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Home My WebLink AboutCavalieri Cesspool Service - 12/31/2021*16_9 7'flwn of Monsj7eld - Board ofHeo th Em Town of Mansfield 6 Park Row Mansfield, MA 02048 r r Sepla cal G Haulers Applieudon DATE: / o/mil/ace ( r` LICENSE NUMBER: BUSINESS NAME: MAIL ADDRESS: TOWN: 61-B �� ,tyo STATE: � � � n / ZIPCODE: E: NAME OF OWNER: WiIIiA-i-+ BUSINESS TELEPHONE: Svf-G 0-(360 CELL.,5� -J;7d --1J'V FAX: EMAIL: Cavali�ri, w Ilfgr J l 9w�i I, car FEDID/SSNO: OL(' aV7&r- 04' ALTEMAIL: FEE PER TRUCK: $100 NUMBER OF TRUCK(S): A Truck Registration number: '7%S- 4 V Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: y Circle one: eptage FOG Circle one: ep age 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: 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: Town of Mansfield 6 Park Row, Mansfield, Massadmi-ear 02048 Health Department Any D onouan-Palmer, MPH, RS Health Agent October 22, 2020 Septage/FOG Haulers: Your current Septage/FOG Hauler Permit will expire on December 31, 2020. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 25, 2020. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. • Septage/FOG Hauler Permit Application (Attached) • Tax Certification Form (Attached) • Workers' Compensation Insurance Affidavit: General Business. (Attached) • Workers' Compensation policy declaration page: The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address. The current Mansfield BOH fee is $100 per truck. According to Title 5, 310 CMR 15.505(1), all trucks that transport the contents of privies, cesspools, septic tanks or tight tanks must be inspected and approved by the Health Department. For the 40 year, there will be a joint truck inspection held at Gilette Stadium in Parking Lot P10 (across from Patriot Place) Route 1, Foxboro, MA 02035. PLEASE DO NOT BRING PAPERWORK TO THIS EVENT. Paperwork should be submitted directly to the Health Department. The Health Department is electronically tracking local pumping, as required by Title 5. Please submit the attached form electronically monthly. Please contact the Health Department if we can be of any additional assistance. Sincerely, A-1MnI)�U�JCfYa.TkMn. Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 • Fax (508)261-7425 Email adpolmer@monsfieldma.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: 0-8 Z f/ �� City/State/Zip: k4aItt td M f?&A (Y�r�p C.i)hone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with employees (full and/ or part-time).* 2. ® I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ RestaurantBar/Eaiing Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑Entertainment 10.❑ Manufacturing I Ln Health Care 12.❑ Other *Any applicant that checks box H 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 H 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Comnanv Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration Date: 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, an der the_pins offitpeigalties 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 Phone www.mass.gov/din 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. ignature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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:\Users\sleite\Desktop\Scotts Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc CAVAW01 D10/26/202ATE YY) 10/26/2020 ,4coRo° CERTIFICATE OF LIABILITY INSURANCE 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 endorsements . PRODUCER 508-695-0314 R.A. Relnbold Ins. Agency Inc. 860 Landry Ave P.O. Box 68 CONTACT Jeanette Barry, AAI,CRIS,CPIA NAMPHONE 508-695-0314 FAX 508-699-2583 (A/C, No, Sal): INC, No E"MAIEss:jeanette@reinboldinsurance.com N. Attleboro, MA 02761- Douglas J. Reinhold I_NSURERISI AFFORDING COVE RAGE NAICW _ __. -, INSURER A; Nautilus Insurance Com an INSURED William P. Cavaliers XltB COTTAGEFallsT 02763 INSURER B: Safety Insurance Company ----- INSURERC_ - INSURER D : INSURER E : INSURER F: COVERAGES CERTIFICATE NUMRER: REVISION NIIMRFR- THIS IS TO CERTIFY 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. INS& TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY E%P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE n OCCUR NN1186426 10/15/2020 1011512021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occu a ce $ 100,000 MED EXPy LAn one.e ersan _ $ 6,000 PERSONAL B ADV INJURY 110001000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY ❑JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG _ $ 2,000,000 B AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY X AUTOS ONLY 6238583 05/2312020 05/23/2021 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per arson $ BODILY INJURY Per accitlent $ X PROPER c&itleT nl ANIAGE $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ _ DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICERMEMBER EXCLUDED?ECUTIVE ❑ (Mandatory In NH) If yes, tlundo, DE ResuibeIPTI NOFOPERATIONS below NIA PER OTH- IS E I E E.L. EACH ACCIDENT $ E.L.DISEASE-EAEMPLOYEE $ --- E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION MANSFIE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of ACCORDANCE WITH THE POLICY PR IONS. Attn: Board of Health 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Douglas J. Reinbold ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD