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Home My WebLink AboutMr. Cesspool, 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 1 This is to certify that: CHARLES LEONARD Doing business as: MR. CESSPOOL, INC. P.O. BOX 50027 NEW BEDFORD MA 02745 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 12 TRUCK REGISTRATION NUMBER(S): S16315 BOARD OF HEALTH gblichaeCHeaCey, Chairman i aTown of Mansfield Torun gl'Mansfielrt�t oartj q f' f� Ct 4 � 6 Park Row f; Mansfield, MA 02048 Septa e Pumpers Application DATE: /0- i� �/� LICENSE NUMBER: BUSINESS NAME: /`//"• G�✓��/ ��• MAIL ADDRESS: A�/,es,-d-X/ JDd TOWN: AM) STATE: llot ZIP CODE: O4�Z�5� Xc�l�/ relit' NAME OF OWNER: /Ql"1'j f-eO!aly ll BUSINESS TELEPHONE: gV�-OO9/CELL: FAX: E-mail: %{p�fyJi CESS��XJd lC'O,00,7 Alt E-mail: FED ID/SS NO: SC% -W 7691�1 . NUMBER OF TRUCK(S): / REGISTRATION NUMBER(S): 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: G/r DATE: ��19 ........................................................................................................................................................................... TRUCKS INSPECTIONS: DATE: NOVEMBER 8, 2018 TIME: 7:30am-10:30am PLACE: FOXBOROUGH DPW, 70ELM 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 .....i 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 lndi dual or Corporate Name - ya-76 %W **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, 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:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The, Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street a Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Phone Arree yyoy an employer? Check the appropriate box: Business Type (required): 1. t '1 I am a employer with _�_ employees (full and/ 5. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment 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. El We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] _ *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 fo rmy employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. # 4,r �� Expiration Date: 3 0� 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, unde�he pgil�nd ofperjury that the information provided above if true anti correct Phone #: 07 tf ' ;�Ve4' _1:511�l�j 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.gowma AC40R LI® CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDIYYYY) 11/14/2018 11/14/2010 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 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 Eastern Insurance Group LLC 233 West Central St Natick MA 01760 ry0 E CT Karen Bernier PHONE (800)333-7234 FAX No: E-MAIL AODREss:kbernier@easterninsurance.com INSURERS AFFORDING COVERAGE NAIL p INSURERA:Ohio Security INSURED Mr Cesspool Inc, DBA: and Charles R Leonard P O BOX 50027 New Bedford MA 02745 INSURERB:OhiO Casnalt In811ranCe Co/Lib Mtl INSURER C: INsuRERO: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:CL1810938275 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 LT TYPE OF INSURANCE ADD B POLICY NUMBER P ppY EFF MO�CDY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR BK857844348 3/7/2018 3/7/2019 EACH OCCURRENCE $ 11000,000 AMAGE TO PREMISES ERENTEDa n $ 300,000 MED EXP(Any one person) $ 15,000 PERSONAL& ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS HIRED AUTOS X NON -OWNED AUTOS HA957844348 3/7/2018 3/7/2019 COMBINE INGLE UMTT— Ea actltlem $ 1,060,000 X BODILY INJURY (Per Person) $ BODILY INJURY (Peracdtlen0 $ PPROPPEERTTY; DAMAGE $ INCLUDED UNINSURED MOTORIST $ 300,000 B X UMBRELLA UAS EXCESS LIAR X OCCUR CLAIMS -MADE US057844348 3/7/2018 3/7/2019 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DEC) I X I RETENTION$ 10,000 1 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORJPPRTNER/EXECUTNE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) H yes, describe under DESCRIPTION OF OPERATIONS below NIA XWO57844348 3/7/2018 3/7/2019 X STATUTE X ER EL EACH ACCIDENT $ 500 000 E.L. DISEASE - EA EMPLOYEd $ 500,000 E.L. DISEASE -POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tOl, AtltlHlonal Remarks Schedule, may be attached W more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE Koegel/KBERNI � �'�' SG- g ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 r2In401I L.. Annual Collaborative Septic Hauler Inspection DaV (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ roxborough ❑ Mansfield ❑ Norton ❑ Plainville Company Name: Address: Telephone#:U`5 Operator at Inspection: Tank Capacity: Truck License #: "2 \ �� Registration Exp. Date: Truck Inspection U f Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair amps (leak proof) ji�y c /� d y ,\ Operator at Inspection Inspecto l \ �0 Date (Updated: September 2018)