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HomeMy WebLinkAboutBaker Commodities, Inc. - 12/31/2021bU51Nt55 NAMt: /w" - MAIL ADDRESS: TOWN:1,Tj/�1'0&,?& A-e- STATE: 01,19 ZIP CODE: a/p 6 NAME OF OWNER: ��0 �� ✓ram/�' BUSINESS TELEPHONE: 9%/ �fyCELL: FAX: p EMAIL: FED ID/SS NO: fIs -��3/d FEE PER TRUCK: $100 ALT EMAIL: NUMBER OF TRUCK(S): r/ ?SS�d Truck Registration number: //5-5-3 f yLTruck Registration number: 9J /,//J Truck Registration number: Circle one: Circle one: Circle one: Septage Septage Septage 41 Truck Registration number: Circle one: Septage Truck Registration number: Circle one: Septage 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: 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. N>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: //,,Ie --i, - DATE: 16, ;"� 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 By: Corporate Officer (Mandatonj, if Applicable) *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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 4zs�s:. oao L REGISTRY of MOTOR VEHICLES APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 01Jul-2020 EXPIRATION DATE: 30-Jun-2021 MAILING: REGISTRANT AC CT/YEARf S U P P: 7580001-2021-0 BAKER COMMODITIES INC LOCATION: BAKER COMMODITIES INC PO BOX 132 134 BILLERICA AVENUE N BILLERICA MA 01862-0132 N BILLERICA MA 01862 MOTOR CARRIER RESPONSIBLE FOR SAFETY USDOT: 0034909 NAME AND ADDRESS: BAKER COMMODITIES INC 4020 BANDINI BLVD VERNON CA 90058 PLATE: 79563 UNIT#: 3548 VIN: 3C7WRMCL4HG547960 PLATE TYPE: Apportioned Normal UNLADEN WEIGHT: 7419 VEHICLE TYPE: Truck MAKE: DODG FUEL: D OWNER: BAKER COMMODITIES INC MODEL: RAM COLOR: White INSURANCE CO: THE TRAVELERS INDEMNITY COMPANY YEAR: 2017 SERVICE REP: �J0[ Weight JOc Weight JW Watch M Weight M Weight J1a Weight AB 11793 FL 26000 MB 11793 NO 26000 OK 26000 'TN 26000 AL 26000 GA 26000 MD 26000 NE 26000 ON 11793 TX 26000 AR 26000 IA 26000 ME 26000 NH 26000 OR 26000 UT 26000 AZ 26000 10 26000 MI 26000 NJ 26000 PA 26000 VA 26000 BC 11793 IL 26000 MN 26000 NI. 11793 PE 11793 VT 26000 CA 26000 IN 26000 MO 26000 NM 26000 QC 4 WA 26000 CO 26000 KS 26000 MS 26000 NS 11793 RI 26000 'WI 26000 CT 26000 KY 26000 MT 26000 NV 26000 SC 26000 WV 26000 DC 26000 LA 26000 NB 11793 NY 26000 SO 26000 WY 26000 DE 26000 MA 26000 NC 26000 OH 26000 SK 11793 Issued under the authority of the Registrar of Motor Vehicles for the Massachusetts Department of Transportation im Registrar of Motor Vehicles 25 Newport Avenue Extension, 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 mass.gov/nnv C 35 REGISTRY of MOTOR VEHICLES APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 014ul-2020 EXPIRATION DATE: 30Jun-2021 MAILING: BAKER COMMODITIES INC PO BOX 132 N BILLERICA MA 01862-0132 REGISTRANT ACCT(Y EARNS U P P: 7580001-2021-0 LOCATION: BAKER COMMODITIES INC 134 BILLERICA AVENUE N BILLERICA MA 01862 MOTOR CARRIER RESPONSIBLE FOR SAFETY USDOT: 0034909 NAME AND ADDRESS: BAKER COMMODITIES INC 4020 BANDINI BLVD VERNON CA 90058 PLATE: 95110 UNIT#: 5346 VIN: 3AKJGBDV6DSFG8867 PLATE TYPE: Apportioned Normal UNLADEN WEIGHT: 16820 VEHICLE TYPE: Tractor MAKE: FRHT FUEL: D OWNER: BAKER COMMODITIES INC MODEL: 113 COLOR: White INSURANCE CO: THE TRAVELERS INDEMNITY COMPANY YEAR: 2013 SERVICE REP: �Jur Weight Jur