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HomeMy WebLinkAboutDrain Remedy, Inc. - 12/31/2021I 0 ( 5D- (0 of Town of Mansfield - Board of Health u Town of Ma sf eI`df:r 8"Park Row Ikrld,MA o2048 ,SeptagelFOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME: ; Ott �j (: YIMe t( �rHc MAIL ADDRESS: TOWN:LAG \Y j.rC_iiUtic C�x���le.�. ZIP CODE: �ici NAME OF OWNER: b.,�-�t BUSINESS TELEPHONE: 6: L, CELL: AX: EMAIL: 0 t"�'l v1 TT � xYIE„� �,iy �� ' a'Y1eS-tS�',CiC,% o FED IDtSS NO: ----- ALT EMAIL: I. - FEE PER TRUCE :,_$j �.? NUMBER OF TRUCK(S): Truck Registration number: _� ;�j 4?�J Circle one: Septage ) FOG Truck Registration number: Circle one: Sep a FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG SEPTAGE PUMPERS: 310 EMR 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. kL_ 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: 2 _ __ DATE: / �f 3 n5&-) 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. n � acre 1-'cafU �— Signature of Individual or Corivrate Name By: Corporate Officer (Mandatory, if Applicable) 01t- 3(6 co 1\ C) "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:\Usem\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc l ILG I. UI/L ULVILYVL'KLL/L Vf lYf KJJKlAL11JGLl.I Department of Industrial Accidents i� Office of Investigations ic. Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 �a www.rttass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel=_ibly Name (Business/Organization/Individual): Drain Remedy, Inc. 46 Pearl Street Brockton, MA 02301 Phone Are you an employer? Check the appropriate box: 1. am a employer with 14 4. ❑ I am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' comp. insurance.$ [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 L❑ Plumbing repairs or additions 12.❑ Roof repairs IAM OtherDrain Cleaning *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number, I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: The Hartford Policy # or Self -ins. Lie. #:8D809778 Job Site Expiration Date:1012212021 City/State/Zip: 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 certi/fyy tinder tthheep�,ains and penalties ofperjury that the information provided iabov ijs t-r�ue and correct Ph..nP il.Gl rlr,� ii��"� C7 �r Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (check one): 101loard of Health 20 Building Department Inspector 6.00ther Contact Permit/License 300ty/Town Clerk 4.❑Electrical Inspector 5❑ lumbing Phone A� " CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDYYVV) 12/24/2020 - 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 Eastern Insurance Group, LLC. 233 West Central Street Natick MA 01760 CONTACT NAME: Katie Pacione PHONE FAX c o t); 800-333-7234 ac Na:76t-586-8244 ADDRESS: kpacione@easterninsurance.com INSURER(S) AFFORDING COVERAGE NAIC# _ _ INSURERA: Evanston Insurance Company 35378 _ INSURED 39835 INSURER B : Drain Remedy Inc 46 Pearl Street INSURER C: Brockton MA 02301 INSURER D: E: _INSURER INSURER F: COVERAGES CERTIFICATE NUMBER: 2009565315 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. ILTR TYPE OF INSURANCE ADS [SU —BR=0 POLICY NUMBER MMIDDV/YYVY MM/DDEFF Y EXP /YYYY LIMITS A X COMMERCIAL GENERALLIABILITY MKLVl PRC000804 2/13/2020 2/13/2021 EACH OCCURRENCE $1,000,000 _ CLAIMS -MADE 1K OCCUR AGE TO RENTE PREMISES JEa occu ante $100,000 MED EXP (Anyone person) $ 5,000 PERSONAL& ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL $2,000,000 -AGGREGATE PRODUCTS -COMPIOP AGG $2,000,000 X PHI- POLICY PRO- JECT❑ LOG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY(Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY H AUTOS ONLY BODILY INJURY(Peraccident) $ PROPERTY DAMAGE Per accident $ _, A X UMBRELLALIAB X OCCUR MKLVlEUL102260 2/13/2020 2/13/2021 EACH OCCURRENCE $5,00,000 AGGREGATE $5,000,000 EXCESS LIAR CLAIMS MADE DED I I RETENTION$ $ WORKERS COMPENSATION ANO EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE PER 0TH- STATUTE ER E.L. EACH ACCIDENT $ EL.DISEASE-EA EMPLOYEE $ OFFICERIMEMBEREXCLUDED7 ❑ (Mandatory in NH) NIA _ E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) PLUMBING, SEWER AND DRAIN CLEANING. rctar¢tn ATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ,ate J?a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIOO YYYY) 12/07/2020 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 pollcy(ies) must 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 ATLANTIC INSURANCE GROUP AGENCY INC CONTACT NAME: Lori McLoughlin _ P"�" o ,. (s17) sss-zzoo ac Not E-MAIL lori atlantic uotes.com ADDRESS: @ q INSURER S AFFORDING COVERAGE NAIC p 245 Willard Street Suite 200 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 Ouinc MA_02169 INSURED INSURER 8: INSURERC: DRAIN REMEDY INC INSURER D : INSURER E : PO BOX 674 INSURER F: STOUGHTON MA 02072 r:nVFRAr:FC CERTIFICATE NUMBER: 602368 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. IN TYPE OFINSURANCE ADbL SUBR POLICY NUMBER POLICY— MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE1:1 OCCUR DAMAGE TO RENT D PREMISES Ea occurcence $ MED EXP (Any one person) $ _ PERSONAL B ADV INJURY $ N/A GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ JECT D LOC PRODUCTS-COMPIOP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident)_ $ BODILY INJURY(Per parson) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N/A -- PPRQPPERdTYOAMAGE $ --- UMBRELLALIAS OCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LIAB CLAJMS-MADE N/A OED TFRETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) N/A NIA 6S60U68D80977820 10/22/2020 10/22/2021 �/ X STATUTE ERH AC AACCIOENT E.L. EACH " $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees Only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.moss.gov/lwd/workers-compensation/investigations/. nre .n nee CANCFI.I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF MANSFIELD 6 PARK ROW AUTHORIZED REPRESENTATIVE I MANSFIELD MA 02048- Daniel M. Croy, CPCU, Vice President -Residual Market-WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD