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Home My WebLink AboutBay State Sewage Disposal, Inc. - 12/31/2021Town of Mansfield - Board of Health E Town bf PWA10f!Pid cS Park Row " 8 j�,t , Mansfield, MA 02045`6 Septage/FOG Haulers Application DATE: W3C-)I 2_L) LICENSE NUMBER: BUSINESS NAME: ejE� �t tC .{,,CA_k - 9�- � S�X� 1 )rli_- MAIL ADDRESS: TOWN: PD P" STATE: ZIP CODE: C :9-+ � IQ�LLv A \t C' NAME OF OWNER: YZiC±I 3r �.1 F CV)�L ,S BUSINESS TELEPHONE: 5C8' l 1 2U31sA CELL: FAX: EMAIL:D�;7ySj`1t : S� tt,}� ..C'Gr� FED ID/SS NO: k'-)L� ALT EMAIL: P�� FEE PER TRUCK: $100 NUMBER OF TRUCK(S): 20 Truck Registration number: S lr S iL'I_i7 �,- Circle one: Septage k0o. 25 Truck Registration number: K1 t 1 C 1,, '� Circle one: Septage FOG` L�,5 Truck Registration number. n `e, 1. r- S_-S Circle one: OG rblD Truck Registration number: i (_) Z 1S ✓ Circle one: (Septa a FOG �J- 1, Truck Registration number: --szf .)I_I% ✓ Circle one: Septage 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. C )Y I ;"} l 1 - 1t_=.tY 1 C ,(, j �t ��',; � t i C `,C h", --V ('.�v-+Q (is t jhca i h� 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: Cj G 2-0 --......--- - - _I 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. of Individual or Cdr rate Name By: C rpo fate Officer (Mandatory, if Applica e) "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 Doeuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 1/L4 liV/IL/IGV�L IVGWLLIL � lI1 WVJKY/GYLV �.44U Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I1-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lesibly Business/Organization Address: 105 Kingman Street Bay State Sewage Disposal, Inc. City/State/Zip: Lakeville, MA 02347 Phone #: 508-947-2636 Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 40 employees (full and/ S. ❑ Retail oi-part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Nou-profit 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 no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp. insurance req.] 12.E Other Service *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy mtomtanon. **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 is providing wor/rers' conrper:sation insurance for my employees. Below is the policy infornation. Insurance Company Name: Hartford Underwriters Ins. CO. / The Hartford Insurer's Address: PO Box 5600 City/State/Zip: Hartford, CT 06102-5600 Policy # or Self -ins. Lie. #6S6OUB4N31205019 Expiration Date:06-15-2021 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify, under thepains andpenalties ofpeiyeny that the informationprovided above is true and correct. 508-947-2636 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Issuing Authority (check one): loBoard of Health 2.❑ Building Department 50Selectmen's Office 6. ❑Other Permit/License # 3.0City/Town Clerk 41hicensing Board Contact Person: Phone AU o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNY ) 6/15/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 RogersGray, Inc. - Kingston Branch 63 Smith Lane Kingston MA 02364 CONTACT NAME' FAX MC ac No Exit- 508-746-3311 ac No: 877-816212156___ nooalEss: mail@roqersqray.com INSURER(S) AFFORDING COVERAGE NAIC# _ _ INSURERA: Arbella Protection Insurance Company, Inc. 41360 INSURED BAYSTAT-N Bay State Sewage Disposal Inc 105 Kingman St INSURERB: AmTlvst Insurance COm an of Kansas �----— INSURERC: 15954 INSURER D: Lakeville MA 02347 INSURER E : _ INSURER F : COVERAGES CERTIFICATE NUMBER: 409350726 REVISION NUMBER: THIS IS TO CERIIFY 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. INSR R TYPE OF INSURANCE INSO ADDL WVD SUER POLICYNUMBER MWDD/YYYV Y Err MMI�D/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 8500069716 1/18/2020 1/18/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE 1XI OCCUR DAMAGE TO RENE PREMISES (Ed ocaurence $30D,000 MED EXP(Anymm person) _ PERSONAL B AOV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 PRO - POLICY JE� X LOC PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY Y Y 102007999802 1/18/2020 1/18/2021 COMBINED SINGLE LIMIT Eaaccident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraucident $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY $ A X OCCUR Y 4620089131 1/18/2020 1/18/2021 EACH OCCURRENCE $5,000,000 AGGREGATE _ $5,000,000 JUMBRELLALIA13 EXCESS LIAR CLAIMS-MAOE DED X I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Y WWC3479512 6/15/2020 6/15/2021 X PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICEWMEMBEREXCLUDED? NIA EL DISEASE - EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS be. E.L. DISEASE -POLICY LIMIT $1,000,000 A Leased Rented 8500069716 1/18/2020 1/18/2021 Limit $100,000 A Workeile Pollution 8500069716 1/18/2020 1/18/2021 Limit $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield Health Department Town Hall 6 Park Row- 1st FIT Mansfield MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD