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Home My WebLink AboutPump Grump - 12/31/2021Town of'Mansfield - Board of Health opyf �- £NASA, Town bfansfield 6 Park Row Mansfield, MA 02b�i8 Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSiNEPS NAME: %�t! Y11 (—r Ulm i MAIL ADt,RESS:TOW'FSTATE: �1� ZIPCODE: NAME OF OWNER: I)`r G SIC I1' BUSINES , TELEPI'7M c: 5-1) k •- 6 / �' �),R/ CELL: FAX: EMAIL: 1G>°✓CQ f9L-e , %)d 1,1-p e GO69'1 CC1,�T• lZG74 FED ID/St NO: 0 - f 3-33 Y- —1 ALT EMAIL: FEE PER :-RUCK: $100 NUMBER OF TRUCK(S): % Truck Reg;strati<,n nu nbrr; i I O Circle one Septage OG Truck Reg'stratiun m,ml er: _ Circle one. Sep age FOG Truck Reg strati.in r vaber; Circle one: Septage FOG Truck Registration c,2rnber: _ Circle one: Septage FOG Truck Rey'stration number: _ _ Circle one: Septage FOG ...................... .... :.................... . _ _ ............................................................................................................. SEPTAGE PUN �ERSf 310 CMR 15.50, Equipme,d: hs person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or c her offem e auastaoces unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPF CTIONS: DLTE: THURSDAY, NC VEMBER 12, 2020 TIME: 7:00AM-11:00AM PLACE: GILET 'E'STADIUM PARKING LOT P1 J PLEASE BE TH' RE{ OR CAL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE .......................................................................................................................................................................... FOG PUMPERS Town of Mansfie J BOP Fatr, Oi', accGrease (F( G) Regulations Article 3, Sectior 9: As of Je.w iry ':: 19, all Sep is/FOG Hauler trucks that service systems in the Town of Mansfield will be required 1 , have a S-ptio/F( iacler Perry it. Septic/FOG Haulers must provide a list of all FOG customers as part of the pern t applicatic, PLEASE NOTE: Onsite logs n drr: b•, a at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pun:ders will record the % Combined Solids and Grease on the onsite logs. All documents m st be con doted dgn,O and to the Health Department with the appropriate payment. Checks can be made payaL e to o,.;, of Mnnsfiel.+ Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA C 1048. SIGNATURE DATE: TAX CERTIFICATION FORM I ce tify 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 lii-'ividuai or Corporate I'\ ame By: Corporate Officer (Mandatony if Applicable) d 3J. �b_/ **Social Security No. (Vohottary) or Federal Identification Nutnher *T?ds liceri6e will rot.bt� issued unless this certification clause is signed by 4 he applicant. ** Your social s,z urity 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:\User; sleite\DeskWr,\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ine uommonweattn ofmassacitusens - Department of Industrial Accidents _ — Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: aw& Fas� Hew, /lsl�. ✓ City/State/Zip: Vd 1-761 Hd - d0/ 911 CP Phone M Jr1)' ? A � 5 71 eJ Are yog an employer? Check then appropriate box: Business Type (required): 1. I 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] 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]* I LM Health Care I. ❑ We are a non-profit organization, staffed by volunteers, / with no employees. [No workers' comp. insurance req.] 12.� Other Sam J 1 C. 1ny 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 ganization should check box #1. am an employer that Is providing workers' compensation insurance for my employeeA Below is the policy information. isurance Company Name: f I U l7 J f iw t /-tt-YIGY /C' C- (yr r ip /7vei:�, je/ci tsurer's Address:__ "ZU U / / f/ 6t /,� o 1TJ/f , Clf) % J tL / %C _7 lGG ity/State/Zip: .J d-eitsOii /7 ,��j / le r� FL. e?A A 'Y� p7 h �j alicy # or Self -ins. Lie. # Vtf 6 t/ A V / A T Expiration Date: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Fup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify, under �t✓. a pains and penalties of perjury that the information provided nbov/e/)'slt�rue7anti co�rjrecR// y ionahrre� .• "- •'�.'�-'�% '� Data. I 0 / OJ 171 / !/ I Pam% /9 hone #: '5 to 0 ' � Ii/7 - J-VIA 0 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 www.mass.gov/dia Phone WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY —INFORMATION PAGE INSURER: MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 JACKSONVILLE, FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: ALEC RICH (SEE NAMED INSURED ENDT) NORTON MA 02766-0292 LEGAL ENTITY: INDIVIDUAL POLICY NO: WCO2972T RENEWAL OF: WCO2972T NCCI Company No: 27103 Account No: CACO2972T AGENCY NAME AND ADDRESS: TAYLOR INSURANCE AGENCY 448 TURNPIKE STREET SOUTH EASTON, MA 02375 AGENCY PHONE NO.: (508) 230-2244 AGENCY NO.: 201040 OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POLICY PERIOD: From: 03-07-2020 To: 03-07-2021 Effective 12:01 A.M. Standard Time at the Insured's mailing address. REM 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: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 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. ITEM 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: $ 316 Audit Period: ANNUAL Date: 01-28-2020 WC 00 00 01 A Annual Premium: $ 1,189 Countersigned by Copyright 1887 National Council on Compensation Insurance INSURED COPY