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Home My WebLink AboutJ. Hockman, Inc. -12/31/20207:f �-4K ()'A NOV (:3 21 Townof Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME: iWoc,wutl /N _i- L MAIL ADDRESS: i I Sh ea L o u d Ice Je TOWN: fv orel-0t'K STATE: Ate- t ZIP CODE: bQ G3Z NAME OF OWNER; BUSINESS TELEPHONE: v`��CELL: FAX: EMAIL. l yA%/} h 04t11Pt?&_91 . ALT EMAIL: C-�r ,alp Q A"t.po_�Gry FED ID/SS NO: 0 4/ t`C1 4.i-d-� NUMBER OF TRUCK(S): (�_ o FEEPERTRUCK: /00 �l Truck Registration number: Circle one: FOG Truck Registration number: Circle one: pta FOG Truck Registration number: r 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 septi tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of H th. RUCKS 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: t I? DATE: c INSURER: NGM INSURANCE 4601 TOUCHTON SUITE 3400 JACKSONVILLE, COMPANY ROAD EAST FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: J HOCKMAN INC C/O C.L. HOLLIS INSURANCE 140 MARION RD WAREHAM MA 02571-1460 LEGAL ENTRY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: WORKERS COMPENSATION AND EMPLOYERS' LU161LITY INSURANCE POLICY —INFORMATION PAGE POLICY NO: WCP681IN NEW BUSINESS NCCI Company No: 16322 Account No: PBCP6817N AGENCY NAME AND ADDRESS: CL HOLLIS INSURANCE 140 MARION ROAD WAREHAM, MA 02571 AGENCY PHONE NO.: (508) 295-9500 AGENCY NO.: 201423 (See Workers Compensation Location Schedule) REM 2 POLICY PERIOD: From: 06-26-2019 To: 06-26-2020 Effective 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 B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 1 90,000 each accident Bodily Injury by Disease: $ 1, 000, 000 policy limit Bodily Injury by Disease: $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here: all states except: ND, OH, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Al information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 341 Annual Premium: $ , 909 Audit Period: ANNUAL Date: 06-17-2019 Countersigned bell WC 00 00 01 A copyrigm 19p Nallomi Council on compensation Insurance INSURED COPY The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, ,quite 100 2 Boston, MA 02114-2017 wnb mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Business/Organization Name: J Hockman Inc 11 Sherwood Drive Norfolk, MA 02056 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 15 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.] Phone #:508-384-1400 Business Type (required): 5. ❑ Retail 6.❑RestaurantBar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 1 L[] Health Care 12.❑� Other septic and excavating *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 isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Hollis Insurance Agency Insurer's Address: 140 Marion Road City/State/Zip: Wareham, MA 02571 Policy # or Self -ins, Lic. #WCP6817N Expiration Date: 6/22/2020 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. 508-384-1400 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 Phone 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 of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **Social Security No. (Voluntan/) 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 talc 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. 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