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HomeMy WebLinkAboutAll Seasons Septic Service - 12/31/2020Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 OCT 2019 "'i Septage/FOG Haulers Application -^ DATE: LICENSE NUMBER: BUSINESS NAME: ALL SEASONS SEPTIC SERVICE MAIL ADDRESS: 200 Cushing St., Ste 7 Stoughton, MA 02072 TOWN: p: 866-822-6846, f: 781-344-5788 ZIP CODE: NAME OF OWNER: allseasonsoffice@yahoo.com k`ftre".11E„d1 C, BUSINESS TELEPHONE: CELL: FAX: EMAIL: ALT EMAIL: FED ID/SS NO: U NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: GLr`/ f Circle one: FOG Truck Registration number: J �_'3! / T Circle one:FOG We Truck Registration number: 7- 9 ��� T Circle one: FOG Truck Registration number: Circle one:FOG Truck Registration number: Circle one: Septage ............................................................................................................................................ FOG 1012,111 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 o rs for BOH records. _ I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be complbtey signed and returned to the Health Department with the appropriate payment. Checks can be made paya a t Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. DATE: 7A �� ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE 09118/201918/2019 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsement(s). PRODUCER A.E. Barnes Insurance Agency, Inc. 141 Pleasant Street P. O. Box 85 South Weymouth MA 02190 NAME; T Sharon E. Wlliams (71) 3@35-1589 7 E:x: Eswi6ebarnes.com INSURER(S) AFFORDING COVERAGE NAIL N MSURERA: Republic -Franklin Ins CO 12475 INSURED All Seasons Septic Service, Inc; Orlando 5, Inc. 200 Cushing Street #7 Stoughton MA 02072 INSURER B: Pilgrim Ins. Co. 21750 INSURERC: Utica Mutual Insurance Co 25976 INSURER D: INSURER E : 1 INSURERF: CnVFRAnFC CERTIFICATE NUMBER: CL194883343 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. SR LTR TYPE OF INSURANCE ADDL D SUER WVD POLICY NUMBER MOLIC/YEFF PMODYEFF POLICY9XP P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE NIOCCUR DAMAGE IURIENIIED PREMISES Ea occurrence $ 100,000 MED EXP(Any oneperson) $ 5,000 PERSONAL SADV INJURY $ 1,000,000 A CPP4104867 02/12/2019 02/12/2020 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMPIOPAGG $ 2.000,000 X POLICY ❑ JECOT El LOC $ OTHER: 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ANVAUTO B OWNED M SCHEDULED AUTOS ONLY HIRED NOWOMED ONLY AUTOS ONLY CSCOOOOIO01473 02/12/2019 O2/12/2020 BODILY INJURY(Per accitlent) $ (Per acuden DAMAGE $XAUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ $ 0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN V / N CUTIVE � ANY PROPRIETOREXCL EXCLUDED? OFFICE(MandataryIn NH) EXCLUDED9 (Mantlatory In NH) NIA 4101564 04/14/2019 04/14/2020 vl PER ER E.L. EACH ACCIDENT $ 1,000,000 E. L. DISEASEEAEMPLOYEE $ 1,000,000 E. L. DISEASE POLICY OMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached If more space Is required) Specimen for Record Only. CPRTIFICATF Hnl nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVEJN,' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ,_ Department oflndustrialAccidents (j 1 f r' Office of Investigations �= 600 Washington Street �. ? ,- ix Boston, MA 02111 www.n:ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual):AII Seasons Septic Service, Inc. Address: LQ1 200 Cushing Street, U#7 CM�...6«.... nnA Mf170 naa.. 000 RnAR t-none Are you an employer? Check the appropriate box: 1. ® I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 5• ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.® Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contactors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the police and job site information. Insurance Company Policy # or Self -ins. Lic. Job Site Utica Mutual Insurance 4101564 Expiration Date: 4/14/2020 City/State/Zip: 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 c wil tort! a pains rind penalties ofpeifiny that the information provided above is trite and correct. c:....on....• ilmte• 9/19/19 Official rrse only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Permit/License # 3. City/Town Clerk 4. Electrical inspector 5. Plumbing inspector Contact Phone Town of Mansfield 6 Park Amv, Mansfield, Massadjuselts 02048 Health Department AnP, Donovan -Palmer, MPH, AS Health Agent October 18, 2019 Septage/FOG Haulers: Your current Septage/FOG Hauler Permit will expire on December 31, 2019. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 27, 2019. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. ❑ Septage/FOG Hauler Permit Application (Attached) Rr Tax Certification Form (Attached) ;�- Workers' Compensation Insurance Affidavit: General Business. (Attached) 2' Workers' Compensation policy declaration page. The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address. The current Mansfield BOH fee is $100 per truck. According to Title 5, 310 CMR 15.505(1), all trucks that transport the contents of privies, cesspools, septic tanks or tight tanks must be inspected and approved by the Health Department. For the 3`dyear, there will be a joint truck inspection held at the Foxborough DPW, 70 Elm Street, Foxborough, MA, on November 131h, 2019, from 7:30am-10:30am (see flyer). PLEASE DO NOT BRING PAPERWORK TO THIS EVENT. Paperwork should be submitted directly to the Health Department. The Health Department is electronically tracking local pumping, as required by Title 5. Please submit the attached form electronically monthly. Please contact the Health Department if we can be of any additional assistance. Sincerely, rr1 �)am - Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Emailadpalmei@manrfieldma.com 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 dffic'O' landatory, if Applicable) 0_S4- 3 '119 2�,Z3 "Social Security No. (Voluntary) 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. 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