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Home My WebLink AboutWind River Environmental LLC (Septage) - 12/31/2020Town of Mansfield Town of Mansfield - Board of Health 6 Park Row JAN 4 ? �kW Mansfield, MA 02048 Septage/FOG Haulers Application DATE: LICENSE NUMBED:\ i, BUSINESS NAME: l�`�(J MAIL ADDRESS:,, ��``��^ TOWN: kNC'( G Y%-0 STATE: ZIP CODE: <n NAME OF OWNER: �rrr� BUSINESS TELEPHONE: �r�j, ucl� ,, WTELL: FAX: EMAIL: 4 v 1 (\ U C\��C1C�CC1 ALT EMAIL: FED ID/SS NO: NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: �5� S) 1\ Circle one: e a e FOG Truck Registration number: �U Circle one: p a FOG Truck Registration number: _ Circle one: e e FOG Truck Registration number: Circle one: a FOG Truck Registration number: Circle one: �eptage FOG ........................ ......... --...................................................... ............. ....................................................... SEPTAGE PUMPERS: 310 CMR 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. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:OOAM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. _ I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signe and returned to the Health Department with the appropriate payment. Checks can be made payable16 Tow of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. I / I SIGNATURE: DATE: 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. Signat o ndividua o e Name By: Corporate Officer (Mandatory, if Applicable) C)q—L�::t7 **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:\Useis\sleite\Desktop\Scott's Documents\Food Eslablislunen(s- Temp\TAX CERTIFICATION FORM.doc e DepamnentoffindushWAccidents office of Invesfigations II A 9 Compensation Insurance Affidavit: General Businesses BusineWor8 'On Name: Address: has nl757 phone onnao 188 Are you an employer? Check the appropriate boa: 1. ® 1 am a employer with employees (full and/ or part-time).* 2.0 1 am a sole proprietor or par uwahip and nd have no employees working for me in any p ty [No workers' comp. insurance required) 3.0 We are a corporation and its officers have exercised thair right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required] 4.0 We aro a non-profit organization, staffed by volunteers with no employees. [No workers' comp. insmance req. Business Type (required): 5. ❑ Retail 6. ® RestavreaVBar/Eatind Establishment 7. ® Office and/or Sales (mcl. real estate, auto, etc.) S. ❑ Nan -profit 9. ❑ Entertainment ion manufacturing 11.0 Health Care 12.® Other " ` A 4anitatinn -- pay appllemi tbd ehseia bw: #I ores: eko ail nut the teetion below oonohas othm Mptoyase wcam ocompem don policy is aqulnsd ad such u1 *If the emponme offiow hive CKWA d dMadves, but the coryomn 46.o tl1 ea Below is taepauy uvu.m1...1V.M d am an employer be, lsprop,&V wor&ers' compensadon insurancefor trg employ insurance Company Name: ins nes Address: 725 S. Fi ueroa St. Ckry/State/Zip: Los A ales CA 90 17 Expiration Date• Policy # or Self -ins. Lia # 1000003291 showing the policy number and expiration date). Attach a copy of the workers' compensation policy declaration page ( sihon of criminal penalties of a Failure to segue coverage as minined under Section 25A of MGL c. 152 can lead W the impo fine up to $1,500.00 and/or one year im ant, as well as civil penalties in the form of a STOP WORK ORDER and a fore of up to $250.00 a day against the violator. a advised that a copy of this stetemert may be forwarded to the Office of _.. .,sae verification fr true only. Do not write In this area, to be cot lded by city or town O ficfaL PermWLfeense # City or Town: lssidng Authority (circle oue): Department 3. Citg/fown Clerk 4. Licensing Board 5. Selectmen's O ce L Board of Health 2. Building 6.Other Phone #: Contact Person: ACCORD ® CERTIFICATE OF LIABILITY INSURANCE 6/30/2020 9/13/2019 -`II �UpoNrHE THIS CERTIFICATE IS ISSUED JI:3 YI CERTIFICATE DOES NOT AFFIRMAT VE YElt OF INFORMATION ONL'OR NEGATIVELY AMEND, EXTENDIFICATE HOLDER.THIS jIIND OOR AL ER THE COVERAGE AFFORTDED 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. or -beendomed. It ItSUBROGATIONISeWANED, subject, to the to®ms0and eondltRiDns of the ED, the Ipotiey,)eerleln polfelesOmay require Sen endorsements A statemen on this certificate does not confer rl me to the cert9leste holder in lieu Of SU NAME:doreement s . PRODUCER LnCklon 1nSUmt10C BDINT rokers,LLC PHONE use No CA License #0F15767 ft.0 AIL 777 S. Figueroa Street, 52nd A NAG e Los Angeles CA 90017 INSURERS AFPORDI11GCOVERAGE 38318 213-689.0065 INSURER A: Starr Inderani & Liabili Com Rn INSURER B:*** SEE TTAC MENT*** INSURED Wind River Environmental, LLC 1448815 INSURERC: 46 L:T a gh INSURER D Marlborough MA 01752 _ ERTIFY THAT 1 Nt 111. eI . ..1 - NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEDD BY AND CONDRIONS OF SUCH POLICIES_ LIMITS SHOWN MAY HAVE BEEN N I NJ 1000090512191 CWMSIMDE a] OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: a] JEG O LOD POLICY OTHER, N' N ]0001988371 A AUTOMOBILE LIABILITY ]000198836i A ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS OWNED HIRED AUTOS ONLY AUTOS ONLY X Com /Coll D IX VeTiOUS B UMBRELLA LIAR OCCUR N N See Attached X EXCESSLIAB CLAIMS -MADE DED RETENTION WORKERS COMPENSATION N 1000003291 A AND EMPLOYERS' LIABILITY YIN ANY PROPRIETONPARTNER/EXECUTIVE is NIA OFFICERIMEMBER EXCLUDED? 14740892 Evidence of insurance 6/30/2019 1 6/30/2020 BODILY 6/30/2019 1 6/30/2020 11/30/2019 16/30/2020 f WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS, b S 3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ExlRATIO TTHEREOF, NOTI E WILL BE DELIVERED IN AWITH P UE ACORD 25 (2018103) The ACORD name and logo are registered marks of ACORD Attachment Cade: D551077 Master ID: 1448815, Certificate ID: 14740892 Insurer: Insurer: 8, $1,000,000 Occurrence $1,000,000 Aggregate $10,000 Retention $10,000 Deductible $5,000,000 Occurrence $5,000,000 Aggregate $10,000 Deductible $150,000 Maximum Occurrence $1,000 Deductible -309-75-96 $1,000,000 dicy Term: $25,000 Deductible 1/2019 - 4/3/2020 11 M., a,. National Union Fire Insurance Cc Pitts. PA Attachment Code: D532557 Master 1D: 1448815, Certificate 11): 14740892 Excess Liability $3,000,000 Occurrence / Aggregate Auto Carrier: Gemini Insurance Company Policy # GVE100230101 Effective: 6/30/2019 — 6/30/2020 $5,000,000 Occurrence / Aggregate Auto $8,000,000 Occurrence / Aggregate General Liability Carrier: Evanston Insurance Company Policy# MKLV5EUL301790 Effective: 6/30/2019 — 6/30/2020 $6,000,000 Occurrence / Aggregate Auto & General Liability Carrier: Aspen Specialty Insurance Company Policy# CXOOD4Y19 Effective: 6/30/2019 — 6/30/2020 Total Excess Liability Limits: $14,000,00o Occurrence/Aggregate AtNM IN iAI January 14t12019 To whom it may concern: WSG (Water Solution Group) a Wind River Environmental LLC. Company. Located in Taunton MA at; 35 Mozzone Blvd. Taunton, MA 02780 Plant contact phone number P: 508-880-9992 will accept non -hazardous septic and grease trap waste Water Solutions Group (WSG) located in Taunton MA loads from Wind River Environmental LLC. Branches in New England. Mark Farrefl, VP 3 ( YYIRONW FtAI Your Septic, Grease and Drain Service Experts! vvev, Reglss[ry of YAokar Vehiolos J ,APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2019 EXPIRATION DATE: 06/30/2020 MAILING INFORMATION WIND RIVER ENVIRONMENTAL LLC 46 LIZOTTE DR MARLBORUGH, MA 01752 - IRP REGISTRANT INFORMATION ACCTJFLEETNEAR/SUPP: 26050-1-2019-0 LEGAL NAME: WIND RIVER ENVIRONMENTAL LLC DBA NAME: ADDRESS: 46 LIZOTTE DR MARLBOROUGH, MA 01752 USDOT: 846857 NAME: WIND RIVER ENVIRONMENTAL LLC ADDRESS: 46 LIZOTTE OR MARLBORUGH, MA 01752 PLATE: 93124 UNITM 1921 VIN: 1FVHGNDV3DOBZ0500 PLATE TYPE: APN UNLADEN WEIGHT: 19016 VEHICLETYPE: Truck MAKE: FRHT FUEL: Diesel OWNER: WINDRIVER ENVIRONMENTAL LLC MODEL: CORONA COLOR: Green INSURANCE COMPANY: STARR INDEMNITY & LIABILITY COMPANY YEAR: 2013 SEATS: NA SERVICE REPRESENTATIVE: Jqr Weight JLL Weight Jur Weight JJur Welch Jur Weight Ju-rr Weight AB 29029k GA 64000 ME 64000 NJ 64000 PE 29029k WA 64000 AL 64000 IA 64000 MI 64000 NIL 29029k OC 5AXLE WI 64000 AR 64000 ID 04000 MN 64000 NM 64000 RI 64000 WV 64000 AZ 64000 IL 64000 MO 64000 NS 29029k SC 64000 WY 64000 BC 29029k IN 64000 MS 64000 NV 64000 SD 64000 «« «««« CA 64000 KS 64000 MT 64000 NY 64000 SK 29029k «« «««« CO 64000 KY 64000 NB 29029k OH 64000 TN 64000 CT 64000 LA 64000 INC 64000 OK 64000 TX 64000 DC 64000 MA 64000 NO 64000 ON 29029k UT 64000 DE 64000 MB 290291k NE 64000 OR 64000 VA 64000 ** **** FL 64000 MD 64000 NH 64000 PA 64000 VT 64000 ** **** Issued under the authority of the Registrar of Motor Vehicles for the Control: 9001-2204.4029 Massachusetts Department of Transportation. &ems Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor. Quincy, MA 02171 Tel: (857) 368-8120 www.massrmv.00m I � try r. N APPORTIONED REGISTRATION CAB CARD ya EFFECTIVE DATE: 07/01/2019 EXPIRATION DATE: 06/30/2020 ""'" 'ORMATION - IRP REGISTRANT INFORMATION ACCT/FLEET/YEAR/SUPP: 28876-1-2019-0 LEGAL NAME: RYDER TRUCK RENTAL INC DBA NAME: RYDER TRUCK RENTAL INC 329 JEFFERSON RD ADDRESS: gROAD as 85 WOOD A WOOD W02184 ROCHESTER, NY 14623 UNIT: 513234 / MOTOR CARRIER RESPONSIBLE FOR SAFETY , 1-002670 ! r USDOT: 237271 CUSTOMER: WIND RIVER NAME: CONSUMER PRODUCT DISTRIBUTORS INC ENVIRONMENTAL LLC ADDRESS: 705 MEADOW ST CHICOPEE, MA 01013-4820 i/FHlr:l C e.IC/l O\Ah TIl1\I PLATE: 90223 UNIT #: 513234 VIN: 1 M2AX04CI DMD18540 PLATE TYPE: APN UNLADEN WEIGHT: 17000 VEHICLE TYPE: Truck MAKE: MACK FUEL: Diesel OWNER: RYDER TRUCK RENTAL LT MODEL: GU713 COLOR: White INSURANCE COMPANY: HARTFORD FIRE INSURANCE CO YEAR: 2013 SEATS: NA SERVICE REPRESENTATIVE: Jur Weiaht Jur Weight Jur Weight Jur Weight Jur Weiabt Jur Weight AB 29483k GA 65000 ME 65000 NJ 65000 PE 29483k WA 66000 AL 65000 IA 65000 MI 65000 NL 29483k CIC 4 AXLE WI 65000 AR 65000 10 05000 MN 65000 NM 65000 RI 65000 WV 65000 AZ 65000 IL 65000 MO 65000 NS 29483k Sc 65000 WY 65000 BC 29483k IN 65000 MS 65000 NV 65000 SD 65000 CA 65000 KS 65000 MT 65000 NY 65000 SK 29483k CO 65000 KY 65000 NB 29483k OH 65000 TN 65000 CT 65000 LA 65000 NC 65000 OK 65000 TX 65000 •* ««.` DC 65000 MA 65000 NQ 65000 ON 29483k UT 85000 DE 65000 MB 29483k NE 65000 OR 65000 VA 65000 FL 65000 MD 65000 NH 65000 PA 65000 VT 65000 Issued under the authority of the Registrar of Motor Vehicles for the @Control: 9001-2216-4350 Massa husetts Department of Transportation. Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 2514ewport Ave Ext., 4lh Floor Quincy, MA 02171 TO (857) 38&8120 vnvw.massrinv.com pq aj {�.... x( n R t•r.k APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2019 EXPIRATION DATE: 06/30/2020 MAILING INFORMATION PENSKE TRUCK LEASING CO LP PO BOX 405 READING, PA 19603-0405 - IRP REGISTRANT INFORMATION ACCT/FLE EUYEARISUPP: 1401= LEGAL NAME: PENSKE TRUCK LEI DBA NAME: ADDRESS: 30 FULLER ROAD CHICOPEE, MA 01020-3792 USDOT: 846857 NAME: WIND RIVER ENVIRONMENTAL LLC ADDRESS: 46 LIZOTTE DR MARLSORUGH, MA 01752 PLATE: 89714 UNIT#: 674672 VIN: 1FVHG3DV2EHFL9158 PLATE TYPE: APN UNLADEN WEIGHT: 18388 VEHICLE TYPE: Truck MAKE: FLT FUEL: Diesel OWNER: PENSKE LEASING AND RENTAL COMPANY MODEL: 114sd COLOR: Green INSURANCE COMPANY: NEW HAMPSHIRE INSURANCE COMPANY YEAR: 2014 SEATS: NA SERVICE REPRESENTATIVE: Colleen Sheidy Jur Weight Jur Weight JJu Weight jgf Weight JM Weight JJurr Weight AB 29029k GA 64000 ME 64000 NJ 64000 PE 29029k WA 64000 AL 64000 IA_ 64000 MI 64000 NL 29029k QC 5AXLE WI 64000 AR 64000 ID 64000 MN 64000 NM 64000 RI 64000 WV 64000 AZ 64000 IL '64000 MO 64000 NS 29029k SC 64000 WY 64000 BC 29029k IN 64000, MS 64000 NV 64000 SD 64000 CA 65000 KS 64000 MT 64000 NY 64000 SK 29029k CO 64000 KY 64000 NB 29029k OH 64000 TN 64000 ** *••• CT 64000 LA 64000 NC 64000 OK 64000 TX 64000 DC 64000 MA 64000 ND 64000 ON 29029k UT 64000 DE 64001 MB 29029k NE 64000 OR 64000 VA 64000 FL 64000 MD 64000 NH 64000 PA 64000 VT 64000 Issued under the authority of the Registrar of Motor Vehicles for the Control: 9001-2116-7431 Massachusetts Department of Transportation. 64.) e .�W�IIIIrpNilltA�hlllQd+:�➢ IWbk}I�f�ili Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 41h Floor Quincy, MA 02171 674A7) Tel: (857) 368-8120 gg714 MA www.messrmv.com 674672 TAL LLC WINO RIVER ENVIRONMEN Renew £ x; APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2019 EXPIRATION DATE: 06/30/2020 MAILING INFORMATION RYDER TRUCK RENTAL INC 329JEFFERSON RD ROCHESTER. NY 14623 UNIT: 65983836 LOC: 2670 CUSTOMER: WIND RIVER ENVIRONMENTAL LLC - IRP REGISTRANT INFORMATION ACCT/FLE ET/YEAR/SUPP: 28876-1-2019-0 LEGAL NAME: RYDER TRUCK RENTAL INC DBA NAME: ADDRESS: 285 WOOD ROAD BRAINTREE, MA 02184 - MOTOR CARRIER RESPONSIBLE FOR SAFETY USDOT: W867 NAME; WIND RIVER ENVIRONMENTAL LLC ADDRESS: 46 LIZOTTE OR MARLBORUGH, MA 01752 IIITL: 1"i7 9 UNIT#: 659886 VIN: iM2AX04COGM032496 1'LAIF TYPL.. AI",N. UNIADGNW[IQIr 22000 VLIIIC.I,F TYPE: Truck MAKE: OAA ,k; FUEL: Diesel OWNER: RYDER TRUCK RENTAL LT NIOCc1: G , /r3 C01-Gb=: (3m—o INSURANCE COMPANY: NEW HAMPSHIRE INSURANCE COMPANY YEAR: 201E SEATS NA SERVICE REPRESENTATIVE: Jur Weit Jur Weight Jur Weight Jur Weight ,lug Weight Ju�r Weight AB 294831k GA 65000 ME 65000 NJ 65000 PE 29483k WA 66000 AL 65000 IA 65000 MI 65000 NL 29483k QC 5AXLE WI 65000 AR 05000 1D 65000 MN 65000 NM 65000 RI 65000 WV 65000 AZ 65000 IL 65000 MO 05000 NS 29483k SC 65000 WY 65000 BC 29483k IN 65000 MS 65000 NV 65000 SO 65000 CA 65000 KS 65000 MT 65000 NY 65000 SK 29483k CO 65000 KY 65000 NB 29483k OH 65000 TN 65000 CT 65000 LA 65000 NC 65000 OK 65000 TX 65000 DC 65000 MA 65000 ND 65000 ON 29483k UT 65000 ** **** DE 65000 MB 29483k NE 65000 OR 65000 VA 65000 FL 65000 MD 65000 NH 65000 PA 65000 VT 65000 Issued under th�epaltrnent authority of the Registrar of Motor Vehicles for the ( Control: 9001-2216-4305 Massachusetts of Transportation. MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 www.massrmv.com f APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/01/2019 EXPIRATION DATE: 06/30/2020 MAILING INFORMATION RYDER TRUCK RENTAL INC 329 JEFFERSON RD ROCHESTER, NY 14623 UNIT: 659895 /e% LOC: 2670 41 CUSTOMER: WIND RIVER ENVIRONMENTAL LLC - IRP REGISTRANT INFORMATION ACCTIFLEETNEARISU PP: 28876-1-2019-0 LEGAL NAME: RYDER TRUCK RENTAL INC DBA NAME: ADDRESS: 285 WOOD ROAD BRAINTREE, MA 02184 - MOTOR CARRIER RESPONSIULL rUK bArt i r USDOT: 846867 NAME: WIND RIVER ENVIRONMENTAL LLC ADDRESS: 46 LIZOTTE DR MARLSORUGH, MA 01752 Pu-.TE. fl7903 UNIT M. 659895 VIN: 1M2AX04COOM032501 P'LAI&IYPFi API -I UNLADEN WE'lGHT-221)00 VEHICLE TYPE: Truck MAkE 64ACK FUEL: Diesel OWNER: RYDER TRUCK RENTAL LT MODEL- CAl719 COLOR: Green INSURANCE COMPANY: NEW HAMPSHIRE INSURANCE COMPANY YLAH- 2016 SEATS: NA SERVICE REPRESENTATIVE: Jy[ LAIdQh Jur Weight Jur Weight Jur Weight Jur Wejaht Jur Weight AB 29483k GA 65000 ME 65000 NJ 65000 PE 29483k WA 66000 AL 65000 IA 65000 MI 65000 NL 29483k CIC 5 AXLE WI 65000 AR 65000 ID 65000 MN 65000 NM 65000 RI 65000 WV 65000 AZ 65000 IL 65000 MO 65000 NS 29483k SC 65000 WY 65000 BC 29483k IN 65000 MS 65000 NV 65000 SD 65000 CA 65000 KS 65000 MT 65000 NY 65000 SK 294831k "• «"«« CO 65000 KY 85000 NB 29483k OH 65000 TN 65000 «« «««« CT 65000 LA 65000 NC 65000 OK 65000 TX 65000 «« «««« DC 65000 MA 65000 ND 65000 ON 29483k UT 65000 •• «««« DE 65000 MB 294831k NE 65000 OR 65000 VA 65000 «« «««« FL 65000 MD 65000 NH 65000 PA 65000 VT 65000 Issued under the authority of the Registrar of Motor ehicles for the Massachusetts Department of Transportation. e Registrar UST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor Quincy, MA 02171 Tel: (857) 308.8120 Control: 9001-2216-4295