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Home My WebLink AboutHometown Pumping, Inc. - 12/31/2021Ga *Soy /Oo Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 I � i IM /021 Septage/FOG Haulers Application FEBDATE: LICENSE NUMBER: ' BCISINESSNAME:j-10Wte+0U IPUmpmq,1nC. MAIL ADDRESS: TOWN: b S?V\1nG Vb�(2 VA STATE: M (k ZIP CODE:-V'OYbC)vO O w35 NAME OF OWNER: Q Ao V) 1� tOV2Sl�fCCa AS DOOI e'J BUSINESS TELEPHONE: �Oe -a \VO -0 a-((6 CELL: �Zy c'-v, - FAX: EMAIL: PUVI�tyc)CcDgVC'IA\,CYXyN 5oe--58- �ea� FED ID/SS NO: ALT EMAIL: FEE PER TRUCK: $100 NUMBER OF TRUCK(S): Truck Registration number: '� q P) 5 2,0 Circle one: (CeItage- Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: THURSDAY, NOVEMBER 12, 2020 TIME: 7:OOAM-11:00AM PLACE: GILETTE STADIUM - PARKING LOT P10 PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE .................................................. ............ •--.................................... ...................................... ...................... FOG PUMPERS: ,/V7 I 5 one'$ ycfl vy5 o 44t 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 occur for BOH records. 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: F117 DATE: j 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. ' /y Signature o Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identifi'eation Number By: Corporate Officer (Mandatory, if Applicable) *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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc N \ l /lG �UMMU/{WV"t"t Vf III µJJUL/LµOCIW e1Lk Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individuat):"o m'e--` Low �tk kni \nL Address:U ` Ybu\t- RI -A, -V-oxhC(D MA CM)Z:5 Phone -a1lp- Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 'A 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity, employees and have workers' comp, insurance.# 9. ❑ Building addition. [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their I LFJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.0 Other nC. �I Y1 DIY employees. [No workers' comp. insurance required.] *Any applicant that checks box pl must also fill 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C_f1^ oMu h S,CN\C" VWM\\ nSlA�f�\(Ce NnCAl �nC. Policy # or Self -ins. Lic. #: % Expiration Date: 110� S 112o a, a Job Site 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 foe 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 cert�}pgnder theins and 0yaldes_9,fyerjury that the information provided above is true and correct. Phone #• 5 n i 9 — -1 1 o rb Zi 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. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of IndusMal Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia )rnni Revised 5-26-05 A� b® CERTIFICATE OF LIABILITY INSURANCE DATE MMIDDM") 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(les) 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 Cavallo & Signoriello Insurance Agency Inc 190 Chauncy St Mansfield MA 02048 CONTACT PHONE FA% ,M), 508-339-2951 ac No): 508-339A811 candsins.com aouaess: jessica@candsins.com INSURERS AFFORDING COVERAGE NAIC9 INSURERA: Merchants Mutual Insurance Company 23329 _ INSURED 38304 INSURER B : Hometown Pumping Inc 6 Spring Brook -- INSURERC: INSURER D: Foxboro MA 02035 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 375116800 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. INSR LTR TYPE OF ADDL SUBRPOLICY POUCYNUMBER EFF MMIOD/YYYY MM/DDNYYYPY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR CTRIOD3657 112512021 1125/2022 EACH OCCURRENCE $1,000,000 DAMAGE T A ET ENTED PREMISES Ea occurrence $500,000 MED EXP(Any one person) $5,000 PERSONAL &ADV INJURY _ $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- ❑ LOG ECT OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OP AGG $2,000,000 $ A AUTOMOBILE LIABILITY AUTO XSCHEDULED AUTOS ONLY AUTOSHIRED X NON -OWNED AUTOS ONLY AUTOS ONLY MCA1003037 1/25/2021 1/25/2022 COMBINED SINGLE LIMIT EaaccidentANY $1,000,000 BODILY INJURY(Per person)OWNED H BODILY INJURY (Per accitlanf) $ PROPERNDAMAGE Per accident $ UMBRELLALIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ LED RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WCA9103238 1/25/2021 1/25/2022 X STATUTE ERPEH E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS ) VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Town of Mansfield Board of Health 6 Park Row Mansfield MA 02048 .gG10 PI q al Tl r Lal OI 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 REPRESENTATIVE ,1,4 tk1 tiU�i,�w� reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD