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Home My WebLink AboutCavalieri Cesspool Service - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: WILLIAM P. CAVALIERI Doing business as: CAVALIERI CESSPOOL SERVICE 61-B COTTAGE STREET NORTH ATTLEBORO MA 02763 LI/ 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 4 TRUCK REGISTRATION NUMBER(S): J31-444 BOARD OF HEALTH NichaeCHeaCey, Chairman z- Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE:iia 1 & /I k LICENSE NUMBER: BUSINESS NAME: �r40A /(Eal MAIL ADDRESS: b (-13 [ro"-AUF- TOWN:/Io'A-� 4-vz-/r6v,w STATE: A/A/ S ZIP CODE: (!) J 76, NAME OF OWNER:ii�(ii tpCaurT�lt=-t7i BUSINESS ''TELEPHONE: SO> "L�iS-G��t�hC�EVLL—:Sc4-d -)- 37 FAX: ( &ukliCiem W1010"'- �� "'Al r'kll:"t6Q1L�CCj(�� E-mail: c t E• ll: FED ID/SS NO: ( �� - _S66 .#NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): ✓ �i f` 4q 1 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 Mansfiel Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: / Z/ //_7 __ F ................. ............................ .................. ...... ............................. -..................... - .............................................. TRUCKS INSPECTIONS: DATE: NOVEMBER 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: 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. Si at re of In Qual or Corporate Name "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:\Users\sleite\Desktop\Scott's Doc=entAFood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents O ice of Investigations a 600'Washington Street Boston, MA 02111 wM www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name Address: (e. City/State/Zip:/a, rull-�,_ A-K (;(,)0(l-u ecYi ' #: `/S-� 366 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. D4, I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers' comp. insurance req.] 12. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration 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 certify, under thegains andpenalties of prerjury that the information provided above is true and correct Phone#: 3;(1,F-6r5—(�_5'670 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/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mass.gov/dia CAVAW01 OP III: Jz' CERTIFICATE F LIABILITY INSURANCE ATLD10/09JDDIYYY,, 10/0912U18 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. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to 1 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 Phone: 508-695.0314 R.A. angry ldIns. Agency Inc. Fax:508-699-2583 860 Landry AveINC.No P.O. BOX 68 N. Attleboro, MA 02761- CONTACT NAME: Jeanette Barry, AAI,CRIS,CPIA PHONE 508.695-0314 F"" E.0, �ac Na1:508.699-2583 _ E-MAIL - ADDSEss: Jeanette@relnbOldinsuranCe.COm Douglas J. Reinhold INSURER(S) AFFORDING COVERAGE NAICN INSURER A: Safety Insurance Co. INSURED William P. Cavalieri 61 B Cottage Street North Attleboro, MA 02760 INSURERS: --- INSURER C : _ INSURER D _INSURER E: _ INSURER F: CERTIFICATE 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. ti 18R !L1R TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY E%P MMIDDJYYYY LIMITS i GENERAL LIABILITY EACH OCCURRENCE ) $ COMMERCIAL GENERAL LIABILITY JCLAIMS -MADE OCCUR DRMAGUTO RENTED PREMISES IEa occurrence)_ _ -_I $ MED EXP(Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE I GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG $ I 1 �.J '� POLICY PRO- LOC $ - - AUTOMOBILE LIABILITY Ea aBcMeD1SINGLE LIMIT $ ,i 000 601) BODILY INJURY (Per person) $ A ANY AUTO 62385113 03/1712018 03117/2019 ALL AUTOS DINNED AUTOSSCHED X HIRED AUTOS I X NONOWNEDPROF F AUTOS BODILY BOOILI' INJURY (Per accident) -- $ FEW DAMAGE Per accident $ _ _ { $ — UMBRELLA LIAB OCCUR EXCf`SS LIAB CLAIMS -MADE 111 A EACH OCCURRENCE -- $ AGGREGATE $ `, DED RETENTION$ VJORHERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORMARTNER/EXECUTIVE OFFICERIMEMSER EXCLUDED? (Mandatory in NH) WC STATU- 101TF TORY LIMIT r _ _J_ER E.L. EACH ACCIDENT $ - E.L._DISEASE-EA EMPLOYEE -� $ I ! If yes describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1 I i DESCRIPTION OF OPERATIONS / LOCATIONS J VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) MANSFIE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Douglas J. Reinbold @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Annual Collaborative Se Inspection Day (1n accordance with 310 041215.505) INSPECTION REPORT Which Towns are you currently licensed with? (cheek all that apply) ❑ Foxborough ❑ Mai"' Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: r Truck Inspection 12( Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leakproof 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) (Updated: September 2018)