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HomeMy WebLinkAboutAll Seasons Septic - 12/31/2020ro a� u Town o19 AIahsfield - Board of Health OCT Z6 20 t Disposal Works Installer Application LICENSE NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 APPLICANT: :I BUSINESS NAME: MAIL ADDRESS: CITYITOWN: BUSINESS PHONE: BUSINESS FAX: E-mail: Alt E-mail: ALL SEASONS SEPTIC SERVICE 200 Cushing St., Ste 7 Stoughton, MA 02072 p: 866-822-6846, f: 781-344-5788 allseasonsoffice@yahoo.com DERAL IDISS NUMBER: 0:/3 y _?r BUSINESS CELL: LICENSE HELD: Town }(�� LICENSE HELD: Town LICENSE HELD: Town_✓ ZIP CODE: Year Licensed Year Licensed Year Licensed I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage". I understand that deviation from them may be cause for revocation of this permit. Permit Expires December FEE: $ 100.00 SIGNATUREf " DATE: Please make appropriate changes. jSin?dete, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 October 18, 2019 Onsite Disposal Works Installer: Town of Mansfield 6 Park Korv, Mansfield, Marradwsetts 02048 Health Department Anry Damoau-Pabnm MPH, AS Health Agent Your current Disposal Works Installer Permit will expire on December 31, 2019. To renew your permit, please submit the following documents and payment to the Health Department. 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. ❑ Disposal Works Installer Permit Application (Attached) Ff Tax Certification Form (Attached) d Workers' Compensation Insurance Affidavit: General Business. (Attached) I/ 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. Please contact the Health Department if we can be of any additional assistance. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Emailalpalrner@marrafeldma.com f►wwww� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYY) 09/18/2019 THIS CERTIFICATE IS ISSUED ASA 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 lieu of such endorsement(s). PRODUCER A.E. Barnes Insurance Agency, Inc. 141 Pleasant Street P. O. BOX 85 South Weymouth MA 02190 CONTACT NAME: Sharon E. Williams PAHCN oBan, (781) 335-1589 1 (FMA)CI.Na): (781) 335-0287 EMAIL swilliams@aebarnes.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC 11 INSURERA: Republic -Franklin Ins Cc 12475 INSURED All Seasons Septic Service, Inc; Orlando 5, Inc. 200 Cushing Street #7 Stoughton MA 02072 INSURERS: Pilgrim Ins. CO. 21750 INSURERC, Utica Mutual Insurance Cc 25976 INSURER D: WR 1 INSURERF: CLIVFRAAFS CERTIFICATE NUMBER: CL194883343 REVISION NUMBER: 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 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. LTR TYPE OF INSURANCE I SD WVD POLICY NUMBER MMIDDIYYYY MMIODIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 Cl -AIMS -MADE OCCUR PREMISES Eaoxupence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL A ADV INJURY $ 1,000,000 A CPP4104867 02112/2019 02/12/2020 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY JE LOCEl LOC PRODUCTS - COMP/OP AGO $ 2000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ ANYAUTO B OWNED X SCHEDULED v AUTOS ONLY AUTOS CSCOOOOI001473 02/12/2019 02/12/2020 BODILY INJURY (Par accid.nt) $ PROPERTY DAMAGE $ Per accident HIRED v NON -OWNED X AUTOS ONLY X AUTOS ONLY $ UMBRELLA LIAR OCCUR EACH OCCURRENCE It AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION $ $ 0 WORKERS COMPENSATIONOTH- AND EMPLOYERS' LIABILITY YIN ANY OFFICE MEMBERIPARTNDED'I GUTIVE (MandatoryIn NH) EXCLUDED? (Mas, NIA 4101564 04/14/2019 04/14/2020 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 descb and Dyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 7- DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Specimen for Record Only. CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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 REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD c' x_\ The Commonwealth of Massachusetts Department of LtdustrialAceidents �(f 15,1 Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):AII Seasons Septic Service, Inc. Address: U 200 Cushing Street, U#7 C4......1.4.... ILIA nonw occ onn coec rrione if: 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. El I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 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.$ 5. ❑ 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 11: ❑ 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 -contractors have employees, they must provide their workers' comp, policy number. I ant an employer that is providing workers' compensation insu ance for my employees. Below is the policy and job site information. Insurance Company Name: Utica Mutual Insurance Co. Policy # or Self -ins. Lie. #: 4101564 Job Site 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 line 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)9surance coverage verification. I no hereby cgrtjfy unr�KX pains and penahies ofpetytay that the information provided above is trite and correct. 9/19/19 Official use only. Do not write is 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M Christopher George From: Kevin Orlando <allseasonsoffice@yahoo.com> Sent: Thursday, November 14, 2019 1:39 PM To: Christopher George Subject: Re: Board of Health Permits 2020 Sorry for the delay. The answers to your questions are as follows; Sharon: every year, for the last decade Walpole: every year, for the last decade Avon: for the last five years "Septage" for each truck listed Regards, Laurie All Seasons Septic Service, Inc. 200 Cushing St., Ste. 7 Stoughton, MA 02072 ph: 866-822-6846 Ex: 781-344-5788 On Wednesday, October 30, 2019, 10:25:12 AM EDT, Christopher George <cgeorge(cmansfieldma.com> wrote: To Whom It May Concern, You recently submitted applications for Disposal Works Installer and Septage/FOG Haulers with the Town of Mansfield's Board of Health. We are missing information on the applications. Please see below for details and respond with the required information to continue your application process. Disposal Works Installer Application: Please provide a list of at least three Towns in which a Disposal Works Installer Permit is held and the years licensed. Septage/FOG Hauler Application: For each truck listed, we ask that you identify if they're for Septage or FOG. Please let me know the designation for each of the following trucks listed on your application. o Truck: P62004 o Truck: J93012 o Truck: T90076 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, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. 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 dfficq{Mandatory, if Applicable) "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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc