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HomeMy WebLinkAboutFlowmaster Corp. - 12/31/2020Town of Mansfield Town of Mansfield - Board ®f Health 6 Park Row Mansfield, MA 02048 SeptagelFOG Haulers Application DATE: LICENSE NUMBER: BUSINESSNAME: Flowmaster Corp. MAILADDRESS: 191 Bedford St/ TOWN: Middleboro STATE: MA ZIP CODE: NAME OF OWNER: Mark Arakelia.n BUSINESS TELEPHONE: 508 946 5066 CELL: FAX: 02346 508 238 8067 EMAIL: karenara@flowmasterseptic.cALIfEMAIL: com FED ID/SS NO: NUMBER OF TRUCK(S): 1 FEE PER TRUCK: Truck Registration number: T 609S 3 Circle one: Septag FOG Truck Registration number: Circle one: ge 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. Ix 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: -3 .. , - _ l(� l� �, �5 Sa � q�� S�by ARACO-1 DATE 10/111201 YY) 10/11/2019 CE FICATE OF LIABILITY INSURANCE 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 508-543-1067 Raynham 1244 Broadway co raCT Katherine Dustin PHONE 508-543-1067 FAX 774-409-2770 A/C, No, Ext : A/C, No : Raynham, MA 02767 Katherine Dustin EDDAIE SSI INSURERS AFFORDING COVERAGE HAIG# INSURER A: Liberty Mutual INSURED Araco Sewer and Drain Service Inc INSURER B : INSURER C: Flowmaster, Inc. 920 Washington Street Easton, MA U2375 INSURER D INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION 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 TYPE OF INSURANCE ADDL INSE, SUB VIVOPOLICY NUMBER POLICY EFF O6/27I2019 POLICY EXPJJ& LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR BKS60010068 O6/27I2020 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED 300,000 MED EXP An one ersan 15,000 PERSONAL B ADV INJURY $ 1,000,000 GENT X AGGREGATE LIMIT APPLIES PER: POLICY ❑ jC� LOC OTHER GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 1 2,000,000 A AUTOMOBILE LIABILITY OWNED SCHEDULED AUTOS ONLY X AUTOS p AUTOS ONLY X AUTOS ONLY BAS60010068 06/27/2019 06/27/2020 COMBINED SINGLE LIMIT 1,000,000 BODILY INJURY Perperson) $ IxANYAUTO BODILY INJURY Per accident PPeOr acc -ZtDAMAGE A X UMBRELLALIAS EXCESS LIAB X OCCUR CLAIMS -MADE US060010068 06/27/2019 06/27/2020 EACH OCCURRENCE 2,000,000 AGGREGATE S 2,000,000 DED I X I RETENTION$ 10000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY V,/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) I/ es, describe untler DESCRIPTION OF OPE 0 below NIA IPER OTH- ISTATUIE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Town of Mansfield 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. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC ?O bl® CERTIFICATE �� OF LIABILITY INSURANCE DATE(MWDD/YYYY) 10/23/2019 THIS CERTIFICATE IS ISSUED AS 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, subjectto 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 Boynton Insurance Agency 72 River Park Street Needham MA 02494 CONTACT NAME: Boynton Insurance PHONE (781) 449-67B6 NC No: (781)445-4269 E-MAIL ADDRESS: certificates@boyntonina.com INSURERS AFFORDING COVERAGE NAIC p INSURER A: Merchants Mutual Insurance Company 23329 INSURED Araco-Sewer and Drain Inc. Flowm3ster Corporation 920 Washington Street Easton MA 02375 INSURERS: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CL1731511818 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, IN5R LTR TYPE OF INSURANCE ADDLS n POLICY NUMBER MMIOPOLIDYEFF POLICY EXP MWDD1YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Not written by agency EACH OCCURRENCE $ PREMISES Ea occuffence $ MED EXP Any one person) $ PERSONAL IsADV INJURY $ GENIAGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- ❑ LOC ECT OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS NONOWNED HIREDAUTOS AUTOS Not written by agency COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE Not written by agency EACH OCCURRENCE $ AGGREGATE $ DED • RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑N (Mandatory In NH) It yes, descrbe under DESCRIPTION OF OPERATIONS below N/A WC49100605 4/23/2019 4/23/2020 yL11 PER OTH - STAT TE E E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE, POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,A0EItlonal Remarks Schedule, maybe attached if more space Is required) tY CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health Six Park Row .. AUTHORIZED REPRESENTATIVE Mansfield, MA 0204E - David Polutchko/DPOLw.rja<r V T9uu-YUT4 AUUKU GUKPUKAIIUN. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) n