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Home My WebLink AboutWaste Water Services, Inc. - 12/31/2021q05 NAMEOFOWNER: Jdtdplt aAl(2b BUSINESS TELEPHONE: 5-()g Lgt7'r2nl7Y CELL669329-A/00 EMAIL: #D6 t-o7^rci2HAAb 6) cow6-TJFPg4- 4Om FED ID/SS NO: 0 -c ' .3 579,37 9 FEE PER TRUCK: $100 Truck Registration number: S2-Zoq Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: ............................................................................ SEPTAGE PUMPERS: ALT EMAIL: NUMBER OF TRUCK(S): FAx:6oz L- l-W7`7 Circle one: Septage FOG Circle one: Septage FOG Circle one: Septage FOG 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 ...........I ................ .......................... ................. ...................... ........... ................... ....................... 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. II 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: `�7 C\J_ — DATE: �ZO The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center ' 2 Avenue de Lafayette, Boston, MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: WASTE WATER SERVICES INC Address:1997 BEDFORD ST City/State/Zip: BRIDGEWATER MA 02324 Phone #:508 697-9974 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑■ I am a employer with 26 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] g• ❑ 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, TRANSPORTATION with no employees. [No workers' comp. insurance ieq.] 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:ACADIA INSURANCE / MORSE INSURANCE Insurer's Address:285 WASHINGTON ST City/State/Zip: NORTH EASTON, Policy # or Self -ins. Lie. #WCA5363803-11 Expiration Date:10/20/2021 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. 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 eery under the pains a d penalties ofpei jtery that the infornmtion provided above is trite and correct. -A -'-s—/ j 10/22/2020 508 697-9974 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 2.17 Building Department 5.❑ Selectmen's Office 6. ❑Other Permit/License # 30 City/Town Clerk 4. El Licensing Board Contact www.mass.gov/dia Phone AcoRO® CERTIFICATE OF LIABILITY INSURANCE DATE (mMmomvvl 10/22/2020 THIS CERTIFICATE IS ISSUEDAS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTER 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 endorsement(s). PRODUCER CONTACT Margaret Viera NAME: Morse Insurance Agency, Inc. AICNN Ell, (508) 23&0056 FAIL, No): (508) 230-8367 E-MAIL s: maggieviera@morseins.com ADDRE 285 Washington Street INSURER(S) AFFORDING COVERAGE NAICM North Easton MA 02356 INSURERA: Union Insurance Company 25844 INSURED INSURER B: Continental Western Insurance Company 10804 INSURER C: Acadia Insurance Company 31325 Waste Water Services Inc INSURER D : 1997 Bedford Street INSURER E : 1 INSURER F: Bridgewater MA 02324 COVERAGES CERTIFICATE NUMBER: 20-21 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. TR TYPE OFINSURANCE INSD MD POLICYNUMBER POLICY EFF MMIDDIYY)N) POLICY EXP JMMIDD)YYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR CPA5363800-12 10/20/2020 10/20/2021 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occunence $ 300,000 MED EXP (Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE X LIMITAPPLIES PER: POLICY [g JECT O. FX LOC OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 It B AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY MAA5363801-12 10/20/2020 10/20/2021 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Par person) $ BODILY INJURY (Par aecidann $ PROPERTY DAMAGE Peraccidenl $ $ C X UMBRELLA LIAB EXCESS LIAB I Xl OCCUR OLAIM.MADE CUA5363802-12 10/20/2020 10/20/2021 EACH OCCURRENCE $ 6,000,000 AGGREGATE $ 6,000,000 DED I I RETENTION S $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORRARTNERIEXECUTIVEIM❑N OFFICEREMBER EXCLUDED? (Mandatory in NH) Ifyes, detente under DESCRIPTION OF OPERATIONS below NIA WCA5363803-12 10/20/2020 10/20/2021 X STATUTE ER E.L. EACH ACCIDENT $ 500,000 EL DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is regnl.d) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048 ^M All rights reserved- ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. a Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) Oy-3S7g37$ **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. 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