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Home My WebLink AboutDrain Shooter, Inc. - 12/31/2020 (2)Town of Mansfield Town q 1)dans� , del d - Board ofIlt?S` lth 6 Park Row Mansfield, MA 02048 A�taa£a7�fsti;�'�S'��b %�ia�ffada?F'� 1��ffd'�daft'4°£fa9`ges (r` �. fr DATE: LICENSE NUMBER: BUSINESS NAME:(�q��,'t�`_�. MAIL ADDdfRESS: ,� A �} TOWN: Pk1"—)?)VCk- 7 STATE: Yt NAME OF OWNER )' ( �i7 BUSINESS TELEPHONE:" v� �" CELL: EMAIL: -C'( W' ' f l { (4 i f r E I t, t 3(`! ALT EMAIL: FED ID/SS NO: ;fit — 11P } {;` NUMBER OF TRUCK(S): FEE PER TRUCK: Truck Registration number: ty '15A 14 Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: ZIP CODE: 0:) ?j, q FAX: Circle one: Septage ` FOG Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG 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 occur for BOH records. v I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and retumed to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: C} 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 "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:\Usem\sleite\Desktop\Scou's DocumentsTood Establishments- Temp\TAX CERWICATION MRM.doc The Commonwealth of Massachusetts [=g Department of Industrial Accidents ! 1 Office of Investigations ( ;} 600 Washington Street W y Boston, MA 02111 f W _tom= www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip: i`)C' rv`` i 8 } ' .�J"'4 Phone #: ~} j i ` / 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/EatingEstablishment 2.Fj 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. 1--j Entertainment their right of exemption per c. 152, §1(4), and we have 100 Manufacturing no employees. [No workers' comp, insurance required]* 11.0 Health Care 4.Fj We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.® Other( -LI j c -Airy applicant that checks box 8I most 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 all organization should check box 91. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: LK,',' r A, ( i i (TI p Policy # or Self -ins. Lic. #€` 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 of perjury that the information provided above is true and correct. f Signature: 1y'��f" ��, t �� Date: l /J 7 j� r i Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: 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 Christopher George From: Mimi Wigman <Mimi@drainshooter.com> Sent: Monday, January 13, 2020 9:36 AM To: Christopher George Subject: RE: Recently submitted Fog Hauler Application Good Morning, I am sorry, I misunderstood what you were looking for. We empty grease traps at: Medtronic 100 Hampshire Street Mansfield, MA 02048 Medtronic 15 Hampshire Street Mansfield, MA 02048 Thank you, Mimi Wigman Drain Shooter, Inc. 2 Columbia Road, Suite 10 Pembroke, MA 02359 781-331-0171 Office 781-829-8500 Fax suDDort(@drainshooter.com www.drainshooter.com From: Christopher George <ceeorge@mansfieldma.com> Sent: Monday, January 13, 2020 8:20 AM To: Mimi Wigman <Mimi@drainshooter.com> Subject: RE: Recently submitted Fog Hauler Application Good Morning, On your application it's listed that you only perform Fat, Oil, & Grease pumping/hauling for the Town of Mansfield. Do you have a list of restaurant establishments that you perform this for? Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 I From: Mimi Wigman [mailto:MimiCcbdrainshooter.com] Sent: Friday, January 10, 2020 8:30 AM To: Christopher George Subject: RE: Recently submitted Fog Hauler Application Good Morning, I have attached the information you requested. Thank you, Mimi Wigman Drain Shooter, Inc. 2 Columbia Road, Suite 10 Pembroke, MA 01359 781-331-0171 Office 781-829-8500 Fax support@drainshooter.com www.drainshooter.com From: Christopher George <caeoree@mansfieldma.com> Sent: Thursday, January 9, 2020 9:04 AM To: Support <Support@drainshooter.com> Subject: Recently submitted Fog Hauler Application Hello, You recently submitted a Permit application to the Town of Mansfield for Septage/FOG Haulers. Can you please provide a list of all establishments you currently provide FOG services to? Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, 2