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HomeMy WebLinkAboutSoares Sanitation Pumping, Inc. - 12/31/2021136't � _ � p0, MAIL ADDRESS: TOWN:,;&s y)ros v NAME OF OWNER:1206Ar4- 3 p0.reS BUSINESS TELEPHONE: 50% 8 a4 $370 S" STATE: MP- ZIP CODE: oal8v CELL: EMAIL: eS,S►C0.@800XeS9UMPI119.COM FED ID/SS NO: 0+-A94-) ) Oa FEE PER TRUCK: $100 Truck Registration number: 3M(:6b04$ Truck Registration number: Truck Registration number: (�_,,,,,,,,,,,,�F,,SS Truck Registration number: o2`i99 Truck Registration number: SEPTA GE PUMPERS: FAx:So9 8a494Q5 ALTEMAIL: SaAe$(9gcarespump)ng,COM NUMBER OF TRUCK(S): `{' Circle one: a to a FOG Circle one: Se tag FOG Circle one: toFQO 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 Me field. Mail to: Bo } d of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. >7 SIGNATURE: DATE: 10 1 a9 l a 0g O 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. r Soo res 'Son 1�0.AloC1.g�u��&�� . L -W Ar Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0'+-294 710;L "Social Security No. (Voluntanj) 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:\Uscrs\sleite\Desktop\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts 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 N 5' a.n i ao_i ion Po rri Address: (R2lS hras�2 aree-4- City/State/ZipTaunkon 11'1 A oangu Phone #: 50 a %a`+ %3)l0 mac, Are you an employer? Check the appropriate box: Business Type (required): 1.;Z 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 (inel. real estate, auto, etc.) employees working for me; in any capacity. [No workers' comp. insurance required] 8. Ej 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 100 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I Ln Health Care with no employees. [No workers' comp. insurance req.] 12. Other g}r tPy tC 110-Cl lef *Any applicant that checks box #] 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 Insurer's M City/State/Zip: &0,ll 1 O `� A e, WC a t.;n 1 Policy # or Self -ins. Lie. # WC '`j0$ ] 0"1 `f' Expiration Date: b (l9 1 a 1 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 Investieations of the DIA for insurance.eoveraee verification. I do hereby CertiKj? the ains alpenalties ofpetiry that the information provided above is true and correct. Phone #: :508 8a`i $370 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www,mass.gov/dia SOARSAN-02 PAMARAL s►coRO" CERTIFICATE OF LIABILITY INSURANCE `.--� D 10129/2020 Y) 10/29/2020 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. 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 # 1780862 CONTACT Megan Bodyul NAME: PHONE FAz (A/C, No, Est): (508 ) 235.2231 _ _ __(A /c, No): aDt€ss: megan.bodyul@hubinternational.com HUB International New England 222 Milliken Boulevard Fall River, MA 02721 INSURER 3 AFFORDING COVERAGE NAIC If INSURER A: Selective Insurance Company of South Carolina 19259 INSURED INSURER B: Selective of the Southeast 39926 INSURERC:lronshore Specialty Company 25445 Soares Sanitation Pumping, Inc. INSURER D: 285 Thrasher Street Taunton, MA 02780 ----- INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. ILT R TYPE OF INSURANCE DDLSUBR INSDA WVD POLICY NUMBER POLICY EFF POLICY M DD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR S2190987 1/1/2020 111/202, DAMAGE TO RENTED PREMISES IEa..u1mm;p)_ 500,000 $ — MED EXP (k4,y one person)_,_ _j 15,000 PERSONAL &ADV INJURY $ 1,000,000 AGGRE�GATE LIMIT APPLIES PER: POLICY I "J jEo ❑X LOG GENERAL AGGREGATE $ 3,000,000 GENL PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea sccidggt) 1,000,000 $ __. ANY AUTO A9100369 1/1/2020 111/2021 BODILYINJURY Per erson,_.$ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY Per accident)_ $ „ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY P01EERtlTn DAMAGE $ _ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 EXCESS LIAB CLAIMS -MADE S2190987 1/1/2020 1/1/2021 DED RETENTION$ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMB�R EXCLUDED? (Mantlatory in NH) NIA WC 9081074 6/19/2020 6/19/2021 X STATUTE ERH- E.L. EACH ACCIDENT --- — E.L. DISEASE - EA EMPLOYE 500,000 - -- —000 $ 500'000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT 500,000 $ C Pollution I Environm 002617504 1/1/2020 1/1/2021 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Board of Health 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIIZ/ZE))D REPRESENTATIVE ACORD 25 (2016/03) © 1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Christopher George From: Stephanie Lewis <Stephanie@soarespumping.com> Sent: Tuesday, December 1, 2020 1:20 PM To: Christopher George Subject: RE: 50 lawndale road Attachments: town installer ref.pdf Hi Chris, Attached are the referenced from other town licenses. As far as the FOG customers we only service Cold Stone in Mansfield Crossing 280 School Street Suite D160. Please let me know if you need anything else. Thank You! Stephanie Soares Pumping, Inc. 195 Thrasher Street Taunton, MA 02780 Tel: 508-824-0487 Fax:508-824-9429 Email: steohanie@soaresoum of ng.com From: "Christopher George" <cgeorge@mansfieldma.com> Sent: Monday, November 30, 2020 11:07 AM To: "Steohanie(@soaresoumoing.com" <StephanieColsoaresoumoing.com> Subject: RE: 50 lawndale road Hi Stephanie, The application requires 3 references and was left blank on the application. Copies of the permits works for me because then I don't need to call the other towns to verify. We also need a list of FOG establishments you service for the FOG Pumper/Hauler permit application Thank you, -Chris George Administrative Assistant, Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 From: Stephanie Lewis [mailto:Steohanie@soarespum iinnp.comj Sent: Monday, November 30, 2020 11:04 AM To: Christopher George Subject: RE: 50 lawndale road Stephanie Scares Pumping, Inc. 195 Thrasher Street Taunton, MA 02780 Tel: 508-824-0487 Fax: 508-824-9429 Email:stei)hanie@)soaresr)umping.com Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 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