The URL can be used to link to this page

Home My WebLink AboutCroome Sanitation, 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: EARL T. P. CROOME, JR. Doing business as: CROOME SANITATION, INC. 26 HILLSIDE AVENUE REHOBOTH MA 02769 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 6 TRUCK REGISTRATION NUMBER(S): MA 4938A, 41189 BOARD OF HEALTH MlchaeCHeaCey, Chairman V bP Town of Mansfield Town of Mansfield - Board of Health ' 6 Park Row Mansfield, MA 02048 BUSINESS NAME: Septage Pumpers Application DATE: /Ole �l LICENSE NUMBER: G 1?,0omE SANI=V C_ MAIL ADDRESS: `a(o 1-1 � I IS t D1:�_ AVE TOWN: R E �4 0 60TH STATE: MA ZIP CODE: O -7 NAME OF OWNER: C,, A e-L 11 . P- C(CO D mom- BUSINESS TELEPHONE: 50jf_aSd-[fU� CELL: FAX; So$'aS�-s/tFtf E-mail: C(�OOMC_SA�ItTt�Tlo� 3�E-mail: , nl6T FED ID/SS NO:04 -3) 31 -2-2q NUMBER OF TRUCK(S): Z REGISTRATION NUMBER(S): 01 A 4549 A '+ tl l ($'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 Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: /0 ................ ......................................................................................... ............................................... .......... ..:... 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: B. Venting of Mobile Tanks: _ Securely mounted on truck _ Vent permits escape of gas, but not liquid _ Watertight C. Hose: Leak -proof cover _ Suction or pressure hose in good repair Tight discharge tanks D. Pumps: Maintained to prevent leaking of sewage A Acceptable Inspected by: NA = Not Acceptable Inspected on: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf wwmmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C 2OOM L SA J 1-11 A —El 01J T LlC Address: z6 C l S I Avo- City/State/Zip: �Q �bo MA 6a1�9 Phone #: �0 g' a S2- - YG 6 Are you an employer? Check the appropriate box: Business Type (required): LI 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (met. 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 thew right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, I with no employees. [No workers' comp. insurance req.] 12.90ther f c- QfV e_ *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. I am an employer that is providing/lworkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: A C (AD 1 A T I0 S U?- A O (GL' Insurer's Address: 99 0 'D6 vie, l d J LU t ck ' A✓ l v j City/State/Zip: M &A ` u .r t7 U MA 0 17 S b- 7 7/y Policy # or Self -ins. Lic. # W Cfl L7 0 V 9 ill � - l S 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 the pains and penalties ofperjury that the information provided above is true and correct. r-1�_�_ Cionahrrer �� Date: / 0 Is h g asa.- F_AJLI 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 www.mass.gov/dia Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY W0000001B0115 Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 -g RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5089473 - 15 Previous Policy No.: 5089473-14 1. Name Insured and Address Agency Name and Address 07431 Croome Sanitation Inc (508) 824-8666 26 Hillside Avenue FBinsure Rehoboth, MA 02769 P.O. Box 509 Taunton, MA 02780 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 042472921 Risk ID No.: Bureau File No.: 000158630 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 04/06/2018 to 04/06/2019 12:01 AM Standard Time at the insured's mailing address. COVERAGE 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 01 B 01 15 Includes copyrighted material of The National Council on Compensation Page 1 of 4 Insurance, with their permission. Ann 7ollaborative Septic Ha Inspection Day (In accordance with 310 CMR 15,505) INSPECTION REPORT Which Towns are you currently licensed with? (check all Anal apply) ❑ Foxborough ❑ Mansfield ❑ Norton ❑ Plainville Company Name: l v 4%i1 ( ,n Address: 7, (t ��ti �t ` it� ��yk ,, 1t.4• �t-4.7-. LIJ Telephone t#: � i= zI<' ,' -r ` G r -�. - L( G J � b Operator at Inspection: V�' Iy'v` C — t �j Tank Capacity: i L' Truck License #: Registration Exp. Date: Truck Inspection Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight d6charge valves) Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair (leap proof) 0 1t�d n—. _ O rntot• at Inspection I atee Inspector `J (Updated; ,Sep(ernber 2018) 9 Collabo Inspection Day (In accordance with 310 CMR 15,505) INSPECTION REPORT Which Towns afro you urgently licensed ith? (check all that apply) Foxborough EMansfield Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: �7�2J1fl (�yo L' 4t1`ut Truck I11speCtl{)I1 Urb 41 �. �l 0�� 4 { 7 M Mobile Tank (securely mounted on truth, watertight, necessary odor controls, leak -proof cover, tight discharge valves) Venting available to allow tile escape of gas on Mobile Tanks (properly constructed) mSuction or Pressure close in good repair dPumps (leak proof) srig' � Operator at inspection inspector Date (Updated: September 2018)