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Home My WebLink AboutPatriot Services - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that., Doing business as: KATHLEEN BLANCHARD PATRIOT SERVICES P.O. BOX 294 BRIDGEWATER MA 02324 Town of Mansfield 6 Park Row Mansfield, MA 02048 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 14 TRUCK REGISTRATION NUMBER(S): 566083 BOARD OF HEALTH Michae(HeaCey, Chairman TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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) 1r i, l t t **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:\Usem\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 UlfBoston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: !"w J Lk C f -> Address: Phone Are you an employer? Check the appropriate box: Business Type (required): 1. d 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 (met. 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12. ff Other *Any applicant that checks box # t 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: 1 t � ,,1 D n Z]:- i t I r't r C 0 Insurer's Address: ` .p g�� - City/State/Zip: xr Policy # or Self -ins. Lie. # i _7 '� r";t' E r ( ��``'i � Expiration 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certjfy� under the pains and penalties of perjury that the information provided above is true and correct. i,�) k 3 �- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mus.gov/dia V 6 e 9 S-L WASTE WATER SERVICES INC October 12, 2018 Patriot Services Inc. 940 Plymouth Street Halifax Ma 02338 Waste Water Services Inc 1997 Bedford Street Bridgewater Ma 02324 W. W.S.I. is a full -service wastewater transportation and disposal company. We have extensive experience in managing the transportation and disposal of liquid wastes in New England, W W.S.I. is constantly in contact with disposal facilities throughout New England to insure our customers always have options. W.W.S.1. has received approval to dispose of your waste at Earth Source in Raynham Ma as well as several organic digesters. W. W.S.1 understands the operations of Multi Tank Systems, Sewage Treatment plants, large or small. W. W.S.I can service all your septic and sewer system needs W.W.S.1 will provide 24-hour Emergency service. Waste Water Services Inc. Pumps, Transports and disposes of Patriot Services Inc. Tight Tank grease at your facility on 940 Plymouth Street Halifax Ma 02338. PROPOSAL: Pump, transport and dispose of Tight Tank Grease IVY)'• BedlLrd Street. BrideiatoMA 023_t 1'hnnc: (?0.S) 87WINS1(9974) 1,ax: 15OS1697-9979��cm�e.te�esinfin,t.eam �G5NC7 Yj i F.R uV of Mansfield a Town of Mansfield - Board o � � �� ' a Row 2 11n ela, MA 02048 AS A7Y'tQ1 Septage Pampers Application DATE: LICENSE NUMBER: E$ BUSINESS NAME:t.,t�r MAIL ADDRESS; TOWN tS'. ='tr STATE: C+;v° ZIPCODE: NAME OF OWNER:a_`�E�G'e BUSINESS TELEPHONE:' .� , =1<t „c CELL:"ram _ € ; FAX:, E-mail t .; - , Alt E-mail: .a/ C FED ID/SS NO: �t t NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): 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. / r SIGNATURES..: �i , :?�e, ,�5�=�J? � t � s r'z � R� DATE:. TRUCKS INSPECTIONS: DATE: f11Jil=11 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 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 ,...a 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: AC<>RO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYM 10/25/2018 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: R the certificate holder Is an ADDITIONAL INSURED, the policy(Tes) must have ADDITIONAL INSURED provisions or be endorsed. N SUBROGATION IS WAIVED, subject to the terns 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 a . PRODUCER D'Agosdno Insurance Agency C E Marisa Lima (508) 686-0414 A' No ; (500) 584-7432 ik:%Ilma@rfdlnsurence.com 111 Torrey St Suite 1 INSURMSI AFFORDING COVERAGE MAID INSURERA: TRAVELERS IND CO OF AMER 25666 Brockton MA 02301 INSURED INaURER a: TRAVELERS CAS INS CO OF AMER INSURERC: TRAVELERS INSURANCE 25658 PATRIOT SERVICES INC INSURERD: TRAVELERS IND CO OF CT 115 HAYWARD PL INSURERE: IN RERF. BRIDGEWATER MA 02324 COVERAGES CERTIFICATE NUMBER: RFVHUnNI NIIMRFR- 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 TyI,E OR INSURANCEDL SUER NU pOL1CYEFF YELP UMIfB A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE®OCCUR 6807C436024 02/25/2018 02/25/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISE $ 300,000 MEDEXP one $ 5,000 pERSONALSADVINJURY $ 1.000,000 OENL AGGREGATE LIMIT APPLIES PER: POLICY jE� LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 $ B AUTOMOBILE LIA9aJTY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY SA4K438784 02/2512018 02/2512019 COMBINED SINGLE LIMIT and ent S 1,000,000 BODILY INJURY (Per parson) $ BODILY INJURY eoddent) $ PROPERTYDAMAGE Per ont $ $ C UMBRELLAUAB EXCESSLUI1 OCCUR CLAIMSMADE CUP7C751811 02/25/2018 02(25/2019 EACHOCCURRENCE s 2,000,000 AoGREGATE $ 2,000,000 I DED RETENTION $ D WORMERS COMPENSATION Y ANDEMPLOYERWUABILRYIN ANY PROPRIETORIPARTNERMXECUTNE OFFICERIMEMSEREXCLUDED7 ❑N (IAndatwyInNH) If yyeeaa doWbounder DESdRIPTION OF OPERATIONS bePow NIA UB8C48834A 02/25/2018 02/25/2019° PER O - 3TATU E E EN EL EACH ACCIDENT EL.DISEASE -EAEMPLOYEE $ 1,000,000 -- $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 DESCRIPTION OPOPERATIONSILOCATIONSIVEHICLES (ACORD 101. AddlBonai Berner" Seheduta,maybe suacbed Nmore epaa is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PATRIOT SERVICES INC ACCORDANCE WITH THE POLICY PROVISIONS. 115 HAYWARD Pl. AUTHORIZED REPRESENTATIVE BRIDGEWATER MA 02324 -- m 1988-2015 ACORD CORPORATION. All Hahts rasawad ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Annual Collaborative Septi Inspection Day (In accordance with 310 CM 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ Foxborough D Mansfield ❑ Norton /0 Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration l:xp. Date: Truck Inspection Lt 141obile Tank (securely mounded on truck, watertight, necessary odor controls, leak -proof cavor, tight discharge valves) ling available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair Pumps (leak proof) U 1 �v tr Operator t Inspection �tt� Date ((Updated: Septeniber20t8)