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Home My WebLink AboutWaste Water Services, Inc. - 12/31/2020- Board of Health -:-#I-� -�6 Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: J O 122/ t LICENSE NUMBER: BUSINESSNAME: LOAS�-j tofttUi2 6C WILtES SAIL MAIL ADDRESS: l em 7 Be-DT-vv-b sT TOWN: P)(21'h)65&bL) }-It—{2 STATE: /AA ZIP CODE: C>,2-3-2- NAME OF OWNER: BUSINESS TELEPHONE:Sc)S 6 10- )q N CELL.,S62 b,q -` q7q FAX: S6'9 6,01 EMAIL:'p-06(S D7TL--04Ajk� (a?( XIS-1vPA#C0%ALT EMAIL: FED ID/SS NO: 0-35-7637 B NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: .� 226A Circle one: Septage OOGG 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. x- I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents most 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�� DATE: �D Z2, 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. W « w,,f —Icr saeodt5 1N6 Signature of Individual or Corporate Name bcl — _6J _� Z c3 _7d "Social Security No. (Voluntary) or Federal Identification Nionber By: Corporate Officer (Mandatary, if Applicable) *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. CAUsecs\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations If 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print' bly Business/Organization Name: (-eJASIC t,Jr4tFg 6E12U16-ES Address: J q'q % ��' � :Si City/State/Zip: �f21�6� Ca�/}i�12 t�u4 b�ZiPhone #: SvF Are you an employer? Check the appropriate box: L ® I am a employer with Z 6 _ 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] 3.0 We are a corporation and its officers have exercised thew right of exemption per a 152, § 1(4), and we have no employees. [No workers' comp. insurance required]" 4.R We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. Q Retail 6. Q Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. ❑ Entertainment 10,R Manufacturing 11.❑ Health Care 12.®Other I �rR1�57V1�11U1_ *Any applicant that checks box #I must also fill out the section below shaving their workers' compensation policy mtonnatron. **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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: AcAbtA P-642—APCE eP /Mores ItiSutL�N�F Insurer's Address: xaS l�62:7rH ��iS�oj�J City/State/Zip: / iration Date: Policy # or Self -ins. Lic. # �� S � �Jg03- � � Ex P 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 a a fine up to $1,500,00 and 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 for warded to the Office of Investigations of the DIA for insurance coverage verification. do hereby certify, under the pains anti penalties of perjury that the information provided above is true and crrrrect. Z7 U :L-�fTD o i�a-,_QC-7c.l 'hone #: o - e t F6.only. Do not write in this area, to be completed by city or town official n: Permit/License # hority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone #: son: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY W0000001A0711 Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 r • ♦ "—ILIABILITY INSURANCE • POLICY RENEWAL INFORMATCON PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5363803 - 11 Previous Policy No.: 5363803-10 1. Name Insured and Address Agency Name and Address 07711 Waste Water Services, Inc. (503)238-0056 dba Heritage Pumping Morse insurance Agency, Inc. 1997 Bedford Street 285 Washington Street rkdWl a,.,atar MA 02324 North Easton, MA 02356 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 043578378 Risk ID No.: 000425604 Bureau File No.: Entity of insured: Corporation POLICY PERIOD 2. The Policy Period is from 10/20/2019 to 10/20/2020 12:01 AM Standard Time at the insured's mailing address. ------------------------------------------- COVERAGE 3. 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 our liability under Part two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except NO, OH, WA, WY and states designated in item 3.A. of the Information page- D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements' WC 00 00 01 A 07 11 Includes copyrighted material of The National Council on Compensation Page 1 of 4 Insurance, with their permission. Policy No.: WCA 5363803 - 11 PREMIUM 4. The premium for this policy will be determined by cur Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below Is subject to verification and change by audit. See Schedule of Operations Minimum Premium $ .00 Date EST ANNUAL Standard Premium $ 38,684.00 Loss Constant $ .00 Expense Constant $ 338.00 Premium Discount $ -1,387.00 Estimated Annual Premium $ 37,635.00 Terrorism $ 444.00 MA D.I.A. Assessment Fee $ 1,268.00 Total Estimated Annual Premium $ 39,347.00 Authorized Signature Page 2 of 4 Includes copyrighted material of The National Council on Compensation WC 00 00 01 A 07 11 insurance, with their permission. POLICYLIABILITY INSURANCE SCHEDULE OF OPERATIONS Massachusetts Ii N WCA 5363803 - 11 Po Cy 0.: Name Insured and Address Agency Name and Address 07711 Waste Water Services, Inc. (503)238-0056 dba Heritage Pumping Morse Insurance Agency, Inc. 1997 Bedford Street 285 Washington Street Rridnwwatar_ MA 02324 North Easton, MA 02356 Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Annual Lac ST No. Classification Remuneration Remuneration Premium 1 MA 8380 AUTOMOBILE SERVICE OR 50,000 2.49 $ 1,245 REPAIR CENTER & DRIVERS 1 MA 8742 SALESPERSONS COLLECTORS 180,000 0.12 $ 216 OR MESSENGERS -OUTSIDE 1 MA 9403 REFUSE, ASHES OR GARBAGE if any 8.71 $ 0 COLLECTION & DR 1 MA 8810 CLERICAL OFFICE EMPLOYEES 400,000 0.07 $ 280 NOC 1 MA 9402 SEWER CLEANING & DR 850,000 3.92 $ 33,320 Subtotal: Premium Subject to Modification $ 35,061 9807 Increased Employers Liability Limits 1.00%a $ 351 0930 Waiver of Subrogation Factor .020 $ 701 9898 Experience Mod, Eff 10/2012019, Factor 1.030 $ 1,083 0277 ARAP 1.040 $ 1,488 Total State Standard Premium $ 38,684 9740 Terrorism 1,480,000 0.03 $ 444 WC 00 00 01 A 0711 Includes copyrighted material of The National Council on Compensation Page 3 of 4 Insurance, with their permission. ,YLIABILITY INSURANCE POLICY Policy No.: WCA 5363803 -11 Name Insured and Address Waste Water Services, Inc. dba Heritage Pumping 1997 Bedford Street Bridnewater. MA 02324 Agency Name and Address (508)238-0056 Morse Insurance Agency, Inc. 285 Washington Street North Easton, MA 02356 LOC INSURED NAME S LOCATION ADDRESS Waste Water Services, Inc. (dba Heritage Pumping) 1997 Bedford Street, Bridgewater, MA 02324 PEIN No. 043578378 07711 Page 4 of 4 Includes copyrighted material of The National Council on Compensation WC 00 00 01 A 0711 Insurance, with their permission. Christopher George From: Robert Lotterhand <roblotterhand@wwsiofma.com> Sent: Tuesday, November 5, 2019 1:08 PM To: Christopher George Subject: RE: Board of Health Permits 2020 Hi Chris, I apologize for not including that. The only FOG customer we have in Mansfield is as follows: Wendy's 64 Copeland Dr. Mansfield, MA 02048 If you have any further issues feel free to write or call me. Thanks, Rob Lotterhand Waste Water Services, Inc. Phone:508-697-9974 Cell: 781 254-2056 Fax:508-697-9979 Web: www.wwslofma.com 1997 Bedford St. Bridgewater, MA 02324 From: Christopher George <ceeorge@mansfieldma.com> Sent: Monday, November 4, 2019 12:31 PM To: Robert Lotterhand <roblotterhand@wwsiofma.com> Subject: Board of Health Permits 2020 To Whom It May Concern, The Mansfield Board of Health recently received your Septage/FOG Hauler Application. Please provide a list of all FOG customers as requested within the application. Please let me know if you have any questions. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, 1