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HomeMy WebLinkAboutCavalieri Cesspool Service - 12/31/2020Town of Mansfield - Board of Health 6 Park Row Mansfeld, MA02048� Septage/FOG Haulers Application DATE: 111;7h i LICENSE NUMBER: BUSINESS NAME: CAUA. Il �Ot t `� 55rcV l fLkVC6L MAILADDRESS: (,1- (3 COTrAc�c S=r vofuti 14J`t'l,-6o2D N A 5 5 TOWN: AIdA7ti 4/-I,-'6DRD STATE: /'14-5S ZIP CODE: (ja76J NAME OF OWNER: 44%11101 C,i VO4// r---/k1 i BUSINESS TELEPHONE: .S(i"/rj`:4360 CELL:SOV-c%70-,)3;7 FAX: EMAIL:S14(7411,-A 1A%r16&\J-4gq-g!'i�Aii,C0A1ALT EMAIL: FED ID/SS NO: 51N 69°���tp'"tNUMBER OF TRUCK(S): FEE PER TRUCK: Mo rJJ Truck Registration number: X % 5 - 6 Y 1 Circle one: a to a 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: (t' 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. 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: 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. s Z; Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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/Organization NNa+me: LAB Z /c� / 6 SZ l )j4P,1PL Address: to B L L F`2 ,,46- r rrr-- City/State/Zip: Are you an employer? Check the appropriate boz: " I '— LE] I am a employer with employees (full and/ or part-time).* 2.51 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'rgquired 4. ❑ We are a non-profit organization, staffed by volunteers with no employees. [No workers' comp. insurance req. Phone #: Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment t0.❑ Manufacturing i't.n Health Care 12.❑ Other *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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. 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 Investieations of the DIA for insurance coverage verification. I do hereby certify, uij&rshe pains and that the information provided above is true and correct. 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 Person: Phone www.mass.gov/dia CAVAW01 OP ID: SD A�RU" CERTIFICATE OF LIABILITY INSURANCE O10/2912019ATE V) 10/29/2019 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 endorsements . PRODUCER R.A. Reinbold Ins. Agency Inc. 860 Landry Ave P.O. Box 68 N. Attleboro, MA 02761- CONTACT PHONE Jeanette Barry, AAI,CRIS,CPIA FA1c OVC. ac Na, 508-699-2583 nouaess: jeane!!e@reinboldinsurance.com - INSURER(S) AFFORDING COVERAGE NAIC# Douglas J. Reinbold INSuRERA: Nautilus Insurance Company INSURED William P. Cavalier! 61 B Cottage Street North Attleboro, MA 02760 INSURER B:Safet Insurance Company INSURER C__ INSURER D INSURERE: _ INSURER F COVERAGES 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 L.TR TYPE OF INSURANCE L B POLICYNUMBER POLICY EFF IMMIDDNYYYI POLICY EXP JMMIDDNYYY)LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR NN1021169 10116/2019 1011512020 EACH OCCURRENCE $ 1,000,00 PREMISES Eaoccurence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY IRI- IFQT LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ B AUTOMOBILE LIABILITY ANY AUTO AOX SCHEDULED AUUTOSS AUTOS HIRED AUTOS X NON -OWNED AUTOS 6238583 05/23/2019 05/23/2020 COMBINED SINGLE LIMIT Ea accident 1,000,00 BODILY INJURY (Per person) $ ( ) BODILY INJURY Per accident $ X PROPERTY DAMAGE PER ACCIDENT $ UMBRELLA LIAB EXCESS LIAB El OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC STATU- OTH- `I LIMIT, E. L. EACH ACCIDENT IS E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addlllonal Remarks Schedule, If more space Is required) MANSFIE Town of Mansfield 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 Douglas J. Reinbold ©1988.2010 ACORD CORPORATION. All riahts ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD