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HomeMy WebLinkAboutMr. Cesspool, Inc. - 12/31/2020K C.i f (�r r..i BUSINESS NAME: /"` �9 ,0/ P 7*e MAILADDRESS:�D TOWN: Gf%���/�f�/ STATE: Aw- NAME OF OWNER:0*'-/"-�!; BUSINESS TELEPHONE: -P1 •01 Z1V1' CELL: DATE: LICENSE NUMBER: ZIP CODE: Da7f s FAX: EMAIL: ✓eel yLy9 • N toVIA LT EMAIL: FED ID/SS NO: �I6 ���%� %ly NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: L:2�y94; Circle one: Set 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 occ s 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 of7ansfieMail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048, ) 7 SIGNATURE: / E: O U� "-1 MRCESSP-01 LBRO DATE YY) A`ORO CERTIFICATE OF LIABILITY INSURANCE 101241201 10/24f2018 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 endorsements). PRODUCER S.OACT Loretta Brown FBlnsure, LLC l PPENONE FAX 128 Dean Street Wc, No Ext: (508) 824 8666 (Arc No):(508) SSO-0142 Taunton, MA 02780 p'i �LBroWn@fbinsure.com _ INSURERISI AFFORDING COVERAGEi NAIC# IINSURE_RA:Ohio Securityinsurance Co '24082 INSURED INSURERa:Ohlo Casualty Ina CGmDany 124074 Mr Cesspool Inc ' NSURERC: 690 Main St ;INSURER D. Acushnet, MA 02743 !INSURER E' INSURER F: COVERAGES CFRTIFICATF NUMBER: - RFVIAION NIIMRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAT/E BEEN ISSUEDTO THE INSURED NAMEDABOVE FORTHE 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 REDUCEO BY PAID CLAIMS. _ ILTR NSR 1 rVM TYPE OF INSURANCE VDL1jUSR1 POLICY NUMBER POLICY EFF POLJCY EXP 1 LIMITS A IXCOMMERCIAL GENERAL LIABILITY ! EACH OCCURRENCE IS 1,000,000 j CLAIMS -MADE X OCCUR X X BKS69679666 3RI2019 317/2020 j Prm,0JJ ,RENT D,) ! $ 300,000 MED EXP one 1 $ 16,000 ! PERSONAL&AOV INJURY S 1,000,000 r— -- 2,000,000 GEML AGGREGgTE pL�IMpIT APPLIES PER: ( I I GENERAL AGGREGATE $ 1 POLICY' JEC'r ! X I LOC ! i PRODUCTS-COMP/OPAGG I S 2,000,000 I I is OTHER: g A AUTOMOBILE LABILITY &ONISINEDSINGLE LIMB S 1,000,OOD L ; ANY AUTO ;.- X X BAS69679666 317/2019 31712020 I BODILY INJURY(Perperson) 1 $_ I I OWNED SCHEDULED AUTOS ONLY XJ 'gU7pSI I BODILY INJURY (Pwaccldenn l$ X UOONLY X %EER°AMAGE �A N� $ _ I I IS A LX UMBRELLA LIA13 X OCCUR j I I EACH OCCURRENCE I S 3,000,000 1 i EXCESS LAB CLAIMS MADEi X X US059679686 3R/2019 ! 3R/2020 AGGREGATE $ 3,000,000 1 DED 1 X! RETENTION s 10,000 i 1 $ B AMCog PLOY ammo i . X %RAIWE I ER YIN ! ! - I "-- IANt'PROPRIETCR/PARTNERSXECUTIVE ,I X �XWOS9679666 , 3R/2019 3R/2020 E.LEACHACCIDENT $ 500,000 ppFFFPIl E0 yjki f)EXCLUDEDt N :N/Ai ! ' I(Myaes tory in NH) EL DISEASE - EA EMPLOYEES 500,000 ( DESCRIP'IONOOPERATIONS below ) 1 !!EI. DI EASE -POLICY LIMIT lS 500,000 1 1 i DESCRIPTION OF OPERATIONS / LOCATIONSI VEHICLES (ACORD 101. AddItIOMl Remark, Schad ma be attached a more spaoy b required) For the vrork performed by Mr. Cesspool, Inc. at UMass Dartmouth Dorm PrGjecf S 2�g089. Suffolk Construction Company Inc.; Greystar GEDR Development, LLC a Delaware Limited Liability Company; the University of Massachusetts Building Authority; the University of Massachusetts; the Commonwealth of Massachusetts; Massachusetts Development Finance Authority; Provident Commonwealth Resources 11, Inc.; The Bank of New York Mellon Trust Company, N.A. as Trustee; and any Other Additional Insureds required by the agreement are Additional Insureds on a primary and non-contributory basis on the General Liability, Automobile Liability, and Umbrella liability (follow form) policies. A Waiver of Subrogation in favor of the Additional insured applies to all policies when required by written contract Policies contain no residential exclusions. OL Form CG8810 4113 (Blkt P&NC, Waiver) and 00849412108 (Wrap-up Exclusion), and CA Form AC8606 6/19 (Bikt Al, P&NC, Waiver) are attached. GL Forms CM79 4113 (Slkt Al ongoing ops) and CG8980 4113 (Blkt Al completed ops) will be forwarded when received (samples attached). WC Form WC000313 4184 (Slit Waiver) will be forwarded when received. CERTIFICATE HOLDER CANrFi I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE ACORD 25 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, Business/Organization Are you an employer? Check the appropriate box: 1. 2 I am a employer with employees (full and/ or part-time).* 2. ❑ 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.] Phone #: ;�)/Id-- �7V`0 " U ZZ/ Business Type (required): 5. [:]Retail 6. ❑ Restaurant/Ban'Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I Ln Health Care 12. [VOther "Any applicant that checksbox gl must also fill out the section below showing t'eir workers' compensation policy information. ' *"If the corporate officers have exempted themselves, but the corporation bas other employees, a workers' compensation policy is required and such an organization should check box 91. I am an employer that is providing workers' compensation insurance for ny eniploySes. Below is the policy information. Insurance Company Insurer's Address: / `g lye($'(/%P / ��4 City/State/Zip: t � Policy # or Self -ins. Lie. # �,'1y,9� %9�rY,b Expiration Dater Attach a copy of the workers' compensation policy declaration page (showing the policy number add ex iratlon 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. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License . GJ 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 www.inus.gov/dia 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. Signature of fndividua or Corporate Name By: Corporate Officer (Mandatory, if Applicable) -�dz���� "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