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HomeMy WebLinkAboutWaste Water Services, 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: JAMES BAIRD Doing business as: WASTE WATER SERVICES INC. 1997 BEDFORD STREET BRIDGEWATER MA 02324 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 20 TRUCK REGISTRATION NUMBER(S): 5220A BOARD OF HEALTH NichaeC9CeaCey, Chairman v"uc ncr''� Town ofaOfield ti x Town of Mansfield - Board of Hea((fil 9A 5 Row ` 8 E t nsfleld, MA 02048 r�ASAD�s,: ki Septage Pumpers Application DATE: 113119 LICENSE NUMBER: BUSINESS NAME: Was4e WcAcf Services i-rc MAIL ADDRESS: ) 9 9.7 G eb'6rJ Sk. TOWN: &r,69¢ L,)o}e( STATE: MIN ZIP CODE: pL3p'' NAME OF OWNER: J" me-S BUSINESS TELEPHONE: S08-497-997y CELL: SZ*-930-97(af FAX: sbB-697-777`f E-mai1:6o66renAmnQQb05'ro�Mrn.cum Alt E-mail: j0brenkon@wwsi0eMA-ccM FED ID/SS NO: Dq - 3S-7,53 7$ NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): 522,0,A---`: FEE PER TRUCK: $ 10p — 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: _ "� DATE: .............................................................................................................................................................................. 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 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 g-,�-�''",'';^ D. Pumps: Maintained to prevent leakin�— Inspected by: d Inspected on: r 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. biaSie Wo,+e( secvl`ces Signature of Individual or Corporate Name By: Corporate Officer (Man a plicable) Dy- 3 s 7837,F **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:\UseB\sleae\Desktop\ScotPs Documents\Food Establishinents- Teinp\TAX CERTIFICATION FORM.doc Request for Taxpayer Give Form to the Form ■■ VW-Q Identification Number and Certification requester. Do not (Rev. November2017) send to the IRS. Department Internal of the Treasury Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your Income tax return). Name is required on this line; do not leave this line blank. Waste Water Services Inc 2 Business name/disregarded entity name, if different from above to 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to mfollowing seven boxes. certain entitles, not individuals; see a instructions on page 3): p ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership Trust/estate N single -member LLC Exempt payee code (if any) d c 0 0 � � ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► `p Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting H LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code (if any) .c another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that o. o is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ❑ Other (see instructions)► (Applies ro amowis malnWnedcmmne the us) I N 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 1997 Bedford Street wo 6 City, state, and ZIP code Bridgewater Ma 02324 7 List account numbers) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid i social security number backup withholding. For individuals, this is generally your social security number (SSN. However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. Fj�(('�� 10141 — 3 1 5 1 7 1 8 1 3 1 7 1 8 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. . Iwnl I Signature of r 4 Here I U.S. person► Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to wwwJrs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat, No. 10231X Form W-9 (Rev. 11-2017) A CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD YY) 01/04/2019 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(tes) 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 Morse Insurance Agency, Inc. c0 TAcT Margaret Viera NAME: qICNo Ext : (508) 238-0056 AIC, No(08) 2230-8367 E-MAIL maggieviera@morseins.com ADDRESS: 285 Washington Street INSURER(S) AFFORDING COVERAGE NAIC N INSURERA: Union Insurance Company 25844 North Easton MA 02356 INSURED INSURERS: Acadia Insurance Company 31325 INSURER C: Waste Water Services Inc, DBA: Heritage Pumping INSURER D 1997 Bedford Street INSURER E INSURER F: Bridgewater MA 02324 uuaaoco. 