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HomeMy WebLinkAboutLifecycle Renewables - 12/31/202043IqD-�' e Town of Mansfield Town.of Mansfield - Board of Health 6 Park Row 1 Mansfield, MA 02048 Septage/FOG Haulers Application DATE: jola)lgolq LICENSE NUMBER: BUSINESS NAME: L. I icec yl e kenet � ab t e6 MAIL ADDRESS: -75 fnduf frict) Avon te, TOWN:-T&J<5bun t STATE: � ZIP CODE: OIL -Ap NAME OF OWNER: ROYLI &aV n I BUSINESS TELEPHONE: ?'Wg)ytoi_R9-31 CELL: FAX: EMAIL: J QtAQ of Qrkaae @IcFe )e Yin ALTMAIL: Rob CD f+- c�C)E3 f�rteWGiblLS m Ct)r✓t FED ID/SS NO: d �`c(J J 140 Zt f NUMBER OF TRUCK(S): 5- FEE PER TRUCK: Truck Registration number: -3519 Truck Registration number: Truck Registration number: T(o 1 0 T l Truck Registration number: 'PLi 1 6819 Truck Registration number: V I Li 1 4-1 SEPTAGE PUMPERS: Circle one: Sep age OG Circle one: Sep age OG Circle one: Sep age OG Circle one: Circle one: Sep age Sep age �OG J 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 �s for BOH records. occ 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: i k }1J°A C0__. DATE: n JO CL ar,(e CIDI ��j ne")Qbles. COM 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 Andividual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) s6d, 33 y © W I "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\Scott's Docwneats\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 r www.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: $ Phone #: Are yotyan employer? Check the appropriate box: Business Type (required): 1. I am a employer with �1employees (full and/ 5. Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnership and have no 7. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3 f We are a corporation and its officers have exercised 9. Entertainment their right of exemption per c. 152, § 1(4), and we have 10E] Manufacturing no employees. [No workers' comp. insurance required]* I I h Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' camp. insurance req.] 12Q Mliier *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 #I. I rant an employer that is providing workers' compensation insurrnace for nay ei!!Ployees. Below is the policy iaafornratio». Insurance Company Insurer's City/State/Zip: tan hVlICJ (7o Policy # or Self -ins. Lie. # tuc7ogoqcio Expiration Date:�l_._ Q 61�1Q0 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 certif, , under the pains and penalties ofpeijaiy that the inforanation provider/ above is true and correct. Official use only. Do not write in this area, to be completed by city or town offleiral, City orTown: 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: www.iiiass.gov/dia Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 Issued by The Stock Insurance Company WC000001 A POLICY NUMBER PREVIOUS POLICY NUMBER WC 9080900 1 NEW SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA 3426 TORINGDON WAY, CHARLOTTE, NC 26277 INFORMATION PAGE NCCICOMPANYNO. 23957 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ITEM 1. NAME OF INSURED & MAILING ADDRESS PRODUCER'S NAME AND MAILING ADDRESS LIFECYCLE RENEWABLES INC HUB INTERNATIONAL NEW ENGLAND LLC PO BOX 1144 PO BOX 696 MARBLEHEAD, MA 01945-5144 WILMINGTON, MA 01887 INSURED IS: CORPORATION FED ID NO. 262334041 AGENT NUMBER: 26-00-20014-00000 ITEM 2. POLICY PERIOD 'fire Policy Period is from MAY 1, 2019 To MAY 1, 2020 12:01 A.M., standard time at the insured's mailing address. ITEM 3. COVERAGE A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law of the states listed here: MA & NH B. Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury By Accident $1,000,000 each accident Bodily Injury By Disease $1,000,000 each employee Bodily Injury By Disease $1,000,000 policy limit C. Other Slates Brsurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND,OH,WA & WY. ITEM 4. PREMIUM: The premium for this policy will be determined by our manuals of rates, classifications, rates and rating plans. All information required below is subject to verification and change by audit. Code Premium Basis Rate Per Estimated CLASSIFICATION No. 'total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE ATTACHED SCHEDULE(S) MULTI -STATE POLICY Mininnun Premium $l,000 Total Estimated Cost $30,579 If indicated below, interim adjustments of premium shall be made: ❑ Semi -Annually ❑ Quarterly ❑ Monthly Deposit Premium $30, 579 This policy includes these endorsements and schedules: REFER TO WC-52 D/B - 10 - 801691223 Issue Date: MAY 10, 2019 Issuing Office: NORTHEAST REGION, 07826-0480 Authorized Representative Form-64 (07/08) Copyright 1987 National Council on Compensation Insurance. INSURED'S COPY MANSFIELD INSIDE GREASE TRAP CUSTOMERS GENO'S RESTAURANT COUSIN'S PIZZA & SUBS CIBO MATTO SAKE STEAK HOUSE CLASSIC PIZZA KYOTO JAPANESE STEAK HOUSE GREAT WOODS PIZZA 409 N MAIN STREET MANSFIELD 660 EAST STREET MANSFIELD 254 CHAUNCY STREET MANSFIELD 280 SCHOOL STREET MANSFIELD 242 CHAUNEY STREET MANSFIELD 242 CHAUNCY STREET MANSFIELD 428 ELM STREET MANSFIELD