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Home My WebLink AboutJ. Hockman, 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 Pern This is to certify that: JASON HOCKMAN Doing business as: J. HOCKMAN, INC. 11 SHERWOOD DRIVE NORFOLK MA 02056 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 10 TRUCK REGISTRATION NUMBER(S): J-800 PUMP BOARD OF HEALTH _%1ichaeC_HeaCey, Chairman z 9 tq own of Mansfield Town of Mansfield - Boll(r # ,� 'edh%20t8 Pansfield, Park Row MA 02048 Septage Pumpers Application DATE: �/I�1 k LICENSE NUMBER: BUSINESS NAME:. J acicl'2m Id MAILADDRESS: TOWN:STATE: /f1A ZIP CODE: oaOSz- NAME OF OWNER: J,4 S O A) 11-01_1eP?t I" d BUSINESS TELEPHONE: 5do'""" /y�CELL: FAX: 6-doP"-'�Y �FS� E-mail: Alt E-mail: //P`c. (T'v-r ��r) FED ID/SS NO: U �3tj yAS �(/ (/ NUMBER OF TRUCK(S): REGISTRATIONNUMBER(S): At MP -j—b'z9O 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 Fark Row, Mansfield, MA 02048. SIGNATURE: ^1 _._ DATE: Z46 Rd � .. ^......................................................................................... 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 AGENTS USE ONLY 0- --rm A 310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sews 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. Signature of Individual or Corporate Name By. Corporate Officer (Mandatory, if Applicable) .017(3 V/'l�S-779 "Social Security No. (Voluntanj) 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. CAUsem\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTTFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwx.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Auulicant-Information Please Print Le¢ibiy Business/Organization Name: J HOCKMAN INC Aririrt-mw 11 SHERWOOD DRIVE NORFOLK Phone #:508-384-1400 Are you an employer? Check the appropriate box: I. ❑✓ I am a employer with 14 employees (full and/ or part-time).* 2. ❑ I am.a sole 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 exercise their right of exemption per c. 152, § 1(4), and we h ve no employees. [No workers' comp. insurance requir d]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Business Type (required): 5. ❑ Retail 6. ❑Restaurmt(Bar/Eating Establishment 1. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.0 Other SEPTIC & EXCAVATING CO *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. **Tf 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. . lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: HOLLIS INSURANCE AGENCY Insurer's Address: 140 MARION ROAD City/State/Zip: WAREHAM, MA 02571 Policy # or Self -iris. Lic. # 4219101 Expiration Date:6120/2019 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, and q the ofperjury that the OJJ7eial use.only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # we is true and correct >,Y-.70/S, 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 #: UTICA NATIONAL INSURANCE GROUP WC 000001A 180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page 1. The Insured and Mailing Address: J. HOCKMAN, INC. C/O C.L. HOLLIS INSURANCE 140 MARION ROAD WAREHAM. MA 02571 Entity of Insured: Corporation Other workplaces not shown above: Insured's I.D. Number: 043496500 - Risk I.D. Number: MA:000409854 Policy Number: 4219101 Prior Policy Number: Producer: C.L. Hollis Ins Agency 140 Marion Road Wareham MA 02571 Producer Number: 70102 - SIC#: 1711 NCCI Company Number: 15717 2. The policy period is from 06/26/2018 to 06/26/2019 - 12:01 AM Standard Time at the insured's mailing address. 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 $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Policy Limit Bodily Injury by Disease $1,000,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, WY _ D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ❑ See Extension of Information Page Classifications Code No. Premium Basis Total e Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium Minimum Premium: $ 460 - MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ If indicated below, interim adjustments of premium shall be made: Deposit Premium $ Issuing Office: New Hartford, NY 13413 Date of Issue: 06-20-2018 Countersigned by 8-D-WC Ed. 08-2008 Copyright 1988 National Council of Compensation Insurance BILLING NO. 100948457 Annual Collaborative Inspection Day (In accordance with 310 CAM 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) 4 Foxborough Mansfield Norton 67 Plainville Company Name: Address: Telephone #: f4� 0z� \Lko b Operator at Inspection: Tank Capacity: L\c60J Truck License Registration Exp. Date:,�3\, \ g, Hauler J/_ Truck Inspection C� Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair (leak proof) OperatoP at Inspection Inspecto Date i (Updated: September 2018) Town of Foxborough Town of Mansfield Town of Norton Town of Plainville 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT SC '- PaEiRd:M ATE: oa� PY "�y / l fN First T i-Town Inspection Day COMPANY NAME: U(Wlflv,/ ADDRESS: Nc�Follti ` TELEPHONE#: od OPERATOR: C �1 c (C %n TANK CAPACITY: TRUCK LIC. NUMBER: C oc) Equipment d1. Mobile Tank (securely mooted on trucks, watertight, necessary odor controls, leak -proof cover, fight discharge valves) dY 2. Venting (gas) of Mobile Tank (properly constricted) 6 3. Suction or Pressure Hose in good repair u/ 4. Pumps (leaf( -proof) o This vehicle is in compliance with 310 CMR 15.505. 77