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Home My WebLink AboutFlowmaster Corp. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: Doing business as: MARK ARAKELIAN FLOWMASTER CORP. 191 BEDFORD STREET MIDDLEBORO MA 02346 Town of Mansfield 6 Park Row Mansfield, MA 02048 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 TRUCK REGISTRATION NUMBER(S): L60983 BOARD OF HEALTH MichaecHeaCey, Chairman Town of Mansfield - Board ®f 11 . y 29 �� Town of Mansfield 6 Park: Row Man;field, MA 02048 Septage Pampers Application DATE: LICENSE NUMBER: BUSINESS NAME: Flowmaster Corp. MAIL ADDRESS: 191 Bedford Street TOWN: Middleboro STATE: MA ZIP CODE: 02346 NAME OF OWNER: Mark Arakelian BUSINESS TELEPHONE:508 946 5066 CELL: FAX: 508 238 8067 E-mailkarenara@flowmasterseptic.com Alt E-mail: FED ID/SS NO: 04-3336032 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): L60983 FEE PER TRUCK: Please make approprl ' changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, T n o Mgnsfield, Six Park Row, Mansfield, MA 02048. TRUCKSI DATE: DATE: N 'Zvi I ( 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: 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 i NA = Not Acceptable 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. Flowmaster Corp. Signature of Individual or Corporate Name 04 3336032 "Social Security No. (Voluntary) or Federal Identification Number l By: orporate Officer (Mandatory, if Applicable) *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\sleile\Desktop\ScoWs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name I-iow-%bIaster F`,:ii.:I Jr` ant Cam,,) Address: 920 `'J`Jisiling,tcn, Su ao( Easton, 0 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 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 (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. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *My applicant that checks box #I 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 workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: � G h I Ct [ vttj, Insurer's City/State/Zip: Policy # or Self -ins. Lie. # 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 WORT{ 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 ce tdfy, gr the pasand penalties ofperjury that the information provided ablovee, is true and correct. Signature: "� Date: Phone #: v SaFi qqc7 so ("V Official use only. Do not write in this area, to be completed by city or town offteial, 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 A� ® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 19 /1t /9M a 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(les) 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 CONTACTy* NAME: Boynton Insurance Boynton Insurance Agency 72 River Park Street PHONE (781)449-6786 FAX. Ive1r44e-4zsa 0./cNo: AIL ADDRESS:certificates@boyntonins.com INSURERS AFFORDING COVERAGE NAIC N Needham MA 02494 INSURER A: Merchants Preferred Insurance Group INSURED INSURER B: Merchants Mutual Insurance CO Araco Sewer and Drain Inc. INSURER C: Flowmaster Corporation and Hajar Realty Trust INSURER D: 920 Washington Street INSURER E: Easton MA 02375 1 INSURER F: 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. INSR LTR TYPE OF INSURANCE ADDL BUSH POLICY NUMBER POLICY EFF WMUDD POLICYEXP MIMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence)$ 300, 000 MED EXP (Any oneperson) $ 5,000 CNIl9155932 3/30/2018 3/30/2019 PERSONAL S ADV INJURY $ 1,000,000 GENIAGGREGATE X LIMITAPPLIES PER: PRO- POLICY 0JECT LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eat accident $ 1,000,000 BODILY INJURY (Per person) $ A ANVAUTO ALL OWNED SCHEDULEDMCA0000163 AUTOS 3 30/2018 / 3/30/2019 BODILY INJURY Per acdtlenl 1 ) $AUTOS NON -OWNED M •CA9948 exoad Soxm X PROPERTYDAMAGEHIREDAUTOSAUTOS (Per den t $ $ Pollution Endt Included X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2 000 000 AGGREGATE $ 2 000 000 B EXCESS LIAB CLAIMS -MADE CUP9148837 3/30/2018 3/30/2019 DED I X I RETENTION 10,000 $ 1 Umbrella is Follow Form A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N (Mandatory in NH) If yes, describe under N/A WCA9100605 4/23/2018 4/23/2019 X PER OTH- SIAlUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached It more space is required) CERTIFICATE HOLDER CANCELLATION Town of Mansfield Board of Health Six Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Polutchko/DPOL o.✓,if.l�%r-' V 19BO-2014 ACORD CORPORATION. All rights ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) 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) Foxborough 0 Mansfield -' Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: Truck Inspection 9/Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 'id Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair Pumps (leak proof) Ip�peet0) (Updated: September 2018)