2018 THIS IS TO CERTIFYTHAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 X COMMERCIAL GENERALLIABILITY CLAIMS -MADE Fx_] OCCUR INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYV POLI EXP MMIDOfYYYY LIMITS EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 16,000 A CPA 5363800 10/20/2018 10/20/2019 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: X LOC X ❑ FX GENERALAGGREGATE $ 2,000,000 PRODUCTS -COMPIOPAGG $ 2,000,000 POLICY JECT JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANVAUTO BODILY INJURY (Per accident) $ A OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED X NON-OWNEO X AUTOS AUTOSONLV MAA 6363801 10/20/2018 10/20/2019 PROPERTY DAMAGE Per accident $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CWIMS-MADE CUA6353802 10/20/2018 10/20/2019 EACH OCCURRENCE $ 6,000,000 AGGREGATE $ 6,000,000 DED X RETENTION $ 10,000 WORKERS COMPENSATION X PER ER $ E.L. EACH ACCIDENT $ 500,000 B AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE � OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, tlescribe under DESCRIPTION OF OPERATIONS below NIA WCA 5363803 10/20/2018 10/20/2019 E.L. DISEASE -EA EMPLOYEE $ 500,000 EL, DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) 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. Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048 �'�- UUA^� n H%RA_9Aic Acnan CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department.of Industrial Accidents Office 6fInvestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: W C1 s+e W a,A-e(- .Sefv ices :Enc . Address: i 9 9 7 Sec) r6rj City/State/Zip: ri eWa}2( f� Dd3o%y Phone #: 5b& - 697 Are you an employer? Check the appropriate box: Business Type (required): 1.2 I am a employer with _� 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. [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 no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance teq.] 12.® Other SC' ��c. ]A aQ1 eC *Any applicant that checks box #1 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ICCCC)]N IASVCCAV\Ce- COMeCN, Insurer's Address: City/State/Zip: N(or-V+h `Crc,5412o I AA Oa356 W Policy # or Self -ins. Lic. # C A 6(.3963 Expiration Date: j © 2-0 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 and penalties 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 official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Mlfya' 0T U93thusetts eepnronent or nanspprtneon ®9lstry of Motor Vehicles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2018 EXPIRATION DATE: 06/30/2019 MAILING INFORMATION IRP REGISTRANT INFORMATION ACCTIFLEETNFAR/SUPP: 28975-1-2018.0 LEGAL NAME: WASTE WATER SERVICES INC WASTE WATER SERVICES INC 1997 BEDFORD ST BRIDGEWATER, MA 02324 ucuirt c n.�cnou nr,nu 1! A2170 T6si14 ADDRESS: 1997 BEDFORD ST BRIDGEWATER, MA 02324 USDOT: 2092168 NAME: WASTE WATER SERVICES INC ADDRESS: 1997 BEDFORD STREET BRIDGEWATER, MA 02324 PLATE: 5220A UNIT#: 10 VIN: 1NKDLPEX2HJ178066 PLATE TYPE: APN UNLADEN WEIGHT: 19497 VEHICLE TYPE: Truck MAKE: KW FUEL: Diesel OWNER: WASTE WATER SERVICES INC MODEL: T800 COLOR: Green INSURANCE COMPANY: OHIO CASUALTY INSURANCE COMPANY YEAR: 2017 SEATS: NA SERVICE REPRESENTATIVE: & Weight JuL Welaht ,Ll1C Weigh fir Weigh t JMI Welaht lur Welaht AB 32658k GA 72000 ME 72000 NJ 72000 PE 32658k WA 72000 AL 72000 IA 72000 MI 72000 NL 32658k QC 6+AXLE WI 72000 AR 72000 ID 72000 MN 72000 NM 72000 RI 72000 WV 72000 AZ 72000 IL 72000 MO 72000 NS 32658k SC 72000 WY 72000 BC 32658k IN 72000 MS 72000 NV 72000 SO 72000 •• "'• CA 72000 KS 72000 MT 72000 NY 72000 SK 32658k *" ••'• CO 72000 KY 72000 NB 32658k OH 72000 TN 72000 •••` CT 72000 LA 72000 NC 72000 OK 72000 TX 72000 '• '•'* DC 72000 MA 72000 NO 72000 ON 32658k UT 72000 «,«« DE 72000 MB 32658k NE 72000 OR 72000 VA 72000 " •`•• FL 72000 MD 72000 NH 72000 PA 72000 VT 72000 "` '• Issued under the authority of the Registrar of Motor Vehicles for the Control: 8001-1337-0217 Massachusetts Department of Transportation. & e '& % Registrar ORIGINAL MUST BE CARRIED IN VEHICLE ATALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor Quincy, MA 02171 Tel: (857)368-8120 www.messrrnv.conn Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check a(l that apply) Q/6xborough 0-Mansfield 0,Norton QTlainvillc Company P Y Name: \W!,`�P \uC&PC Address: Telephone Operator at Inspection: c_ Tank Capacity: Truck License #: ja 0�t;- Registration Exp. Date: Co I )A - Truck Inspection LyJ1VlObile 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 U/ Pumps (leak proof) Operator at 14spection nspect Date (Updated: September2018)