The URL can be used to link to this page

Home My WebLink AboutClaude Dubord & Son, Inc. - 12/31/20204- 06 'oj[yp�ansfteId -Board of Health s Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: 1612'b 7 LICENSE NUMBER: BUSINESS NAME: MAIL ADDRESS: `15 Mel e TOWN: 6 Ad e ujv STATE: ✓f ZIP CODE: 0'7-'3 NAME OF OWNER: A', BUSINESS TELEPHONE: 5oY &4 "2-6 CELL: $ole you 73 2.(v FAX:50 Y'61 2- EMAIL:(LAv dL�/��Z�J��/c�a,,J AS•torry ALTEMAIL: FED IDISS NO: 0Ll Z(, p —j�32_ NUMBER OF TRUCK(S): 3 FEE PER TRUCK: 10 u' 00 Truck Registration number: (s N 163 Circle one: FOG Truck Registration number: 5 3 N XY Circle one:FOGTruck &ea Registration number: E09 MJ'L- Circle one: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. 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:C� - 0 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. L16 . l.J �l L� Signature of Individual or Corporate Name By C p rate ficer (Mandatory, if Applicable) 011 7 lei 0 -3 D - -7's "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\Scoll's Docmnents\Food Establishmems- Temp\TAX CERTIFICATION FORMAoc �i The Coinnionivealth of Massachusetts Department of Industrial Accidents Office of Invesrigatlons 9 600 Washington Street Boston, MA 02111 wunv, mass,gov/dia Workers' Compensation Insurance Affidavit; General Businesses Business/Organization Name: Ci Aro ou en employor7 Check Ore appropriate box: I.R I am a employer with 0— employees (full and/ or part-time),* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' oomp, insurance required) 7. ❑ We area oorporatlon 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 art a non-profit organization, staffed by volunteers, with no employees. (No workers' comp, insurance req.) hone # Business Type (required): S. ❑ Retail 6, ❑ RestsurunbBar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) B. ❑ Non-profit 9. ❑ Entertainment lo.❑ Manufacturing 11.0 Health Care 12.ZOther 'Any spplianttluioheoks box #1 must also fill out the section below showing (heir worken' compensetion policy information. "If tho eorporsteotlleen have exempted themselves, but the corporslion has other employees, a workers' compensation policy is required and such on organisation should chock box g I, 1 am an employer that is providhng Iva rKersI compensation lnsurancefor my employees, Below is the policy Usfonunitch, insurance Company Name:__ �. r. /1i MU i U d L.It15 Cd Insurer's Address:_4070 Cirylstatisaip: 1teIIt hq ID n 1 AA 0/go7Q Policy # or Solf=ins, Lic. 7,02, L3 tQ�, 61 ' on Date: `N Attach a copy of the workers' compensation policy declaration page tsnuwing the policy number and explrati da(e). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of crlan nai pone16" of a fine up to 51,$00,00 and/or one-year bnprisonmcnt, 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 1 do hereby cert(q, uVf the pains qq pe#W#es orper/ury drat the information provided ahovP i.r tru P And ra rrnei Official use only. Do not' write to this area, to be completed by city or town orfictal. City or Town: Permlt/Llcense N 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.mass, goy/die Phooe # DUBOR-1 DATE (MMIDDlYYYY) 05/24/2019 ACORCI `Ia� 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 endorsements . PRODUCER 508-697-6963 Estabrook & Chamberlain Ins P. O. Box 277 Bridgewater, MA 02324-9986 Thomas T. Chamberlain CT Thomas T. Chamberlain PHONE 508-697-6963 Fqx FAX-697.5809 (AIC, No, Ext): (AIC, No): XMESS: INSURERS AFFORDING COVERAGE AIC p INSURERA: National Union Fire Insurance INSURED Claude Dubord&Sons, Inc. INSURERS: New Hampshire Insurance Co. 45 Mae Avenue Bridgewater, MA 02324 INSURER C : INSURER D : INSURER E : 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILSR