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HomeMy WebLinkAboutAll Seasons Septic Service, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: KEVIN ORLANDO Doing business as: ALL SEASONS SEPTIC SERVICE, INC. 200 CUSHING STREET, SUITE 7 STOUGHTON MA 02072 Town of Mansfield 6 Park Row Mansfield, MA 02048 is hereby granted a SEPTA GE PUMPING AND TRANSPORTING PERMIT to engage in the pumping or transporting of the contents of privies, cesspools, septic tanks and other offensive substances. This permit is granted in conformity with the STATE ENVIRONMENTAL CODE. 310 CMR 15.02(2) and MGL chapter 111 section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 1 TRUCK REGISTRATION NUMBER(S): J93012 P62004 T90076 BOARD OF HEALTH MichaeCHeaCey, Chairman 9wo1^ ' NOV Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: /01m�/s / LICENSE NUMBER: BUSINESS NAME: /9// S�� 5'� r ,S�h �' /7 r C c one . MAIL ADDRESS: cU &ze TOWN: S;Vez,U? Vr,-2 STATE: ZIP CODE: �- NAME OF OWNER: BUSINESS TELEPHONE: c464 P-­�A h'` CELL: FAX: E-mail: ol/ Pe�;Sa,n� 11L41 �- � 6J �r2 -ct-) e_6mAlt E-mail: FED ID/SS NO: O-V, 31117 -61,=3 NUMBER OF TRUCK(S): / REGISTRATION NUMBER(S): 19,3 0 /a;, FEE PER TRUCK: $100 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansf' Six Park Row, Mansfield, MA 02048, SIGNATURE: i DATE: loIok ..................... ....... . ....... ...... .. .... ­ ........................................................... I ........ % ............................... TRUCKS INSPECTIONS: DATE: OVEMBER 8, 2018 TIME: 7:30am-10:30am PLACE: FOXBOROUGH DPW, 70 ELM STREET, FOXBOROUGH PLEASE BE THERE OR CALL (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOR HEALTH AGENTS USE ONLY 310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.502 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents. 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. A. Mobile Tank: _ Securely mounted on truck _ Watertight _ Leak -proof cover Tight discharge tanks = Acceptable NA =Not Acceptable B. Venting of Mobile Tanks: Vent permits escape of gas, but not liquid C. Hose: Suction or pressure hose in good repair D. Pumps: Maintained to prevent leaking of sewage Inspected by: Inspected on: 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. r; Signature of ividu or Corporate Name By: Corporate Officer (Mandatory, if Applicable) i CJ,f- 6,41% /-S-3 *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\slcite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Department oflndushiaCAccidents Office of Investigatdons 600 Washingion Street Boston, AM 02111 ` www massgov/dia Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers Aimlicant Information Please Print Legibly Name (Business/organization/individual): Address: All Seasons Septic Service, Inc. 200 Cushing St., Ste. 7 City/State/Zip: Stoughton, MA 02072 Phone #: 866-822-6846 Are you an employer? Check the appropriate box: Type of project (required): 1. [-)S I am a employer with 4 4. 0 I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub -contractors have g. 0 Demolition working forme in any capacity. employees and have workers' insurance.$ 9. ❑ Building addition (No workers' comp, insurance comp. 5. ❑ We are a corporation and its 10.0 Electrical repairs or.additions required ] 3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.® Other employees. [No workers' comp. insurance required.] •Any applicant that checks box #l: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 than hire outside oontraci is must submit a new affidavit indicating such. Tcont actors that check this -boa must attached an additional sheet showing the name ofthe sub -contractors and state whether or not those entities have employees. If the sub -cunt actors.have employees, they must provide their workers' comp. policy number. lam an employer that isproviding workers' compensation insurancefor my employees: Below is thepolicy andjob site information. - Insurance Company Name: Utica National Insurance Group Policy # or Self4ris.. Lic. #: 4101564 Job Site Expiration Dom. 4/14/2019 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 ce ams and penalties ofperjury that the infonnatii� n pFovided overy and correct VOL .s` c;o„at,,,•e• i _ __ Date: Officiai use only. Do not write in this area, to be completed by city or town ofNeW 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 #: A� V CERTIFICATE OF LIABILITY INSURANCE OATE(MM/ODYYYY) 7/16/2018 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 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 Maria Andrade NAME: PHINE E (781) 335-1589 FWC AX(781)335-0287 -MAIL mandrade@aebarnes.com ADDRESS: INSURERS AFFORDING COVERAGE _ NAICO INSURER A:Re ublic-Franklin Ins Cc 12475 INSURED All Seasons Septic Service, Inc; Orlando 5, Inc. 200 Cushing Street #7 Stoughton MA 02072 INSURER B:Pil rim Ina. Co. 21750 INSURERC:Utica Mutual Ins Cc INSURER D: INSURER E : 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1S41746262 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 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. INSR TR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER MM/�I�Y� MMIDD//YYYPY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE aOCCUR CPP4104867 2/12/2018 2/12/2019 EACH OCCURRENCE $ 1,000,000 PREMISES Ea ocDAMAGE TO cur ence $ 500,000 MOD EXP(Any one person) $ 15,000 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY FJECOT �LOC OTHER: GENERAL AGGREGATE $ 2,000,000 X PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS CSCOOOOIO01473 2/12/2018 2/12/2019 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peramidenl1 $ Uninsured motorist combined $ 25/50 UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED I I RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE NH) WMEEXCLUDED? OFFICE In ( NH) (MandaIN]tory If yes, describe under DESCRIPTION OF OPERATIONS belo•.v NIA 4101564 4/14/2018 4/14/2019` X STATUTE X ERH E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CFRTIFlr.ATF HOI nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Preston Hoffman/MA7 ✓,. •/!Fv':�% ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) INS025011141H1 The ACORD name and logo are registered marks of ACORD Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ FOxb01'OUgh ❑ rI MH�e Nn1A Nn.Nnn 1'1 Plntnvnln Company Name: Address: Telephone #: Operator at Inspection: Tunic Capacity: Truck License #: Registration Exp. Date: l 71-19 t'C Track Inspection obile Tank (securely mounted on buck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) M�Venting available to allow the escape of gas on Mobile Tanks (properly constructed) ❑"Suction or Pressure Hose in good repair (leak proof) Date (Updated: Sept nbar 20M) Annual Collaborative Septic Hi Inspection Ida (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ roxborough ❑ Company Name: Address: Telephone #: Operator at Inspection'. Tank Capacity: Truck License #: Registration Exp. Date: Truck inspection 0 Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) ❑ Venting available to allow the escape of gas on Mobile Tanks (properly constructed) ❑ Suction or Pressure Hose in good repair ❑ Pumps (leak proof) /ter J//,////�"/f�.//�f✓ Oper ifor at Inspec Date (Updated, Sepionber 2016) f Ins ecdgn Dff �(In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed ith? (check all that apply) ❑ Toxbo'ough ❑ Mansfield [Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp, Date: J xk Zed; 0 (la 0�- lawl, c> ,�,7� )-9-/ S Truck Inspection (Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) / Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure hIose in good repair umps (leak proof) Operator Date (Updated: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 1d119�/g �± " �j LICENSE NUMBER: BUSINESS NAME: fill 1n_.ccS'OrJs �e� � SIV, `L' e.. , :��O ' MAIL ADDRESS: o20U o2aShiJt j S�f, O A �e TOWN: S_1'"jjVV i STATE: M 1'S- ZIP CODE: NAME OF OWNER: BUSINESS TELEPHONE: ®6L BSA 68/ACELL: FAX: E-mail: Gt//Jet fpn i 6IA6 ce_ P yQI w. cOmAlt E-mail: FED ID/SS NO: 04- �-Pe.23 NUMBER OF TRUCK(S): / REGISTRATION-NUMBER(S): jrj 3 0 /a� 'P6 d 0 0 -/, 7 V e 6 /6 FEE PER TRUC$100 Please make appropne a changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mans, Six Park Row, Mansfield, MA 02048. j SIGNATURE: ,,-'DATE: 4 TRUCKS INSPECTIONS: DATE: OVEMBER 8, 2018 TIME: 7:30am-10:30am PLACE: FOXBOROUGH DPW, 70 ELM STREET, FOXBOROUGH PLEASE BE THERE OR CALL (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOR HEALTH AGENTS USE ONLY 310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.502 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents. 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. A. Mobile Tank: _ Securely mounted on truck _ Watertight _ Leak -proof cover Tight discharge tanks A = Acceptable NA = Not Acceptable B. Venting of Mobile Tanks: Vent permits escape of gas, but not liquid C. Hose: Suction or pressure hose in good repair D. Pumps: Maintained to prevent leaking of sewage Inspected by: Inspected on: