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HomeMy WebLinkAboutRibeiro Enterprises - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage Pumping and Transporting Permit This is to certify that., DYLAN RIBEIRO Doing business as: RIBEIRO ENTERPRISES P.O. BOX 455 NORTON MA 02766 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 111 section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 16 TRUCK REGISTRATION NUMBER(S): R83245 BOARD OF HEALTH MichaeCHeaCey, Chairman G LICENSE BUSINESS NAME:(�`��• y r`S Se MAIL ADDRESS: /010 _& X Vg'=� 4141k�7 /ftj (ja76 �(/rJ6/ TOWN: rj�j STATE: �/7AA ZIP CODE: NAME OF OWNER: )Pla? R, 4I,01-tz BUSINESS TELEPHONE: SO�f �* 3167 CELL: Safi FAX: 34y E-mail: P/44 /y �JPlroL x4i/avl ca, Alt E-mail: FED ID/SS NO: OY) -,I 7p - SIO NUMBER OF TRUCK(S): f REGISTRATION NUMBER(S): /f P5 FEE PER TRUCK: Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of sfiel ix Park Row, Mansfield, MA 02048. SIGNATURE:rIX_ DATE: ____ �� ✓� .................... ....... .................. t......................................................................................................... .. •................. 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 AGENTS 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) aye- 27,-' - 510 **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:\Userstsleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: / 3 � A4.4f4e(/ W, Uld6?Phone #: .SGS' e0e-S 3/4x7 Are y, an employer? Check the appropriate box: Business Type (required): 1. H I am a employer with iZ� employees (full and/ 5. [:]Retail 2. ❑ or part-time).* I 6. ❑ Restaurant/Bar/Eating Establishment am a sole proprietor or partnership and have no employees working for me in any capacity. 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) [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 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, I L ❑ Health Care with no employees. [No workers' comp. insurance req,] 12.❑ Other *Any applicant that checks box kl 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 NI. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Nat Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie, 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 certify, ugder the pai nd penalties ofperjury that the information provided above is true and correct Siattature: Date' Phone #: r ;'k5 316 % 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 www.moss.gowaia Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such' employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary), A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file, for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 an CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/24/2018 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 ORDERINSUREBY BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificatp holder is an ADDITIONAL INSURED, the policy(los) 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 Partners Insurance Group, LLC CONTACT NAME: Maria Arruda PRO ac No:508-0913108 Arc Na E><8 508-4913,76 560 Wilbur Avenue Swansea MA 02777 E-MAIL DD SS: MArruda arm --;ns r llc.com INSURERS AFFORDING COVERAGE NAIC It INSURERA: NGM Insurance Company 14788 INSURED RIBE0 Ribelr0 Enterprises Inc. INSURER B: _INSURER C: Dylan J. Ribeiro P.O. Box 455 INSURER D: Norton MA 02766 INSURER E: NSURER F: (:(TVFRA GGC — ..... _. .. _ .._... _._... RCV to IUN INUMtStK: 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 ADO UBR —' LTR TYPE OF INSURANCE WVDPOUCYNUMBER MMIOD/VBYVY MWDOY/YVYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MPT2783C 10/4/2018 10/4/2019 EACH OCCURRENCE S1,000,000X DAMAGE TO RENTED Mansfield MA 02048 //�� L! eGGs-i�T(` Ea occurrence $500,000 CLAIMS-MADEPREMISES OCCUR MED EXP (Any one person) $10,000 PERSONAL$ADV INJURY $1,000,000 — GENERAL AGGREGATE $2,000,000 A MiT2783C 10/4/2018 10/4/2019 -- GEN'L AGGREGATELIMIT APPLIES PER: X POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS TOS X NNOOi�WNED PRODUCTS -COMP/OPAGG $2,000,000 COMBINED SINGLE LIMIT Ea acradent $ BODILY INJURY (Per person) $500,000 8ODILY INJURY (Peraccidenl) $1,000,000 PROPERTY Pea Oen DAMAGE S A A LALL A LIAR IAB X OCCUR CLAIMS-MADEAGGREGATE NIA MiT2783C WCT2783C 10/4/2018 11110/2018 10/4/2019EACH 11/10/2019 OCCURRENCE $1,000,000 $1,000,000 RETENTION$10000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYCERIMEETORIPARTNER/EXECUTIVE YIN (Mandatory InN REXCLUDED? ❑N (Mandatoryin NH) Ifyes.tlescribeunder DESCRIPTION OF OPERATIONS below WC STATU- $ OTH- YL E.L. EACH ACCIDENT $500000 -'---- - --- E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CFOTICU`AT= Unl nvo (01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD �w r rvry 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 02048 //�� L! eGGs-i�T(` (01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD Annual Collaborative Sceptic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT 7wh Towns are you�urrently licensed�vith? (check all Haat apply) Foxborough L� 1Vlansfield m Norton ❑ Plainville Company Name:..!,. tZ: \n v? ;; 0 Address: Grp t{5 Iia itis �N' rn Y� 6 .l') L.L Telephone #: Operator at Inspection: Tank Capacity: Truck License f#; l j t3 Registration Exp. Date: 17 , �y Truck Inspection 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) 1 �Suction or Pressure Hose in good repair Pumps (leak proof) k� Operator at Inspection 1� Date F) Inspecto (updated. Sepleniber 20/8)