TR TYPE OF INSURANCE ADDD SUe POLICY NUMBER POLICY EFY POLICY EXP LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMSMADE OCCUR 01-LX-059312766-2 05/14/2019 05l14/2020 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED $ 100,000 M D EXP An one person 5,000 X Blkt add I CG2003 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY jEpj LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG 2-0001000 B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUUoTTNOpSSWW EEpp ALTO ONLY X AUiO50NNLY Ix 01-CA-069969546.2 05/1412019 05/14/2020 Ee ecddent COMBINEDSINGLELIMIT S 1,000,000 BODILY INJURY Par arson BODILY INTNJURY Peraccident $ Pe�eccRdent AMAGE $ 8 A X UMBRELLA Lige EXCESS LIAB X OCCUR CLAIMS -MADE 29-UD-066746793-2 05/14/2018 05/14l2020 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2r000'000 DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROWPREIEETTO�RIPARTNERIENECUTIVE Y r N IMentlatory In NH) EXCLUDED? If nye, describe under DESCRIPTIONO OPERATIONS below NIA PER OTH- E.L. EACH ACCIDENT $ E.L. OISEASE-EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS (VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace Is required) Y`CIPTICR-ATF WO CPP CANCFI I ATION MANSFI6 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. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE �iLtY7'lno,. C�� ACORD 25 (2016103) OO 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD n`aRa" CERTIFICATE OF LIABILITY INSURANCE DATE05/24/DOYYYYI 5/24/2019 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(les) 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 endorsement(s). PRODUCER ESTABROOK & CHAMBERLAIN INSURANCE CO T NAME: Kerrl Maguire AICNNo Exl: (508) 697-6963 1 FA AIC No AoorslEss: kmagu ire estabrookchemberlaln.com 45 MAIN ST INSURER 3 AFFORDING COVERAGE NAIC# INSURERA : AIM MUTUAL INS CO 33758 BRIDGEWATER MA 02324 INSURED INSURER B: CLAUDE DUBORD & SONS INC INSURER C: CLAUDE DUBORD & SON INC INSURERD: 45 MAE AVENUE INSURER E BRIDGEWATER MA 02324 INSURERF: COVERAGES CERTIFICATE NUMBER: 407007 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. TOR LTR TYPE OF INSURANCE SO wvD POLICY NUMBER IMMIDDIYYYYI (MMIDDIYYYYILIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMSMADEOCCUR PREMISES Ea occurrence)$ MED FXP jAny one arson) S PERSONAL$ ADV INJURY $ N/A LIMIT APPLIES PER: GENERAL AGGREGATE $ GEMLAGGREGATE POLICY JE� LOG PRODUCTS - COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LT Ea acddent $ BODILY INJURY(Per Person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A BODILY INJURY(Peracddenn $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAa OCCUR EACH OCCURRENCE $ EXCESS DAB CLRMS-MADE N/A AGGREGATE 8 DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AYPROPRIORJPARTNOF IC R(MEM ER XC UDEI09ECUTIVE NIA NIA NIA AWC40070263102019A 05/25/2019 05/25/2020 I X STATUTE ERTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 (Mandatory In NHl If YYes describe under DESdRIPTIONOFOPERATIONS below E.L. DISEASE POLICY UMIT - $ 1,000,000 N/A DESCRIPTION OF OPERADONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space In required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization Is given to pay claims for benefits to employees in states other than Massachusetts Ifthe Insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of Insurance). The status of th is coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/twd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Six Park Row AUTHORIZED REPRESENTATIVE (-`-� Mansfield MA 02046 Daniel M. CI I y, CPCU, Vice President —Residual Market— WCRIBMA O 1988-2014 ACORD CORPORATION. All rights reserved. AGO RD 25 (2014/01) The ACORD name and logo are registered marks of ACORD