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Home My WebLink AboutBaker Commodities, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: JAMES ANDREW Doing business as: BAKER COMMODITIES INC. 134 BILLERICA AVENUE NORTH BILLERICA MA 01862-0132 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 I II section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 22 TRUCK REGISTRATION NUMBER(S): MA95642 BOARD OF HEALTH AichaeCHeaCey, Chairman Septage Pumpers Application DATE: / LICENSE NUMBER: L fCf/C" ild�<S /fIL BUSINESS NAME: MAIL ADDRESS: lj,Y TOWN: IV, jjSTATE: A/ NAME OF OWNER:i lG/i�,5i✓/ tJf �cf�f BUSINESS TELEPHONE: } -fy%ELL: E-mail:i�/�Zr`Cnre✓'c� �rff<ra"'f�'f�l:"t%.�'i�o'��rAltE-mail: ZIP CODE: ,f6 L, C%ii r✓Sf�FAX: �,�� .Jif�� FED ID/SS NO: 75 —,W,7 J JjY NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): /; 1ve vt FEE PER TRUCK: 11: — Town SIGNATURE: TRUCKS INSPECTIONS: DATE: I DATE: _ ,fie `- r/'? ......................................................................... TIME: PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO. MAIN STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THESE DATES 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: 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 Officer (Mandatortj, 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:Wsers\sleite\Desktop\Scott's Documents\Food Establishinents-Temp\TAX CERTIFICATION FORM.doc Qyff fee ®j J18fl9iS'tie8agacvrsv 600 V.,ashington Street = Bosfony MA 02111 t*� ' pNkvfV.tigass. gov1dia Workers' Con"PensaltiOn Insurance Affidavit: GenelrM Businesses 1F9ea§e &_rin Busiuesstloyganization Male! L& Kt (— Address: a City/State/Zip: Are you all employer? .Check the appropriate box: 1. IS I all, a employer with �4 employees (full and/ or part-time)." 2,[71 1 all, a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. [J We area 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 organization, staffed by volunteers, with no employees, [No workers' comp, insurance req.] Business Type (required): 5, ❑ Retail, 6. ❑ RestaurantlBar/Eating Establishment 7. ❑ Office and/or Sales (inct, real estate, auto; et 8, ❑ Non-profit 9. ❑ Entertainment 10.[] Manufacturing 11.❑ Health Care 12, O Other S er V 1 G "Any applicant that checks box N l must. also Fill out the section below showing their workers' compensation policy information, —I f the corporate officers have exempted themselves, bill the cotporalion has other employees, a workers' compensation policy is required and such an organization should check box VI ^TN an: an employer that I'spro viding workers' cornpensahon if1914 Pail ce joP my employees. Belo Ill is the policy informati Insurance Company N Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie, # Expiration Date: Attach a copy of tine workers' compensation policy declaration page (showing the policy number and expiration dr Failure to secure coverage as required under Section 25A of MIR c, 152 can lead to the imposition of criminal penalties tine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and 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, X do hereby certify, under the pains and penalties of perjury that the information provided above is trite and correct. Si nature: ^' ( ljXIA0 r Date rt— / 0 — Official use only, Do not write in 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/'gown Clerk 4. ]Licensing Board 5. Selectmen's Office . � ® n7�:�u u; r *s £.%eYarr„en; of'rraw;spmYxtlan OT rtegists y of Motor Vehicles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2018 EXPIRATION DATE: 06/30/2019 MAILING INFORMATION BAKER COMMODITIES INC PO BOX 132 N BILLERICA, MA 01862-0132 IRP REGISTRANT INFORMATION — ACCT/FLEET/YEAR/S U PP: 768.1-2018-0 LEGAL NAME: BAKER COMMODITIES INC DBA NAME: ADDRESS: 134 BILLERICA AVENUE N BILLERICA, MA 01862 USDOT: 34909 NAME: BAKER COMMODITIES INC ADDRESS: 4020 SANDINI BLVD VERNON, CA 90058 PLATE: 95842 UNIT#: 7 VIN: 1FVHG3DV7FHGP3956 PLATE TYPE: APN UNLADEN WEIGHT: 18508 VEHICLE TYPE: Truck MAKE: FRHT FUEL: Diesel OWNER: BAKER COMMODITIES INC MODEL: 114SD COLOR: White INSURANCE COMPANY: TRAVELERS INDEMNITY CO YEAR: 2016 SEATS: NA SERVICE REPRESENTATIVE: JJur Weight J_ur Weigh JJri Weight Jurr Weigh Jtur Weight Jur Weight AB 24493k GA 54000 ME 54000 NJ 54000 PE 24493k WA 54000 AL 54000 IA 54000 MI 54000 NIL 24493k OC 5 AXLE WI 54000 AR 54000 1D 54000 MN 54000 NM 54000 RI 54000 WV 54000 AZ 54000 IL 54000 MO 54000 ' NS 24493k SC 54000 WY 54000 BC 24493k IN 54000 MS 54000 NV 54000 SD 54000 CA 54000 KS 54000 MT 54000 NY 54000 SK 24493k ** **** CO 54000 KY 54000 NB 24493k OH 54000 TN 54000 ** " CT 54000 LA 54000 NO 54000 OK 54000 TX 54000 DC 54000 MA 54000 ND 54000 ON 24493k UT 54000 DE 54000 MB 24493k NE 54000 OR 54000 VA 54000 FL 54000 MD 54000 NH 54000 PA 54000 VT 54000 *' Issued under the authority of the Registrar of Motor Vehicles for the Control: 8001-1325-1867 Massachusetts Department of Transportation. UL e ,&w� Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 www.massrmv.com Agr A`O CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDNYYY) 04102/2018 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. IMPORTANT: If the certificate holder is an ADDITIONAL 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 onndorsement(s). PRODUCER NAME: MARSH RISK & INSURANCE SERVICES PHONE FAX o 777 SOUTH FIGUEROA STREET ) CA LICENSE #0437153 ADDRESS: LOS ANGELES, CA 9D017-5822 INSURERS AFFORDING COVERAGE NAIC# Attn: LosAngeles.CertRequest@marsh.com IF: 212-948-0535 25674 400036-BAKER-GAWU.18-19 INSURER A: Travelers Proe Casualty Go of America INSURED INSURER B : N/A NIA INsuRER c The Travelers IndemnilY Com an BAKER COMMODITIES INC. B. C. DRAIN SERVICE, INC. THE GREASE COMPANY INSURER 0: INSURER E : ISLAND PUMPING AND SERVICES, INC. 4020 BANDINI BOULEVARD VERNON, CA 90068 INSURER F: co. COVERAGES I tzm I Irwn l c ___----- .-._-. OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE' POLICIES TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSft TYPE OFINSURANCE ADOL SUBR POLICY NUMBER POLICY EFF MWDDNYYY PMIOLICDOIYYYY EXPY M LIMITS LTR A X COMMERCIAL GENERAL LIABILITY TC2JGLSA419J6422-TIL-18 04101/2018 0410112019 EACHOCCURRENCE $ 1,000,000 _ DA A TO RENT `T PREMISES Ea occunence $ 100,000 El OCCUR 5,000 CLAIMS -MADE MED EXP(Any one person) It PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X ❑ JECT El LOC POLICY OTHER: TC2JCAP419J6434-TIL-78 04"I120" 0410112019 COMBINED SINGLE LIMIT Ea awident $ 1,000,000 A AUTOMOBILE LIABILITY BODILY INJURY (Per person) s A X ANY AUTO TC2JCAP419J6446-TIL-18 04I010018 0410112019 BODILY INJURY (Peracciden) $ A X OWNED SCHEDULED 7JBAP419J646A-TIL-18 0410112018 04N1I2019 AUTOS ONLY AUTOS X HIRED X NON-0WNED APD ComplColl Deductible: $25,000 PROPERTY DAMAGE Per accitlenl $ AUTOS ONLY AUTOS ONLY It UMBRELLAUAS OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ OTH X PER_ $ 01011201Q.::;: A WORKERS COMPENSATION TC2JUB419J2804-TIL-18 ,' STATUTE C AND EMPLOYERS' LIABILITY YIN TRKUB419J6410-IND-18 00112018 04/0112019 " E.L. EACH ACCIDENT $ 1,000,000 ANYPROPRIETORIPARTNERIEXECUTIVE NIA E.L. DISEASE - EA EMPLOYEE $ 1,000,000 EXCLUDED? (MFandatory In NHRCERIMEMBER E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be atu ched if more apace Is required) m,cira rc HOLDER CANCELLATION 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 REPRESENTATIVE of Marsh Risk & Insurance Services Janice Hsuk�o,>-.-� - U 1968-2016 ACORD CORPORATION. ION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Baker Commodities Inc. - Customer Services System 1 Page 1 of 1 Baker Commodities Inc. Customer Services System Customer Routes Accounting Reports Business System Log Off 12 6llence Customer Management Ada Customer Search parameters Customer Search Results... Filters mapsR¢tl open rl=m seaah Code NA Customer Name Address City St. Zip Sere No. Business Unit-, 32664 NO Fresh Catch 30 Chauncy St Mansfield MA 02048 I: TP - Trap Customers = 33420 No Mansfield Country Square. U.C. 321 School St Mansfield MA 02048 1 Location: McDonald's Restaurant - 06097 No #2080 BC-012 175 Mansfield Ave Norton MA 02766 11647 F v : . 33461 No Mooyah Burger #272 321 A School St Manzfleld MA 02048 E -. Broker: 32950 No Orange Lear 321 School St Mansfield MA 02048 a Affiliate: Fridey's#2>508< - 23981 No O12 School 280 St Mansfield MA 02048 1250 F, Chain: -� �I Customer owner: IV product: — E v Is Active: &Yes ON. OAR National Account: OYes ONO *All Vmzion:1 912 http://css.baker.com/Customer/Customer_Browse.aspx 1/16/2019 Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CAM 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) [A Foxborough Mansfield Ej Norton Gl/ Plainville Company Name: Address: Telephone#: `�'\71$ Operator at Inspection: Rcx.V .CA '&- Tank Capacity: 'a%c06 Truck License #: '5 0 L- a Registration Exp. Date: �-Z A �q Truck Inspection U 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) n suction or Pressure Hose in good repair E Y Pumps (leak proof) Operator at Inspec io nspecto Date (Updated: September 2018) k4 k� J ~ & - a 2 :y *!!®7K Jr!