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HomeMy WebLinkAboutMiles of Excavating - 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: TIMOTHY KONOWITZ Doing business as: MILES OF EXCAVATING 242 PARK STREET WRENTHAM MA 02093 is hereby granted a SEPTAGE 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 11 TRUCK REGISTRATION NUMBER(S): N79901 BOARD OF HEALTH MichaeCHeaCey, Chairman V pglEdAS A Town of Mansfield Torun ®f Mansfield ® Board of Health B Park Row Mansfield, MA 02048 LICENSE N R: ) BUSINESS NAME: MAIL ADDRESS:— TOWN:STATE: ZIP CODE: NAME OF OWNER: \ BUSINESS TELEPHONE: ��,'3 �(S �(� CELL:�Jj�'la(a g�►�J FAX:}-ll-tj� (� E-mail: Nt\JeS c>=C2GCCcco=j\f\()Cxhc�At "J i FED ID/SS NO: C) (- } UMBER OF TRUCK(S): REGISTRATION NUMBER(S): ' V I C1c©' FEE PER TRUCK: $100 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town o >ansffield,Six Pa ow, Mansfield, MA 02048. SIGNATURE DATE: it) . / 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 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) o V -3 VS r8/ �- "*Social Security No. (Voluntary) o 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:\Usem\.sleite\Desktop\Scotfs Doeuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Pepartment oflndastrialAccidents Office of Investigations n 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: t Address: ,Qq:)— c -_ City/State/Zip: e Phone #: Jb c, - Are ou an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 3 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 10.0 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.] 12.0 Other *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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Dater 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 here b rd !er the pains a nalties of per,/ that the information provided above is true and correct Siertature ,�J,/ Date: Phone#:�JJi� Official use only. Do not write in this area, to be completed by city or town oflleiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityffown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia MILEOFE-01 CWOODSI ACORa CERTIFICATE OF LIABILITY INSURANCE 1 07J31/20TE V8 `—� mll 3v2o16 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 endorsament(s). PRODUCER License # 1780862 uQ(j�pcT Michelle Wolf INSURED England PHONE. E.n: (508) 888-2183 Miles of Excavating Timothy Konowitz dba 242 Park Street Wrentham, MA 02093 COVERAGES CERTIFICATE NUMBER: RFVIRION N111MRFR- 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. rypE OFINSURANCE AUDLSUBR INSIINSR pOLICY NUMBER POLDDYEFF PffYYYi �DpYEXP LIMITS A X COMMERCIAL GENERAL LIABIUTY CLAIMS -MADE FIX,]OCCUR X BKS58621919 02127/2018 0212712019 FACHOCCURRENCE $ 1,000,000 DRAMAGETORENTEO MISES(E pccurrence $ _ 100,000 MEDEXP(Anyoneperson S 15,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE 5,2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ j�7 L� LOG PRODUCTS-COMPlOP AGG_ $ _— 2,000,000 S OTHER: B AUTOMOBILE LIABILITY OMB;IdEDSINGLE LIMIT $ 1,000,000 BODILY RY_(Per erson)_OOS $ ANYAUTO AUTSU�D AUTOS OS BHDLXX 02/27/2018 02127/2019 BODILY INJURY Peracdtlent), $ PPAOTOP a0PERNJAMAGE eNeJnUt) --- $X X MSNNLY p $ I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ _ EXCESS LIAR CLAIMS -MADE DEG RETENTIONS $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERJEXECUTIVE QQ��FlpCEWRMEMgEp EXCLUDED? �N (MantlatcryIn NH) desenthe under DESCRIPTION OF OPERATIONS below NIA WWC3365078 08123/2018 08/2312019 PER OTH- STAT.UIE_ E.L.EACH ACCIDENT EL DISEASE EA EMPLOYEE 500,000 500,000 $it E.L. DISEASE -POLICY LIMIT _ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD ID1, Additional Remarks Schedule, may be attached If more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield Board Of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE AUUKU ZO (LUTOIU3) ©1988-2015 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD Native Septic Ha Inspection Day (In accordance with 310 CAIR 15.505) INSPECTION REPORT n)jch Towns are you currently licensed with? (check' df that app1j) El Foxborough 041ansfield U'Norton K3 Plainville Company Name: jig L) r i t'�-f "s/___ Address: Telephone #: S Operator at Inspection: Tank Capacity:�� Truck License #: S ) 119 o "i Registration Exp. Date: ; •2 1 le Truck Inspection ©/ Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) d Venting available to allow the escape of gas on Mobile Tanks (properly constructed) 9 Suction or Pressure hose in good repair Pumps (leak proof) Operator at Inspection h iB�l�• Date Inspect)rr (Updated: Sep(onber 2018)