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Home My WebLink AboutAll Seasons Septic, Inc. - 12/31/2021BUSINESS NAME: 200 Gusn§99 W-, " Str,a? t¢ton, MA 029121 MAIL ADDRESS: TOWN: STATE: NAME OF OWNER: BUSINESS TELEPHONE: 'CELL: ''CELL: EMAIL: CZllsao. awe96f f-o— .CD,m FED ID/SS NO: / ALT EMAIL: FEE PER TRUCK: $100 Truck Registration number: Truck Registration number: C Truck Registration number: �G Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: NUMBER OF TRUCK(S): 3 3 Gp 6 ZIP CODE: FAX &/, ' Circle one:*�S�eptaab FOG Circle one:FOG Circle one: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: THURSDAY, NOVEMBER 12, 2020 TIME: 7:OOAM-11:OOAM PLACE: GILETTE STADIUM - PARKING LOT P10 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 signed and returned 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: 446(12P,7�o-- 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. t CW Si re of vidual or Corporate Name By: Corpora Officer (Mandatory if Applicable) **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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 1 Congress Street, State 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ALL SEASONS SEPTIC SERVICE, INC. Address: 200 CUSHING ST., U#7 City/State/Zile: STOUGHTON, MA 02072 Phone #: 866-822-6846 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 4 employees (full and/ 5. ❑ Retail. or part time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 1 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. 8• ❑ Non-profit [No workers' comp. insurance required] 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 4. ❑ no employees. [No workers' comp. insurance required]* We by 11. ❑ Health Care are a non-profit organization, staffed volunteers , with no employees. [No workers' comp, insurance req.) 12.(4 Other *Any applicant that checks box #I must also fill out the section below shoving 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 #1. I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: TRAVELER'SINDEMITYCO Insurer's Address: ONE TOWER SQUARE City/State/Zip: HARTFORD, CT 06183 Policy # or Self -ins. Lie. # US-8P210683 Expiration Date: 04/14/21 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 cerfW jmde/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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone CERTIFICATE OF LIABILITY INSURANCE DIYY DATE 11/03/2020 ) 020 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 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 Malcolm & Parsons Insurance Agency 713 Washington Street P.O. Box 527 Stoughton MA 02072 CONTACT Jaime Gonsalves NAME: NC NO Ext: (781)344-3200 AC No: (781)344-1425 'MAIL jll@malcolmandparsons.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC q INSURERA: Ohio Security Insurance Company INSURED All Seasons Septic Service Inc 200 Cushing Street Suite 7 Stoughton MA 02072 INSURER B : Travelers Casualty Ins Cc 19046 INSURER C : Travelers Indemnity Cc 25658 INSURER D : INSURER E: INSURER F: RAnee nPPTIFIr:ATE NIIMRFR- Master 614/20 REVISION NUMBER: V THIS IS TO CERTIFY THATTHE 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE INSADDD WVD POLICY NUMBER MMIR�IYEVVV MMIDDIYVW LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 15,000 A BKS(21) 60955059 02/12/2020 02/12/2021 PERSONAL& AOV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERA -AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 PRO-JECT LOC X POLICY 0 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accitlenl $ 1,000,000 BODILY INJURY (Per person) _ $ ANY AUTO BODILY INJURY (Per awidend $ B OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED XAUTOS ONLY X AUTOS ONLY BA-6P002260 02/12/2020 02/12/2021 PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN IE%ECUTIVE � ANY PROPRIMBEIR EXCLUDED? OFFICER/M in NH) E%CLUDEOP (Mandatory, in NH) NIA UB-8P210683 04/14/2020 04/14/202, PER OTH- STATUTE ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEABE - EA EMPLOYEE 1,000,000 $ E.L. DISEASE - POLICY LIMIT 1,000,000 $ It yes. describe under DESCRIPTION OF OPERATIONS below Per Act $100,000 A Contractors Errors & Omissions BKS(21) 60955059 02/12/2020 02/12/2021 Aggregate $100,000 Deductible $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Septic System Services CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Wrentham ACCORDANCE WITH THE POLICY PROVISIONS. 79 South Street AUTHORIZED REPRESENTATIVE Wrentham MA 02093�� 91988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD