HomeMy WebLinkAboutWind River Environmental -12/31/2021BUSINESS NAME: � 6 \Ve;
MAIL ADDRESS: -3AA5 \VV MQe,,�� , "
TOWN: C ck-cV Q rc STATE: t� ^w� ZIP CODE:
NAME OF OWNER:
BUSINESS TELEPHONE: � (�;'Lkflfi( " W� (� CELL: FAX:
EMAIL:lt�q ®j��vtrC��rYt2,tct Ca�fiALTEMAIL:
FED ID/SS NO: NUMBER OF TRUCK(S):
FEE PER TRUCK: ! oo ® �
Truck Registration number:
Circle one:
Septage
FOG
Truck Registration number: M
Circle one:
Septage
FOG
Truck Registration number:
Circle one:
Septage
FOG
Truck Registration number:
Circle one:
Septage
FOG
Truck Registration numb VCircle
one:
Septage
FOG
SEPTAGE PUMPERS:
310 CMR 16.505 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: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:OOAM
PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO
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
Jocurs for BOH records.
�-, acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs.
All documents must be completed tgned and returned to the Health Department with the appropriate payment.
Checks can be made payable to own of Mansfd. Mail to: Board of Health, Town of Mansfield, Six Park Row,
Mansfield, MA 02048.
SIGNATURE: DATE: , 30 2eiz-
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.
Signature of Individual or Corporate Name
"Social Security No. (Volantary) or Federal
Identification Nlnnber
By: Corporate Officer (Mandatory, if Applicable)
ermit to:
please return p
W inrl River Environmental
2.45 I.Mouth Street
Carver, MA 02330
*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:AUsersAsleireADesktop\Scotts DocnmentsAFood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of IndustrialAceidents
^ 1 Office of Investigations
1,=r
Lafayette City Center
2Avenue de Lafayette, Boston, MA 02I11-1750
t www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Wind River Environmental
46 Lizotte Drive
Marlborough MA 01752 Phone #: 978-562-4500
Are you an employer? Check the appropriate box:
1.0 I am a employer with +1000 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' camp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance reauired.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 1.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑■ Other Sewer/Sanitation
*Any applicant that checks box #1 must also fit out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number,
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: See Attachment
Policy # or Self -ins. Lie. #:
Job Site
Expiration Date:
City/State/Zip:
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 DI for insurance coverage verification.
I do hereby certify un`erY#le pai*v gnd penalties of perjury that the information provided above is true and correct.
Official use only. Do not write ht this area, to be completed by city or town official.
City or Town:
Permit/License #
11.16.2020
Issuing Authority (check one):
I❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 51DPlumbing
Inspector 6.❑Other
Contact Person: Phone #:
AC 1?br CERTIFICATE OF LIABILITY INSURANCE
6/30/2021
FDATE(MMIDDNYYY)
1 6/30/2020
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 endorsement(s).
PRODUCER LOckton Insurance Brokers,LLC
CONTACT
NAME:
CA License 110F 15767
777 S. Figueroa Street, 520d ❑
Los Angeles CA 90017
PHONE FAX
AIC No Ezt : A/C No.
E-MAIL
ADDRESS:
213-689-0065
INSURERIS) AFFORDING COVERAGE
NAICq
INSURER A: Starr Indemnit &Liability Company
38318
INSURED
Wind River Environmental, LLC
**
INSURER B : * * * SEE ATTACHMENT
_
INSURER C
1448815 46 LiZOtte Dr.
Marlborough MA 01752
INSURER D:
INSURER E:
_
INSURER F :
COVERAGES NVINRI01 CERTIFICATE NUMBER: 14761348 REVISION NUMBER: XXXXXXX
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
LTR
TYPE OF INSURANCE
ADDL
INSD
SUER
WVD
POLICYNUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MM/DDIYYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
N
N
1000090512201
6/30/2020
6/30/2021
EACH OCCURRENCE
$ 2,000,000
DAMAGE TO RENTED
PREMISES Eaoccurre J
MED EXP(Anyone person)
8 300,000 _
S 10,000
GEN-L
PERSONAL B ADV INJURY
S 1,000,000
AGGREGATE LIMIT APPLIES PER:
POLICY � JECT 1XI LOC
OTHER:
GENERAL AGGREGATE
S 4,000,000
PRODUCTS - COMP/OP AGO
_
S 4,000,000
_
$
A
A
AUTOMOBILE
_
XHIRED
X
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY _X AUTOS
NON OWNED
AUTOS ONLY X AUTOS ONLY
Com /Coll D dX I Various
N
N
1000198837201 ((MA))
1000198836201 (AOS)
6/30/2020
6/30/2020
6/30/2021
6/30/2021
COMBINED SINGLE LIMIT
1Ea eooidenl
$ 2000000
BODILY INJURY (Par person)
$_XXXXXXX
BODILY INJURY Per accident
( )
PROPERTY DAMAGE
Per_a_ccid_ent
$ XXXXXXX
$ XXXXXXX
$ XXXXXXX
B
X
UMBRELLA LIAB X I OCCUR
EXCESS LIAB_ CLAIMS -MADE
DED RETENTION$
N
N
See Attached
6/30/2020
6/30/2021
EACH OCCURRENCE
$ 14,00Q000
-AGGREGATE
$ 141000,000
$ XXXXXXX
A
WORKERS COMPESATNPER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNEWEXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
If yes, d..rdb. under
DESCRIPTION OF OPERATIONS below
NIA
N
1000003291
6/30/2020
6/30/2021
X I STATUTE ERH
E.L. EACH ACCIDENT
$] OOO OOO
E.L. DISEASE -EA_EMPLOYEE
$ ] 000000
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION See Attachments
14761348
Evidence of Insurance
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPR
@ 1688-201!rACCMD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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Water Solution Group, Inc.
35 Mozzone Blvd. Taunton, MA 508.880.9992
December 2, 2020
Wind River Environmental
46 Lizotte Drive
Marlborough, MA 01752
To Whom It May Concern:
Water Solutions Group (WSG) owns and operates the Wastewater treatment facility located at 35
Mazzone Blvd, Taunton, Massachusetts 02780. WSG operate under a City of Taunton's Industrial User
Permit No. 93-2021.
The plant is located to serve southeastern Massachusetts and surrounding area; and has no geographic
restrictions and can receive septage and approved wastes from other areas.
WSG is willing to continue receiving septage from WRE provided that WRE maintain the required City of
Taunton septage hauler's permits. Haulers permits expire December 3111 each year.
We thank you for your business and if you should give any further questions, please contact me.
Sincerely yours,
A-1 11{°I-ell
Mark Farrell
VP, Operations Wastewater
®. WE 1 i* NINE
1/13/2020 Rubicon
1/22/2020 C&W Services/Stop & Shop
1/24/2020 Shaw's Supermarkets
2/3/2020 Mahoney Environmental
287 School Street
377 Chauncy Street
390 West Street
321 School St
2/10/2020 B, Good (Jason Sweeney)
280 School Street
2/19/2020 SLM Facilities Solutions
280 School Street Unit D100
2/20/2020 SLM Facilities Solutions
2/25/2020 Great Woods Pizza
390 West Street
428 Elm Street
3/20/2020 Village at Willow Crossing
4/1/2020 C&W Services/Stop & Shop
25 Cobb Street
377 Chauncy Street
4/9/2020 Shaw's Supermarkets
4/9/2020 Shaw's Supermarkets
390 West Street
390 West Street
4/10/202Q Rubicon
287 School Street
4/27/2020 Mahoney Environmental
321 School St
5/18/2020 SLM facilities Solutions
5/18/2020 SLM Facilities Solutions
390 West Street
280 School Street Unit D100
5/22/2020 B, Good (Jason Sweeney)
6/1/2020 Great Woods Pizza
6/18/2020 Village at Willow Crossing
7/8/2020 Shaw's Supermarkets
280 School Street
428 Elm Street
25 Cobb Street
390 West Street
7/8/2020 Shaw's Supermarkets
390 West Street
7/13/2020 C&W Services/Stop & Shop
377 Chauncy Street
7/15/2020 Vixxo Alliance/Global
905 South Main Street
7/17/2020 Rubicon
287 School Street
7/20/2020 Mahoney Environmental
321 School St
8/18/2020 B. Good (Jason Sweeney)
280 School Street
8/20/2020 SLIM Facilities Solutions
390 West Street
8/26/2020 Great Woods Pizza
428 Elm Street
9/11/2020 Village at Willow Crossing
25 Cobb Street
9/15/2020 SLM Facilities Solutions
10/3/2020 Rubicon
280 School Street Unit D100
287 School Street
10/3/2020 Mahoney Environmental
321 School St
10/13/2020 Vixxo'Alliance/Global
10/15/2020 C&W Services/Stop & Shop
905 South Main Street
377 Chauncy Street
10/23/2020 Shaw's Supermarkets
10/23/2020 Shaw's Supermarkets
390 West Street '
390 West Street
11/4/2020 Great Woods Pizza
11/4/2020 B. Good (Jason Sweeney)
428 Elm Street'
280 School Street
11/4/2020 SLM facilities Solutions
12/7/2020 SLM Facilities Solutions
390 West Street
280 School Street Unit 1)100
12/7/2020 SLM Facilities Solutions
12/15/2020 Village at Willow Crossing
280 School Street Unit D100
25 Cobb Street