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HomeMy WebLinkAboutSoares Sanitation Pumping, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: ROBERT SOARES Doing business as: SOARES SANITATION PUMPING, INC. 285 THRASHER STREET TAUNTON MA 02780 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 17 TRUCK REGISTRATION NUMBER(S): SM1455, SM65688, SM77545 BOARD OF HEALTH michaeCHeaCey, Chairman 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. &at.res gonr �or-.P�mp!'nq Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FOE?Kdoc The Cofinhonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street u,p Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ADPlicant Information Please Print Legibly Business/Organization Name: >t�ri►�ci-lion �ump�r� Address: Ti 14'CIS�NIE►' S ree % City/State/ZipTewnA-Ont "PP 0Q_l%0 Phone#: 50$ Z 2`i' ZS70 Are you an employer? Check the appropriate box: Business Type (required): NI:1 a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restamant/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] S. ❑ 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, HE Health Care y with no employees. [No workers' comp. insurance req.] 12.WOther _ p 1 1 C V"0_U j P,►_ *Any applicant that checks box #I 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 «n: mi employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 3} ay -In.6u ro nc e, CO M P A y Insurer's Address: PO Box 31130 City/State/Zip: Tampa i FL 33 63l - 3130 tr�� Policy # or Self -ins. Lie. # WCoa'40199 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 I do hereby Phone #: 5bg OaT O3�) O that the information provided above its true and correct Date: q1 la '' g Official use only. Do not write in this area, to be congdeted 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 #: li www.mass.gov/dia SOARSAN-02 DCARVALHO ACOizO" CERTIFICATE OF LIABILITY INSURANCE `—� D912412ATE Y01 8 09/24128 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 License # 1780862 go AffT Diane CaNelhO HUB International New England 222 Milliken Boulevard Fall River, MA 02721 PHONE JAIC. No, EXi: FAX A/C, No): A, bss, diane.carvalho@hubinternational.com INSURERIS) AFFORDING COVERAGE NAIC It INSURER A: SOIeCtiVG Insurance Company Of South Carolina 19259 INSURED INSURERS_. StarInsurance COTIf)any_ 18023_,___ Soares Sanitation Pumping, Inc. INSURERC: _ INSURER D: 285 Thrasher Street Taunton, MA 02780 —" INSURER E 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. INSft TYPE OF INSURANCE ADDLSUSR POLICY NUMBER POLICY Ell POLICY EXPLTR 01/0112019 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR S2190987 01101/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED REMISES(Ee occurmncel Sgp�ggg MED EXP LAny oneperson) ___,,,______ $ 15,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JEo u LOC GENERAL AGGREGATE_ PRODUCTS - COMP/OP AGG 310001000 $ 3,000,000 $ OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(EQaaiden0—_..______.._. 1,000,000 ANYAUTO A 9100369 0110112/18 0110112019 BODILY INJURY Perperson) $ INJURY Per accident OWNED X SCHEDULED AUTOS ONLY AUTOS X pBppOpDILY lReOecctl nt)AMAGE $_ -- A�TOS ONLY X AUT090NLDV A X UMBRELLA LIAB X I OCCUR EA CHOCCURRENCE $_ 3,000,000 EXCESS LIAB CLAIMS_MADE S2190987 0110112018 0110112019 AGGREGATE $ 3,000,000 DED RETENTION$ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANFFYPRRRO//PRIETgO�REXCLUDED'ECUTIVE I'"'-'�j �M80'a10 YIn NH)EXCLUDEDT LJ NX� SCdescribe under DESCRIPTION OF OPERATIONS below NIA WCO220789 06119/2018 06/19/2019 PER OTH- ___..STATUTE ER E.L.EACH ACCIDENT____ $ _ 500,000 E.L. DISEASE - EA EMPLOYE 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 [1D DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be aNached It more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Annual Collai Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ Foxborough ❑ Mansfield ❑ Norton ❑ Plainville c Company Name: J6CWe'<z'- Hauler Address: % G>� (�i�c s,'�Q✓ (� } 1 0z Telephone #: \ Operator at Inspection: G. W\- Tank Capacity: Ci co 0. Truck License #: 5 / G `✓ Registration Exp. Date: 17 Truck Inspection 'Iobile 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 Pumps (leak proof) .GLPI-� Op ator at Inspection Date (Updated: September 2018) r N ' -- Board ofr alth A Mansfield Row aid. MA 02048 Septage Pumpers Application DATE: LICENSE NUMBER: BUSINESS NAME: SO01es %-V0.+0 n 'Pumping. -Thiz. MAIL ADDRESS: ag5 Thytashe f Strep+ TOWN: -F0_uAtbn STATE: MA, ZIP CODE: NAME OF OWNER: RObeA Spo rQS BUSINESS TELEPHONE: SOH 92t $310 CELL: FAX: 568 $2t4 C14Q9 E-mail: 30.I¢S®Soo re$puM?1n3, CeM Alt E-mail: FED ID/SS NO: 6+_;tq't"I I Oa NUMBER OF TRUCK(S): 3 REGISTRATION NUMBER(S): SM14ss' 3Mb5108$, SM-1-IS4S FEE PER TRUCK: $100 Please make appropriate changes. SignAate. and enclose check payable to Town of Mansfield. Mail to: Board of Hea , T an Id, Si ark Row, Mansf, Id, MA 02048. SIGNATURE: _ DATE: 9a9 18 .................................................. ..................................... ....................................................... ....... .................... 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 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 8. 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: Coll Septic Hauler Inspection Day It � (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all lhal apply) ❑ Foxborough ❑ Mansfield ❑ Norton ❑ Plainville Company Name: 3r�r`e, � �, 111 Address: ^JjJ 5 2-w-e„' 56 ,z j Telephone #: Operator at Inspection: Tank Capacity: 'Truck License #: Registration Exp. Date: Truck Inspection V Mobile Took (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) ED/Venting available to allow the escape of gas on Mobile Tanks (properly conslrueted) Suction or Pressure 1-lose in good repair umps (leak proof) AR.r Op a •at at I spectran Date f 1pdated • September 2018) I ., PAMARAL 1 144c"M"' CERTIFICATE OF LIABILITY INSURANCE 46� DATE(MMIDDNYYY) 1 12131/2018 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(fes) 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 LlCenee # 1780662 HUB International New England 222 Milliken Boulevard Fail River, MA 02721 NANEACT Diane Carvalh0 PHONE FAX (NC, No, Eat): INC, No): E oREss diane.Carvalh0@hubinternational.com INSURER(S)AFFORDINGCOVERAGE NAICN INSURER A: Star Insurance Campan 18023 INSURED INSURER B : INSURERC: Soares Pumping, Inc INSURER D : 195 Thrasher Street Taunton, MA 02780 INSURER E INSURER F : COVERAGES CERTIFIQATP MI HUIRPM- REVISION NUMBER - THIS IS TOVCERTIFY 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 WTH 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 TYPE OF INSURANCE AODp yyyp POLICVNUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE S DAMAGE TO RENTED JPREMIaE6- Ea occurrence $ MED EXP An one ersonl $ PERSONAL &ADV INJURY $ GEHL AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEpT LOG OTHER: GENERAL AGGREGATE $ PRODUCTS -COMPIOP AGO - $ $ AUTOMOBILE LIABILITY ANY AUTO OVMIED SCHEDULED AUTOS ONLY AUUTTOOS�A�IEp ALBS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Eaaccident $ BODILY INJURY Per arson $ BODILY INJURY(Peraccident $ PPerraccci enl AMAGE $ _ UMSRELLAUAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPREIIETggORIPARTNER/EXECUTIVE VIA OFFICERNg NHR EXCLUDED? `� I(yes, descnhe under DESCRIPTION OF OPERATIONS helm NIA WC0428766 01123/2018 0112312019' �SR TE EORH " EL EACH ACCIDENT 600,000 $ E.L. DISEASE -EA EMPLOYE SOQOOO $ E.L. DISEASE - POLICY LIMIT $ 50Q000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Mansfield Board of Health 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) U 1988-2015 ACORU CUKPUHA I IUN. AN rlgnts reservea. The ACORD name and logo are registered marks of ACORD SOARSAN-02 PAMARAL r ,acoRO" CERTIFICATE OF LIABILITY INSURANCE L—� DATE(MM/ODWYYY) 12/3112018 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 License # 1780862 N�J�PCT Diane Carvalho PHONE