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Home My WebLink AboutUnited Site Services NE, Inc. - 12/31/2021luo k, 19 Town ansfield�c(f f' Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 0 Septage/FOG Haulers Application C DATE: 161-q/a 0 � LICENSE NUMBER: BUSINESS NAME: f�/�� A"OrAeasf_Plc- MAIL ADDRESS: TOWN: I( g, Fian�e(-s Rd STATE: Iq# ZIPCODE: NAME OF OWNER: LA)eSr r0 M9R At /3o-klho BUSINESS TELEPHONE: sD8 _ yob -5 0 3tf CELL: FAX: EMAIL: ap�(.,cr1�.�S��cSefviCnSCrdm 339/ FED IDISS NO: 6 ��a v1 ALT EMAIL: ®µy e/Ct 9u%pn 0 Url, lec/Si �r� ePs, FEE PER TRUCK: $100 NUMBER OF TRUCK(S): Truck Registration number: MA Circle one: 1. 3 FOGTruck Registration number: �� - A Circle one: *Selliaeo FOG Truck Registration number: Circle one: 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: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 cccuuP for BOH records. V 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: /) October 22, 2020 Septage/FOG Haulers: Town of Mansfield 6 Park Rom,, Mansfield, Musacbusetts 02048 5 Health Department C �, Amy Donovan -Palmer, MPH, RS � „�,✓ Health Agent Your current Septage/FOG Hauler Permit will expire on December 31, 2020. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 25, 2020. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. • Septage/FOG Hauler Permit Application (Attached) • Tax Certification Form (Attached) • Workers' Compensation Insurance Affidavit: General Business. (Attached) • Workers' Compensation policy declaration page. The Health Department Is communicating with permit holders mainly through email. Please be sure to include a valid email address. The current Mansfield BOH fee is $100 per truck. According to Title 5, 310 CMR 15.505(1), all trucks that transport the contents of privies, cesspools, septic tanks or tight tanks must be inspected and approved by the Health Department. For the 4th year, there will be a joint truck inspection held at Gilette Stadium in Parking Lot P10 (across from Patriot Place) Route 1, Foxboro, MA 02035. PLEASE DO NOT BRING PAPERWORK TO THIS EVENT. Paperwork should be submitted directly to the Health Department. The Health Department is electronically tracking local pumping, as required by Title 5. Please submit the attached form electronically monthly. Please contact the Health Department if we can be of any additional assistance. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 • Fax (508)261-7425 • Email adpalmer@monsfieldma.cam 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. ;� �U�CP.o d'2�Rc�c�.4vLL� ature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) *'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. CA1JsemNs1eit6Dmktop\Scotes DocumentsTood 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 Annlicant Information Please Print Leeibly Business/Organization Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/ or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. FIo workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, jNo workers' comp. insurance req.] *Anv aonlicant that checks box #I must also fill out Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other **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 #i. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy irtformatiott. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration 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 Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penattles of perjury 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 offtctal 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 Person: Phone #: www.mass.gov/dia The Commonwealth ofMassaelruseas Department oflndusolalAccidents t I Cangresssireet, Suite 100 Boston, MA 02114-2017 wwikmass,gov/dia Workers' Compensation Insurance AfOdavit: General Businessel. TO DE FILED wrm THE rERMI'1TBgG AU'I'HORM, Applicanthformafion t Please Print Lobbix Business/Organization Name_UrNAe1. ;i' Se2o;ces �)aQAoa-c,4 Ind Address: I i >c (a n b e rs /Z� Are you an employer? Check the appropriate bar. I. ® 7 am a employer with a 3 8 employees (full and/ or part-time)-* 2. ❑ l am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insumncerequhed) 3. We are a corporation and its officers have exercised their right of excmption per a 152, §I(4), and we have no employees, [No workers' comp. insurance required 4; ElWe are a non-profit organization, staffed by volunteers with no employees, [No workers' comp, insurance req, Phoao M. 1— M' Business Type (required): ' 5, DRetan 6. QRestaurant/Bar/Ealing Establishment 7. [] Office and/or Sales (incl. teal estate, auto, etc,) 8. ❑ Non-profit 9, [] Entertainment 10,[] Manufacturing 11.[] Health Cars II 12,® Other )?QL5 ''Ittho corparok oTJ=bgvt exanpkd themutvn, but thocorpontlan has otheremployee; arvmkc& eampmssum polity it required "such as a rasnbstionshould checkboa#l, Ion an employeriltalisprovldingtvorkera'campamadon lnsigancefor my employees Below it tlropoftcy leforttrnfion Insurance InsurcesAddress: Ii3oZ. M Policy # or Self -ins, Lie. M. L)S 4 el1 4 3-IQ Expiration Date; 1 I 3 1 e10 Attach a copy of the workers' compensation policy dedaratlen page (showing the policy camber and expiration date). Failure to secure coverage as required under Section 25A ofMGL a,152 can lead tb 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 $250,00 a day against the violator, Be advised that a copy ofthis statement may be forwarded to the Officw of Investigations of the MA for insurance coverage verification. Offlelml use only. Do nohprYe In this ores, to be eampleled by city or town official City or Town: Parmit/Licensa W. Issuing Authority (circle one)- I. Board ofHeolth2.BufldingDepartment3.CftylTownClark 4.LlcenaingBoardS.Selectman's Office 6.Other ContactPeramu Phone Page 1 of 1 1 ® AC�/ `llrD CERTIFICATE OF LIABILITY INSURANCE OA E(MMeDY il/0112019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE, DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder le an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or he endorsed. If SUBROGATION IS WAIVED, subject to ills lotto$ 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 1190 of such endarasment(s),' PRODUCER Nillia of 1,1 xaneea, Inn, c(o 26 hent.Ay taiy xlvd P.O, Box 305191 CONTACT PHONE it 1_071-945-7378 FAx 1-688-467-2378 AIC lo• EMAIL mertSfioateaAwillia.aom O0R Raahville, Tn 372305191 USA INSURER(S) AFFORDING COVERAGE NAICs - INSURER A: Safety National Casualty Corporation 15105 INSURED United site Sarvimee Rertheaat, Ina. INSURERS: n specialty Insmraame Company 37605 119 rlaodera Aoad, Salt. 1000 INSURER C: .--- INSURINRDI ReatMroe9h, NA 01591 USA INBDRER E: '. INSURER F: CERTIFICATE NUMBER I413129089 14Cvlaluni NUMBER; evr eraeavro THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE 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. �TTRR TYPEOFINSURANCE INS BR POUCYNUMBER POLICY EFF LA AD POU IXP MAIM LIMIT X I COMMERCIALGENERALUABIUTY S 1,000,000 CLAIMS -MADE OCCUR mATmoal, S 1,000,000 — eM- S. 10,000GL4057787 MEA�HW�RRENCERENCE DVINJURY - S 1,000,000 11/03/2019 11/03/2020 GENLAGGREOATEUMITAPPUFSPER: REGATE s2,000,000 OMPIOP AGG S 2,000,000POLICY ❑PRO-❑ JECT LOCSOTHER: AUTOYOSAEUASRLTY NGLE LIMIT Pjapye S 3,000, 000 BODILY INJURY(Perpmson) S X A,A� BODILY INJURY (Par amd t) S A &, SCHEDULED, ONLY NOt40Vvt•IED HIRED Im140NLY AUTOS ONLY CAS4047379 11/02/2019 11/03/2020 OPER1Y?MAGE eraWdent S S B X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS-MADEUS00076933LI19A 11/03/2019 11/03/2020 EACHOCCURRENCE S 1,000,000 AGGREGATE $ 1,000,000 DEO X RETENriONS101000 WORKS COMPENSATION ER X PER O F E S EL EACH ACCIDENT $ 1,000,000 A ANOEYPLOYERSUASILITY YIN ANYRiOPRIEfIXLPARTNER,FXECUrIVE No ryB1NIXI IXCLUDFlJ7 M yyesk9cn0e Mger DESCRIPTION OF OPERATIONS bebvi NIA WS4047370 11/03/2019 11/03/2020 EL DISEASE -EA EMPLOY S 1,000,000 EL DISEASE -POLICY UMIT S 1, 000, 000 ,O,WPTIONoFOPERATIONS/LOCATIONSIMEHICL.ES(ACORD 101, Additional Remarks SohodUla, MAY beanached if more space la squired) - SHOULD ANY OF THE ABOVE DESCRIBED; POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE .WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORREOREPRESENTATIVE Doited Bite Services Northeast, Ina. 119 Ylandera Road, Smite 100 2 4restborovah, SDI 01591 Ldv^- CORPORATION. All fights reserved. ACORD 25 (2016I03) The ACORD name and logo are registered marks of ACORD SA m: 19752115 aAmcer 143881.9