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HomeMy WebLinkAboutDrain Shooter, 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: DONNA DOODY Doing business as: DRAIN SHOOTER, INC. 2 COLUMBIA ROAD, SUITE 10 PEMBROKE MA 02359 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 25 TRUCK REGISTRATION NUMBER(S): N95947 BOARD OF HEALTH NlchaeCHeaCey, Chairman Town of Mansfield Toim (?f Mre infield - B r_ � (Okl�jlq% 6 Park Row t. Mansfield, MA 02048 Se h-,ege Pi.wi ei;s Application DATE: 4/23/2019 LICENSE NUMBER: BUSINESS NAMEDraln Shooter, Inc. MAIL ADDRESS: 2 Columbia Road Suite 10 TOWN: Pembroke STATE: MA ZIP CODE: 02359 NAME OF OWNERDonna Doody BUSINESS TELEPHONE: 781-331-0171 CELL: FAX: 781-829-8500 E-mail: support@drainshooter.com Alt E-mail: FED ID/SS NO: 04-3218018 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): E3054 U q-� q �-i ��1r1SjJQL�) FEE PER TRUCK: _ Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfi=44 Park Row, Mansfield, MA 02048. IGNATUR3 * 01)WIn/ICr, __ — DATE: 4/22/2019 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 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. a Signature of Individual or Corpora ame By: Corporate Officer (Mandatory, if Applicable) � -3Q l **Social Security No. (Voluntary) Federa 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. CAUsemWeite\DesktopVScotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc T1tt Cannaonti+eallFS iif iMassaehiesteps - Department of Industrial Accidents OKIce of Investigations n00 Washington Street 3oston, MA 02111 Nww.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le2ibly , Business/Organization Name: City/State/Zip: ?hone ts: �'?% I - I — Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ (' Retail or part -toe] * ti. 7 RestaurartBar/Eat ng Establishment 2. ❑ 1 anva sole proprietor or partnership and have no Office and/or Sales (ind. real estate, auto, etc.) employees working for me in any capacity. _ [No workers' comp. insurance required] 3. Non-profit 3. E1 We are a corporation and its officers have exemisea 1. Entertainment their right of exemption per a 152, §I(4), and we nave i 10.1A. Manufacturing no employees. [No workers' comp. insurance reawrecil*"I 1 . t I Health Care4. ❑ . We area non-profit organization, staffed by volunteers n r^ , ,C��, with no employees. [No workers' comp. insurance rea I !(N ;2. Othe 1 1 -;Any applicant that checks box N I must also fill out the section below showing their worxers comuensatton policy information. -*If the corporate officers have exempted themselves, but the corporation nas Omer emmovees, a woncerscormcmation policy is required and such an organization should check box p 1. lam an employer thal is proviid�i"n�K5 g�workers' compensations insurance for mV ernplgyees. Below it Aepo&y iy%Womol/n. Insurance Company Name: rWi 11 re. i �1f MlAi�L Ll7 (OCJ Tnj Insurer's Address: 110 �liiy) Atye f City/Stale/Zip: W ti Kel�l par r l PIN QI cn 0 Policy # or Self -ins. laic: # D 1 )i 9 19 j SR iration Date:_ Wo"1 Attach a copy of the workers' compensation policy declaration page (snowing the policy number and expiration date} Failure to secure coverage as required under Section 25A of MGL c.:52 can lead to the imposition of criminal paoakica off fine up to $1,500.00 and/or one-year Imprisonment, as well as cuvii Densities tit the f inn of a STOP WOPX OR= and a tips • . . of up to S250.00 a day against the violator. Be advised that a copy or this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do kereby certify,y,�under the pates a penalties of perjury that the information provided above is true and correct. Siggature: 7�Lt9,.'-� I ( gate: 011[=ar11111e Official use only. Do not write in this area, to be completed by city or town offrciat City or Town: 'ermitfLicense N Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Seketmen's (Mice b. Other Contact °. v _mass.gowdia 'hone A�®RDr CERTIFICATE OF LIABILITY INSURANCE DATE/0 1 04130/30/2019 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 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 endomement(s). PRODUCER CONTACT Nancy Bums NAME: Cleary Insurance Inc pxoxE (617) 723-0700 FAX (617) 723-7275 MC o Eat: AIC Na 226 (`.aUeaWay Street gOOR1ESS: nt]timS�CleafylOSUmnCe.COm Suite 302 INSURER(S) AFFORDING COVERAGE NAICN Boston MA 02114-2155 INsuRERA: Ohio Security Insurance Company 24082 INSURED INSURER e: Netherlands Insurance Company 24171 Drain Shooicq Inc. 24074 INSURERC : Ohio Casualty Insurance Company 2 Columbia Road INSURER D: NorGUARD insurance Company 31470 Unit 10 INSURER E : Pembroke MA 02359 INSURER F COVERAGES CERTIFICATE NUMBER: 20i8-o.LAUIUUMH aFvrclnbl N I IMRFfA 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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE SD WVO POLICY NUMBER POLICYYTYFY M LIIUY� LIMBS A X COMMERCIAL GENERAL LIABILITY CLAIk15Mi< OCCUR Products & Completed BKS55691829 11/14/2018 11/14/2019 EACH OCCURRENCE $ 1.000,000 a E MEADADC PREMISES Ea xnainucs $ 300,000 X MED ExP (Any one n,wn7 g 15,000 Operaflons PERSONAL A ADV INJURY $ 1,000.000 AGGREGATE LIMIT APPLIES PER: POLICY ® JECT LOG GENERALAGGREGATE 3 2.000,000 GENT PRODUCTS -COMP/OPAGG s 4000,600 S OTHER' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea a. JOmt $ 1,000,000 ANY AUTO BODILY INJURY (Pot Perann) $ B OWNED x SCHEDULED AUTOS ONLY AUTOS BAA55691829 ilf14/2018 11114/2019 soDILYiNJURr Peroodders 5 X HIRED X NOR OWNED AVO$ ONLY AUTOS ONLY PROPERTY DAMAGC Unt attiderl $ Uninsured motorist g 300,000 %� UMBRELLAUAB �/ X OCCUR --•'•-••'���,,.e•-".'•'. [ACII OCLURRCNCE E 5,000,000 C ExCESSLwe CLAIMS MADE US055691829 11/142018 11/14/2019 AGGREGATE. g 5,000.000 X OLD REYCNTION S 10,006 g D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIXECUTIVE a OFFIL[WMEMSER EXCLUDED? (Mandatory In NH) Il yes, tleSrs,"idar DESCRIPTION OF OPERATIONS below N/A DRWC962182 06/22/2018 O6/22/20.19 PER OTFb STATUTE CR @LEACH ACCmCNT $ 1,000,000 EL. VIa[ASE [A EMPLOYEE E 1'D6D'666 EL DISUSE -POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 104. Additional RemaNm Sclladan, maybe attached if mom apace la squired) CERTIFICATE HOLDER CANe Fi I ATIFIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield -Board of Health ARnA. Doucette ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORRbu REPRESENTATIVE Mansfield MA 02048 ) r(1K �r ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are youururrently licensed with? (check all that apply) ❑ Foxborough q Mansfield ❑ Norton ❑ Plainville Company Name: \--x cMc c9 Address: Telephone Operator at Inspection: �G-ul Tank Capacity: "';� 130 e Si Truck License #: US Z��'�-1 Registration Exp. Date: Cad `� Truck Inspection 0 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 Pumps (leak proof) Operator at Inspection nspec� CD'f�\'�� Date (Updated September 2018)