remedy, Inc. - 12/31/2020Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 BUSINESS NAME: r C�iYI MAIL ADDRESS: TOWN: PjCC7C 'K0r) NAME OF OWNER: 60�f-t BUSINESS TELEPHON9� C3 m�lu, c STATE: MC CELL: EMAIL: Ora' \n ALTEMAIL: FED ID/SS NO: O'.��) Q (i NUMBER OF TRUCK(S): LICENSE NUMBER: ZIP CODE: 0-,�' 0 FAX FEE PER TRUCK: t4 'iso e Septage/FOG Haulers Applieation Truck Registration number: Circle one: Septage FOG Truck Registration number: DATE: BUSINESS NAME: r C�iYI MAIL ADDRESS: TOWN: PjCC7C 'K0r) NAME OF OWNER: 60�f-t BUSINESS TELEPHON9� C3 m�lu, c STATE: MC CELL: EMAIL: Ora' \n ALTEMAIL: FED ID/SS NO: O'.��) Q (i NUMBER OF TRUCK(S): LICENSE NUMBER: ZIP CODE: 0-,�' 0 FAX FEE PER TRUCK: Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: age 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: r 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 02048Lzk SIGNATURE: ( ! LLL DATE: !_ - 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. -)c�4t:1yil Signature of Individual or Corporiate Name By: Corporate Officer (Manda0y, if Applicable) C2} — 6uI tC) "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\Scat's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ^l ,. mag- 0T CERTIFICATE OF REGISTRATION T L M.GL. Chapter 90 Section 248 makes it a crime to alter this Certificate RMV Division PIatYE iTP! pF0131MYNkl NUMBER CON T56005 aE0151MYlIX1 YVVE COMMERCIAL EFFECtIVE pAiE 01/01/49 Ek�lpaa �,.^ Ip 11 MstllpA °P'` >j..;: MONTH TurniMNSACYION NUMOFH •. 12 19 02830201296469 MUDS MODEL YEAR MANE MODEL 00DYSrvLWVPE COLOR 2008 FORD LGTCON BOX WHITE VEHICLE IOENtIFMAYIONMIMtlEn IN,fVnANCE COMI'ANV TILE NUMnPII Ndta Ildwli u 1 p�tlplal }('9ii'. (, sl nalU e;yl{ ` yR� 4''?� g f 41 QgI�tVBrb nffISYNAH CAapYINO PABSENOERS FOR HRIE: MAXIMUM WEIOIIr FORAEAEO COMMIROM v6H,CL6 OR THASER 3PRNF65B39V0RENT1 ARBELLA PROTECTION BJ736151 NVMDEA OP TEAT DE THAT SEATED. RESIDENTIAL AppDE63 (IP DMPE6ENn 030000 NAMEISI OF OWNEnp) AND MAILING A60AESS I I I I I I I I I I I I I I I I I glllnd1111'IIIIIIIIIIIIIIIIIII'IIIdII'II'I FEES REGISTRATION 600.00 026497 *******AUTO**5-DIGIT 02301 TITLE 0,00 DRAIN REMEDY INC 46 PEARL ST Ev6cru PLATES 0.00 BROCKTON MAL '02301-2018 SALES T. - 0.00 TOTAL 600.00 MASSACHUSETTS DEPARTMENT OF TRANSPORTATION REGISTRY OF MOTOR VEHICLES DIVISION --_'---'�-TF'e-recoMsotYhe-RMVdd4ebdsa�conslltOte-lhevfllliahstacus-ef-Ibewahlcle-reglaHallon.-----.._.___._ -___._...._ _.__..._..__.______._..; SPECMLMESSAGE IF THIS VEHICLE IS NEWLY ACQUIRED, IT CHANGE OF ADDRESS . MUST BE INSPECTED WITHIN SEVEN (7) '. DAYS OF REGISTRATION. STRIP ADDRESS CITY, STATE. ZIP CODE Important Information for Vehicle Owners • Every person operating a motor vehicle shall have the Certificate of Registration for the motor vehicle and for the trailer, if any, and his/her license to operate, upon his/her person or In the vehicle, In some easily acdessible place. • By law, you must report any change of address to the RMV within 30 days in writing. Address changes can be made on the RMV website: www.mass.gov/rmv. Once you have reported the address change to the RMV, please write corrected address In box provided above. • Cancel the registration plates IF - The vehicle has been sold or junked and the registration is not going to be transferred to another vehicle. Keep a copy of the Bill of Sale, Title, and completed Reassignment of Title for your records to document the transfer, - You move to another state and you register the vehicle In that state. - The Insurance policy is not renewed or is cancelled and there Is no plan to obtain a new policy. Massachusetts's law does Doi require an Insurance card. The law. M.G..L. Chapter 90, Section 34A IA requires the vehicle's owner to maintain a compulsory motor vehicle Insurance policy or bond for lapses. The vehicle owner is then notified by the RMV to obtain new Insurance within 10 days or the registration will be revoked. Bonds are filed with the State Treasurer's Office. WIF, • Trsnsferrina Vour pMassachusetts law (M.G,L. Chapter 90, Section 2) allows you to transfer valid registration plates from V-1 this vehicle to a newly acquired new or used motor vehicle or trailer while you obtain Insurance and a new registration. Sae the Transferring a Registration section on the RMV's website at WWy601ds6a_QVLrmX for more Information. 1. Gently peel the decal from the form. 2. Place the decal on the rear plate In the top right corner next to the wogassachusetts. 