FAX (AIC, No, Ext): (AIC, No): HUB International New England 222 Milliken Boulevard Fall River, MA 02721 noo"alE,B: diane.carvalho@hubinternational.com INSURERS AFFORDING COVERAGE NAIC9 INSURER A: SeIBOKMIRSUranCe Company Of $OU01Carolina 19259 INSURED INSURER B: Star Insurance Company___ 18023 INSURER c:lronshore Specialty Company 2_5445 Soares Sanitation Pumping, Inc. _ INSURER D : _ 285 Thrasher Street Taunton, MA 02780 INSURER E : _ INSURERF: 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 L TYPE OFINSURANCE ADDLSUBR p WD POLICY NUMBER POLICYEFF DD POLICY EXP DDVp LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR S2190987 01101/2019 01/01/2020 RRENCE $ 1,000,000 RENTED Ea oc -a.- $ 500,000 n onerarm15,000 ADV INJURY 5 1,000,000 GENE AGGREGATE LIMoIIT APPLIES PER: POLICY JECT� LOC OTHER: GGREGATE $ 3,000,000 -COMP/OP AGG $ 3,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS ONLY UOMY A9100369 0110112019 01101/2020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY Per ersan $ BODILY INJURY Per accident $ eWnlAMAGE PO()a�XAO $ A X UMBRELLALIAB X OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTIONS S2190987 01/01/2019 01101/2020 EACH OCCURRENCE S 3,000,000 AGGREGATE $ 3,000,000 B WORKERS COMPENSATION ANDEMPLOYERS'DATNER' YIN ONFICEpOp/PM11R�MBEERIEXCLUDEDj ECUTNE ❑ Ffandalory`In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WCO220789 0611912018 0611912019.. PER TE ORH- , E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT 500000 S , C Pollution I Environm 002617503 01101/2019 01101/2020 3,000,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park ROW Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SOARSAN-02 PAMARAI ,acoszb' CERTIFICATE OF LIABILITY INSURANCE ilh � ''-� DATE(MMIDDIYYYYI 1213112018 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 endorsements . PRODUCER License # 1780862 HUB International New England 222 Milliken Boulevard Fall River, MA 02721 CONTACT Diane Carvalho NAME: PHONE FAX (AIC, No, Ext): (AIC, No,; noo IEss diane.Carvalh0@hubinternational.com INSURER�AFFORDING COVERAGE NAIC# INSURER A: Selective Insurance Company of South Carolina 19259 INSURED INSURERS:Ironshore Specialty Company 25445 INSURER C : _ Soares Pumping Inc INSURER D : 195 Thrasher Street Taunton, MA 02780 - INSURER E 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 TYPE OFINSURANCE ADDINSDL SUaDR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR S2190987 0110112019 01101/2020 EACH OCCURRENCE $ 1'000'000 DAMAGE TO RENTED PREMISE Ea occu ¢rice $ 500,000 M ED EXP (My oneperson) $ 15,000 PERSONAL B ADV INJURY $ 1,000,000 GENT AGGREGATE LqIIMoIIT APPLIES PER: POLICY jEpT LOD OTHER' GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGG $ 3,000,000 • AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUUTOS ONLYAUTT,NOSWWNNEBOORDILY OS ONLY X AUTO ONLY Ix A9100369 01101/2019 01/01/2020 COMBINED SINGLE LIMIT Es accident $ 1,000,000 BODILY INJURY Per erson _ $ 1,000,000 ITTNVVJURY Per accidentALR PPe�acolRtlanl AMAGE $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE S2190987 0110112019 01/01/2020 EACH OCCURRENCE g 3,000,000 AGGREGATE $ 3,000,000 DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICER%IEMBER EXCLUDED9 ECUTIVE ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- TA UTE E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT 5 B Pollution Environm 002617503 01/0112019 01/0112020 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. 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 Which Towns are you currently licensed with? (check ll that apply) Foxborough Mansfield Norton Plainville Company Name: Soo�ce S v M v� Address: Telephone#: Operator at Inspection: Tank Capacity: lz�' 0o d) Truck License #: Registration Exp. Date: \2 1 // Truck Inspection U'IV obile 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) Suction or Pressure Hose in good repair Pumps (leak proof) Operator at Inspection Date nspector (Updated: September 2018)