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HomeMy WebLinkAboutBay State Sewage DIsposal - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: RICHARD & MARGARET CHAVES Doing business as: BAY STATE SEWAGE DISPOSAL 105 KINGMAN AVENUE LAKEVILLE MA 02347 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 3 TRUCK REGISTRATION NUMBER(S): 98205 86514 K91905 BOARD OF HEALTH Michae(HeaCey, Chairman i 9 5 �bwn of Mansfield Town of Mansfield - Boa 11� _ Park Row ansfield, MA 02048 Septage Pampers Application DATE: a0/� `p LICENSE NUMBER: h BUSINESS NAME: � ! " Q� �' " JI r05 � J MAIL ADDRESS: /0,5 1 /u�%"/Aj (S,{126V TOWN: LA-4l vrllu STATE: , A ZIP CODE: 01 t/ f NAME OF OWNER: 6`6 yi -&, lal-tpi..(fi`T BUSINESSTELEPHONE(SQ�q i %G'-=GCELL: FAX: f?)iC l/F E-mail: Dea/MS baySMkYtt l� Alt E-mail: "I c J C cal, J �c y��r� eta�ce FED ID/SS NO: 01,-1-301,5 (13) NUMBER O,F,YYTRUCK(S): REGISTRATION NUMBER(S): C19,A05 3 5� oS i `1 FEE PER TRUCK: $100 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, '1 Town of Mansfield, Six Park o_w, Mansfield, MA 02048. g SIGNATURE:DATE: P�!�a�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 S. 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. of Individual or Corporate Name By: Corporate Officer (dandatory, ifApplicable) oq-301-53) **Social Security No. Cv'oluntary) 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. The CotInnonweatth gf4fassachusetts 1d _ Department gfIndustrial Accidents Office tf Investigations ,.r 600 Washington Street Boston, ATA 02111 i vttnv, mass.gov/dia Workers' Compensation InsuranceAffidavit: Bit ilders/Contractors/Electricians/I?lttntbers 6hlic"xnt inlot nation 1 lease Pritri Lcaib1), Name (Business/organizationfudivid BAY STATE SEWAGE DISPOSAL, INC _„- Address 105 KINGMAN STREET _-_._.._.____.__ MA 02347 phone Are you an employer? Check the appropriate box: 1. 1 am a employer with _ 3 4- ❑ I am a general contractor and I employees (full and/or part-time)." have hired the sub -contractors 2. ❑ I aru a sole proprietor or partner- listed on the attached slice(. ship and have no employees These sub -contractors have working for me in any capacity- employees and have workers' [No workers' comp. insurance required.] 3. ❑ I our a homeowner doing all work myself. [No workers' comp. insurance required.] t comp. insurance.-' 5. [] We are a corporation and its officers have exercised their right of exemption per MGL e. 152, $1(4), and we have no employees. [No workers' court). insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition l0.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.­ other SERVICE *rya. q)pii urnihnt cheers bQX ffI ❑n t"t also fill out the secnun below showing their vorl, rs' contpensaui(n policy intnIwoirnI, t Houlcottansrs who sabmit this anbiav it indicating they are doing all work and then hire wiside content tots must submu t now affidavitindicating such. tContractors that check this box most attached an addition at sheet shoving the name of the sub -contractors and state whether or nor those entities have enrploy"s, If the sub -contractors have e®ployecs, they Host provide their workcrs' comp. policy oumher. I urn an emplgver that is providing workers' compensation insurance for nev employees. Below is the policy anti job site information. Insurance Company Name; ACADIAINSURANCE .COMPANY , Policy # or Self -ins. Lic. # WC# MAARP301685 Expiration Date:__06/_1.5L2Q.19_____... .lob Site Address:- P.O. BOX 59143 � City/Statc/7.ip:_M)NNEAP—011S,_MN_55459-0143 Attach a copy of the workers' compensation policy declaration page (showing the police' number and expiration date). Failure to secure coverage as required under Section 25A of MCrL c, 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 aad/or one-year imprisonment, as well is 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebvcecertiify under thepains and pets ies of perjury that the information provided above is true and correct. Cinna6vw/ Y,�'(tl� C . PRESIDE(�LL_ Date: �b/o(/Old_---_--.- ut,,.. u r;QA-P47-2636 Official use only. Do not write in this area, to be completed by city or town gfficial City at, Town: Permit/License # _ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector S. PlumbiR9Inspector 6. Other ---_ Contact Person: Phone #:----_--------.-.---_-- BAYSTAT-02 LBROWN T ACOizO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYI'YY) 06/27/2018 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(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 CO TACT Loretta Brown a°, N Est); (508) 824$666 1240 ac, No: FBinsure, LLC Tau Dean Street Taunton, MA 02780 A�1,E LBrown@fbinsure.com ADDREss� INSURER(81 AFFORDING COVERAGE NAIC# INSURER A: Selective Ins Co of SC 19259 INSURED INSURER B: INSURER C: Baystate Sewage Disposal Inc INSURER D: PO BOX 886 Lakeville, MA 02347 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER' 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 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 LTRA TYPE OF INSURANCE ADSD WVDI SUBR POLICY NUMBER POLICY EFF 0Mi pY EXP LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Blkt Add'llns S 2056663 01,18,2018 01,18/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PRE EA occurrence 600,000 $ X MED EXP (Amy one rson 15,000 X Blkt Waiver PERSONAL &MY INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [X1 TEC6 LOS OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGG $ 3,000,000 $ A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED ONLY NON-OWNED ONIV X Incls Poll Transit A 9098990 01/18/2018 01/18/2019 COMBINED SINGLE LIMIT .acuent 1,000,000 $ BODILY INJURY Per rson $ BODILY INJURY Per accident $ PROPERTY AMAGE Per accltlent $ $ A X UMBRELLA LIAR EXCESS LIAB X OCCUR CI -AIMS -MADE S 2056663 01/18/2018 01/18/2019 EACH OCCURRENCE $ 6,000,000 AGGREGATE 6,000,000 DED I X I RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETgORIPARTNERIEXECUTIVE ❑ (Mandatory In BH)EXCLUDED9 If yes, tlescribe Nunder DESCRIPTION OF OPERATIONS below NIA PERT FOTH- E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ A Equipment Floater S 2056fl85 01/18/2018 01/18/2019 Leased Equipment 60,000 DESCRIPTION OFOPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more a ace is required) Septic Tank Cleaning & Repair Contractor. Automobile Liability policy includes Pollution Transit Liabi sr... coverage. Leased Equipment coverage is Actual Cash Value -Special Form with $1,000 Deductible. CFRTIFICATF Hint nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Health Department Town Hall 6 Park Row -1st Fir Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE � ,/1_ X. S. t, ~` ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCE L►/" DATE (MMIDD YYW) 06/1912018 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 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 CONTACT NAME' Loretta Brown INCNE 506 824-8666 J.K NO: FBINSURE LLC "'MAIL ADDRESS: loretta@fbinsure.com INSURER(S)AFFORDING COVERAGE NAIC# 128 DEAN ST INSURERA: ACADIA INS CO 31325 TAUNTON MA 02780 INSURED INSURER B: INSURER C: BAYSTATE SEWAGE DISPOSAL INC INSURER D: INSURER E: PO BOX 886 INSURER F: LAKEVILLE MA 02347 COVERAGES CERTIFICATE NUMBER: 282235 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. LTR TYPEOFINSURANCE ADD JNM S R MID POLICY NUMBER MM/DDVEFF MMIDD EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIM&MADE ❑ OCCUR DAMAG ENT D PREMISES Ea occurrence $ MED O(P(Any one person) $ PERSONAL B ADV INJURY $ N/A GEN'L AGGREGATE LI MIT APPLIES PER: GENERALAGGREGATE $ POLICY JEPI CTT LOG PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANVAUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AlJi05 N/A PROPERTY DAMAGE Per accident $ NOWMNED HIREDAUTOB HAUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION$ I I$ I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPRA OFFICEOR/MEMBEREXCLUDED?ECUTIVE NIA (Mandatory in NH) NIA NIA MAARP301685 06/15/2018 06/15/2019 PER Or X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 EL DISEASE -EA EMPLOYEE S 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace la required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/Iwd/workerscompensatiordinvestigations/. CFRTIFICATF HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield - Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall -6 Park Row 1st Fir AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Crowily, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD rl Collaboraj Inspection Day (in accordance with 310 CM R 15.505) is Hagler INSPECTION REPORT Which Towns are you cyrrently license"ith7 (check all that apply) O Foxborough I21'Mansl;eld c1!1 Norton Ci Plainville Company Name: '!