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Home My WebLink AboutJohn Sewer & Drain Cleaning - 12/31/202049116-� LICENSE NUMBER: BUSINESS NAME:J0C\tl SCLUU 4 dVo t'n (teCA" in MAIL ADDRESS: (-{ 'ex'u—c� 0o'e- TOWN:�k)ij,(k(r) STATE: yr,1,V\ NAME OF OWNER: < O� �i( DcY ctld BUSINESS TELEPHONE: CELL: I - 1p (p�rS EMA ALT EMAIL: t n� FED ID/SS NO: NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: i � Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: ZIP CODE:0\ W FAX:-76j-S-V/-iv&7�� Circle one: Septage F Circle one: Septage OG Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG 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 occ rs for BOH records. 7 1 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. 1l r Iv SIGNATURE: � t�b4 � � DATE: /"1s u 1 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. 21A, r Ci,r2Gn Ig -nI, � Chi RP" Signature of Individual or Corporate t,4arne By: orporate Officer (Mandatory, if Applicable) gy ISIK `*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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street e Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lelribly Business/Organization Name: Address:(—( Q:Y{'CZ� ON(2 City/State/Zip: A('1tVA6 C))MI Phone #:1i51-Skocl Are you an employer? Check the appropriate box: Business Type (required): 1. [� I am a employer with _ 7D employees (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 (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]**11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.V] OtherAY j *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 #l. I ann an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ODn " Or �'Cwf c�nce CCU Insurer's Address: f iL� �[ PlCC\t City/State/Zip: U2CXC2 S- r t 1�—A Policy # or Self -ins. Lie. # w «/ylk'�i S 9"O -2- Expiration Date: glmlo Attach a copy of the workers' compensation policy declaration page (showing the policy number ind 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 certify, under the pains and penalties ofperjury that the information provided above is true and correct Cd CA, Date: �O 12, 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.rnass.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 pennit/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 bum 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 Fonn Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 10/25/2019 image.png AIR p® CERTIFICATE OF LIABILITY INSURANCE °"tt'1°"s 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 ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder to an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED Previsions or be endorsed. It SUBROGATION IS WAIVED, subject t0 ilia terms and conditions of the policy, contain Policies may require an andoweamenf. A statement on this certificate does not center rights to the certificate holder In lieu of such endorsemen!(s). PRODUCFR CONIIACT Michelle Landers NAME: Brown&Broom of Massachusetts. LLC PHONENSEN: (781)4S5-8664 faG Not: 333 Elm Streak, Suite 300 0.DORlBs: inland015®bbdedham.com INsUREk161AFFOROwG coveRAOe NAM:s Dedham MA 02026 wSLAZAA: The Honorerelvurance COmpCompany 22292 IMMURED wsukeke: Allmedca Financial Benefit Insurance Company 41840 Johns Sewer 8 Pipe Cleaning, Inc. wtuRERc: 4 Breed Ave INSURER O: • •• — wSURER!- Woburn MA 01801 LWURER F: COVERAGES CERTIFICATE NIIMRER- MASTER2018-2010 CUUMAM ulmuOca. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE HPFN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CON0171ON 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, OR TYPE OF INSURANCE INED WM POUCYNUNBER 1" 4muoo"yl LIMITS X1 C0111AERCIAL GENERAL. LIABWTY CUIMS. MADE OCCUR ,A EACH OCCURFSNCE 1,000,000 { pRErMSES (€a oaurmrrs (E . 10>ETJ1E77'___ S 166,666 MEDIENPjAn unc Anon/ s 10,000 A BlankalAdd'I Ins Y ZHND"6100 12109I2018 12N1wmill X FORh1 $21-2915 PERSOIUA4ADVANJURYS 1.00g000 GENLAGGREGATE LIMIT APPLIES PER. POLICY LOC GENERAAAGGREOAIE s 2,000,001) pRODUCTE.COMMpAGG S 2,000.000 OTHER Property damage -single s AUTOMOBILE LIANEJTY G..Ndlarll s 1,000.000 X ANYWITO BOOILYiNJURYiPer PNPni $ g OWNED SC.14!OLRF AUTOS ONLY AUTOS MINED D ED NON,OWNED AUTOS ONLY AUTOS ONLY AWND446146 12MI2018 12/09=19 emILY INJURY(R.amnarl s pnaa:ilran s s x UMBRELLA LiAN OOCUA EACHOCCURRENCE S 5,000,000 A ECATE s 5-000,000 A excess ut" CLAw+s.MADs UHND446101 12M02018 1P1O912019 OED X RETENT1m s 10,000 s A SATION AND ENPLtlVBR6• UABIL/TY ANDIf€PLOYS ILIABIIT IN ANY PROPRETORPARTNEIVEXEmTNE Yj"'u"i OFFICEINMEMIEREXamilo? u (Mmnd"t.NH) OESCRPT ONOF OPERATNkJS mkr NIA VJHND370727 12IM2018 12f0912019 X TA TE NR E.L EACH ACCIDENT s 1.6001000 LLDISEASE.EAEMPLOYEE S 1,000,00D EA. fXBEASE-PCAICY LIMIT $ 1,000,000. ePSCRIPTION OF OPERA11d161LOCAt'qNs 14!!IC[LS (ACORO 1w, AJtlISooN Witika scboA�lE,may OoalaoMW Mmwe apArwls ngiiaRj SumEYllle Center Spe. LLC, Burnsville Minnesota, LLC, CBLBAssooiates limited Parinmt ip. CBLSAssodales Properties, Inc., CBL Hoidings I, Inc.. CBL B Associates Management. Inc., Wells Fargo Commercial Mortgage Servicing, ERMC, LLC and Sacurame Ica, LLC are included as Addi Tonal Insured vdth respects to General Liabiity, Automobile and Umbrella Liability policies, as required bywitlen contract. https://mail.google.com/mail/u/0/#inbox/FMfcg=DrtxzdXvvjHfrgJDLdgqtnmXs?protector=1 ill Cb- SEWER & DRAIN CLEANING November 1, 2019 TOWN OF MANSFIELD HEALTH DEPARTMENT 6 PARK ROW MANSFIELD, MA 02048 Enclosed is our customer list in the Town of Mansfield to go with our application you have already received. Let me know if you need anything else Sincerely, Tiffany Rojas Customer Service Rep 781-569-6695 4 Breed Avenue Woburn, MA 01801 Phone (781) 569-6695 Fax (781) 569-6694 MANSFIELD CROSSING- 280 SCHOOL ST QDOBA \ COST BERTUCCI'S A SAKE �Ktc rn PAPA GINO'S TGIF BGOOD