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HomeMy WebLinkAboutLifecycle Renewables - 12/31/2021Towh ofnsfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application "I1 DATE: f LICENSE NUMBER: BUSINESS NAME: (—'-t'C..0 C_I�. ��(le-�'s 1� MAIL ADDRESS: TOWN: V' 1 a i FlUSTATE: i n rh ZIP CODE: �, 8 NAME OF OWNER: CELL;y FAX: BUSINESS TELEPHONE: s& �i4p1-g4i31���Ld�S EMAIL: �� (t C�C(2YZYKwublkS Cdlri FED IDlSS NO:,ap- j33Lt0 q j ALT EMAIL: 5R.rV Ca � f F� [yC'leYen�tei ,b[15 c_nm FEE PER TRUCK: $100 NUMBER OF TRUCK(S): F [� O Truck Registration number: Circle one: Septage FO Truck Registration number: Circle one: Septage Truck Registration number: Circle one: Septage G Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG SEPTAGE PUMPERS: 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: 7:00AM-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 SOH 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 -7cu s 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: lr ©� 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. Signature of hidividual or Corporate Name 0 to- r� 33 gP141 "Social Security No. (Voluntary) or Federal Identification Number By: pora e 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:\Iicciv`,zleite\DedktoplSentt's Doeuirmts'.Food Establishments. Temp'.TAX CERTIFICATION FORMAm �\ 111C livessrrvrsrvcaeue s!t IrI K.rAuuaN.]GLEJ 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 Name: Address: ni-`5 yL,l-9'?,3 Are ypu an employer? Check the appropriate box: Business Type (required): 1. ,l I am a employer with /7 employees (full and,' S. ❑ Retail or part-time).* 6. ❑R.estaurant/Bar/F.atingEstablishn,cnt 2. ❑ I am a sole proprietor or partnership and have no Z ❑ Office and/or Sales (incl. real estate, auto, ctc.) employers working for me in any capacity. [No workers' comp, insurance required] $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §t (4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11 ❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, l2. //��Other PzeL CIt ✓1 with no employees. [No workers' comp. insurance req.] Any applicant that checks box 01 must also fill out the section below showing their wurkely' cumpmisntinn policy information. *If the eottauute oll9cets flaw exempted themselves, but the corporation bas other employees, a workers' cnmpeasation policy is required and ,such an rganizatlon sliould check box .fit. one an employer that Is providing workers' compensation insurance for my employees. Below is the policy information. nsurance C'nmpany Namc:� - I M LAUC'1 nsurer's Address:_F"• Cy ' tUtljh.,•- —I Li 'rV 'ity/State/Zip: Uk 'olicy A or Self -ins- Lic. # t urilZ- aOQ'PExpirathntDare: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 'ailurc to secure coverage as required tinder Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a inc 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 if up to S250.00 a day against (he violator. Be advised that a copy of this statement may be forwarded to the Office of nvestisations of the DIA for insurance coverage verification, under the pains and pen • ofperfaty that the information provided a de(Jryove is tt we and correct. i// 1 l/ i 1 T7are: 1 O !f I official use only. Do net write in this area, to he completed by city or town afficiaL City or Town: Issuing Authority (circle one): 1, Board of Ilealth 2. Building Dtpartment 6. Other Contact Person: Permit/License 3. City/'town Clerk 4. Licensing Board 5. Selectmen's Office www.maes.gov/din Phone Lifecycle Renewables Inc ' X Insured Agent t Sub -Broker �— Paperless HUB International New England LLC PO Box 696 Wilmington, MA 01887 01005-001 WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 HUB International New England LLC PO Box 696 Wilmington, MA 01887 Lifecycle Renewables Inc P O Box1144 Marblehead, MA 01945 F Insured: 8007701 Lifecycle Henewables Inc P O Box1144 Marblehead, MA 01945 A.I.M. Mutual Insurance Company Producer; 01005.001.001 HUB International New England LLC PO Box 696 Wilmington, MA 01887 Insured FEIN: '-'"'4041 Issue Date: 06/3012020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 Policy Period: 05101 /2020 - 05/01 /2021 Endorsement Number: 1 AMENDMENT OF INFORMATION PAGE Experience Modification and ARAP Endorsement amended release date/no premium change Change in Premium: $0 Nothing herein contained shall waive; alter, or extend any condition or Provision of the policy other than as above stated. Countersigned by �7-- c MISC (07111) A.I.M. Mutual Insurance Company Insured: 8007701 Producer: 01005-001.001 Lifecycle Renewables Inc HUB International New England LLC P O Box 1144 PO Box 696 Marblehead, MA 01945 Wilmington, MA 01887 Insured FEIN: ' `4041 Issue Date: 06/30/2020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: Policy Period: 05/01/2020 - 05/01/2021 Endorsement Number: 1 CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Policy Unit Name: Lifecycle Renewables Inc Classification Class Description Code No. GREASE OR OIL MIXING OR 4557 DRIVERS, CHAUFFEURS AND THEIR 7380 CLERICAL OFFICE EMPLOYEES NOC 8810 05/01/2020 Unit State Code: MA Billing Plan: 25 % Down & 9 Monthly Payments Payroll Rate Estimated Amount Per $100 Premium 69,000 1.69 1,097 549,170 5.96 32,731 780,074 0.07 546 Manual Premium 34,374 Rate Deviation 10.00°% (3,438) Deviated Premium 30,936 Excess Employers Liability 2.00% 619 Premium Subject to Exp Mod 31,555 Experience Mod 0.84 (5,049) Standard Premium 26,506 ARAP Charge 1.00 0 Premium Discount 6.6% (1,749) Expense Constant 338 Terrorism Act Surcharge 419 Total Estimated Premium 25,514 DIA ASSESSMENT 3.510% 1,013 Total Estimated Premium & Surcharge(s) 26,527 GlassCode&h (04111) A.I.M. Mutual Insurance Company Insured: 8007701 Producer: 01005-001.001 Lifecycle Renewables Inc HUB International New England LLC P 0 Box 1144 PC Box 696 Marblehead, MA 01945 Wilmington, MA 01887 Insured FEIN: "-""4041 Issue Date: 06/30/2020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 Policy Period: 05/01/2020 - 05/01/2021 Endorsement Number: 1 CLASSIFICATION CODE SCHEDULE Policy Unit: 002 Unit State Code: NH Policy Unit Name: Lifecycle Renewables Inc Billing Plan: 25 ! Dawn & 9 Monthly Payments Classification Class Payroll Rate Estimated Description Code No. Amount Per $100 Premium DRIVERS, CHAUFFEURS AND THEIR 7380 87,706 4.79 4,201 Manual Premium 4,201 Excess Employers Liability 1.100/. 