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Home My WebLink AboutUnited Site Services, NE, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that. ELI SANTANA, MANAGER Doing business as: UNITED SITE SERVICES, NORTHEAST, INC. 118 FLANDERS ROAD WESTBOROUGH MA 01581 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 111 section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 18 TRUCK REGISTRATION NUMBER(S): R90719 T54038 BOARD OF HEALTH MichaeCHeaCey, Chairman 1zL -y^ try A& "I'll% Town of Mansfield - Board of Health Septage Pumpers Application gR �qy s a T n f Im4fliq 2018 6 r ow M s Id, MA 02048 DATE: LICENSE NUMBER: BUSINESS NAME: MAIL ADDRESS: TOWN: b STATE: ZIPCODE: NAME OF i WINILR: : E]�' r BUSINESS TELEPHONE: CELL:;`4 FAX: E-mail: oj Cow-AltE-mail: FED ID/SS NO: _cNUMBER OF TRUCK(S): REGISTRATION NUMBER(S): FEE PER TRUCK: $100 Please make appropriate cl�janges. Sign, date. d enclose check payable to Town of Mansfield. Mail to: Board of Heal(h ?own of, ansfield, Six P Row, Mansfield, MA 02048. DATE: H - / & - / 1 ......... - ----------------------------------------------- TRUCKS SPEC ONS: DAT : 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 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. "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:\Users\sleite\Desktop\Scolds 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 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel?ibly Name (Business/OrganizatiorOndividual): United Site Services Northeast, Inc Address: 118 Flanders Road City/State/Zip: Westborough, MA 01581 phone #: 1-800-TOILETS Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 000 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub -contractors 2, ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 5. M We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.l 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I LEl Plumbing repairs or additions 12.❑ Roof repairs 13.® Other Portable Sanitation *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Safety National Casualty Corp. Policy # or Self -ins. Lie. #: LDS4047370 Expiration Date: 11/03/2019 Job Site Address: all United Site Services projects City/State/Zip: various 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 WORT{ 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 pejifyC nder tihe pains andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town gffieiaL City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone AC R ® � CERTIFICATE OF LIABILITY INSURANCE GAT w .DZ n 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 Ann Risk Insurance services West, Inc. LOS Angeles CA office 707 Wilshire Boulevard Suite 2600 CONTACT NAME: NC. No. EX1: (E66) 283-7122 ac NO : (800) 363-0105 EMAIL A60RESS: INSURER(S) AFFORDING COVERAGE NAIC# LOS Angeles CA 90017-0460 USA INSURED INSURER& Evanston insurance Company 35378 united site services Northeast, Inc. INSURER a: Allied world Assurance Company (us) Inc 19489 118 Flanders Road suite Flanders suite INSURERG: _Safety National Casualty Corp 15105 INSURER D: XL specialty Insurance Co 37885 Westborough MA 01581 USA INSURER E: NSURER F: COVERAGES CERTIFICATE NUMBER: 570073794374 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. Limits shown are as requested IN Lm TYPE OF INSURANCE AUDI INSU BR WVo POLILYNUMBER MMIDO Y EFF MMIDO LIMITS C X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR GL 2018 2019 EACH OCCURRENCE $1,000,000 DAMAGETO NTED PREMISES Ea Occurrence $1.000,000 MED EXP(Anyene person) $10,000 PERSONAL& AOV INJURY $1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY ❑X PRO-JECT ❑LOG OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS COMPIOPAGG $2,000,000 C AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY CA54047379 11/03/201811/03/1019 COMBINED SINGLE LIMIT aacddem $3,000, 000 BODILY INJURY (Par person) BODILY INJURY(Peraccldent) PROPERTY DAMAGE denl D % UMBRELLAUAe EXCESS LIAR I % I OCCUR CI -AIMS -MADE US00076933LIIBA 11/03/2018 11/03/2019 EACHOCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED I X IRETENTIONC10,000 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERI EXECUTIVE YIN (Ma CERIMEMBEREXCLUDED4F—N (MatoIn NHl If yes, describe under DESCRIPTION OF OPERATIONS below NIA LDS4047370 11 03 2018 11 03/2019 =X I STATUTE ETH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOY EE ES,000, 000 E.L. DISEASE-P000Y LIMIT $1,000,000 B Env site Liab 03115276 18-19 Env Site Liab 09/19/2018 09/19/2021 Aggregate Limit Per occurrence Limi- $1,000,000 $1,000,000 770CATIONS I VEHICLES (ACORD 101, Addilonal Remarks Schedule, maybe auach n! ttmore space is required) CERTIFICATE HOLDER CANCELLATION E SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, United site services Northeast, Inc. AUTHORIZED REPRESENTATIVE 500 Washington St., suite 100 Westborough MA 01581 USA c.�'an ✓92dtGtmPrm �ct�d � �iut 01986.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD `a Ann eptic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) 1] Foxborough 0 Mansfield d Norton ❑ Plainville Cotnpany Name: Address: Telephone th Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: 11�C J 5 x r ) -z Zz�. Truck Inspection Ib /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) Suction or Pressure Hose in good repair (leak proof) Date (1 (Updated: September- 2018) Jane Doucette From: Amy Donovan -Palmer Sent: Friday, December 28, 2018 3:48 PM To: Jane Doucette Subject: Fwd: Emailing: United Site Services Hi Jane, can you double check R90719 from United site services? They say it was inspected at the Foxborough event. Thanks