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HomeMy WebLinkAboutR. Moreshead Excavating, 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 This is to certify that: RYAN MORESHEAD Doing business as: R. MORESHEAD EXCAVATING, INC. 46 RYDER CIRCLE NORTH ATTLEBORO MA 02760 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 13 TRUCK REGISTRATION NUMBER(S): V26726 BOARD OF HEALTH NichaecHeaCey, Chairman v/ 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. Sign9fure of Individual or Corporate Name **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\Scod's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information // Please Print Legibly Business/Organization Name:�rL, 14i ct r,S Llecj Address: c{(u gvGjlnf t 01-G kc Phone#: 5'& /--q5,�-rc�Zi Are y an employer? Check the appropriate box: Business Type (required): LZ I am a employer with 3 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. 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, §I(4), and we have 10.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We by 11.❑ Ijealth Care are a non-profit organization, staffed volunteers, P 4--f- f, with no employees. [No workers' camp. insurance req.] 12. Other *Any applicant that checks box NI 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 #l. I am an employer that is providing workers' //compensation insurance for my employees. Below is the policy information. Insurance Company Name: -e � t - t VC III i v✓ e�,J- Insurer's Address: �j -7 ii Ale c, r r - 411 City/State/Zip: Policy # or Self -ins. Lic. # S ,, t [ CJ 4 D Expiration Cj 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, under the pains andgenalties ofperjury that the information provided above is true and correct. SY-76-) 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 #: Nnvw.mass,gov/dia 01C �LA g 3 y .. Town of Mansfield- aotlaltlt° Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: Lih l(q LICENSE NUMBER: BUSINESS NAME: �� Mort 5 4 u` MAIL ADDRESS: (b ar C r'-: (4' TOWN: Af, k k i Et loy ro STATE: M A ZIP CODE: c � ` 6C NAME OF OWNER: P�,YC�A M GTY 5 (+C(11� BUSINESS TELEPHONE: CELL: FAX: E-mail: r y wr rA o iY- u �� t 6c,w-V Alt E-mail: FED IDISS NO: q a 16 ,� t _70 NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): V� 67,;Lt 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. SIGNATURE: TRUCKS INSPECTIONS: DATE: DATE: 'i /I // 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: A` ORO� CERTIFICATE OF LIABILITY INSURANCE DATYY) 4/9/2019 9/9/2 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 NAME: PHI EAD, 401-431-9200 AIC No: CROSS INESRAN CE INC - RHODE ISLAND PO BOX 4830 E-MAIL ADDRESS: INSURER(Sl AFFORDING COVERAGE NAIC R RUMPORD RI 02916-0830 INSURER A: SELECTIVE INS CO OF THE SOUTHEAST 39926 INSURED INSURER B INSURERC: R MORESHEAD EXCAVATING INC INSURER D: ..:46 RYDER CIRCLE INSURER E: NORTH ATTLEBORO HA 02760 INSURER F : COVERAGES CERTIFICATE NUMBER: 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 R TYPE OF INSURANCE ODL AINSO SUER MAY) POLICY NUMBER MM%�O EFF MMIOONYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE %� OCCUR X S 2110340 4/28/2018 4/28/2011 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ee em urance $ 500,000 MED EXP(Any one person) $ 15,000 A PERSONAL BADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY [X—] PRO- K LOC JECTPRODUCTS-COMP/OP AGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ancient $ BODILY INJURY (Per person) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par accident) $ PROPERTY DAMAGE Peraccident $ HIRED AUTOS NON -OWNED ONLY AUTOS ONLY 8 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE BED I I RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN PER OTH- STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, desodbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES IACORD 4ei, Additional Remarks Schedule, maybe attached If more space Is required) This Certificate of Liability Insurance wan created by Selective on behalf of the agent. town of manefield is included ae additional insured with respect to General Liability as required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION town of manefield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 park road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. ACCORDANCE WITH THE POLICY PROVISIONS. manefield MA 02048 AUTHORIZED REPRESENTATIVE R-d c ul.7.f� ©1988-2015 ACORD CORPORATION. All rights reserved.' ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: A d�' ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY CROSS INSURANCE INC - MODE ISLAND NAMED INSURED R HORESHEAD EXCAVATING INC 46 RYDER CIRCLE NORTH ATTLEBORO NA 02760 POLICY NUMBER S 2110340 CARRIER SELECTIVE INS CO OF THE SOUTHEAST NAIC CODE 39926 EFFECTIVEDATE: 4/28/2018 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: A oRG D zs FORM TITLE; JOB ft JOB LOCATION CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC"R& CERTIFICATE OF LIABILITY INSURANCE 11 DATE(MMIDDIYYYY) 04/10/2010 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 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 Beth Deschene NAME: Cross Insurance, Inc.- RI A/oNNo Eat: (401)431-9200 FAX No: (401)431-8201 ADDRIESS: bdeschena@crossagency.COm 376 Newport Avenue INSURERS) AFFORDING COVERAGE NAICN P. O. Box 4830 INSURERA: Selective Insurance Co of Southeast 39926 East Providence RI 02916 INSURED INSURER B: Selective Insurance Group INSURER C -.R MORESHEAD EXCAVATING INC INSURER D : 40 RYDER CUR INSURER E : Unit 2 INSURER F: NORTHATTLEBORO MA 02760-1915 COVERAGES CERTIFICATE NUMBER: CL1941083768 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. ILTR TYPE OF INSURANCE INSD MD POLICYNUMBER MMIDDIVYYY MMDDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ;;11 CLAIMS -MADE OCCUR DAMAGE TO RE TIED PREMISES Es occurrence 500,000 $ MED EXP(Any one person) $ 15,000 PERSONAL B ADV INJURY $ 1,000,000 A S 2110340 04/28/2019 04/28/2020 GEWLAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 3.000,000 POLICY � j COT LOC PRODUCTS-COMP/OPAGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaaldenl $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO B OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A9107117 04/01/2019 04/01/2020 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccldenl $ UMBRELLALIAB OCCUR EACH OCCURRENCE if AGGREGATE $ EXCESS LIAB CLAIMS -MADE BED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN CUTIVE ❑ ANY EMBEREXCL EXCLUDED? In NH) EXCLUDEW (MandatoryNH) If NIA WC 9080488 02/11/2019 02/11/2020'-,. X /� STATUTE ER E.L. EACHACCIOENT 500,000 $ E.L. DISEASE - EA EMPLOYEE 500,000 $ yes. describe Dyes. describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be aaached If more space Is requited) CERTIFICATE HOLDER CANCELLATION 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 Road AUTHORIZED REPRESENTATIVE Mansfield MA 02048 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Wh}'�h Towns are you c ently licensed with? (check all that apply) tvoxborough it �+ q [ Mansf ield ❑ Norton ❑ Plainville/ Company Name: fiblQa I� _ (f11rny�SA `�iECt,i.�`ol Address: �(Q Rod6— LYl -c. flan-ft, YWbrNd i vi eA Telephone #: 50� `ZI (0, - (�2-lr')I Operator at Inspection: ' S No' t— Tank Capacity: ( I C) Truck License #: /L V ij0 - ltj�i Registration Exp. Date: d • il�P(1 Iz 31 1�1 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) or Pressure Hose in good repair (leak 6z:� Ope ator at Inspection L`. 11 Date n ector (Updated: September 2018)