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HomeMy WebLinkAboutDumont Pumping Service - 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: ALEC RICH Doing business as: DUMONT PUMPING SERVICE P.O. BOX 292 NORTON MA 02766 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 7 TRUCK REGISTRATION NUMBER(S): S18408 BOARD OF HEALTH .%lichaeCHeaCey, Chairman V or' LICENS" _.._.ER: E NUMBER: BUSINESS NAME:} MAIL ADDRESS: TOWN: f 4CX\ STATE: fft'S NAME OF OWNER: BUSINESS TELEPHONE:,,_, ) CELL:m E-mail: c�� C ec ict� ( .mac t �., tie} All E-mail: FED ID/SS NO: NUMBER OF TRUCK(S): REGISTRATION NUMBER(S):� ZIP CODE: vavi E� c% FAX: 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: DATE: C �) 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 .. __.= Acceptable._...._.,.--_.�, NA = Not Acceptable J 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, havefiled all statetax returns and paid all state taxes required under law. signature of Individual or Corporate Name "*Social Security No. (Voluntary) or Federal Idaltification Number By: Corporate Officer (Mandatory, if Applicable) *Thislicensewill not be issued unlessthis certification clause is signed by the applicant. ** Your social security number will befurnished to the Massachusetts Department of Revenueto determine whether you have met tax filing or tax payment obligations. Licenseeswho fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under theauthority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Department of Industrial Accidents Office of Investigations -_ _-_— 600 Washington Street = Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 0 L Goy~ , c City/State/Zip: YIIi C� Phone t�v�ft) Are yoyan employer? Check the appropriate box: Business Type (required): I. 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 (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We by 1 l.❑ Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.] 12.[4 Other N I C . *Any applicant that checks box #1 must also fill out the section below shoving 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 # I. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1'Ylt r_. V ra c?A f —_ YMe t l c cL C„Ta fi Insurer's Address: t7C) ' J)C(_)t--t City/State/Zip: �A (l?s`k3li �y Policy # or Self -ins. Lic. # CS( i)'�1 1 a,� Expiration Date: 'i / 10i Attach a copy of the workers' compensation policy declaration page (showing the policy number and z xpiration 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 do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct w Sienature: 'G" Date: G� 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 Person: Phone #: www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY —INFORMATION PAGE INSURER: MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 JACKSONVILLE, FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: ALEC-RICH (SEE NAMED INSURED ENDT) PO BOX 528 TAUNTON MA 02780-0528 POLICY NO: WCO2972T NEW BUSINESS NCCI Company No: 27103 Account No: CACO2972T AGENCY NAME AND ADDRESS: TAYLOR INSURANCE AGENCY 448 TURNPIKE STREET SOUTH EASTON, MA 02375 AGENCY PHONE NO.: (508) 230-2244 AGENCY NO.: 201040 LEGAL ENTITY: INDIVIDUAL OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POLICY PERIOD: From: 03-07-2018 To: 03-07--2019" Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: 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 liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 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 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements, ITEM 4. PREMIUM: The premium for' this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 347 Annual Premium: $ 1,434 Audit Period: ANNUAL Date: 03-08-2018 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance INSURED COPY A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYYY) 10/29/2018 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($). PRODUCER Taylor Insurance Agency dba Easton Insurance Agency 448 Turnpike Street South Easton MA 02375 CONTACT Taylor Insurance Agency NAME: ALCNnio E.t, (508)230-2244 FAc, No: (508)238-5014 E-MAILADDRESS' INSURERnn AFFORDING COVERAGE NAIC p INSURER A: Main StreetAmerlca Ins. Co. 29939 INSURED --DUMONT PUMPING PUMP GRUMP PO BOX 528 TAUNTON MA 02780-0528 INSURER B: National Grange Mutual Insurance Co. 14788 INSURER C: Main Street America INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: Master 2018 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 MAYBE 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY Err MMIDDNYYY POLICY EXP MMIDDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I �l OCCUR MP02972T 02/08/2018 02/08/2019 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 500,000 MED EXP(Any oneperson) $ 10,000 GENTAGGREGATE X PERSONAL B ADV INJURY $ 1,000,000 LIMITAPPLIES PER: PRO- LOG POLICY DJECT OTHER. GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 B AUTOMOBILE LIABILITY ANYAUTO OWNED X AUTODULED AUTOS ONLY HIRED AUTOS WNED AUTOS ONLY AUTOS ONLY M102972T 02/08/2018 02/08/2019 COMBINED SINGLE LIMIT Ea awitlenl $ 1,000,000 BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peremidenl $ S UMBRELLA LIAB EXCESS LIAB OCCUR CIAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'UABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandate, in NH) f1 yea, aescnbA under DESCRIPTION OF OPERATIONS below NIA WCD2972T 03/07/2018 03/07/2019 X STATUTE ORTM- E.L. EACH ACCIDENT 100,000 $ E.L. DISEASE - FA EMPLOYEE 100,000 $ EL DISEASE -POLICY LIMIT is 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) un, ncc CANCFI I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048.— V 1988-ZU10 AGVKU GVKYVKAIIUIV. All rigrrts reserVeu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Annual Collabori Sceptic Hauler Inspection Day (In accordance with 310 CMR 15,505) INSPECTION REPORT ri'ch Towns are you cyrrently licensed with? (check a hat apply) Foxborough ©VMansfield 1Norton Plainville Company Name: w Address: Telephone Operator at Inspection: �� �tt ( `l Tank Capacity: Ld P D Truck License #: < 14), Y Registration Exp. Date:�1� I t Truck Inspection 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 1 (a Dat / -C— T r (Updated: September 2018)