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HomeMy WebLinkAboutFlowmaster Corp. - 12/31/2021-;;�. 7M log Torun ®f I rrnsIielyd - Boar d ®j'Hea th wn of Mansfield "Y 'ark Row nsfield, MryA 02048 SeptagelFOG Haiders Alyficatior2 DATE: (21(T$1cid."6 LICENSE NUMBER: 2-( f BUSINESS NAME: T 1OIliMU"S�'� , , Copp ® l41 6ed�d sleeer / MAIL ADDRESS: TOWN: (Y1jp�i�GWk0 STATE: MA ZIP CODE:oc*n 4G NAME OF OWNER: mft j.K f}L't99e/4r,J BUSINESS TELEPHONE: 5 0 S, q�q& $4 (, CELL: FAX: S6T/ oPR7 A06 EMAIL: JeAre IIIO'C'R4%r*Q-S"C•C0K FED ID/SS NO: Gy 533 (Roo ALT EMAIL: FEE PER TRUCK: $100 Truck Registration number: L(oo-` a 9 Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: NUMBER OF TRUCK(S): Circle one: Se tag FOG Circle one: -Septage 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-11:00AM 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: 1 1926-20- 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. �j-��w�e Cv�P• Signa reof Indiv or Corporate Name G� 33 WL **Social Security No. (Voluntary) or Federal Identification Number BLCoEWde 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:\UsersWeite\Desktop\.Scotfs DocumentsWood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts Department oflndustrial Accidents - ; Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: rWW3tr: Ent:ipmerti Co. Address: 920 Was'a ngton Street City/State/Zip: Phone Are you an employer? Check Pe appropriate box: Business Type (required): I.XI am a employer with 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] g• []Non-profit 3.0 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 I Ln Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12, Other (VX_9L *Any applicant that checks box #1 must also fill out the section below showing their workers' compensanon policy mtormatwn. **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 workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:, Insurer's City/State/Zip: Policy # or Self -ins. Lie. #_ Expiration 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 e ify er the pains and penalties ofperjury that the information provided above is true and correct Si nature: r Date: Phone 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 Person: Phone #: www.nrass.gov/dia ACORO" ARACO-1 `-.-� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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 ri hts to the certificate holder in lieu PRODUCER of such end.orsements 508-543-1067 c TACT I.E.D. Insurance &Financial Katherine Dustin MA 020 Dustin Drain Service Inc THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE OR 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 PAIn r`I Alanc COMMERCIAL GENERAL LIABILITY CUMMS-MADE a OCCUR GEN'L AGGREGATE LIMIT APPLIES PER, X POLICY ❑ P LPi ❑ L, OC T E AUTOMOBILE LIABILITY IANY AUTO AUTOS ONLY X SCHEDULED I NE AUpTN�.1OppS LED AUTOS ONLY X AUTOS ONLY UMBRELLA LIAR [ X I OCCUR EXCESS LIAB f—'—I CLAIMS -MADE ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OpFICER/MEMBEqq EXCLUDED? � ry (Mandatory In NH) 0068 06/27/2020106/27/2021 04/23/2021 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101. AddHlonal Remarks Saheduls, may ba adaehsd it mare apace Is raqul.d) Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 WORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD