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Home My WebLink AboutRaggs Septic Service - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: STACEY J. ABATO, PRESIDENT Doing business as: RAGGS SEPTIC SERVICE, INC. P.O. BOX 1027 CONCORD MA 01742 Town of Mansfield 6 Park Row Mansfield, MA 02048 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 21 TRUCK REGISTRATION NUMBER(S): 91224 BOARD OF HEALTH NichaecHeaCey, Chairman t as t$ ,-Pwn of ansfield Town of Mansfield - Board of �il�t Park Rojv Mansfield, MA 02048 Septage Pumpers Application BUSINESS NAME: R ✓ (C GJ fO Rc- SP-(IILe L, (N)c MAIL ADDRESS: Q 0,COX 1031) TOWN: C'orjccir0 STATE: fM-,A NAME OF OWNER: Y�&, Fy J - A-Oqo r Graf BUSINESS TELEPHONE:" a)J ,)8I SS((/ CELL: DATE: LICENSE NUMBER: E-mail: i n (0 -S t r) c, brW Alt E-mail: FED ID/8S-NO'70tf311a!0-0 NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): 91d Y- FEE PER TRUCK: ZIP CODE: U) 7 V Z FAX: 9 i cf 6 7 -? 39'VQj 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: /�/t/+��, i /�`_� DATE: TRUCKS INSPECTIONS: DATE: 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 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 In ttvidual or Corporate Name By: Corporate Officer Wandatory, if Applicable) DQ3112.9-aa " Soc�eenrity-Nu (huiamtm-y) 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:\Users\sleite\Desktop\ScotPs Documews\Food Estiblishmenfs- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: Qo 6c loa/) tt/L City/State/Zip: (' 6txclvo tyl-A 011 ill- Phone #: Xbo Are you an employer? Check the appropriate box: Business Type (required): 1. VD—T—am a employer wiVU6-/1-C% 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] $• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their riglrt of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.EJ-Mier ID2411-g— *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 out an employer that is providing workers' compensation insurancefir nay employees. Below is the policy inforittatiott. I, Insurance Company Name: Aet` A TJ /Nd UrAd.IG Insurer'sAddressC(a S fXrJLNY-4JCE 1 2-2-cf rVLAtN S7 Sf aA City/State/Zip: SA-C1'Vl 1&1H 030e?`j Policy # or Self -ins. Lic. # W CA 90g9 911a Expiration Date: a43- t,/ 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 (lo hereby cert04 tinder the pains and penalties ofpetjaty that the information provided above is true and correct. Of 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 Person: Phone #: www.mass.gov/dia 01/31/2019 15:39 9788973848 PAGE 01/01 '�,�(�]/rp• RAGGS.1 P , �—� CERTIFICATE OF LIABILITY INSURANCE °ATE'NNI°°nyYY THIS CERTIFICATE IS ISSUED As A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE HOLOQERRTHIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE CE INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(g), AurHORiz60 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If !ha certificate holder Is an ADDITIONAL INSURED, the pollcy(iesj must have ADDITIONAL INSURED provisions or ha endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the Policy, certain policies may require an endorsament. A atatement on this certificate does not confer rl hta to the "Officate holder in lieu of auch endorsements , ODUCER 6Q3.890.Q439 TACT Jason M Mlocek nto Insurance and Financial E: i Main Skeet Suite 2A Papxg THIS IS TO CERTIFY THAT THE POLICIES OF INDICATED. NOTWITHSTANDING ANY REOUI mmbKUTAL GENERAL UADILITY CLAIAISM4ba,� L� CCC,VR L.AGORE ullrr APP1,E�SPIER: ... POLICY X 1 1 LOC TERM ANYAUTO I IMCAO000 AU�ppTppO��SONLy X AUaTNO�SWULNEO AUii[9 CNLy AUT0.90Ryy Pnllutian UMBRELIA LIAe 'I'' x OCCUR EXCEsa DAB OLAIMS MADE CI1P914B1 QED X RETEIM0145 10000 1ERe CON PEN.ATIDN :mployERS'L aa, Y' flffOUUPRIEro�gPoPARTNER/�XECU7IVE N' WCA9099� EXCLUnEQY IN/AI' elpry In NnI A. MA HAVE BEEN ISSUED TO )N OF ANY CONTRACT I021221201810212212019 I I . 0212212018 0212212oi ED NAMED ABOVE FOR THE! POLICY DOCUMENT WITH RESPECT TO WHI D HEREIN IS SUBJECT TO ALL THE .v YLIMi DEBORIPTION OF OPERwil0N9l LOCAT1DN37 VEWCLEa (ACOROdQI,AddMoneI Remarks schedule, may be&anched le mcm apave is ,,deed) C SHOULD ANY CF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE E%PIRAT aN DATE "THEREOF, NOTICE WILL an DELIVER F�'p� IN Town of Mansfield Board ACCORDANCE WITH THE POLICY PROVISIONS. of Health Q Park ROw ANTHORIZED REPRESENTA7WE Hopktntop, MA 0174EI ACORD 25 (2016Io3( The ACORD name and logo are registorad m ®s o88-21115 CORO CORPORATION. All rights f ACOROrogerver Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are y u urrently licensed with? (check all that apply) Foxborough 14Mansfield IR Norton ❑ Plainville Company Name: 21 i- � ��0- t,c U . c Address: Telephone Operator at Inspection: Tank Capacity: \O 0 Truck License #: C>\ \� Registration Exp. Date: Co 1 2)U1 N':"' J Truck Inspection L,Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) denting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair z,, Pumps (leak proof) Operator at Inspection ec Date I- v I3n4spe\e (Updated: September 2018)