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HomeMy WebLinkAboutCroome Sanitation, Inc. - 12/31/2020Zvp. olt?sfield - Board of Health Septage/FOG Haulers Application BUSINESS NAME: LR00rAF SANITA�IOrJ MAIL ADDRESS: 2-6 14 I L-LS I DE A vE TOWN: RCt46 0>OTH STATE: I'VA Town of Mansfield 6 Park Row Mansfield, MA 02048 DATE: LICENSE NUMBER: LNG NAME OF OWNER: EAI-L .-T-I C"0vAC S� BUSINESS TELEPHONE: J©S )SZ bgCELL: EMAIL: Cvoo,Me � i Tr �1nY Q Co�Ct S i , rtei ALT EMAIL: FED ID/SS NO: 0 y — of (3 2-2`7 NUMBER OF TRUCK(S): FEE PER TRUCK: /fro , o-o Truck Registration number: 4119 Truck Registration number: ' f / :3 X M Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: ZIP CODE: U I' WA Z Circle one: �S`e� �tagge FOG Circle one: Se FOG 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: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 °'7 z DATE: TAX CERTIFICATION FORM I certify tinder 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. Cf ooyv-e Y,tJ,-fie0 -TL_4 C Signature of Individual or Corporate Name O�-3131 2-2-7� "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. C:Wseis\sleite\Desktop\Scott's Docnments\Food Establishments-Temp\TAX CERTIFICATION FORM.doc WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001B0115 Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5089473 - 16 Previous Policy No.: 5089473-15 1. Name Insured and Address Agency Name and Address 07431 Croome Sanitation Inc (508) 824-8666 26 Hillside Avenue FBinsure Rehoboth, MA 02769 P.O. Box 509 Taunton, MA 02780 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 042472921 Risk ID No.: Bureau File No.: 000158630 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 04/06/2019 to 04/06/2020 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 Land 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 ND, 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 B 01 15 Includes copyrighted material of The National Council on Compensation . Page 1 of 4 Insurance, with their permission. daze t 'ATTa@BBBZrBBBverrd8%B r lda"(ass'racd'BetsreSfs %®IP�6 A'ga �.CB�'BA�bUFA3o8�'�d&Ffl insurance AORdav& QmelR@'ral �tltn&flIlQ;4f7�'� / I� e�a�tiw� �Bati®a°� aaa�S®aa .Pala s�3tt LFt� , a g aHauy �ttSiRrP.S:i/Ux' Ra[aizc'ttion.Nanne; P-romom- Narx.i. Avtalvnme• 26 IIi.Ii,side Ave„ Rehoboth, MA 02769 Are yen an craployta-? 17heck tilt appR'opriate box; 1. C11 I ant a employer with .- enrptoyres (hill and/ or pail-Eitue).^' 2. ] jam a solo proprieenr or lRartnerslrip and have no employees working for pre in any capacity. [No workers' comp. iti.armice requited] 3. (_] We are a corporation and its officols have exereised their O hoof exemption por C. 152, ,rj1(41 and ive have no cnepinyees, fido workers' comp, insurance wM.d M' 4. (,3 We area nna-profit organization, staffed by volunteers, with nn e_m1}loyecs. [No workers' (omp. Insurance MCI.) Auy applicant ihnt cheeks box hSl must niso fill out the erutivn hmov ahm+ingthe it tisaekehs' cntup4risation t nit y utfon'nAnotr 1f tho wipor:te officers have exonpteA tkemsehves, bur the a pompon has otlrr employes, a uo[kers' cantponsition Lnhcy is tegoiNA <nd",m orgaoizatiou should check box 01. (ant MP et7R,(Id0}'L'i ital IsinovT(IIMg TV01.1fe®.4' COFid71c'i],S!@PI088 t`F8.4'!4Y(rYAC(_fQlb' jnj? emp1q),eaY, 134110I1? I4 the P&He6' %7B,lOYBI lah' l@. InsumieecinapauylAmc: Acadia Tns,ttrance 1.'bolto 508-25211-4668 Business Type (requIR'ed): 5, 1_] Iketail 6, 1-1 Best nrantl(Dar/tiatiu}, Gstablishntent 7. ( Office and/or Sales (incl, real estate, tnno, etc.) a. (] Non -groin 9, (_� Inteaiaipment a4mothicturitat r HenIYh Caro r�.( gnc�r Sra1�L•ic. .uerer-J00a Insurer's Address: 290 Donald 0. Lynch I1.1 V - Marlborough, MR 01 752 4710 CitylStatc/7i1r: — _ WCA �089_47� 1l Policy n of Snms l c l..- --------- Attack . . fB copy of the wnx'l(e:®:4' e0@}HpenSntion policy declaration page 0hom ing; the policy unittItel'and C%lDlfi titlnlx Cla4k:). b`aihn c Cn sc:curc cnvcral;o as rectuired under Section 7.5A- tW?AGL c. 157 crn lend to the imposi0mt of uknhml 1111wh es "fa One up to p1,500A0 and/or one-year iulprisomuent, ae evell as civil penalties in the rota of a S'I'OP 6vgltl( Qit))F.lt and a lit 1 of up to ,h7.5U,00 a day against rite Minton Be advtsv. that a evpy of tNs statement envy oe torwaedcd to the ofticc of Investigations of the l)IA for instn'ance covet<ge veril_iciniOn. Ada hereby cea'ddfp, aanAV ehe palms and p aautedev af}rcrit@ay that (Ire h@ ernutdon providedabove n (rite (Ind corrcre, 506-252-4668 Earl T.P. CrO01110r Jr. — President f(ifjh tar! rase wady. Do real tvrdee lu ehle area, /it he Completed c!p 4•d(p or aoel'a (?/ at I l; City nr'I'on'U: _------'---_�....--_--. 1'et•mit/License Issuing Authority (circle one): 1. Board of health 2. Building Department 3. t atyffown Clerk 4. licensing Board A 1 ciccttnen's Office l L, 6.Other �'. II Contact Pe son Phone t I