Watch t J1u Weight JZ Weight JW Weigh Jtu Weight AB 36287 FL 80000 MB 36287 NO 80000 OK 80000 TN 80000 AL 80000 GA 80000 MD 80000 NE 80000 ON 36287 TX 80000 AR 80000 IA 80000 ME 80000 NH 80000 OR 80000 UT 80000 AZ 80000 ID 80000 MI 80000 NJ 80000 PA 80000 VA 80000 BC 36287 IL 80000 MN 80000 NIL 36287 PE 36287 VT 80000 CA 80000 IN 80000 MO 80000 NM 80000 QC 5 WA 80000 CO 80000 KS 80000 MS 80000 NS 36287 RI 80000 WI 80000 CT 80000 KY 80000 MT 80000 NV 80000 SC 80000 WV 80000 DC 80000 LA 80000 NB 36287 NY 80000 SD 80000 WY 80000 DE 80000 MA 80000 NC 80000 OH 80000 SK 36287 Issued under the authority of the Registrar of Motor Vehicles for the Massachusetts Department of Transportation Registrar of Motor Vehicles 25 Newport Avenue Extension, 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 mass.govinnv }l}+1�jJ h l �� 1 �i1r1 'i 1. 1� l�, 41��n1 i rt t ,� f� �•}+1 +Y i 1�Qi J �{ iM 1� t,� +4 LILY" �'-.tr},�.f ;f�i/1 ir�� L':j!'�ii�.hi!A..�4�u, y, :.Yt�:�:�M,F>.•• P f�yl�jT''r 1 :r THIE CER1 BE[ ) REP:. If BUT this c, I CN103l'2 NSUREo E r V COVED �® CERTIFICATE OF LIABILITY INSURANCE D0'' oD 1 °ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS : E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES . ;IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 1 TATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ': If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be Endorsed. ,TION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on to does not confer rights to the certificate holder In lieu of such endorsement(s). RISK $INSURANCE SERVICES 01 FIGUEROA STREETINC, SE 90437153 LES,CA 90017-5822 -ngate$,OenRegUeel@mamh.com IF: 212-948-0535 'ER-GAWU.20- BAKER None NO MONTA T NAME: PHONE FAX No ADDRESS: INSURERS AFFORDING COVERAGE NAICN INSURER A: Travelers Property Casualty Co. of America 25074 COMMODITIES INC. ,IN SERVICE, INC. wsuREq e : WA NIA INSURER c: The TravelersIndemnity Company 2$658 INSURER D: 7ASE COMPANY 'UMPING AND SERVICES, INC. ADINI BOULEVARD INSURER E : 1 INSURER F: N,GA 90056 CERTIFICATE NUMBER: LOS-002385031-06 REVISION NUMBER: THIS I :ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED',ABOVE FOR THE POLICY PERIOD INDIGi- NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTI' ' E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCI.'.. - ',AND CONDITIONS OF SUCH POLICIES. LIMITSSHOWN MAYHAVE BEEN REDUCEDBY PAIDCLAIMS, ILTR TYPE OF INSURANCE ADOLSUNIA POLICYNUMBER POLICYEFF MWODIYWl(1 POLICYE P IMWDDNMI LIMITS A X -" �ERCIALGENERALUABIUTY C IAIMS-MAOE M OCCUR TC2J13LSA419J6422-TIL-20 04/01/2020 0410112021 EACHOCCURRENCE 5 1,000,000 DAMAGE TO RENT tu PREMISES His occurafteal $ 100,000 GEC X NED EXP(Any one person S 5-OTO PERSONAL B AOV INJURY $ 1,000,000 ',::,REGATELIMIT APPLIES PER: PRO. 'JY ❑ JECT LOC GENERAL AGGREGATE S 2,OOD,000 PRODUCT$-COMP/OPAGG $ 1,000,000 A A A ALI-.ra.EUABILITY AUTO X : ED SCHEDULED S ONLY AUTOS X H. r % NONOWMED Al.IOS ONLY AUTOS ONLY TC2JCAP419J6434-TIU20 TC2JCAP419J6446-TIL-20 TC2JBAP419J646A-TIL-20 APO OomplColl Deductible:$26,000 04MI2020 0410112020 0410112020 04101 021 04N1/2021 04/01/2021 wewBDsN lG._L_E LIMIT - $ 1,000,000 BODILY INJURY (Perparson) $ BODILY INJURY (Per accident) S PRO ERTY OAMAOE Pe de 5 5 r.ELLAUAs I SSLIAS OCCUR CLAIMS -MADE EACHOCCURRENCE S AGGREGATE $ RETENTION$ 5 A C WOR'(- sCOMPENSATION ANDC: •LOYERS' LIABILITY YIN OARMFFIC. ^ EMBEIPARTNDED2 CUTIVE (MendMEMSERE%CLVOED9 ff eno,.r ryin NH) Dyyes, m .rube antler DE$CRi-ifON OF OPERATIONS belay NIA UB-BM254234-20-51-K UBAL755125.245i-R 0410112020 04A1120T0 0410112021 04/0112021 X I STAT(JTE I I ERH E.L. EACH ACCIDENT $ 1.000.000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE •POLICY LIMIT $ 1.000,000 DESCRIPTo+ OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Columbia Inl . iodal, LLC, Columbia Group Holdings, LLC, and Citable Container Services, LLC are included as addiifonal insured but only as respects liability arising out of the work performed for them by the named Insure.: is required by written contract, with the exception of Workers' Compensation and Employers' Liability. CERTIFI ACORD (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EOREPRESENTAnVE Risk S insurance Samlces I Linda Leigh Long L @ 1988-2016 ACORD The ACORD name and logo are registered marks of ACORD /l't- N Y/J'J 4Lb W✓nusvu+vsr®unnrv.w =� —_ 600 Washington Street' � � Boston, MA 02111 I '' •n wfiow.mass.govIdia Workers' Compensation insurance Affidavit: GenerM Businesses .9jlvtroVucaona �oaQ'®u•u>matB®n 1P9euse �t'uaaQ �e�uQ Busiliess/Organization Name: BgK?IC.4y1tYy nn(l Ai-Ha5 Inc, — Address: I3tt R, ITV' city/state/zip:So6k IIler a MIS, olga Shone Are you an employer? .Check the appropriate box: Business Type (required): 1. IS I ant a employer with qii employees (full and/ 5, ❑ Retail • _ or part-time).'" 6. ❑ Restaurant/Bar/Eating Establishment - El I am a sole proprietor or partnership and have no .i 7. ❑ Office and/or Sales (incl, real estate, auto, et employees worldng'for me in any capacity, [No workers' comp, insurance required] g• ❑ Non-profit 3. E_J We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c, 152, §1(4), and we have 10.7 Manufacturing _ no employees, [No workers' comp, insurance required]'" 4, U We are a non-profit organization, staffed by volunteers, I l,❑ Health Care will) no employees, [No workers' comp, insurance req.] 12.2 Other Sery II cc "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 coiporation has other employees, a workers' compensation policy is required and such ar organization should check box # I. 1 an: ari employer that is providing rvorlter•s' cornperisadon insierance jor my employees. Below is the policy inforrnati insurance Company Name"'C((cxytrl e rs Rrope,(w card Cas W l { U Insurer's .Address: City/Statc/Zip: Policy # or Self -ins, Lie, # Expiration Date: Attach a copy of tite workers' compensation policy declaration page (showing the policy number and expiration d, Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and of up to M0,00 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. ? do hereby certify, under the pains and penalties of perjury that the information provided above is trite and correct _ Si nature: 7 f/ &� lA (Z Date,' P11011e #: / C (1].L� l3 /1 Official use only. Do not write in this area, to bG completed by city or torpn City or'f own: Permit/License Issuing Authority (circle one): 1, Board of Health 2. Building Department 3 City/Town Clerk 4 1Licensin Board 5 Selectmen's Office g 6. Other Request for Taxpayer Give Form to the )atobcr 2018) Identification Number and Certification requester. Oo not sent a thsrneaey send to the IRS. �RevenueseMce ►Bo to w»w.lrsgov/FormM for Instructions and the latest irdormetlon. i Name (as shown on your inane tax retun). Name roqubed on this fine; do net leave this line blank. t� 2 Business namelder"luodd entity name, 0 daf t m above 3 Check appmplate box for federal tax classification of the Parson whose name Is entered on Me 1. Cheek only one of the '4 Exemptions (Coda apply only to following seven boxes cafaln errihles, not kldviduero; see ❑Ndlvitluayea•wopnetorw 02 CCorporetbn ❑SCorporation nPeMenhlp 0TrvsVestsle Instruction m page 3): dngks rms nbsr LLC Exwp1 P" cOy gf &V 0 Limited liability company. Enter the tar cleeefflutlon (C.0 Corpomtlon, S.S corporation, P.POArashlp) ► Note; Check the appropriate box in the Iine above farthe tax classOowner Do of the single-manber ownDo not check Exemption from FATCA reporting LLC If the LLC hi deselfled as a single -member LLC mowner at is disregarded from the or unless the owner of the LLC Is another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a singb-member LLC that ootle pf any) is dhngarded from the owner Should check the appropriate box for the tax Classification of No Owner. other (am n•truCaens)► Nvgbbee[o,.wmww:nxarulWJrW peJ Address (number, SVa01l.a`nd apt or �nNo .. .. Requcdela name and addrse lopllond) ......—...— 'Y '7. 0 Gty, state, and ZIP code il r Ubo(s) et account nunere(optiona0 Tax a er Ident ification Number IN Fr, r your TIN In the appropriate box. The TIN provided must match the name given on line 1 t0 avoid b>: `ip withholding. For Individuals, this Is generally your social security number (SSN), However, for a ro . ant alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other on as, itIs your employer identification number (EIM. If you do not have a number, sea How to get a Tit later. N� If the account is In more than one name, ass the instructions for line 1. Also see What Name and N,tw To Give the Requester for guidelines on whose number to enter. 3 i Certification V ,r penalties of perjury, I certify that: 1. 'he 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 ,m not subject to backup withholding because: (a)1 am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue a m orvice (IRS) that I am subject to backup withholding as a result of a failure to report all interest dividends, a (c) the IRS has notified me that I a no longer subject to backup wlthhotding; and 0, i ern a U.S. citizen or other U.S. person (defined below); and A. Igo FATCA cods(s) entered on this form Of any) Indicating that] am exempt from FATCA reporting Is correct,C, ,,fCation Instructions. You must cross out hem 2 above If you have been notified by the IRS that you are currently subject to backup withholding because y, rave felled to report all Interest and dividends on your tax return, For real estate transactions, hem 2 does not apply. For mortgage Interest paid, v . Asition or abandonment of secured property, cancellation of debt, Contributions to an Individual retirement arrangement (IRA), and generally, payments oth<,r than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions for Port 9, it*. o rat , r Signature of Here D.S.pemon► ode► (+)' General Instrull1114S •form 1099-DIV(dividends, including those fro atooks or mutual funds) Sic-,tion references are to the Internal Revenue Code unless otherwise oct:,d. Future developments. For the latest information about developments related to Form W-9 and Its Instructions, such w legislation enacted after they were published, go to www3M.goV1FormW9. 