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HomeMy WebLinkAboutJ. Hockman, Inc. - 12/31/2021c�� Town of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME: MAIL ADDRESS: TOWN: STATE: NAME OF OWNER: �' 504e- /y Y BUSINESS TELEPHONE: -6l P- ?, S ✓ / yl�p CELL: EMAIL: �-A &f'u s7 ,Lvd2 q of cpCi ,C Mr FED ID/SS NO: p j/5�d� V AALT EMAIL: FEE PER TRUCK: $100 NUMBER OF TRUCK(S): Truck Registration number: J 3 " f " Truck Registration number: aQ Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: ZIP CODE: (2 -J. c u w Circle one: a to FOG Circle one: a ge 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: _L ._.. DATE: %O/hi s�'j �v CERTIFICATE OF LIABILITY INSURANCE DATE IMMIOD/1'YYY) 6/11/2020 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. 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 NAME: 4' Cheryl L. Hollis C.L. HOLLIS INSURANCE PHONE (508)295-9500 (ac NOI: (50e)295-9e99 A C N Eh. 190 Marion Rd �ADDRESS : cheryllee@insurehollis.Com _.. Wareham INSURED J. Rockmart, Inc. 11 Sherwood Dr MA 02571 Insurance (Norfolk MA 02056 (INSURER F' COVERAGES CERTIFICATE NUMBER:CLI96301665 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLSUSR POLICYEFF I POUCYEXP LIMITS LTR TYPE OF INSURANCE POLICYNUMBER IMMIODNYYY1 MMIODIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TOR NTED PREMISES En occurrence $ 500, 000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 10,000 A CLAIMS -MADE rx] OCCUR 4PP6817N 6/22/2019 /22/2020 PERSONAL SADV INJURY $ 1,000,000 X XCU COVERAGE INCLUDED 6/22/2020 /22/2021 X CONTRACTUAL GENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 $ POLICY X PRO LOC JECAUTO MOBILE LIABILITY Ee a cdeDSINGLE LIMIT 1000 000 BODILY INJURY (Per person) $ A ANYAUTO BODILY INJURY (Peraaidenl) $ ALL OWNED SCHEDULED 1P6817N 6/22/2019 /22/2020 AUTOSAUTOS NON -OWNED M /22/2020 /22/2021 PROPERTY DAMAGE Peraocldent $ HIREDAUTOSAUTOS Medical Expense $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS UAB CLAIMS -MADE UP6017N 6/22/2019 /22/2020 A /22/2020 /22/2021 $ DED I X I RETENTION $ 10,00 A WORKERS COMPENSATION WCSTATU- X OEH- AND EMPLOYERS' LIABILITY YIN CP6817N /26/2019 /26/2020 E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PXCLUD (EXECUTIVE NIA E.L. DISEASE - EA EMPLOYEE $ 1,000,000 InN NH) (Mantlatory in NH) (Mandatory /26/2020 /26/2021 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D CONTRACTORS EQUIPMENT OSMSZS4727 6/22/2019 /22/2020 LEASEDNENTED MAX 200,000 /22/2020 /22/2021 LIABILITY..000RENCE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is mqulred) CERTIFICATE HOLDER CANCELLATION TOWN OF MANSFIELD 6 PARK ROW MANSFIELD, MA 02048 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 Hollis/CHERYL ACORD 25 (2010105) © 1988-2010 ACORD CORPORATION. All HE INS025 (20100S).D1 The ACORD name and Ionic, are reaistered marks of ACORD 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. Signature of Individual or Corporate Name ByBy: Corporate Officer (Mandatory, if Applicable) G/ '7 g 91 % z, G�C1 *"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\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc L tie t-ontinuniveattit of mussacitusetis Department of LrdustrialAccidents Office of Investigations Lafayette 007 Center 2 Avenue de Lafayette, Boston, MA 02111-1750 Ivivo v. inass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: J HOCKMAN INC 11 SHERWOOD DRIVE City/State/Zip: NORFOLK,MA 02056 Phone #: 508-384-1400 Are you an employer? Check the appropriate box: Business Type (required): 1. R I am a employer with 15 employees (fill and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp, insurance req.] 12.❑■ Other SEPTIC AND EXCAVATING *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonnatiou. **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 ain an employer that is providing morlrers' coiirpeasntion insurance far my employees. Below is the policy inforination. Insurance Company Name: HOLLIS INSURANCE AGENCY Insurer's Address: 140 MARION ROAD City/State/Zip: WAREHAM, MA 02571 Policy # or Self -ins. Lie. #WCP6817N Expiration Date:06/22/2021 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 tine 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 certif , under the pains and penalties of perjury that the inforuratiorr provided above is true and correct. 11 /1 /2020 Ewe Official use only. Do itot write in this tn•ea, to be completed by citp or town official. City or Town: Permit/License # Issuing Authority (check one): I.❑Board of Health 2.171Building Deparbuent 3.❑ City/Town Clerk 4. ❑Licensing Board 5.❑Selectmen's Office 6.❑Other Contact Person Phone #: WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY — INFORMATION PAGE INSURER: NGN INSURANCE 4601 TOUCHTON SUITE 3400 JACKSONVILLE, COMPANY ROAD EAST FL 32245-6000 REM 1. NAMED INSURED AND MAILING ADDRESS: J ROCK14AN INC C/O C.L. HOLLIS INSURANCE 140 MARION RD WAREHAM MA 02571-1460 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: I POLICY NO: RENEWAL OF: NCCI Company No: Account No: WiP6817N W1P6817N 16322 CACP6817N AGENCY NAME AND ADDRESS: CL HOLLIS INSURANCE 140 MARION ROAD WAREHAM, MA 02571 AGENCY PHONE NO.: (508) 295-9500 AGENCY NO.: 201423 (See Workers Compensation Location Schedule) ITEM 2. POLICY PERIOD: From: 06-26-2020 To: 06-26-2021 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: $ 1,000,000 each accident Bodily Injury by Disease: $ 1,000,000 policy limit Bodily Injury by Disease: $ 11000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OH, 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. REM 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: $ 341 Annual Premium: $ Audit Period: ANNUAL Date: 05-18-2020 Countersigned by WC 00 0001 A Copyright 1987 Negoml Council on compensagon Insurance INSURED COPY