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HomeMy WebLinkAboutRibeiro Enterprises, Inc. - 12/31/2020Town of Mansfield Town of Mansfield - Board of Health 6 Park Row NOV 14 2019 Mansfield, MA 02048 Septage/FOG Haulers Application DATE: t t/t 3/A LICENSE NUMBER: n r\ ION 64(R�Jf;vrt BUSINESS NAME: MAIL ADDRESS: P o &, uS TOWN: p/Ot2)r0^' STATE: /»!3 ZIP CODE: o y�b4 `` NAME OF OWNER: ��IR v t'C yfrd BUSINESS TELEPHONE:''Vd-AS'-- 3lG-7 &/'CELL: FAX: EMAIL: �/ivN�rir (�lA��'•ceen ALTEMAIL: FED ID/SS NO: NUMBER OF TRUCK(S): i FEE PER TRUCK: lU'd 7 � Truck Registration number: 1� g3a��Jt Circle one: Se toe 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: 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 02) 0 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. P4�etfd 46�tTzl5es _Z�, - Signature of Individual or Corporate Name By: Corporat fficer (Mandatonj, if Applicable) Li 4 - )-?-"7X<70 "Social Security No. (Vdnntanij) 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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A �® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/1/2019 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) 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 endomement(s). PRODUCER Partners Insurance Group, LLC 560WilburAvenue Swansea MA 02777 CONTACT NAME: Marla Afmda _ PNONE . 508�91-3176 FAX N°:508-491-3108 AID, ° aooriess: MArruda PartnersinsG LLQcom INSURERS AFFORDING COVERAGE I NAIC9 INSURERA: NGM Insurance Company 14788 INSURED RIBEI-2 INSURERS: Ribeiro Enterprises Inc. Dylan J. Ribeiro P.O. Box 456 NSUREft C: INSURERD: INSURERE: _ Norton MA 02766 INSURER F: rnvcRAOFs CFRTIFICATE NUMBER: 1525466449 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. PIER LTR TYPE OF INSURANCE AODLSUBR POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/OD LIMITS A X COMMERCIALGENERALLUIBILITY CLAIMS -MADE lxl OCCUR MPT2783C 10/4/2019 10/4/2020 EACH OCCURRENCE $1.000.000 DAMAGE TO RENTED PREMISES Ea occwrance_ $500,000 _ MED EXP (Any one person) $10,000 PERSONAL BADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER X POLICY ❑ PRO- LOC OTHER: JECT$ GENERALAGGREGATE . $2,000,000 PRODUCTS-COMPIOPAGG $2,000,000 A AUTOMOBILELIABILITY IANYAUTO OWNED X SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY M1T2783C 10/4/2019 10,412020 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $500,000 BODILY INJURY (Per accident) $1,000,000 PROPERTY DAMAGE $500.000 $ A X UMBRELLA LIAB E%CESSLIAB X OCCUR MS MADE CUT2783C 10/4/2019 10/4/2020 EACHOCCURRENCE $1,000.000 AGGREGATE $1,000,000 CEO X RETENTIONS ln non $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN OFFICEMMEMBER EXCLUDED? (Mandatory in NH) i(yyes descnbeunder 0ES4RIPTION OF OPERATIONS below N/A WCT2783C 11/10/2019 11/10/2020 STATUTE FOR E.L EACH ACCIDENT $500,000 E.L. DISEASE -EA EMPLOYE $50%000 E.L. DISEASE -POLICY LIMIT $600,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORO 101, Additional Remarks Schedule, maybe attached if more space is required) CFRTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD \ The Commonwealth ofMassachtlsetts a - Departinentofluilustria!Accidents I Congress Street, Suite 100 t Boston, MA 02114-2017 ivrvip.tmrss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ? P licaut Information ��jj Please Print Legibly RBusiness/Organization Name: 4elca 6-1 Address: l �3 City/State/Zip: /1&4n1%V /✓P &4'o--74( Phone#: 5- e _R _�"e Are you an employe'? Check the appropriate box: L (-1 am a employer with 14 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] 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 required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp, insurance req.) Business Type (required): 5. ❑ Retail 6. F]Restaur•ant/Bar/Eating Establishment 7. F1 Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Nonprofit 9. ❑ Entertainment loll Manufacturing 11.❑ Health Caren 12•0Other *Any opplicold tlmt checks box ill most also fit) out the section below showing theirworkers' compensation policy intonMuon. **ifiha corporatcoffieers have exempted themselves, but the corpornlion has other employees, a workers' compensation policy is required and such no organization shouid cheek box 111, porllers' canpensallat insurance for my employees, Below is tlrepolicy information. 1 (till an engdgyer lltaf is providir l lnsurance Company insurer's Address: o G✓ -Af,/t_ Aae. City/State/zip: GT, Failure to secure coverage as required under Section 25A of MOL 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 line 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 Pains and penalfPes ofperyrny thal Official use only. Do not ipi'ile hr llds area, to be completed by city of lonvn of/lehtl. City or Town: Permit/Llcensc # above is trlre and correct. //�/d—Aw /9 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone