HomeMy WebLinkAboutClaude DuBord & Son, Inc. - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Septage Pumping and Transporting Permit
This is to certify that: JEFFREY C. DUBORD, PRESIDENT.
Doing business as: CLAUDE DUBORD & SON, INC.
45 MAE AVENUE
BRIDGEWATER MA 02324
is hereby granted a SEPTAGE 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 5
TRUCK REGISTRATION NUMBER(S): MA G41583 E69402 S53488
BOARD OF HEALTH
NichaeC9-CeaCey, Chairman
Septage Pumpers Application
BUSINESS NAME: C k Ae,
MAILADDRESS: qje mei
TOWN: &A/e'A)'Okr
NAME OF OWNER: Jc ��iey
t So,n ZA✓
FFi vL:d :. w
�S�ITATE: IMn✓j
C rMo/a- Y/es,de,f
Town of Mansfield
6 Park Row
Mansfield, MA 02048
DATE: 10l ryll t3
LICENSE NUMBER:
ZIP CODE: 0a3Z_y
BUSINESS TELEPHONE: du b' wet i,. 11, Ll CELL: It' `6 yv p 7 j210 FAX: �;o
E-mail: C 1 4 v le- 0 Cjq de,dubo cLciAkjOAS,I'XitE-mail:
FED ID/SS NO: 0 4 7(9 Q '3 B 32-- NUMBER OF TRUCK(S): 3
REGISTRATION NUMBER(S): G L415 K* ClayLid L " b q,3 q` '
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 anshI d, Six Park Mansfield, MA 02048.
SIGNATURE: DATE: to IIt
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 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.
616A& 0,)Lid too :FnL- JM44�= t�y_ 22:)
Signature of Individual or Corporate Name By: rpo fate Officer (Mandatory, if Applicable)
64 2i0'3�32--
"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\sleile\Desktop\Scott's Documeets\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth ofAfassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwtv.niass,gov/dia
Workers' Compensation Insurance Affidavit; General Businesses
Business/Organization Name:
Address:
Aro ou an employer? Check tire approprinte box:
i. I am a employer with �0__ employees (full and/
or part.time),1
2, ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
(No workers' comp, insurance required)
3. ❑ We are a corporation and its offlcors have exercised
their right of exemption per c, 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We arc a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance reo.l
hone
Business Type (required):
5. ❑ Retail
6, ❑ RostaurawBar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.0 Manufac=ing
11.0 Health Care
12,jf Other ICE
'Any Ipplicsnt thstaheoks box XI must also fill out the section below showing their workers' compemation policy information.
"If the eorpontsofticen havo exempted themselves, bm the corporation his other employees, a workers' compensation policy is required and such an
organization should check box 01.
I am an employer that is providing workers' compensation tnssrrance for my employees. Below is lire policy infornmrlon.
Insurance Company Name:_A}.1 M inu fd a jot:z _12/)
Insurer's Address: Pry, 8n( 4 ?o
City/State/zip: BuRb hglzin� Mir Oig03-%YJ70 _
Policy# orSelf-tns,Lie, # 11lve-�0 ]dot L31020Q4';xpirationDate: 15'-495-19_
Attach a copy of the workers' compengatlon policy declaration page tsnuwing tbo policy number and expirati date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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 a fire
of up to $250.00 a day against the violator. Be advised that n copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance envem ne verifiruNnn
I do hereby ccrik, nVf the pains yfC� pe is o perJrrry tlrof
Information provided above is tr a and correct.
Date-
Official Use only, Do nor write in this area, to be completed by Or or rorvn ojfscinl.
City or Town:
Permit/License
Issuing Authority (circle one);
1. Board of Health 2, Building Department 3, City/Town Clerk 4, Licensing Board S. Selectmen's Office
6. Other
Contact
www.masa.govldia
Phone
ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYYI
06/0112018
�'THIS�ILC 1FICATE 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
A. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REL1dNl
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
- IMRARTANT. It the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
' -sthw arms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
` $rtificate holder In lieu of such endorsement(s).
PRo i W aCONTA
NAME: Kerrl Maguire
L ,YI [ I ;.,
I flOK &CHAMBERLAIN INSURANCE
PHONL E t (508) 697-6963 AIc No:
ADDRESS: kmaguire@estabrookchamberlain.com
ADDRE
,
-
INSURERS AFFORDING COVERAGE
NAICB `
45 MAIN ST.,
'BRID'GEWA"MR MA 02324
INSURERA: AIM MUTUAL INS CO
33758 -
INSURED ---is.
