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HomeMy WebLinkAboutPump Grump - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: Doing business as: ALEC RICH PUMP GRUMP P.O. BOX 292 NORTON MA 02766 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 I I I section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 15 TRUCK REGISTRATION NUMBER(S): T15768 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 Le0bly Business/Organization Name: Address: 1' ') Ql City/State/Zip: Phone #: `30 6 . I<—n . \ C) Are you an employer? Check the appropriate box: Business Type (required): 1. Ltd 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 10.0 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.ROther '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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: i a� , % C4Ptt 1lmP C , < Insurer's Address: PC, t "X tX C�UUt'i City/State/Zip: VC, i �� (, LA2�iI Policy # or Self -ins. Lic. # ) Expiration Date 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 D1A for insurance coverage verification. 1 do hereby certify, under the pains antipenahies ofperjuty, that the information provided above is trite and correct. Phone #• L'� o`i . Lri , Gi \ 01, 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 Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia Phone Ut''PtusG 1 "IftPul o t1��feca.woovn BUSINESS NAME: MAIL ADDRESS: � TOWN: g,Y'A jrG l STATE: 1 NAME OF OWNER:,rA�eo_ CZeQy� BUSINESS TELEPHONE: CELL:�m -. _ --DATE. _-_ - LICENSE NUMBER: E-mail: 0,e_k-Alt E-mail: } FED ID/SS NO: (-,LA NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): ZIP CODE: C-�L-7 (J: FAX: 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: ooi,�.� _ DATE: ....................................................................................................................................................................... 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, havefiled all state tax returns and paid all state taxes required under law. Slgnatureof Individual or Corporate Name L-1 12 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *Thislicensewill not be issued unlessthis certification clause is signed by theapplicant. **Your social security number will befurnished to the Massachusetts Department of Revenueto determine whether you have met tax filing or tax payment obligations. Licenseeswho 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. Q\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE IMMrBDNYYY) 10/29/2018 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: 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 Taylor Insurance Agency NAMETaylor Insurance Agency PHONE (508) 231T2244 FA (508) 238-5014 Eath doe Easton Insurance Agency ADDRESS: INSURER(S) AFFORDING COVERAGE NAICIt 448 Turnpike Street South Easton MA 02375 INSURERA: Main Street America Ins. Co. 29939 INSURED INSURER B: National Grange Mutual Insurance Co. 1478E DUMONT PUMPING/PUMP GRUMP INSURER c: Main Street America PO BOX 528 INSURER D: _ INSURER E: TAUNTON MA 02780-0528 INSURER F: COVERAGES CERTIFICATE NUMBER: Master 2018 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 INSID MD POLICY NUMBER POLICYEFF BMMIDDfYYYYI POLICYEXP MMIDDNYYY LIMITS X COMMERCIALGENERALLIABILITY CLAIMS MADE X OCCUR EACH OCCURRENCE $ 1,000,000 RTed- PREMISES Ea occurrence $ 500,000 MED EXP(Anyone arson) $ 10,000 PERSONAL SADV INJURY $ 1,000,000 A MP02972T 02/08/2018 02/08/2010 GENTAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE g 2,000,000 X POLICY ❑ PRO- ❑ JECT LOC PRODUCTS - COMPIOP ADD It 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT EaacoWere) $ 1,000,000 80DILY INJURY (Per person) $ ANYAUTO B OWNED x aCHEDULED AUTOS ONLY AUTOS M102972T 02/08/2018 02/08/2019 BODILY INJURY (Per aalden0 $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per ecoMenl $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CIAIMS-MADE DIED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN CUTIVE ANY PROPRIETOREXCL EXCLUDED? OFFICER/MEMBER ExctuoeoY (fyos.doryin NH) N/A WCO2972T 03/07/2018 03/07/2019 PER OTH- %� STATUTE ER EL. EACH ACCIDENT $ 100,000 E.L. DISEABE-EA EMPLOYEE g 100,000 byes,RIPTION under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,0D0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mere space is required) 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 0204E ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD nnual C Septic Hi Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check 511lhal appX)j G7 Foxborough ©''Mansfield 13'Norton IT Plainville Company Name: . (Q` (.n �P ' Address: x ti w z' ( Telephone #: Operator at Inspection: '1c-n (- r 1<,o Tank Capacity: �I tit>• Truck License #: Registration Cxp.Date: Truck Insnection ©Mobile Tank (securely mounted on truck, watertight, necessary odor controls, look -proof cover, tight discharge valves) ®Venting available to allow the escape of gas on Mobile Tanks (properly constructed) 19/Suction or Pressure Hose in good repair [3/pumps (leak proof) r �16ui Opei-atar at Inspection Inspectopect Date n (Updnred. September2018)