The URL can be used to link to this page

Home My WebLink AboutDrain Remedy, 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: ROBERT N. COYLE Doing business as: DRAIN REMEDY, INC. P.O. BOX 674 STOUGHTON MA 02072 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 24 TRUCK REGISTRATION NUMBER(S): T56005 BOARD OF HEALTH MichaeCHeaCey, Chairman �A �V Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: LICENSE NUMBER: BUSINESS NAME. MAIL ADDRESS: P . i X TOWN. !�i r 'oak ad STATE: ZIP ODE: NAME OF OWNER ) BUSINESS TELEPHONE: , _ < r } i CELL: C,.3 P - ( FA� E-mail:{tAlt E-mail: L`,�Y�tif FED ID SS NO: NUMBER OF TRUCK(S): REGISTRATION NUMBER(S)i (" (.: (jU J FEE PER TRUCK: Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, lyprisfield, MA 02048. .'SIGNATURE:------yL DATE: TRUCKS INSPECTIONS: DATE: 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 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'-i _= 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. A�, ovllbhel-) Signature of Individual or Corporate Name By: Corporate fficer ( Iandatory, 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:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name -t_1t _1-v (: Address: ` t Are you an employer? Check the appropriate box: ,'A I am a employer with employees (full and/ or part-time). * 2. ❑ I am a solo 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 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.] Plione #: Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (inel. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment I0.❑ Manufacturing 1 I.❑ Health Care 12.Other Y°fV'i *Any applicant that checks box 111 must also Jill 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 Ill. I ant an employer that is prov(rllog workers' compensadon insurance far my employees. Below is the policy information. Insurance Company Name Insurer's Address: ��' I ��. X city/State/Zip: L C ]cXt__', l(� I- i sC'V i-�, _ ��_3 — Policy # or Self -ins. Lic. #L —` Expiration Date: 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. _:1 I do hereby certify, that the Information provided above 's true Dow. Official use only. Do not write irr this area, to be completed by city or town official. City or Town: F fruit/License # Issuing Authority (circle one): A 1. Board of Health 2. Building Department 3. Cityrrown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mms.gov/dia Phone ACORo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIYYYY) 04109/2019 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 Lori McLoughlin ATLANTIC INSURANCE GROUP AGENCY INC PH¢NN E,xa (617) 698-2200 NC No: ADDRESS: lori@atianticquotes.com INSURERS AFFORDING COVERAGE NAIC # 530 ADAMS ST INSURER A: HARTFORD UNDERWRITERS INS CO 30104 MILTON MA 02186 INSURED INSURER B : INSURER C: DRAIN REMEDY INC INSURER D : INSURER E : PO BOX 674 INSURERF: STOUGHTON MA 02072 COVERAGES CERTIFICATE NUMBER: 387921 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. INSRLTR R OF INSURANCE ADDLTYPE INSD SUBR POLICY NUMBER MMIDOf/EYYF1' MMIDDNEI'xYV LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR D AG O PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ N/A GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- ECT LOC PRODUCTS -COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) $ ANYAUTO BODILY INJURY (Par accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A PROPS TYDAMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE N/A DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFCEWMEMSER EXCLUDEANYPROPRIETORIPARTNEWED? NIA (Mandatory in NH) N/A NIA 6S60UB8D80977818 10/22/2018 10/22/2019 �/ /� STATUTE �RH E.L FA. HACCI $ 1,1100,000 AEEN� E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1'000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space 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 dale 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/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED /REPRESENTATIVE \`)✓_ t l l SPX MANSFIELD MA 02048 Daniel M. CrgWJey, CPCU, Vice President —Residual Market— WCRIBMA @ 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Jane Doucette From: OAR@wcribma.org Sent: Tuesday, April 9, 2019 1:42 PM To: lori@atlanticquotes.com; DRAINREMEDY@COMCAST.NET; Jane Doucette Subject: Certificate of Insurance Attachments: certificate.pdf On 04/09/2019, Lori McLoughlin from Atlantic Insurance Group Agency Inc generated the attached Certificate of Insurance based on the information in the WCRIBMA's coverage database. For policy # 6S60UB8D80977818, the named insured is DRAIN REMEDY INC and the Certificate Holder is BOARD OF HEALTH. If you have any questions, please contact Lori McLoughlin at (617) 698-2200 or loriaatlanticguotes.com. PLEASE DO NOT REPLY TO THIS EMAIL USING THE OAR MAILBOX ADDRESS. * * WCRIBMA will not see or respond to any emails sent to the OAR mailbox. * * Annual C native 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 a Mansfield ❑ Norton ❑ Plainville Company Name: c ��V-\ t_ Address: Telephone #: `6 Q G; G?D 20 � k Co Operator at Inspection: 7 L� P C Tank Capacity: ,-2 Truck License #: 717`3-CQ'00`5 Registration Exp. Date: \72� yr Truck Inspection WMobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 17 venting available to allow the escape of gas on Mobile Tanks (properly constructed) ❑ Suction or Pressure Hose in good repair \ \ Pumps (leak proof) Operator at Inspection tspect t Date (Updated: September 2018)