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Home My WebLink AboutBay State Haulers - 12/31/2020q00,60 Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME:P)dq sitt1t- J-u"Au DI C,0 tI61e. MAILADDRESS: PO P)Uy lr TOWN: W(vlk, STATE: PP ZIP CODE: 67t jq`j NAME OF OWNER: nll Y.l i �, rlf;(S l'i f'y € BUSINESS TELEPHONE: Nj{) q�l ri Err,y/CELL: FAX: EMAIL: �(�� i'J(Xl�£�((fSQ(UOi�T il?Wt ALT EMAIL: J FED ID/SS NO: NUMBER OF TRUCK(S): FEE PER TRUCK: { ; Truck Registration number: <S z 05' Circle one:Ve FOG L4 Truck Registration number: f Li -1 A Circle one: FOG Truck Registration number: Ct1 G 19 Circle one: (FOG OTruck Registration number: T (, 09, U L( Circle one: Septage tFOG 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 ...... 1- ............................. .----..... --- ....................................... .._.......................... --............................ ............. 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. 01A 010"( - U (,((e i u( `j Lv (, o .fon '; 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. SIGNATURE: 1-14 --A11 DATE: l' 22 - �q L 1 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. 2 Signa ure of Individual or Corporate Name By. Corporate Officer (Mandatory, ifAp tical, e) **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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Name The Coinniottwealth of Massachusetts Department.ofIbadustrialAccidents I Congress Street, Suite 100 Bostou, KA 0211 4-2 01 7 www>`nassgov/dia \\'orkers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Address: City/State/Zip: Phone Are you an employer? Check the appropriate box. Type of project (required): l.dl am a enirployer with 40 employees (full and/or part-time).- 7. ❑ New construction 2:❑ t am a sole proprietor or partnership and have no employees working for me in g, ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9.. El Demolition 3.0 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 0 Building addition 4.❑ I am ahomeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance oraresole 1 LQ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5,❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Q Roof repairs These sub -contractors have employees and have workers' comp. insurance.t 14. �i Ofllel' /? (/ 6.Q we are a corporation and its officers have exercised their right of exemption per MGL C. 152, F1(4), and the have no employees. [No workers' comp. insurance required.] *Any applicant that checks box ki must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContnctors that check this box must attached an additional sheet showing the name of ilia sub -contractors and state whether or not those entities have employees. If the sub-connactos have employees, they must provide their workers' comp. policy number. 1 aur as employer that is providing workers' compensation insurancefor my employees. Below is the policy andlob site infornratiorr. /' Insurance Company Name: (�,{' i ( A 11 d? ['" J}/ t J-(,yf Yl $ D Il e h / 41-0 CL Policy # or Self -.ins. Lie. #: (0 S G 0 Ia � L{ N 3 I X 0 !T U 19 Expiration Date: D �' 15.1 A N 0 Job Site Address; Attach a copy of the compensation policy declaration page City/State/Zip: flar E ('[yd � 6 -r D ci 10 `�1t _ ng the policy number and expiration date). Failure to secure coverage as required under MGL e. 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 li 4 "1 -- the information Official use only. Do not write in this area, to be completed by city or town official. Citv or Town: Issuing Authority (circle one): L. Board of Health 2. Building Department 6. Other Contact Permit/License true and correct. 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone A�® CERTIFICATE OF LIABILITY INSURANCE OATEIMMIoonvrY) 07/03/2019 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(ies) 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 ROGERS & GRAY INSURANCE AGENCY INC 434 ROUTE 134 SOUTH-DENNIS MA 02660 CONTACT Heather Woods NAME: _ PHCNN _gat (508) 747-6582 ac No: E-MAIL hwoods ro ers ra com Effifi 5: @ 9 9 Y INSURER S AFFORDING COVERAGE NAICIf INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED BAYSTATE SEWAGE DISPOSAL INC & PO BOX 886 LAKEVILLE MA 02347 INSURERS: NSURERC: INSURER D: INSURER E INSURERF: COVE"GES CERTIFICATE NUMBER- A91AR9 REVISION NUMBER: V 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 re O. SUER POUCYNUMBER MMIDDYIYYYY POECEFF MMIDDYANYY LIMITS COMMERCIAL GENERAL LIABILITY Mansfield MA 02048 Daniel M. Crcyiiey, CPCU, Vice President— Residual Market— WCRIBMA EACH OCCURRENCE $ DAMA TED PREMISESIEaoccunence) $ CLAIMS -MADE 11 OCCUR MED EXP (Any one person) $ PERSONAL&ADV INJURY $ N/A GEHL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ _ PRODUCTS-COMP/OPAGG $ PRI- [__] LOG POLICY ❑ JECT 5 OTHER: AUTOMOBILELIABILITY COMBINED SINGLE LIMIT Ea accitlent $ BODILY INJURY (Per person) 5 ANY AUTO BODILY INJURY (Per accitlenl) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS N/A PROPERTY DAMAGE $ Per accident -_ S UMBRELLA LIAR LJ OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESSLIAB CLAIMS -MADE N/A DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOVERS'LIABILITY YIN ANYPROPRIETOrUPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? NIA (Mandatory in NH) NIA NIA 6S60UB4N31205019 06/15/2019 06/15/2020 /� STATUTE EORH X E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,606,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 10i, Additional Remarks Schedule, may be attached if more 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 stales 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 w .mass.gov/lwdlworkers-compensation/investigations/. c unr DER CANCFI I ATION V 19BB-ZU14 AUUKU OUKYUKA I lulu. Ali rlgrus reservect. ACORD 26 (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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield Health Dept 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Crcyiiey, CPCU, Vice President— Residual Market— WCRIBMA V 19BB-ZU14 AUUKU OUKYUKA I lulu. Ali rlgrus reservect. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD A �® CERTIFICATE OF LIABILITY INSURANCE DAT 2/4/20DIYY Y) 2/4/2019 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(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 Rogers &Gray Ins. -Kingston Branch 63 Smith Lane Kingston MA 02364 CONTACT NAME:PHONE FAX ac Na Ea 508-746-3311 ac No: 877-816-2156 nooRlEss: mail@rogersgray.com INSURERS AFFORDING COVERAGE NAIC If 1/18/2019 INSURERA: Arbella Indemnity Insurance Company, Inc. 10017 EACH OCCURRENCE $1,000,000 INSURED BAYSTAT-04 INSURERB: Arbella Protection Insurance Comp, Inc_ 41360 Bay Slate Sewage Disposal Inc 105 Kingman St INSURER C: INSURER D: Lakeville MA 02347 INSURER E, $ INSURER F: AUTOMOBILE LIABILITY HANY AUTO OWNEDX SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY COVERAGES CERTIFICATE NUMBER: 476943181 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 TR OF INSURANCE ADDLTYPE Nqn SUBR POLICYNUMBER MMIDOIYI'EYYV MMI OIYEYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE IJ OCCUR 8500069401 1/18/2019 1/18/2020 EACH OCCURRENCE $1,000,000 -DAMAGE TO REENBE PREMISESEa occurrOance $300,000 MED EXP (Any one person) $15,000 PERSONAL &ADV INJURY $1,000,000 GEN, AGGREGATE LIMIT APPLIES PER: POLICY [X] jECT [XI LOC OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS - COMP/OPAGG $2,000,000 $ B AUTOMOBILE LIABILITY HANY AUTO OWNEDX SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY 1020079998 01 1/18/2019 1/18/2020 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE 4600069402 1/18/2019 1/18/2020 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED I X` I RETENTION$ 1 n nnn $ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETORRARTNER/EXECUTIVE ❑ OFFICER/MEMBEREXCW DED? IMandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA IPEROTH- STATUTE ER -. E. L. EACH ACCIDENT $ E.L. DISEASE EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ A Equipment Floater --t 8500069401 1/18/2019 1/18/2020 Leased/Rented 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield Health Department Town Hall 6 Park Row - 1st Fir 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. REPRESENTATIVE ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD bd State, SEWAGE DISPOSAL, INC. SEPTIC SYSTEMS VACUUM CLEANED 11/26/2019 To Whom It May Concern, The following is a list of FOG customers that we service in Mansfield. If you have any questions please contact us by calling (508) 947-2636. Holiday Inn 31 Hampshire Street Mansfield, MA 02048 Classic Pizza Mansfield 242 Chauncy Street Mansfield, MA 02048 Primrose School of Mansfield 201 Copeland Drive Mansfield, MA 02048 Kind Regards, wwv.berl,Id cabridLe