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HomeMy WebLinkAboutPatriot Services - 12/31/2020• Septage:IF G Haulers Application DATE: tt' O k l BUSINESS NAME: MAIL ADDRESS: TOWN: STATE: tM\ NAME OF OWNER:ya��©.��1r�c] BUSINESS TELEPHONE: (j' (ci''1 "�S� CELL: LICENSE NUMBER: 1,4 ZIP CODE: Oa 6a 4 SO�3 9Ja 999(0 FAX: SC. (0'11 9S(t( EMAIL: ?�Aeko+o (,,.e"f ALT EMAIL: FED ID/SS NO: ciEJ 0s LS14 NUMBER OF TRUCK(S): FEE PER TRUCK: c� Truck Registration number: H89acAl Circle one: Septage FO 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-11:00AM 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. IL 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. SIGNATURfi c':"�,k, � " 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. Si afore of)()(i Individual or Corporate c ry d J� PS , i,__ �?L.I�CY'-P ( Y (� 1 `l gn orporate Name By: Corporate Officer (Mandatory, if Applicable) "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:\Usem\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Let=_ibly Business/Organization Name: Are you an employer? Check the appropriate box: 1. 0 1 am a employer with JL4_ 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] 31-1 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. Fj We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #: Business Type (required): 5. ❑ Retail 6. Fj Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10.Fj Manufacturing 1 I Health Care 12. —f�sJ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 **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 #l. I am an employer that is providing workers' compensudon insurance for my employees. Below is the policy information. 4 Insurance Company Name: i i" ; „v Vp ,.'S '` t`` i x -Ar�C' a Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # l i J (' .`­,?,,(_1-2LQi Pk 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 cerdA, under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: a}?} ' �;, ] - C�k �5 �,,s Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 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.mass.gov/dia Phone M PATRSER-01 MLIMA TE DA10141201grr) '4 CERTIFICATE 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(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 endorsement(s). PRODUCER CONTACT Ronald F D'Agostino Insurance Agency Inc 111 Torrey St Suite 1 Brockton, MA 02301 PHONE FAX (ac, Nc, EXO; (508) 586.0414 lac Nol:(508) 584.7432 E-MAIL info@rfd'irisurance.com INSURER(S) AFFORDING COVERAGE NAICN INSURER A: The Travelers Ind of America 25666 INSURED INSURER B: Travelers Cas Ins Co Of Am 19046 INSURERC: Travelers Pro Cas Ins Co of Am 26674 Patriot Services Inc INSURER 0:The Travelers Ind of Conn 25682 115 Hayward PI Bridgewater, MA 02324 INSURER E: NSURER F: . nnVFRAAFS CERTIFICATE NUMBER: 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 TYPEOFINSURANCE ADDLSUBR INSD WVO POLICY NUMBER POLICY EFF POLICYEXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [ X] OCCUR 6807C436024 2125/2019 2/2512020 EACH OCCURRENCE S 1,000,006 DAMAGE TO RENTED ce. PREMISES Me occurren) MED EXP (Any oneperson)�s $ 300,000 5,000 PERSONAL S ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑Ef LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMPIOPAGG 2,000,000 S B AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY X AUTOOoSVVyyNN X AURTOS ONLY X VIVO VU BA41_16769A 212512019 2126/2020 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) BODILY INJURY Per accident $ ,10Mdanl AMAGE $ S C X UMBRELLAUAS EXCESS LIAO X OCCUR CLAIMS -MADE CUP7C751811 2125/2019 2/2612020 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DELI I X I RETENTION$ 5,000 S D WORKERS COMPENSATION ANOEMPLOYBRSLIABILITV YIN ANY PROPRIETORIPARTNERMXECUTIVE OFFIC1111,M M�ER EXCLUOEOT N andatory n HH�I If yes, deacdbe under DESCRIPTION OF OPERATIONS bebw NIA UB31<499233 2/26/2019 2/2512020 X PER OTH- E.L. EACH ACCIDENT $ 1,000,000 —"--- E.L. DISEASE - EA EMPLOYEd — $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 IT F-E DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Patriot Services Inc. 115 Hayward PI Bridgewater, MA 02324 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 (2016103) 01988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD W.W.S.I. WASTE WAFER SERVICES INC. October 5, 2019 Patriot Services Inc. 940 Plymouth Street Halifax, Ma 02338 Waste Water Services Inc. 1997 Bedford Street Bridgewater, Ma 02324 W.W.S.I. is a full- service wastewater transportation and disposal company. We have extensive experience in managing the transportation and disposal of liquid waste in New England. W.W.S.I. is constantly in contact with disposal facilities throughout New England to ensure our customers always have options. W.W.S.I has received approval to dispose of your waste at Earth Source in Raynham Ma, as well as several organic digesters. W.W.S.I. understands the operations of multi tank systems; sewage treatment plants, large or small. W.W.S.I. can service all your septic and sewer system needs, W.W.S.I. will provide 24-hour emergency service. Waste Water services Inc. Pumps, Transports and disposes of Patriot Services Inc. Tight Tank grease at there facility on 940 Plymouth Street Halifax, Ma 02338. Proposal: Pump, transport and dispose of tight tank grease. Sin / e'ly, 9'U'Q ,,fr' amie Robbins 1997 13Mllad S,ncct. B id cv't r, At F (I'3_r:{ PhoIw: ISO4) 097-'kA V'SI (9179) V ,,A 15nX) n97-9979 �, u.vs„lohwl o'w LOCATIONS OF GREASE TRAPS SERVICED: TASTY RAYS - 20 SOUTH MAIN STREET DECO'S-365 NO MAIN STREET DOMINO'S - 236 CHAUNCY STREET QUAN'S KITCHN - 30 CHAUNCY STREET SAKE STEAK HOUSE - 280 SCHOOL STREET FLANNEL COW CREAMERY - 88 CHILSON AVENUE D'ANGELO'S - 260 CHAUNCY STREET MANSFIELD DELI - 72 PRATT STREET TRATTORIA DELLA NONNA-160 NO MAIN STREET STEFANO'S PIZZA - 30 CHAUNCY STREET WENDY'S - 64 COPELAND DRIVE WHITE'S PASTRY - 321 SCHOOL STREET COLD STONE CREAMERY- 280 SCHOOL STREET CATMAN CAFE -16 OLD COLONY ROAD CAFE ON THE COMMON -12 SO MAIN STREET