INSURERS:
-
INSURERC:
QkMD4UJ:JJ3ORD & SONS INC
INSURERD:
CRUDE DUBORD &SON INC
INSURERE;
4PA8B:lpVPJV,UE
INSURERF:-,'LU:F_7i
i�Rl @CAIATER MA 02324
CERTIFICATE NUMBER: 275946 REVISION NUMBER: "" ',
_AA : YO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
Ihl{))M7d1T2i). NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
-.;;OfiR1FIFICAFE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
4 LUBJONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
s
rtfk±€;.' TYPE OF INSURANCE
INSD
WVD
POLICYNUMBER
MMIDD/YYYY
MMIDDIYYYY
LIMITS
.r. GNMFRCIAL GENERAL LIABILITY
EACH OCCURRENCE
E
CLAIMSMADE 0OCCUR
AUFTO—
PREMISES lEa occurrence
$
MED EXP (Any one person)
$ n
I
,
01%VN/A
PERSONAL &ADV INJURY
$
i
�41FNL AOGREGATE LIMIT APPLIES PER:
GENERA -AGGREGATE
E
I
PRODUCTS. COMPIOP ASS
E
f
4\4 i4ou rt PRO JECT ❑LOC
8
I.A
fd 41fJF�s
,I,TOht
L LIABT
1t ILIY
BiL
COMBINED SNGLE LIMIT
(Eat accident -
$-
BODILY INJURY (Per person)
$
BODILY INJURY acudenl)
$ '
,1
Y
OWNED SCHEDULED
NIA
�,IP�TL
NON�OWNED
PROPERTY AMAGE
Pei acci ar
8
t:
5
cH1ftED AUTOS AUTOS
UMBRELLALIAB
OCCUR
EACH OCCURRENCE
8
AGGREGATE
$
EXCESS LIAR
CLAMS -MADE
N/A
'
OEO
RETENTION $
$
WORKERS COMPENSATION
X STATVTE ER
1
Alto EMPLOYERS' LIABILITY N
AtIY gg01 RI ETORIPARTNERiEXECUTIVE YIN
EXCLUDEDp NIA
NIA
NIA
AWC40070263102018A
05/25/2018
05/2512019'
E.L. EACH ACCIDENT
$ 1,000,000
E.LAASEASE.EAEMPLOYEE$
1001)000.:
CFF'�CFFl/MFMBER
(Mdgditory I?NHI
EL DISEASE - POLICY LIMIT
$ 1000000
1t yyes Je a be antler
i,168 RIPT4 NOP OPERATIONS below
N/A
1 (
Orr F rI •gyp.
_
... .!
n sofef'1o,� OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mote space is required)
b 11/ Jr'diW Compensation enelits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay •' - '1
r,IQI s'.W b6riefits to employees In states other than Massachusetts lithe Insured hires, or has hired those employees outside of Massachusetts.
Thlls'i}�YNI 16'ate 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
TeA &Hot�;of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification t
a6r4h'tcol at www.mass.gov/lwd/wakers-compensation/investigations/
�I,
Y
Cf
R•"!rl`Ei HOLD ER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
4f011" I
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELrvidlk'IN
It;'
}iWi I
4r� Mansfield
ACCORDANCE WITHTHE POLICY PROVISIONS. L -
51 fmr
i kw"' `
AUTHORIZED REPRESENTATIVE
G
t�atA'A,eld
ap Lc}1iP1I
' - MA 02048
jr >I
• niel
Daniel M. Cr y, CPCU, Vice President -Residual Market WORI13YvtA -.
t�{ '01 f O.o J OO 1988-2014 ACORD CORPORATION. All rights reserved.
r C '`�Ss(2Q14/01) The ACORD name and logo are registered marks of ACORD
gp 4
DUBOR-1 OP ID: KMI`
CERTIFICATE OF LIABILITY INSURANCE DATEIMMI°off
O61g11207t
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDS r,.T
CE(,tTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE pQCI�CIES '
�d�A'ft'- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
.AEORE'SENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
jpa, arms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
°'de .Gate holder In lieu of such endorsements .
'gmUCER'
CONTANAME;
Thomas T. Chamberlain
@eta, ok & Chamberlain Ins
P. Q' 07277
PHONE
Alc
Np Ea :508.697-6963 AIC No): FAX-697-5809
EMAIL
Bridgewater, MA 02324.9986
'themassT. Chamberlain
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC a
INSURER A: New Hampshire Insurance Co,
IN U(iEDI , d361ayde Dubord & Sons, Inc.
INSURERB: American International Co.
