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Home My WebLink AboutVillage Septic Service - 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: KEITH SOARES Doing business as: VILLAGE SEPTIC SERVICE P.O. BOX 3806 WESTPORT MA 02790 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 23 TRUCK REGISTRATION NUMBER(S): 5585A BOARD OF HEALTH -%4ichaeC9-CeaCey, Chairman 4 'tQSHOJ ,1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: LICENSE NUMBER: j I BUSINESS NAME: IJ MAIL ADDRESS: '0� TOWN: W� (_•i" STATE: C� ZIP CODE: NAME OF OWNER: K{J (� h Soa(4 3 (s \ BUSINESS TELEPHONE: (Sa4(03(c — CELL: (�la_)9q t4 FAX: «d�-) U30- -335-3 E-mail:VtllzvSQP�j 1SQaJh'140( AItE-mall: hUllysoq�� Ono c�l(tihoJ �d� 1 FED ID/SS NO: 6i� . 16) ry NUMBER OF TRUCK(S): IL REGISTRATION JMBER(S):� FEE PER TRUCK: I OG • a b Please make ap riate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, T wn o ansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: SSI s 1 ) ------------------ ---------------- ----------------------------- - ......... - - t-.-..,...-•----------------------------------- TRUCKS INSPECTIONS: DATE: PLACE: AT THE TOWN HALL, F TIME: 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 i 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 Iealdng 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. = C 3 00"U K i In soa ro !� i nature of Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable) "Social Security No. (Voluntanj) 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\slei(e\Desktop\.Scott's Documents\Food Establishments-Temp\TAX CEIMFICA'rION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf wwminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses c 33J t3 ® O• �0-k 3'9b Co ��. Phone #: (S (M Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/F,ating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) emp4ees working for me in any capacity. 8. Non-profit o workers' comp. insurance required] 3. ` We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 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, 11.❑ H f 12. Other It•C0 with no employees. [No workers' comp. insurance req.] -Any applicant that checks box # ] must also fill out ate section below showing their workers' compensation policy information. *•Ifthe 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 ant an employer that is providing workers' compensation insurance for nay employees. Belmv is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 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 Investisations of the DIA for insurance coveraee verification. I do hereby ee fy, nd r the pains and penalties of perjury that the information provided a ove is (rue and correct. Sienature: r---_.. Date: - aJ (I I Official use only. Do not write in this area, to be contplered by city or town official City or Town: PermittLicense # 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 www.mass.gov/dia Phone TE 4 D� CERTIFICATE OF LIABILITY INSURANCE DA03/2 a12019YY) 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(les) 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 CONTACT LAURIE FERNANDES NAME: COYNE & POWERS INS.AGENCY,INC. la/AND Ent 508-673 1122 N.):508-673 1176 E-MAIL --_- _- - - P.O,. BOX 710 ADDRESS: LAFERNANDES@MSN.COM 151 STATE RD INSURER(SI AFFORDING COVERAGE NAICN WESTPORT MA 02790 - INSURER A: NAUTILUS INS____ INSURED INSIIRFR ft VILLAGE SEPTIC SERVICE, LLC 1634C DRIFT RD. WESTPORT MA 02790 INSURER F: r.nVFRAr FS OFRTIFICATF NIIIMRFR: 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. INS. LTR TYPE OF INSURANCE AOOL 6UBR POLICY NUMBER _ MMIDUIYYYY MMIDOIYYYY — LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 --. PRE 100,000 COMMERCIAL GENERAL LIABILITY ISES,�a PREMISES SEa ocwrtenceL S CLAIMS MADE ®OCCUR MED EXP(My we person) It 5,00 X NN908997 05/23/2018 05/23/2019 PERSONAL B All INJURY $__ 1,000,000 $ 2,000.000 GENERALAGGREGATE PRODUCTS - COMPIOP AGO S INCLUDED GEN L AGGREGATE LIMIT APPLIES PER. I S X POLICY PRO- LUC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea a.0anl ANY AUTO BODILY INJURY (Per person) $ _ - ALL OWNED SCHALTEOULED j BODILY INJURY (Per accident) $ AUTOS '-- NON-0WNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS P.r.id..t)_ '.