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 (SSM, individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIM, 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-IN7 (interest owed or paid) Cat. No. 102SIX • Form 1099-MISC (various types of Income. Prizes, awards, or gross proceeds) • Form 1099-B (stock m mutual fund sales and certain other transactions by brokers) • Form 1009-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network tramaotlons) • Form 1090 (tome mortgage Interest), 109E-E (student ban hderest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1 D99-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 77N, you might he subject to backup withholding. See What Is backup withholding, later. (Rw. 10.201e) eau I Aeporis Page 1 of 1 Include No v Cancelled Bu id AII.e , Drain; Grease Customer, Hardddi�N] *✓] City © NULL i J of 1� A 4 Baker Commodities Inc. 134Rear Billerica Avenue North Billerica, MA 02862 SU BU Nac Cust ID Customer Name Chid Acct DR 33420 Mansfield Country Square, I.I.C. OR 23481 TGI.Friday's 40655 BC-o12 OR: 2 Customers OR 18093 Catman Cafe T OR 28474 Chang Du L/T OR Y 35109 Chipatle Mexican Grill OR 5288 Epicurean Feast @ Coviden OR $2664 Fresh Catch OR 4971 Gann's Restaurant & Lounge OR 36119 Hanger 12 Restaurant OR 32835 Jimmy's Pub &. Restaurant . OR Y 23085 Longhorn Steakhouse OR 23840 Mansfield House ofPiva OR 7701 Quan's Kitchen: T OR 34177 ShavlsSupermraket-96002 OR Y 33794 Shows Supermarket OR 20103 Stefano's Plua L/T OR y 25766. Stop & Shop Supermarket#0007 L/T OR 23481 TGI Friday's#0655 80012 OR 9802 Wendy's Hamburgers CS GR: 17 Customers HM 34177 Shaw's Supermraket-96002 HM y 25766 Stop& Shop Supermarket#0007 L/T HIM: 2 Customers PW 23481 TGI Friday's#0655 BC-012 Pwt 1 Customers TP 32664 Fresh Catch TP 32835 Jimmy's Pub & Restaurant TP 33420 Mansfield Country Square, U.C. TP 23481 TGI Friday's#0655 80012 TP; 4 Customers TS 23481 TGI Friday's #065S SC-012 TS 9802 Wendy's Hamburgers CS TSi 2 Customers Nac Acct Zip Code Proprietary And Conridentiall Report date: View Report NULL V) Find I Next MER LIST Div ID; Buss Unit: 0( lexica „aor ss City 51 3215 hoof St Mansfield Iv 2805 hoot St Mansfield N 16 Oil Colony Rd Mansfield N 249 P orth Main St Mansfield N 287S HOOL STREET Mansfield N 11 H pshire St Mansfield N 30.Ch P uncy St Mansfield N 407 Main St Mansfield N 265F uit St Mansfield N 141 Main St Mansfield N 390 V lestSt Mansfield N 175 N rth Main St Mansfield M 30 Ch runcy St Mansfeld N 390V rest St Mansfield ly 390 V, est St Mansfield N 30 Ch iuncy St Mansfield N 377G aunty St Mansfield N 2805 pool St Mansfield N 64 Col eland Drive Mansfield N 390 est st Mansfield ly 377 Cl aunty St. Mansfield N 280 Sc iooi St Mansfield N 30 CN uncy St Mansfield M 141 N, Main St Mansfield N 321 Sc loolSt Mansfield M 280 Sc ioolSt Mansfield N. 280Sc ool St Mansfield N 64 Co land Drive Mansfield N 7:48:37 AM http://css,baker.com/Report/Report—Viewer.aspx?id=70013030 11/12/2020