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Home My WebLink AboutDrain Shooter, Inc. - 12/31/12021c�v BUSINESS NAME: J) f (,j ) }ri 5f � c MAIL ADDRESS:TOWN: }�NY UOt�Q'Cola,nshlSTATE: ,r NAME OF OWNER: 0i 0q a)� BUSINESS TELEPHONE: �� 70171 CELL: EMAIL: J�!��01`•1.�i c�(�lt�'.� FED IDTSS NO: o - � t f3o jc8U ALT EMAIL: FEE PER TRUCK: $100 NUMBER OF TRUCK(S).._I . Truck Registration nurnber: 0 _ Truck Registration nurnber: Truck Registration nurnber. Truck Registration nurnber: Truck Registration nurnber: --...... ._-• -------------. _. ... .._... _....- ZIP CODE: 03�8? FAX:`' S)-'6a�-Ss2b Circle one: Septage OG Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG SEPTAGE PUMPERS: 310 CMR 15,505 Equipment No person shall use equipment to remove or transport the contents of privies, cesspool, or septic tanks or other offerw�vt substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS, DATE: THURSDAY, NOVEMBER 12, 2020 TIME: I:OOAM-11:00AM PLACE: GILETTE STADIUM -PARKING LOT P10 PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 1366, IF YOU CAN NOT MAKE THIS DATE --------'---"-'------------..-....... ....--- .... ....... .............. 11 1---•-------------- - FOG PUMPERS: Town of Mansfield BOH f ats. Oils and Grease (FOG) Regulations Article 3, Section 9: As of Janaary 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. FEANOTE: Onsite logs, lust be kept at all locations recording the % Combined Solids and Grease when pumping or BOH records. cknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be cunipiated signed and returned In the Health Department with the appropriate payment. Checks can be made payabic to Town of ManSGetd. Mail to: Board of tfealth, Town of Mansfield, Six Park Row, Mansfield, MA 02048, SIGNATURE: -�/ `yi 4441 1 L l 'L f DATE: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. f� , tureoflndi, d or Corpora I amo 04-3218018 **SocialSecuritti \o.(Voluntary)o Federal Identification N trmb tr Donna Doody By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. 'Your social iecurity number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. I,icensces who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is inade under the authority of Massachusetts General Law Chapter 62C'., ection 49A. C:\Usels\sIwt6De61.4,p"=MCS 6xlumnentsWood I.stahhahmenm-temp%I Ax CFk In ICA'[ION MRMAw ........................ -- Department of Industrial Accidents Offiee of Investigations 600 Washington Street Boston, MA 02111 www.macs.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lezibly Business/Organization Name: -Drain Shooter, INc Address: 2 Columbia Road City/State/7,ip: Pembroke, MA 02359 Phone #: 781-331-0171 Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail 1.❑✓ 1 am a employer with 6 employees (full and or part-time).* 6. ❑ Restaurmutllaril acing l istahlishment In I ant a sole proprietor or partnership and have no 7, ❑ 01 rice anth-or Sales (hacl. real estate, auto, etc.) employees working for me hl any capacity. 8. ❑Non-profit 3.❑ INo workers' comp. insurance required 1 We are a corporation and its officers have exercised y. ❑ 1',ntcrtainment their right of exemption per c. 152, § 1(4), and we have I0,❑ Manulacturing 4,❑ no employees. [No workers' comp. insurance required]' We are a non-profit organization, staffed by volunteers, 1 L❑ health (,are 12 ❑ (other with no employees. [No workers' comp_ ittsmance 'Arty applicant flee checks box#1 most also fill out the section below showing their workers' compensation policy information. '*If the eorporste officers have exempted tlrcniselves, but the corporation has other employees, a workers' compensation policy is required and such an xgatuminn should check box #1. ram an employer that is providing workers' compensation insurance for my employees Below is the policy information. nwrance Company Name: Berkshire Hathaway usurers Address: 16 South River Street �ity/Staie17ip: Wilker Barr, PA 18703 'olicy # or ScIF ns. Lic. # DRWC101869 — Expiration Uate 06/22/2021 Vlach a copy of the workers' compensation policy declaration pate (showing the policy number and expiration date). �ailme to secure coverage as required under Section 25A of M(d c. 152 can lead to the imposition of criminal penalties of a ine up to $1,500.00 and/or oue,ycar imprisonment, as well as civilpenalties in the form of a STOPWORK OW ER and a fine )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigatiow of the DIA for insurancc ._overage verification. 'do hereby ce under the pains aylrl Mathes perjury• that the information provided above is free and correct 11/30/2020 'hone #_781-331-0171 �icial use only. Do not write in this area, to be completed Av city or town offieiaL City or Town: Permit/License Issuing Authority (circle one): l: Board of Health 2. Banding Velrartment 3. Cityfl'own Clerk 4. Liccusing Board 5. Scleclmeu's Office 6. Other Contact Person: Phone N'ww mati�.t+.ol; dla T 0 A�i D CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 11/12/2020 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(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 CONTACT Nancy Burns NAME: Cleary Insurance Inc PHONE (617) 723-0700 FAX (617) 723-7275 A C No Ext • AIC Na 226 Causeway Street E-MAIL nburns@clearyinsurance.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC/I Suite 302 INSURERA: Ohio Security Insurance Company 24082 Boston MA 02114-2155 INSURED INSURER B: Netherlands Insurance Company 24171 INSURER C: Ohio Casualty Insurance Company 24074 Drain Shooter, Inc. INSURER D: NorGUARD Insurance Company 31470 2 Columbia Road, Unit 10 INSURER E : INSURER F: Pembroke MA 02359 COVERAGES CERTIFICATE NUMBER: 2020 Master REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE AUULbUaK INSD VIVO POLICYNUMBER POLICY EFF MM/DDIYYYY POLICY UP MMIDD LIMITS A x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE x OCCUR Products & Completed BKS55691829 11/14/2020 11/14/2021 EACH OCCURRENCE $ 1,000,000 'b HLNI cU PREMISES Ea occurrence $ 300,000 x MED UP (Any one person) $ 15,000 Operations PERSONAL &ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY X JEPROCT LOC OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 2,000,000 $ g AUTOMOBILE LIABILITY ANYAUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED v NON -OWNED AUTOS ONLY X AUTOS ONLY BAA56691829 11/14/2020 11/14/2021 COMBINED SINGLE LIMIT Ea accitlenl $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ X PROPERTY DAMAGE Per accident $ $ C X UMBRELLA LIAB EXCESSLIIAB v X OCCUR CLAIMS -MADE US055691829 11/14/2020 11/14/2021 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENTION $ 10,000 $ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRETOB/PACLUDEEXECUTIVE (MandatoryOFFICERIMIn NH) EXCLUDED? (f yes,d scru NH) Dyes,RIPTION under DESCRIPTION OF OPERATIONS below NIA DRWC101869 06/22/2020 06/22/2021 X PER EORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be a(tached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield -Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE ) Mansfield MA 02048 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD