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Home My WebLink AboutDumont Pumping - 12/31/2021LICENSE NUMBER: BUSINESS NAME: �) u-m Cr1/'1 t P u-m Pit? E-- MAIL AD` TRESS: TOY:'N: 1 4, S�-. STATE: lqh NAME OF OWNER:11-lee Rich ✓k/ ar�vv) BUSINES TELEPHOr' _ 5e- k I e - % CELL: EMAIL: adva,')Le 6l'�ral L'p{Y11'QST• IU 7L FED ID/St. NO: &4-yg t,�-i ALT EMAIL: FEE PEK TRUCK: $1:'0 NUMBER OF TRUCK(S): �: ry Truck Reg.stration num`--;r: Truck Rec!stration r „r7ier: _.. /f -Y Truck Registration < <n.ocx ___— Truck Reg`stration nk.mbea. Truck Rea stration number: ................ .................. I ........ .................... ............. ZIP CODE: FAX: Circle one: Se to e , Circle one: Septage E EQG _--) Circle one: Septage FOG Circle one: Septage FOG Circle one: ................................................ Septage FOG SEPTAGE PUM; )ERS 310 CMR 15.50E Equipment: Ro person shall use :quipment to remove or transport the contents of prives, cesspool, or septic tanks or a ier offensive substances unless : uch equipment has first been inspected and approved by the Board of Health. TRUCKS INSPE ;TIO' iS: D V'r`: TH!_ RSDAY, N( VEMBER 12, 2020 TIME: 7:OOAM-11:OOAM PLACE: GILET E STAC'1-iH - PAk'KiSvG LOT PI PLEASE BE 1 i-RE, OR CI'_L 1 HE FCU.,)WING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE ......................................................................................................................................................... FOG PUMPERS, Town of MansfiE d BOH'Fats ' bits and Grease (FOG) Regulations Article 3, Sectioi 9: As of ,' ariu dig 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required I have a S ut�ch�OG i lauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the perm, application. PLEASE NOTE Onsite logs rust be kept at all locations recording the % Combined Solids and Grease when pumping occur r BOH :cords I acknowle Ige'fhat all pumpers will record th . % Combined Solids and Grease on the onsite logs. 2 All documents awskbe cnm• .4ed sinned and retuned to the Health Department with the appropriate payment. Checks can be r,ade p )yabl, to , ovs, of Mansfiel, l Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 0 '048. SIGNATURE -- DATE: _ _ D9 1A -4a) eq TAX'.CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have f,ied all state tax T turns and paid all state taxes required under law. L Sign, tore of Grid; vidual or Ce rpora:.e `; ame By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Fed,.Tal Identi.ication Number *Th;.s license will not be issu 2d unless this certification clause is signed by the applicant. ** Your social s.�curity number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payntent obligations. Licensees who fail to correct their non -filing or delinquenc - will he subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, sect ior149A, CAUse AsleitC\Ded,;i r,�,cotes Documents\Food Esle.olishments- Temp\TAX CERTIFICATION FORM.doc tree C'ommonweaten of mtassacnusens Department of Industrial Accidents _= Office of Investigations - 600 Washington Street = Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address:/ Fa s t " /7 S/-" ✓ City/State/Zip: V&--kP/ /( k - PA 911 c/ Phone #: 51� ? 69 tf /j' 171 eJ Are yoy an employer? Check the appropriate box: Business Type (required): 1. I am a employer with d + employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 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. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑Health Care 3. ❑ We are a non-profit organization, staffed by volunteers , with no employees. [No workers' comp. insurance req.] 12.E�Other Jc''J 1 � kny 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 corporation has other employees, a workers' compensation policy is required and such an ganization should check box # 1. am an employer that is providing workers' compensation insurance for my employee Below is the policy informallon. isurance Company Name: l IdU /'l J f w f zAlnLr le C- (yr /' d7 isurer's Address: 7U V / / ACL r� //) MU ice► , C/fi..>1, J I-L / TC _7-/—eyy ity/State/Zip: J lY t'14SOii (/1IIe FL • ?AA �1 !, v� /7 h Dlicy # or Self -ins. Lic. # IJ ,y o) 7 / A 7- Expiration Date: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Pup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify, under t to pains and penalties ofperjury that the information provided above 's true and correct. 11atr• - fo7At7/AdAb ionafin•P� 3'r-'�% _ hone #: 5-PS-- G -Tel' J-V.A U 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 www.mass.gov/dia Phone FOG Customers, Mansfield, MA Business Name Address 1 Hangar 12 265 Fruit St. Mansfield, MA 2'Mooyah Burger 321 School St. Unit #140 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY —INFORMATION PAGE INSURER: MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 JACKSONVILLE, FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: ALEC RICH (SEE NAMED INSURED ENDT) PO BOX 292 NORTON MA 02766-0292 LEGAL ENTITY: INDIVIDUAL POLICY NO: WCO2972T RENEWAL OF: WCO2972T NCCI Company No: 27103 Account No: CACO2972T AGENCY NAME AND ADDRESS: TAYLOR INSURANCE AGENCY 448 TURNPIKE STREET SOUTH EASTON, MA 02375 AGENCY PHONE NO.: (508) 230-2244 AGENCY NO.: 201040 OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POLICY PERIOD: From: 03-07-2020 To: 03-07-2021 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OR, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 316 Annual Premium: $ 1,189 Audit Period: ANNUAL Date: 01-28-2020 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance INSURED COPY