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HomeMy WebLinkAboutUnited Site Services Northeast, Inc. - 12/31/2020V 2 2ti� Town of Mansfield Town gf2Mansfield - Board of Health 6 Park Row - Mansfield, MA 02048 Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME: MAIL ADDRESS: it f j—lande is R d TOWN: 064-ro sv STATE: IL( rt. ZIP CODE: O l.i F- / NAME OF eWNER:- Mq r 41 601el k o BUSINESS TELEPHONE:,6,sp$-yo6 -Sb3ffCELL: ,50P- 839-- 33 96AX: EMAIL: doKALTEMAIL: FED ID/SS NO: O �- �j� �3v� a NUMBER OF TRUCK(S): C9 FEE PER TRUCK: Truck Registration number: S'VO "/t %%J Circle one:W!e FOG Truck Registration number: Circle one:FOG Truck Registration number: 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:OOAM PLACE: FOX.BOROUGH 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/d DATE: ��� 9 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. ignature of lndivi ual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Volantany) 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:\Uscrs\sleite\Desktop\Scatrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Page 1 of 1 A �Qb CERTIFICATE OF LIABILITY INSURANCE DAT1/01/2019 ) 11/Dl/2D19 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 Ilea of such endorsement(s). PRODUCER Billie of Greater Kansas, Inc. c/o 26 Century Blvd P.O. Bea 305191 CONAME:TACT N PHONE 1-877-945-7378 FAX1-888-467-2378 EMAIL ADDRESScerti£icetes@Willis.com INSURERS AFFORDING COVERAG E NAICS Nashville, IN 372305191 USA INSURER A: safety National Casualty Corporation 15105 INSURED INSURER B: El' Specialty Insurance Company 37865 United Site services Northeast, Inc. 118 slanders Road, Suite 1000 INSURER C: INSURERD: Weetboroegh, MA 01581 INSURERS; INSURER F: r,nrAtc W13692338 RFVLSIDN NUMBER: v 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. E OF INSURANCE ADD S aR POLICY NUMBER MMIDpYEFF MMID�YATYY LIMITS IAL GENERAL LIABILITY FACHOCCURRENCE S 1,000,000 S-MADE � OCCUR PREM SES Ee ocot ante S 1,000,000 MED EXP(Any one pmsan) $ 10,000 WLIABIUW GL4057707 11/03/2019 11/03/2020 PERSONAL a ADV INJURY S 1,000,000 ATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOP AGG $ 2,000,000 nT LOC COMBINED SINGLE LIMITABILITY (Ea acaltlanl $ 3, 000,000 BODILY INJURY (Per Person) S )C ANY AUTO BODILY INJURY(Pmv,ddmA) $ A OWNED SCHEDULED AUTOS ONLY AUTOS WIRED NON-0Ve1JED AUTOS ONLY AUTOS ONLY CAS4047379 11/03/2019 11/03/2020 PROPERTY DAMAGE Par HWldenl $ $ e X UMBRELLA LIAR EXCESS LIAB X I OCCUR CLAIMS -MADE U500076933LZ19A 11/03/2019 11/03/2020 EACHOCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I K I RETENTION$ 10,000 WORKERS COMPENSATION X( STATUTE �RH $ E.L. EACH ACCIDENT S 1,000,000 A AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE No OFFICERIMEMBER EXCLUDED? (Mandatory In NH) It yes, describe urMer DESCRIPTION OF OPERATIONS below NIA MS4047370 11/03/2019 11/03/2020 E.L. DISEASE -EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllonal Remarks Schedule, maybe adached If mote ¢pace is required) CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED DRREPRESENTATIVE EVIDENCE OF INSURANCE '• " ©1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD -- 10: 18763343 BATCH: 1437932 T7ie Commwnvealth of Massach useds U,pDepartment oflndustrialAceidents I Congress Street, Suite 100 Boston, MA 0211120I7 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses, TO DE FILED ATM THEr PERMITTING AUTHORITY, AppHeantInformation f Please Print Le 'bly Business/Organization Narne: 2 <�. ��i �. S e e j- C F S JU,.3a Q-g.4 { i no. Address: 11 9 F (p. it d e 1-5 /Z�,. City/State/Zip; (Dees k,,eovz-Qf<i( 40155'9( Phone#: ! dam- Tas fs Are you an employer? Checkthe appropriate box: 1. Z I am a employer with a 3 8 employees (full end/ or part-time).* 2. ❑ I errs a sole proprietor or partnership and have no employees working forme 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 orgarilmdon, staffed by volunteers, with no employees, rNo workers' comp. insurance real Business Type (required); 5, []Retail 6. QRestaurant/Bar/Ealing Establishment 7. ❑ Office and/or Sales (inel. real estate, auto, etc,) 8, Q Non-profit 9. ❑ Entertainment 10.t] Manufacturing ll. [] Heallb Care 12,0 Other I 'Qrr6 IS *Auy applicaut that checkr box It muscats. fill out the section below showing [heir workers' corepersattion policy information, *+If the corporate officersbave exunpled themselves, but lho corporation has olhcr employees, a workers' compensation policy is rcquurd andsuch an organbetion should cheek box kl. I ont an employer I/sm is providing workers' compalsall n In It nce jar my employees Below Is rite policy ll jorma#orr. Tnsmanca Company Name; Gc"—Pr �+z /�%c(4t2Ch" Insurer's Address: 1 B L Ea. City/state/zip: Policy If or Self -ins, Lie, # j-1 S 4 M -� 3 -� Q Expiration Date: I I 3 I_ciin- 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 ofMGL e. 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 is 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 bereby Offleial use only. Do not wrife In tfit's area, to be completed by city or imvrs official. above is true cold correct. 112P16 % City or Town: rermit/License # 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