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HomeMy WebLinkAboutWind River Environmental, LLC - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: WIND RIVER ENVIRONMENTAL, LLC Doing business as: WIND RIVER ENVIRONMENTAL, LLC 46 LIZOTTE DRIVE, SUITE 1000 MARLBOROUGH MA 01752 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 111 section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 19 TRUCK REGISTRATION NUMBER(S): 93124 89714 95769 92933 BOARD OF HEALTH Nichae(HeaCey, Chairman �ro }�q%,- %per k Town of Mansfield - Board of �R 4 fjF4 AS.A 9�y�S� Septage Pumpers BUSINESS NAME: �tU t-1\vlkvnA)PN 1" C MAIL ADDRESS: r `.. wke TOWN: /V nnaVovw44'\ STATE: N 1 f 2 t Pii7� NAME OF OWNER: 2 4l� wi�\&Wiue�\ BUSINESS TELEPHONE: $00_ 4 - QLCELL: FAX:q�S'_5 E-mail:akk'i 1WM0WW%-CC)M ItwE�ma � •_i t1L� FED ID/SS NO: 3�R�(�? BER OF TRUCK(S):O� 7- REGISTRATION NUMBER(S);51� '1�0223 (j A�RPX\k_n� FEE PER TRUCK: Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Towq onMansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: _ DATE: _` N \1� .................. ..................................................................................................................................... TRUCKS INSPECTIONS: DATE: LIM 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 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 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) N_31TIM "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\UsersWeite\Desktop\Scores DocumemsQbod Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonfvealth of Massaehasefts Depar tniew gmdush•ialAccidents S Office oflnvesligations I Coitgr'ess Street, State 100 Boston, MA 02114-2017 rilivip nmss.gov/dirt 1War1cers' Compensation Insnz•auccAffidavit: General Businesses Applicant Information Please Print I egibly Business/Oagatuzat(iora Name: il�An l Vic- v•ref( u" �• ^z�� _ _ Address: L tzcyi� 2 \J� City/State/Zip: Are on an employer? Check the appropriate box: I all, a employer with `t Co employees (full and/ m• part-time).* 2. ❑ I am a sole proprietor or put mership and have no employees working for me in any capacity. [No workers' comp, insurance requh•ed] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c- 152, § 1(4), and we have no employees. [No workers' comp• insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteer, with no employees. [No workers' comp, insurance reo.l Phone #: ICJ J c- q Btisiiims Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (hra real estate, auto, etc.) 8. 0 Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1L❑ Health Cm•e C� ` 12.jDOtherCwm--,i— 'Any applicant(hat checks box 91 nwst also fill oat the section below showing (heir workers' compensation policy information. "Ifdie cogwrate officershave exempted themselves, bill the corporal loll has other employees, a workers' compensation policy is required and such an organization should clawk box It I. I mn an employer that is providing )vorlferts' compensation hisur•rrnce for my employees. Belonv is the policy brfor»tatiort, Insurance Company Name: fnsurei's City/State Policy If a• Self -ins. Lic. It q�(��1 , Explration Daw; �D \ S 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 ora 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) eerlify, minter the ytrins rarrlpenalties of peryttry that the hiJbi' ration provident above is It -tie and correct. OfTeial use only. Do not tnrite In this area, to be completer) by clip or tonps official. City or Town: PermitlLicense #_ Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. City/Town, Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact aw�ece� CERTIFICATE OF LIABILITY INSURANCE OY) 6/30/2019 7/2/2018 7/2/2018 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: It the certificate holder is an ADDITIONAL INSURED, the Policy(les) 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). Lockton Ins PRODUCER urance Erokers,LLC CON CA Liccnsc HOF15767 NAME: 'PHONE-'- 725 S. Figueroa Street, 35th D. Los Angeles CA 90017 __ 13-689-0065 _--.. INSURE ft(S) AFFORDING COVERAGE _-_ _..___ RAID 8 14481 Wind River Environmental, LLC 448815 46 Lizotte Dr. Marlborough MA 01752 envpRAfZre unuomr ._.__-_. '-"' — •-^-• �Y,a,vr KUlubILIN NUMBER: XXXXXXX 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. __ _ _...—_ [Ran LTR TYPE OF INSURANCE ADOL INSD BR O POUCYNUMBER_ __ _. MWOD YYYI ICYEXP (MWDDNYYYI _... ....._. _.. __ LIMITS D X _COMMERCIAL GENERAL LIABILITY CLAIMS MADE 1XI OCCUR N N 100009051218) 6/30/2018 6/30/2019 EACHOCCURRE14CE S j,00(1.000 RE PREMISES Fe ocmn nee _ 8 100 000 _ MEDEXP(Anr oneperson) -- "' g 5,000 --" -' - --- PERSONAL B ADV INJURY $ 1,000,OQQ GENT. AGGREGATE LIMIT APPLIES PF.Po POLICY I.X I LOC S'�,OQQ,OQQ — GENERAL AGGREGATE PRODUCTS- COMPlOP AGO g 2,000,0QQ JECT OTHER: S b IT1 AUTOMOBILE LIABILITY N N 1000198837181 MA �) 6/30/2018 6/30/2019 COMBINED SI OMBINENGLE LIMIT Ea accident g 2000,000 X ANYAUTO 000198836181 AO. 6/30/2018 6/30/2019019 BODILY INJURY (Par person) $ XXXXXXX SCHEDULED BODILY INJURY(Per accident) TOS ONLY AUTOS NON -OWNED gRED XXXXXXXTOS ONLY AUTOS ONLY PROPERTY DAMAGE POPERYDAMAGXXXXXXX j"NED oin /Coll D IX Various sXXXXXXX BRELLA LIA6 OCCUR NOT APPLICABLEEACtf UAB CLAIMS MADEAGGREGATEg3<XXXXXX OCCURRENC_L _ S XXXXXCESS D RETENTION$ WORKERS COMPENSATION $XXXXXXX fJ AND EMPL ILITPER ERS'LIABILITY YIN N 1000003291 6/30/2018 (/30/2019 X STATUTE oR ROPRIEERAPARTNERI ANY PROPRIETOR/PARTNERIE%ECUTIVE OFFICERNEMBER EXCLUDED? FN N/A � E.I. EAGi ACCIDEM' _ -'- S j 000 000 — (Mandatory To NN) "" ' EL. DISEASE - EA EMPLOYEE 1,000 000 Il yyes, describe under DESCRIPTIOIJ OF OPERATIONS below _S A XS Auto Liab E.L. DISEASE -POLICY LIMIT $ IQOQ QQQ A XS General Liab N N MKLV5F•,UL101095 6/30/2018 6/30/2019 Limit: $3,000,000 R 'I'd XS Layer MKLV5EUL101095, 6/30/2018 6/30/2019 Limit $4,000,000 C 3rdX ELD30000710700 6/30/2018 6/302019 Limit: $5M xs $5M 100030507901 6/30/2018 6/30/2019 1,imir$61VI xs$ I OM DESCRIPTION OF OPERATIONS LOCATIONS(VEHICLES (ACORD101,AdditionaiRemarka Schedul%may be attached If more space Is required) Excess Liability limits for Evanston Insurance Company (policy N MKLV5EUL101095) include $3,000,000 excess the primary Auto Liability and $4,000,000 excess the primary General Liability and Employers Liability. Evidence of LTSnmlice CFRTIFICATF Hnr nro 16473701 c/o Wind River Environmental, LLC 46 Lizotte Dr. Marlborough MA 01752 ACnon 9R loneorno, 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 All rights reserved. •- • ­• --ew r,,,u 1vyv are reglsierea marKS of ACORO 1 E�' t i ��'r ! �`;♦i i�� r i Which Towns are you currently licensed with? (check all that apply) ❑ Toxborough ❑ Mansfield , tf Norton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: �ell, _-) TruC�CtlOtl 1�mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) El Venting available to allow the escape of gas on Mobile Tanits (properly constructed) Suction or Pressure Hose in good repair (leak proof) Date (Updaled SeplemGer101S) (In accordance with 310 CMR 15.505) Which Towns are you currently licensed with? (check all that apply) ❑ Foxborough ❑ Z Mansfield ZrNorton ❑ Plainville Company Name: Address: Telephone #: Operator at Inspection: Tank Capacity: Truck License #: Registration Exp. Date: 7 & C� Truck Inspection �r' {(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) ck�-Suction or Pressure Hose in good repair 19 Pumps (leak proof) Operator at Inspection /� -//)� Date (Updated.- September 2018) 4- Water Solution Group, Inc. 35 Mozzone Blvd. Taunton, MA 508.880.9992 January 1, 2018 Robert Klocek Wind River Environmental 46 Lizotte Drive Suite 1000 Marlboro, MA 01752 Dear Robert: Water Solutions Group (WSG) operates the Route 24 Water Protection Facility in Taunton, Massachusetts. We operate under the City of Taunton's Industrial User Permit No. 93-2018.2. We operate under an annual permit and have no daily limit as to the amount of sept age we can receive. The plant was sited to serve southeastern Massachusetts; however, we have not geographic restrictions and can receive sept age and other non -hazardous sanitary wastewater from anywhere. WSG is willing to continue receiving sept age from WRE provided that you maintain your City of Taunton sept age hauler's permits. Your current permits will expire December 31, 2018. We thank you for your business and if you should give any further questions, please contact me. Sincerely yours, Mark Farrell VP, Operations Wastewater Annual Collaborative e tic ler s ectiy (In accordance with 310 CMR 15.505) Wbich Towns are you currently licensed with? (check that apply) lUlFoxborough 13 Mansfield 0 Norton U Plainville Company Name: U x v.C7 Address:> , Telephone #:� 'w` " I- , Operator at Inspection: ° ' L� , ,, Tank Capacity: Truck License #: Registration Exp. Date: Truck Inspection 0 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 proof) Operator at Inspection Date ; r � 7 f, Inspectorr (Updated: Septeniher 2018) (In accordance with 310 CMR 15.505) W#ich Towns are you ¢itrrently licensed with? (check all Itat apply) El Foxborough ;/ Mansfield G✓Norton ❑ ainville Company Name: �K) �V'6 `Loec "sG C' Address: Li o zc Telephone #: 002 ��� A col7), Operator at Inspection: Vs ec) Tank Capacity: "-A 4606 Truck License #: �M 1p\ Registration Exp. Date: Sa ( � � \-�' Truck Inspection tfd Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 14Venting available to allow the escape of gas on Mobile Tanks (properly constructed) M/Suctiou or Pressure Hose in good repair Pumps (leak proof) �- Operator at Inspection nspecto� Date (Updated September 2018) Annual Collaborative Septic Hauler Ins ection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check o11 that apply) h'oxborough © Mansfield © Norton Er Plainville Company Name: Address: Telephone #: \ `'r:" mil` ir\ Cr> ;: Operator at Inspection: Tank Capacity: Truck License #:� Registration Exp. Date: t— i `truck InSDCction 0 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) Operator at Inspection C Date Inspector ((Updated.• September 2018)