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Home My WebLink AboutMiles of Excavating - 12/31/2021—____ -j:± 1 �u k() _ (o',G� LICENSE NUMBER: BUSINESS NAME: /"//eS r MAIL ADDRESS: TOWN: aG/z 57 STATE: 21P CODE: Chow 73 NAME OF OWNER, l /M je o1Il0 L c__) r4Z <� BUSINESS TELEPHONE: ��C�/ JO `1 7�0 CELL�Og -7d6'V%� S EMAIL:/q�p5&Iel CL'tCYC�t �Oc a/ t�•e0� FED ID/SS NO: jyJJ_O 0 / ALT EMAIL: FEE PER TRUCK: $100 NUMBER OF TRUCK(S): I Truck Registration number: Circle one: Septa FOG Truck Registration number: Circle one: ep age 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 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: 1 DATE: �' i 3' Mll F0FF-n1 CWOODSIDE CERTIFICATE OF LIABILITY INSURANCE DATEs/2a/2o2o24/2020 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 INSURANCEfDOES 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 endorsements . PRODUCER License 111780862 HUB International New England 600 Lonwater Norwell, M02061-9146 Drive Michelle Wolf 50AMPOT PAH/c Nq E# : (508) 888-2183 FAX No): Edo i`ss, michelle.wolf@hubinternatlonal.com INSURERS) AFFORDING COVERAGE NAICIf INSURERA: LIbe Mutual 23043 INSURED Miles of Excavating Timothy Konowitz dba 242 Park Street Wrentham, MA 02093 INSURERS: Commerce Insurance Company 34754 IusuRER c: Wesco Insurance Com an 25011 INSURER°: Acadia Insurance Company 31326 INSURER E INSURER F: ER• REVISION NUMBER: COVERAGES CERTIFICATE NUMB 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 TYPE OF INSURANCE ADDLSUBR p POLICY NUMBER POLICY EPF 00 2127/2020 POLICY EXP 212712021 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMSMAOE OCCUR X 8KS58621919 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED E aoccu e 300,000P $ MED EXP (Any one peraml $ 15,000 PERSONAL &ADV INJURY 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY moo D LOC GENERAL AGGREGATE 2,000,000 PRODUCTS-COMPIOP AGO $ 2,000,000 B OTHER: AUTOMOBILE LIABILITY C MBIN -SINGLE LIMIT $ 1,000'000 BOo1LV INJURV Per arson $ ANY AUTO BHDLXX 2127/2020 212712021 BODILY INJURY Per accident S OWNS SCHEDULED ONLY X AO X Z SNNLY XMOPS OBaiCdieAMAGE S UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS UAS CLAIMS -MADE DED I I RETENTION$ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PRROR//PRIIETOERRIPARTNERIEXECUTIVE IMand.rM In NH) EXCLUDED? If yes, daterlba under DE CRIPTION OF OPERATIONS below Equipment Floater ( OTH- PER II E �ER C D NIA WWC3427626 CIMS140595 812312020 212712020 8123/2021 212712021 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE 500,000 $ E.L. DISEASE- POLICY LIMIT rental $ 500,000 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 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 I ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD TAX CERTIFICATION FORM 0.' . 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 b �/ ,3!ysx�o 7-- **Social Security No. (Volunta j) or Federal Identification Number By: Corporate 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:\Oserslsleite\Desktop\Scotfs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents l Office of Investigations Lafayette City Center 2Avenue de Lafayette, Boston, MA 02111-1750 M t www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le0biy Business/Organization Name: Miles of Excavating Address:242 Park St. City/State/Zip: Wrentham, Ma 02093 Phone #: 508-384-9590 Are you an employer? Check the appropriate box: Business Type (required): 1. Q I am a employer with 4 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 (met. 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. ❑ Manufacturing no employees. [No workers' comp. insurance required]** 11. Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **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: Wesco Insurance Insurer's Address:800 Superior Avenue City/State/Zip: Cleveland, OH 44144 Policy # or Self -ins. Lic. #WWC3427526 Expiration Date:8/23/2021 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. t 52 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 certify, under"t-he pain penalties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (check one): L❑Board of Health 2.❑ Building Department 5❑Selectmen's Office 6.❑Other Permit/License # 3.❑ City/Town Clerk 4.❑Licensing Board Contact www.mass.gov/dia Phone