�` u!' Address: �15 %�rl7trtrtt Telephone #; Operator at Inspection: Tank Capacity: C�1) Truck License #: //°ii� Registration Exp. Date: C - >C•1 `-� cY .,, J/ Truck Inspection O Mobile Tank (securely mounted on true](, watertight, necessary odor controls, leak -proof wver•, tight discharge valves) Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Bose in good repair Humps (leak proof) Operator at Inspectiont/ Date (Updated Seplemher 2018) Annual Collaborative Septic Hal Inspection Day (In accordance with 310 CMR 15,505) INSPECTION REPORT Which Towns arc you currently licensed with? (check all that apply) ❑ Foxborough ❑ Mansfield ❑ Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: 113, 2V �} Truck Inspection Ed Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair Pumps (leak proof) operifoat In(sppectiocnn 11- U-/C- Date (Updated: September 2018) s ` ` Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 1171AO19 LICENSE NUMBER: _I / l BUSINESS NAME: / �S/0 ✓)rt E MAIL ADDRESSS: / d 5 %i%njMak1 v°s rfE TOWN: ko eodle �j STATE: &A G IPCODE: ©Q,5gY NAME OF OWNER: l'LI)LLF`d Y- ��tirT A(l O<<KK" BUSINESS TELEPHONE:,/9k `(/7,;k,'0 & CELL: FAX: E-mail:, t"Oter's @&L Alt E-mail: Jet ILG bettt'S i2.iG SCGt C LUG+" a FED ID/SS NO: d/_ 4J� NUMBER OF TRUCK(S): f REGISTRATION NUMBER(S): FEE PER TRUCK: '1/6)0'M Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Roard of Health. Town of Mansfield. Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: llq l,l / TRU CKS INSPECTIONS: DATE: 171Pll� CUCtA � )'SPeCfd TIME: 7;,40-/U'30 PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COM�ON, 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 AGENT'S 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. Side 5a�� ���— — of Individual or Corporate Name By: Corporate Officer ( andatory, ifA cable) 0q-30)-5L31 **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. The Corntnonwealth of ll'Iassachusetts Department of Industrial Accidents E r a Office of Investigations 600 Itfashington Street Boston, AIA 02111 trot'. nta,s,s,gov/dia Workers' Compensation Insurance Affidavit: Bttitders/Contractors/Eleetricians/Plttmtters Ambeant Infotntatiartf Illcas! Print 1,eaibly Name (f?usines Khgan[zation/tudividual). , BAY STATE SEWAGE DISPOSAL, INC Address 105 KINGMAN STREET LAKEVILLE, MA 02347 Phone di: Are you an employer? Check the appropriate box: 1. � I a n a employer with 23__._ 4. ❑ 1 mu a general contractorand f - employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole Proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ 5. We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp, right of exemption per MGL insurance required,] p c. 152, § 1(4), and we have no cruployees. [No workers' conm. insurance required.] Type of project (requirefly 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition Ill.❑ Electrical repairs or additions ILL] Plumbing repairs or additions 12. ❑ Roof repairs 11LUdOtber_ SERVICE -An rpllbucuft that ch.cVs boxed nu t also till out lbe section below showing thiaT a.orl o r' eonpens ni"n policy inlimuuEinu. t I-loua,mwas in.- the} are douig all wort, and tMn hireonside conuact n s mast suhaut a nov afYidavitit)dicating slim). +Crnrtraclors that check this boor: nwst attached an additional sheet Showing the name of the sutrcouttaoto;'s and state d4retlrer or not thou entities have employees. If the sub-cnNracrors have emplopccs, they r:wst lrmvide their workers comp. policy number. I am an enrplgver that is providing workers' compensation insurance for ttnj envpdovees. Below is the police- and job site information. IitsuranceCompany Namc ACADIA INSURANCE COMPANY Policy # or Self -ins. Lic. #: WC# MAARP301685 _._ Expiration Date: .lob Site Address: P.O. BOX 59143 ^ City/State/7.,i1>;._MINNEAPPPPPPOLLS,_M--.55459-0143 Attach a copy of the workers' compensation policy declaration page (showing thc policy number and expiration datej. Failure to secure coverage as required under Section 25A of MCrL 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 WORT: ORDER and a fine of up to $250.00 a day against the violator. Be advised that a cop), of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains mid yerrglt esafperjury that the information provided above is trite and correct. 4innatme:l U^(/t'I t/ PRESIDERT Date__ Phone #: 508-947-2636 Official use only. Do not write in this area, to he completed by city or town gfficial City or Town: Permit/License# _ _. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Phone # Ac"R" CERTIFICATE 00 LIABILITY INSURANCE DATE (mmloo vyyY) 06/19/2018 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(ies) 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 CONTACT NAME: Loretta Brown PHON o H. (5508)824-8666 FaAC No: FBINSURE LLC ElMA1L ADDREss, Loretta@fbinsure.com INSURERS AFFORDING COVERAGE NAIC# 128 DEAN ST INSURER A: ACADIA INS CO 31325 TAUNTON MA 02780 INSURED INSURER B: INSURER C: BAYSTATE SEWAGE DISPOSAL INC INSURER D: INSURER E: PO BOX 886 INSURER F: LAKEVILLE MA 02347 COVERAGES CERTIFICATE NUMBER: 282235 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 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 TYPE OF INSURANCE ADDLSUBR SD WVD POLICYNUMBER POLICYEFF (MMIDD POLICY EXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIM'MADE OCCUR DAMAGE TO RENTED PREMISES Eaoccuaence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ N/A GENT AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ IR POLICY JECOT0 LOC PRODUCTS-COMPIOPAGG $ $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accltlent $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIREDAUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIM'MADE N/A DED RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) NIA NIA MAARP301685 06/15/2018 06/15/2019 -------- x STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 , E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS bet. E.L. DISEASE - POLICY LIMIT $ 1,000.000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORDIOI,Add'dleaal RemarkeSchedule,maybaetlachedifmorespace is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at w .mass.gov/lwd/workerscompensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield - Health Dept ACCORDANCEWITH THE POLICY PROVISIONS. Town Hall - 6 Park Row 1st FIT AUTHORIZE° REPRESENTATIVE Or Mansfield MA 02048 '—nie"" Dal M. C114ey, CPCU, Vice President— Residual Market— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD BAYSTAT-02 W%> 1 kL ACORO` CERTIFICATE OF LIABILITY INSURANCE `--� D 06127120118Y 06/27/2018 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(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 CONTACT Loretta Brown AM FBinsure, LLC Tau Dean Street Taunton, MA 02780 Pnico, N , Ext : (SOH) 824$666 1240INC, No E1dAIL LBrown@�iTfbinsure.com ADDRESS: LBrown@fbinsure.com AFFORDING COVERAGE NAIC # INSURER A:Selective Ins Co of SC 19259 INSURED INSURER B: INSURER C: Baystate Sewage Disposal Inc INSURER D: PO BOX 886 Lakeville, MA 02347 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TWPOLICYPERIODODINDICATED. NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT VNTH RESPEISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSURANCE ADDL INSD SUER AM POLICY NUMBER POLICY EFF POLICY EXP LIMITA X COMMERCIAL GENERAL LIABILITY �X OCCUR BlktAdd'IIns S 2056663 01/18/201801/18/2019DAMAGE EACH OCCURRENCE ,000CLAIMS-MADE TO RENTED,000PREMISES Ea occurrence X An one rson 6,000MEDIXP X Blkt Waiver PERSONAL&ADV INJURY ,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [XI jEQ LOG OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMPIOPAGG $ 3,000,000 $ A AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Incls Poll Transd A 9098990 01/18/2018 01/18/2019 EOMaBINEED SINGLE LIMIT $ 1,000,000 X BODILY INJURY Per rson) $ BODILY INJURY Per accident)$ PROPERTYDAMAGE Per accitlent $ X A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMSMADE S 2056663 01/18/2018 01/18/2019 EACH OCCURRENCE $ 6,000,000 AGGREGATE 5,000,000 DED I X I RETENTION $ O $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY FFICERPRIIMTgOIVPEXCLUDRIE ECUTIVE ❑ �Mantlatory In NH) Ityes, describe under DESCRIPTION OF OPERATIONS below NIA STATUTE ERTH- E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ A Equipment Floater S 2056885 01/18/2018 01/18/2019 Leased Equipment 50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IOI, Additional Remarks Schedule, may be etteched If mores ace la required) Septic Tank Cleaning & Repair Contractor. Automobile Liability policy includes Pollution Transit Liabi ity coverage. Leased Equipment coverage is Actual Cash Value -Special Form with $1,000 Deductible. Town of Mansfield Health Department Town Hall 6 Park Row -1st Fir Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016/03) © 1988.2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v 5 ` ual Collabo ltic Hauler Inspection Day (In accordance with 310 CMR 15,505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ Foxborough ❑ Mansfield ❑ Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License N: Registration r, xp. Date: Truck Inspection EI Mobile Tank (securely mounted ou truck, wa(ertight, 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 Bose in good repair Pumps (leak proof) Operator at Inspection Date (Updated: September- 2018)