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Home My WebLink AboutHersee Equipment - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Sep tage Pumping and Transporting Permit This is to certify that: SCOTT HERSEE Doing business as: HERSEE EQUIPMENT, INC. 1800 BAY ROAD STOUGHTON MA 02072 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 2 TRUCK REGISTRATION NUMBER(S): T15-344 BOARD OF HEALTH NichaeCHeaCey, Chairman Septage Pumpers Application; DATE: LICENSE NUMBER: I � U BUSINESS NAME:+ �rS�� [1 u i prm e v4 Inc MAIL ADDRESS: I gU� 1 " TOWN:SfcX-)CIkIc-�r-) STATE: HA. ZIP CODE: WYU 0 NAME OF OWNER: SLCM I f tSe BUSINESS TELEPHONE: CELL: -7-8 ((o171Cocl FAX: E-mail: 4-le rs� � r Q rric . LL m Alt E-mail: FED ID/SS NO:O(yJc) (,$ �6 zAc-( NUMBER OF TRUCK(S): ( REGISTRATION NUMBER(S). j FEE PER TRUCK: 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: 4;z� --- TRUCKS INSPECTIONS: DATE: DATE: Apr d ............................................................................ 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 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 ins❑ected and approved by the Board of Health. A. Mobile Tank: B. Venting Mobile Securely mounted on truck Vent permits escape _ Watertight C. Hose: — Leak -proof cover _ Suction or pressure' — Tight discharge tanks D. Pumps: _ c9L) ] Maintained to prey A = Acceptable Inspected by: NA = Not Acceptable I 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) "Social Security No. (Voluntary) 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establislunents- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street e Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: II Phone #: '�� -c, ( -3�41 - I a 30 Are you an employer? Check the appropriate box: Business Type (required): 1. p 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. [No workers' comp. insurance required] 8• ❑ Non-profit 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]* I1.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.M Other((wn+y c\c *My 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 workers' compensation insurance for my employees. Below is the policy information. Insurance Company Namef— L. HC)1 1 S �, &TP r,C t i Insurer's Address: I LS I } r Sk Un c% 2 -,2 A City/State/Zip: ( c �niv �hA l7 CS I Policy # or Self -his. Lie. # (z.) L 2 Ll B Lt ( S IS PO 77-9 1 S Expiration Date: t c 1 119 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 I do hereby certify, under lite pains and penalties ofperjury that the information provided above is true and correct. 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 Phone www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shalt not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/03/2019 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 pollcy(fes) 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 IOI NAMEACT Melanie Keefe PHONE 781 344-8578 AC No; C L HOLLIS INSURANCE AGENCY nooaess: melanie@insurehollis.com INSURER(Sl AFFORDING COVERAGE NAICY 1017 TURNPIKE ST UNIT 2-2A INSURER A: ACE AMERICAN INSURANCE CO 22667 CANTON MA 02021 INSURED INSURER B INSURER C: HERSEE EQUIPMENT INC INSURER 0: INSURER E: 1800 BAY RD INSURER F: STOUGHTON MA 02072 COVERAGES CERTIFICATE NUMBER: 385582 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 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 TYPEOFINSURANCE ADDL SUBfl POLICY NUMBER MMNDNYY POLICYEI(P LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE1:1 OCCUR TO RENTED PDREAMAGE MISE Ea occurrence $ MED EXP(Any one person) $ PERSONAL A ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PRO- ❑ LOC JECT PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OSCHEDULED AUUTOSS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NED HIRED AUTOS AUTOSUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICEOR/MEMBE EXCLUDED?ECUTIVE WA (Mandatory In NH) WA WA 6S62U34635P07918 04/19/2076 04U 9IZOt9 f. X BTY/NER ER E.L EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ 500,000 N/A DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached it more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.ma$$.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION 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 Daniel M. Cr,W)by, CPCU, Vice President —Residual Market—WCRIBMA Daniel. o ACORD 25 (2014/01) 01988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE FDA4i /20 9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 oertifloate holder is an ADDITIONAL INSURED, the polioy(ies) 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,�CTMelanie C.L. HOLLIS INSURANCE 1017 Turnpike St, Unit 2-2A Canton MA 02021 Keefe PHONE (781)344-8578 FAXHVC No: (791)391-0129 E-MAIL ADDRESS: melanie@insurehollis. com INSURERS AFFORDING COVERAGE NAIC N INSURER A: Evanston Insurance Co 35378 INSURED Hersee Equipment Inc 1800 Bay Rd Stoughton MA 02072 INSURERB:Utica Mutual Ins Co. 25976 INSURERC:Ace Group -Chubb invol 80500 INSURER D: NSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CL1921304844 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 ADDLB BR POLICYNUMBER POLICY EFF ffWWDDfYYYYI POLICY EXP (MIWDDfYYYY1LIMITS A X COMMERCUILGENERALUABIUTY CLAIMS -MADE X OCCUR EXCLUDES SNOW OPTS 9AA17101S 4/28/2018 4/20/2019 EACH OCCURRENCE $ 1,000,000 _ DAMAGE TO RENTED PREMISES Ea omurfglrYe $ 100,000 X MED EXP (Any one ereon $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY JECT LOC OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS -COMPIOPAGG $ 2,000,000 B AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS X AUTOS NON -OWNED HIREDAUTOS X AUTOS 9009285 1/12/2019 1/12/2020 COMBINED SINGLE LIMIT uH $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Peraccident) $ X PROPERTY DAMAGE Per acdtlert $ $ UMBRELLA LIAS EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' DABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? a (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS now NIA PLEASE BEE ATTACHED 4/19/2018 4/19/2019 ` I PER OTH- X STATUTE 0.8 _,,, E.L. EACH ACCIDENT $ 500,000 - E.L. DISEASE - EA EMPLOYEE $ 500,000 EL.DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCAnONS I VEHICLES (ACORD 101, AtldHlonal Remarks Schedule, maybe attached If more space Is required) TOWN OF MANSFIELD 6 PARK ROW MANSFIELD, MA 02048 VAPII CLL IIVW 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 Keefe/MFK ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD INS025 1201401) Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are y currently license with? (check all that apply) ElFoxborough k Mansfield Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: ,4 � Truck Insuection ❑,... Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 7, Venting available to allow the escape of gas on Mobile Tanks (properly constructed) [=]'\,Suction or Pressure Hose in good repair t 0, Pumps (leak proof) / J Operator/at Inspection Inspector Date .l (Updated: September 2018)