! !;J, r•! i
XaeAvenue
r (k�Y�.�r
'6 ._; tidgewater, MA 02324
INSURER C:
INSURER 0:
JI IPLO I la
INSURER E:
I'tilaf <[jT.(If"
INSURERF: gd
r'li. I A :e7
CG" CERTIFICATE NUMBER: REVISIONNUMBER:
.. ISS -.0 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY RERIOD- -
IMAGAT5Y. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CjRWUIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS;
.: EXC7 I I&IONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-IL- TYPE OF INSURANCEAUUL
POLICY NUMBER
MMIDDIYYYV
ODIYYYY)
LIMITS
JQMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S 1,000,000
=ii'o
i;«Y'!''CLAIMSMADE
OCCUR
01•LX-059312766.0
OS/14/2018
05/14/2019
PREMISES Eaoccurrence)$
100,000
MED EXP(Any one person)
$ 5,000
X
Blkt addl CG20 33
PERSONAL &ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,Qg0„0qD
N I`GENIrApAdgFE6ATELIMITAPPLIESPER.
r rblIi�3.04'^/i��
JECT FLOC
PRODUCTS-COMP/OP AGO
S -- 2;000,000
..:OTHER:
.
;AUTOM
AILF LIABILITY
9.
COMBINED I BILE LIMIT
Ea accident__
A:-
'
ANY'AUTO
01-CA•069969546.0
05/14/2018
05/14/2019
BODILY INJURY (Per person)
$
"
I
t y
I
J,L,DWNED SCHEDULED
t1Uln$ _ X AUTOS
BODILY INJURY (Per accident)
$
^•,h
tT '411RIED
x NON OWNED
AUTOS X AUTOS
PROPERTY DAMAGE
Per accidanl
�iLjMBRELLA
LIAB
X
OCCUR
EACH OCCURRENCE
$ 2,000,000
EXCESS LIAB
CLAIMS MADE
29-UD-066146793-0
05/14/2018
;0511412019
AGGREGATE
$ 2,000,000
RETENTION$
$
WORRIERS COMPENSATION
PER OH_
I
ANBEMP.LOYERS' LIABILITY YIN
STATUTE ER
E.L. EACH ACCIDENT
$
MW PROPMErORA'ARTNERIE>(ECUTIVE
GFF!'CERIMEMEER EXCLUDED?
(ManddtdFyih NH)
NIA
E.L DISEASECAEMPLOYEE
S
Ityei, describe under
E.L. DISEASE -POLICY LIMIT
S
DBBCRIPTIOk OF OPERATIONS below
Bp SCRIP TION 0I� OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace Is requiredi ,.
'r
E 'T
TE'HOLDER CANCELLATION
r-I MANSFI6
Nil,,; ar :
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
','SR
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
a' of Mansfield
ACCORDANCE WITH THE POLICY PROVISIONS.
6`1?arkRow
'Mansfield, MA 02048
AUTHORIZED REPRESENTATIVE
I ,
' OO 1988.2014 ACORD CORPORATION. All rights reee'ryed.
ACPRD:25.',(2014/01) The ACORD
name and logo are registered marks of ACORD - ..
borative Septic Hauler
Inspection Day
(In accordance with 310 CMR 15.505)
INSPECTION REPORT
Which Towns are you currently licensed with? (check all that apply)
❑ Foxborough Q/Mansfield DINorton ❑ Plainville
Company Name: " `iA-. �1, 1),t 1 u -t t s>I.,"N
Address: i5 OAn 41v_z � 1 rt. Vt
Telephone #: G t ,l
Operator at Inspection: Z 1 :2 t L ^ �dA t . t-.-
Tank Capacity: -1 7 cat)
Truck License #: (3 is
Registration Exp. Rate:
Track Inspection
❑ Mobile Tank (securely mounted on truck, watertight, necessary odor controls, look -proof cover, tight discharge valves)
CAI Venting available to allow the escape of gas on Mobile Tanks (properly constructed)
lx�suetion or Pressure Hose in good repair
12 pumps (leak proof)
6p�rator at Inspection
Date
Inspector'— '
(Updated: 5eplemher 201 H)
nual Collaborative Septic Hauler
Inspection Dar
(In accordance with 310 CAM 15.505)
INSPECTION REPORT
Which Towns are you currently licensed with? (check all that apply)
❑ Foxborough ❑ Mt
Company Name:
Address:
Telephone #:
Operator at Inspection:
Tank Capacity:
Truck License #:
Registration Esp. Date:
Truck Inspection
Mobile Tank (securely mounted on track, watertight, necessary odor controls, ionic -proof cover, tight discharge valves)
Venting available to allow the escape of gas on Mobile Tanks (properly constructed)
L.t Suction or Pressure Rose in good repair
Pumps (leak proof)
( or tet Inspection
Date
((Updated: 6eptember2018)
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)
4 Foxborough P Mansfield EMI Norton "lainville
Company Name:
Address:
Telephone #:
Operator at Inspection:
Tank Capacity:
Truck License #:
Registration Exp. Date:
C COo n
Truck Inspection
(7-'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
(leak proof)
\.
NA
Operatttr�a'(�Inspeetion-• _$��>\>` „\�;
IQ*6et61- ✓ c �.��.. k
Date 1
(Updated September 2018)