46 Subject Premium 4,247 Experience Mod 0.84 (680) Standard Premium 3,567 Premium Discount 6.6% (235) Terrorism Act Surcharge 5 Catastrophe Act 10 Total Estimated Premium 3,347 GlassGodeSch (04.1111 A.I.M. Mutual Insurance Company Insured: 8007701 Producer: 01005-001-001 Lifecycle Renewables [no HUB International New England LLC P O Box 1144 PO Box 696 Marblehead, MA 01945 Wilmington, MA 01887 Insured FEIN: ' **'4041 Issue Date: 06/30/2020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 Policy Period: 05/01/2020 - 05/01/2021 Endorsement Number: 1 CLASSIFICATION CODE SCHEDULE Policy Unit: 003 Unit State Code: CT Policy Unit Name: Lifecycle Renewables Inc Billing Plan: 25 % Down & 9 Monthly Payments Classification Class Payroll Rate Estimated Description Code No. Amount Per $100 Premium INK MFG 4557 55,000 2.30 1,265 DRIVERS, CHAUFFEURS, 7380 75,000 7.75 5,813 Manual Premium 7,078 Excess Employers Liability 1.100/. 78 Subject Premium 7,156 Experience Mod 0.84 (1,145) Standard Premium 6,011 Premium Discount 6.6% (397) Terrorism Act Surcharge 38 Catastrophe Act 15 Total Estimated Premium 5.667 CT Second Injury Fund Assessment 128 CT Workers Compensation Assessment 130 Total Estimated Premium & Surcharge(s) 5,925 GlassCodeSoh(04/11) Insured: 8007701 Lifecycle Renewables Inc P 0 Box 1144 Marblehead, MA 01945 A.I.M. Mutual Insurance Company Producer: 01005-001-001 HUB International New England LLG PO Box 696 Wilmington, MA 01887 Insured FEIN: 262334041 Issue Date: 06/30/2020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 Policy Period: 05/01/2020 - 05/01/2021 Endorsement Number: 1 INSTALLMENT SCHEDULE Units Billed to this Unit,1,2,3 Policy Unit No: 001 Billing Plan: 25 %Down 8 9 Monthly Payments Policy Unit Name: Lifecycle Renewables Inc Installment/ DIA Total Amount Due Date Billed Endorsement No. Assessment Down Payment $318 $8,951 05/01/2020 Billed Installment 1 $106 $2,982 06/01/2020 Billed Installment 2 $100 $2,982 07/01/2020 Billed Installment 3 $106 $2,982 08/Dt/2020 Installment 4 $106 $2,982 09/01/2020 Installment 5 $106 $2,982 10/01/2020 Installment 6 $106 $2,982 11/01/2020 Installment? $106 $2,982 12/01/2020 Installment 8 $106 $2,962 01/01/2021 Installment 9 $105 $2,992 02/01/2021 Total $1,271 $35,799 Installment5ch (04/11) AJ.M. Mutual Insurance Company Insured: 8007701 Producer: D1005-001.001 Lifecycle Renewables Inc HUB International New England LLC P 0 Box 1144 PO Box 696 Marblehead, MA 01945 Wilmington, MA 01887 Insured FEIN: "--"4041 Issue Date: 06/30/2020 Policy Number: WMZ-800-8007701-2020A Endorsement Effective Date: 05/01/2020 Policy Period: 05101/2020 - 05,101/2021 Endorsement Number: 1 POLICY RATING SUMMARY BY STATE Connecticut Manual Premium 7,078 Excess Employers Liability 1.10% 78 Subject Premium 7,156 Experience Mod 0.84 (1,145) Standard Premium 6,011 Premium Discount 6.6% (397) Terrorism Act Surcharge 36 Catastrophe Act 15 Total Estimated Premium 5,667 CT Second Injury Fund Assessment 2.25% 128 CT Workers Compensation Assessment 130 Total Estimated Premium & Surcharge(s) 5,925 Massachusetts Manual Premium 34,374 Rate Deviation 10.00% (3,438) Deviated Premium 30,936 Excess Employers Liability 2,00% 619 Premium Subject to Exp Mod 31,555 Experience Mod 0.84 (5,049) Standard Premium 26,506 ARAP Charge 1.00 0 Premium Discount 6.6% (1,749) Expense Constant 338 Terrorism Act Surcharge 419 Total Estimated Premium 25,514 DIA ASSESSMENT 3.51 % 1,013 Total Estimated Premium & Surcharge(s) 26,527 RatingSum (01 it 2) MANSFIELD INSIDE GREASE TRAP CUSTOMERS 2020-21 GENO'S RESTAURANT COUSIN'S PIZZA & SUBS KYOTO JAPANESE STEAK HOUSE 409 N MAIN STREET MANSFIELD 660 EAST STREET MANSFIELD 242 CHAUNCY STREET MANSFIELD GREAT WOODS PIZZA 428 ELM STREET MANSFIELD