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Home My WebLink AboutJohn's Sewer & Drain Cleaning, 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., SCOTT MCDONALD Doing business as: JOHN'S SEWER & DRAIN CLEANING INC. 4 BREED AVENUE WOBURN MA 01801 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 I II section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 27 TRUCK REGISTRATION NUMBER(S): T91824 BOARD OF HEALTH MichaeCHeaCey, Chairman r 77 t JUN 17 2019 1,) Towfi oflansfield Town of Mansfield - Board of He " tla 6 Pa�k-Row Mansfield, MA 02048 Septage Pumpers Application DATE: 06/12/19 LICENSE NUMBER: 2814 BUSINESS NAME: John's Sewer & Drain Cleaning Inc. MAIL ADDRESS: 4 Breed Ave TOWN: Woburn STATE: MA ZIP CODE: 01801 NAME OF OWNER:SCott McDonald BUSINESS TELEPHONE: (781)-569-6695 CELL: (781)-569-6695 FAX: (781)-569-6694 E-mail: info@johnsewer.com Alt E-mail: FED ID/SS NO: 364448458 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): T91824 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: TRUCKS INSPECTIONS: DATE: 7�ii 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 privies, 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) 364ugr81_/58 "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. RAHmIllMones Documenls\PERMIT APPLICATIONSWAX CERTIFICATION FORMAoc The Commonwealth of'Massachusetts 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: John's Sewer & Drain Cleaning Inc. Address: 4 Breed Ave City/State/Zip: Woburn, MA 01801 Phone M (781)-569-6695 Are you an employer? Check the appropriate box: Business Type (required): 1.2 I am a employer with 55 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] g. ❑ 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.9Other Drain Cleaning *Any 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: The Hannypr Insurance Company Insurer's Address: 440 Lincoln St City/State/zip: Worcester, MA 01653 Policy # or Self -ins. Lic. # WHND370727 Expiration Date:12/09/19 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 Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct, Signature: Date: Phone #: 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 A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOnYYY) 06/06/2019 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 ACONTRACT 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(s). PRODUCER CONTACT Michelle Landers NAME: Brown & Brown of Massachusetts, LLC PHONE (7gi) 455-6664 we No): E-MAIL mlanders@bbdedham.com ADDRESS: 333 Elm Street, Suite 300 INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: The Hanover Insurance Company 22292 Dedham MA 02026 INSURED INSURER B: Allmerica Financial Benefit Insurance Company 41840 INSURER C : John's Sewer & Pipe Cleaning, INSURER D : 4 Breed Ave INSURER E: INSURER F: Woburn MA 01801 COVERAGES CERTIFICATE NUMBER: MASTER 2018-2019 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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. LTR TYPE OF INSD UBR WVD POLICY NUMBER POLICY EFF MMIDDN"Y POLICY EXP MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR T PREMISES Eapccunence $ 100,000 X MED EXP(Any one person) $ 10,000 Blanket Addl Ins X FORM 421-2915 PERSONAL 6 ADV INJURY $ 1,000,000 A ZHND446100 12/09/2018 12/09/2019 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY � PRO. JECT LOG PRODUCTS $ 2,000,000 Property damage -Single $ OTHER: AUTOMOBILE LIABILITY OOMBINED SINGLE LIMIT En accident $ 1,000.000 X BODILY INJURY (Per person) _ $ ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS AWND446146 12/09/2018 12/09/2019 BODILY INJURY (Per eccideni $ PROPERTY DAMAGE Porealdent $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY q $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESSLIAB CLAIMS -MADE UHND446101 12/09/2018 12/09/2019 OEO RETENTION $ 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYCERIMEBERIPARTNDED? UTIVE FN RIMEMBER EXCLUDED? (Mandatory NH) (Mes, NIA WHND370727 12/09/2018 12/09/2019 X PER OTH- STATUTE EH E.L.EACHACCIDENT $ 1,000.000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If Dyes, describe under dasonb DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) 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 V�►:�>7._,s_ ddodAJ 1L @ 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD O W O 2i pi N Ol 7 a d A R a O U N U • G C C d Z C l LLLL Zz L a a c N C D o � > a � coa cu C U c -C 01 co