(— -- -- - UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 _ LAGGREGATE EXCESS LIAB CLAIMS MADE $ OED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH TORY-LIMITS. ER AND EMPLOYERS' LIABILITY YIN _. !ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT 5 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA E L DISEASE EA EMPLOYE _ S If yes,desaibeunder DESCRIPTION OF OPERATIONS below EL. DISEASE -POLICY LIMIT S I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Ie renalradf 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. MANSFIELS, MA 02048 AUTHORIZED REPRESENTATIVE 4?Z ACORD 25 (2010106) V 111013zUTU AL.UPLI t VrrrvrcA nun. An ngnu reserve6- The ACORD name and logo are registered marks of ACORD AFRO® CERTIFICATE OF LIABILITY INSURANCE DAT3/26/2019YT o3/zs/2o19 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 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 COYNE & POWERS INS.AGENCY,INC, CONTnCT LAURIE FERNANDES _ NAME: PHONE 508-673-1122 FAX J 508-673-1176 P.O,. BOX 710 nooriEss: LAFERNANDES@MSN.COM INSURER(S) AFFORDING COVERAGE ___ NAICM 151 STATE RD INSURER -A: NAUTILUS INS. WESTPORT MA 02790 INSURED INSURER B: --- VILLAGE SEPTIC SERVICE, LLC INSURERC; INSURER 0 i 1634C DRIFT RD. INSURER E: INSURERF: WESTPORT MA 02790 CERTIFICATE NUMBER' REVISION NUMBER: V 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 BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOL SUER -BEEN -REDUCED POLICY NUMBER POLICY EFF - MMIDDIYYV POLICY EXP MMIDDIYYYY LIMITS GENERAL IABILITY EACH OCCURRENCE $_ 1,000,000- _ DA GE TO RENTE . PREMISES (Ea occunenw) MED EXP(Anyone Poreon) _ _ 100,000 $ 5,00 -- _ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X NN908997 05123/2018105/23/2019 PERSONALAov INJURY $_ 1000,000 _A GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG_ $__. INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: ! COMBINED SINGLE LIMIT Ea a 'tl U PRO- X POLICY LOG AUTOMOBILE LIABILITY _S_....._- _ BODILY INJURY (Per person) $ - .. ANY AUTO ALLOWNED SCHEDULED AUTOSUT NON -OWNED '. HIRED AUTOS AUTOS i BODILY INJURY (Per accident) $ DAMAGE DAMA (PROPERTY GE �(Perem_tl @nil S S LLA UAS OCCUR EACH OCCURRENCE__- $ __ AGGREGATE $ ]EXCESSLIAB CLAIMS -MADE, RETENTION$ WORKERS COMPENSATIONTORY-L WC STATU- OTH- E S IANDEMPLOYERS'LIABILITY YIN ANYPROMEMBERIPARTNDED? CUTIVE . EACH ACCIDENT EL - EACHACCIDENT S I. DISEASE - EA EMPLOYE IO EXCLUDED? ❑ NIA-- andatoMEMBER '(Mandatory in NH) 1 E.L. DISEASE - POLICY LIMIT $ If yes, doscribs under iDESCRIPTiON OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aaach ACORD 101. Additional Remarks Schedule, if more spade Is required) TOWN OF MANSFIELD 6 PARK ROW MANSFIELS, ACORD 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. nGia➢20AT_ , CORPORATION. All rights reserved. The ACORD name and logo are reglsTeTOU marKS uT wwnu Annual Collaborative Septic Hauler Inspection Dav (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you a rrently licensed with? (check all that apply) ❑ roxborough Mansfield ❑ Norton ❑ Plainville Company Name:y jCAe'o 'EDGQ Address: Telephone #:y�9 - C� (� Gay Operator at Inspection: P P U&\^ -�cr�- a...t�' Tank Capacity: Truck License #: Registration Exp. Date: _// Truck Inspection OJ 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 Pumps (leak proof) ))KV, AY pera or at Inspection \ vA Date —, nspect r (Updated: September 2018)