3. Firmly rub the decal to adhere it to the plate. For best results, bring decal to room temperature before affixing to the plate. The best way to renew your registration is online at www.mass.gov/rmv -1® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/22/2019 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(les) 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 ATLANTIC INSURANCE GROUP AGENCY INC CONTACT Lori McLoughlin PNaN o E 617 698-2200 ac No: E-MAIL tori atlantic uotes.com Mr4a Q INSURERS AFFORDING COVERAGE NAIC If 530 ADAMS ST INSURER A: HARTFORD UNDERWRITERS INS CO 30104 MILTON MA 02186 INSURED INSURER B: INSURERC: DRAIN REMEDY INC INSURER D; 1 INSURER E: PO BOX 674 1 INSURER F: STOUGHTON MA 02072 COVERAGES CERTIFICATE NUMBER: 477021 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 XEREiN 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 jUM ADDL Min SUER POLICY NUMBER POLICY EFF MMIDDY/1'EYY1' LIMITS Daniel M. Croyey, CPCU, Vice President— Residual Market— WCRIBMA COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 1-1 OCCUR DAMAGE ED PREMISES Ea occurrence $ MED EXP (Anyone person) $ PERSONAL &ADV INJURY $ N/A GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ PRODUCTS - COMP/OP AGO $ POLICY ❑ PRO- JECT LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOSAUTOS H N/A PROPERTY DAMAGE $ Par accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE N/A DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYYiN OF ICER/MEMB REXCLUDED?ANYPROPRIETOPJPARTNEPJEECUTIVE NIA (Mandatory In NH) NIA N/A 6S60UB8D80977819 10/22/2019 10/22/2020 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mora space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the Insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CFRTIFICATF HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF MANSFIELD HEALTH DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED REPRESENTATIVE MANSFIELD MA 02048 Daniel M. Croyey, CPCU, Vice President— Residual Market— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACOR& CERTIFICATE OF LIABILITY INSURANCE 14_/ DATE(MMIDD/YYVY) INN MR LTR 11/21/2019 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(les) 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 NAMEpOT Select Department Eastern Insurance Group LLC PHONE 800-333-7234 Opt.3 ac No;TBl-586-8244 77 Accord Park Drive E-MAIL selectwork@easterninsurance.com ADDRESS: Unit Bl INSURERIS) AFFORDING COVERAGE NAIC 0 Norwell MA 02061 WSURERANorfolk 6 Dedham Mutual Fire 23965 INSURED INSURER B Drain Remedy, Inc. INSURER C: 46 Pearl Street INSURER D: INSURER E: 2/13/2019 Brockton MA 02301 INSURER F: COVERAGES CERTIFICATE NUMBERMASTER 19-20 REVISION NUMRFR- 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 TERIW3, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INN MR LTR TYPE OF INSURANCE IN S BR POLICY NUMBER MMIDIDNYYV MOUCYIS Y LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [A] OCCUR EACH OCCURRENCE $ 1,000,000 -DAMAGE TO RENTED 100,000 PREMISES Eacaurrence $ MED EXP (Any one person) $ 5,000 R0506294A 2/13/2019 2/13/2020 PERSONAL &ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ❑jE' 0LOC GENERAL AGGREGATE $ 2,000,000 GEN'L %t PRODUCTS - COMPIOP AGO $ 2,000,000 Blanket Additional Insured $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OSCHEDULED AUUTOSS AUTOS (Per accent) BODILY INJURY id $ -PROPERT-DAMAGE HIRED AUTOS NON -OWNED AUTOS Peraccld.rd) $ X I UMSRELLAUAB X OCCUR EACH OCCURRENCE $ 5 000 000 AGGREGATE $ 5,000,000 A EXCESS UAB CLAIMS -MADE _ DED X RETENTIONS 0 $ U1009648A 2/13/2019 2/13/2020 WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERNEMBER EXCLUDED? �N/A E.L. EACH ACCIDENT $ _-- E.L. DISEASE - EA EMPLOYE $ (Mandatory lnNH) Ueadesc DESCRIPTION under , dbNF OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is required) PLUMBING, SEWER AND DRAIN CLEANING Town of Mansfield Health Department 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. AUTHORIZED REPRESENTATIVE Koegel/PKG ©1988-2014 ACORD CORPORATION_ All riahts reserve ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS0251gn14n11 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/OrganizationName: j,\ g i Address: 4 `+, (`� - t �t C Phone #: C %r -3 , N Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with t 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] g• ❑ 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]* 11.❑Health Care 4. F_1 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insreq.] 12. Other ice} (' j('sYi l i I Ca < r a urance — *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 # I. I am an employer drat is providing worlrers.' compensytion insurance for my employees. Below is the policy information. Insurance Company Name: i n l C E` `C' S` fir,', �__ Ck { Insurer's Address: � L ;x City/State/Zip 1,�j X Policy # or Self -ins. Lic. # 1 i CS € ! Expiration 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, ftt,hhpains and peenallliiees ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completer) by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.nims.gov/dia Phone