Loading...
HomeMy WebLinkAboutRaggs Septic Services Inc. - 12/31/2021Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfiel"A 02048 Septage/FOG Haulers Application �& LICENSE NUMBER: ; BUSINESS NAME: MAIL ADDRESS: TOWN: P Q,(>,OX (02✓i STATE: MA ZIP CODE: NAME OF OWNER: �l�b Staceh rk6A-to, Pre.. -.A BUSINESS TELEPHONE: goo nj 5yI EMAIL: t?X-rMAAS Q. rat.�$Srnc,ca� FED ID/SS-NO: pLf3I(Zka0 FEE PER TRUCK: $100 Truck Registration numbenc) P?N Truck Registration number: Truck Registration number: Truck Registration number: Truck Registration number: SEPTAGE PUMPERS: CELL: FAX: ALT EMAIL: NUMBER OF TRUCK(S): 4@�) FC Circle one: a ge Circle one: 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-11:00AM 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: 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.- BeR'vue� S PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BON 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: &/ j` 4fb ,4 d A. '6s wticf—e a Ik--- 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 By: Corporate Officer fMandatory, if Applicable) DL(-.3 i 1a �-ao ** tary) or Federal Identifi'catian Nwaber *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\Desk(op\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc O" 1 rev l+V//{//LV/E IV6{LLH{ Vf �YL wJJRNLKJ 6LLJ 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 Name:T"S ou(— Address: f U (a;o City/State/Zip: MA-00V2, Phone #: 8W D.�-j SS q7 Are you an employer? Check the appropriate box: 1. `:]l am a employer with U&.rw 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.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I LE] Health Care 12.ther d4dtl (. *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 am an employer that is providing workers' compensation insurance for aty employees. Below is the policy information. Insurance Company Name: Me-(rH -YuB oijurA"-rG Insurer's Address: 0,fp S&ID (tuoVrA,�:" MAIAiS t -RT-aA City/State/Zip: SkLe,.in gH 030 )pj Policy # or Self -ins. Lic. # LOC/ 099 gc2 Expiration Date: 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 penalties ofperjury that the information provided above -isAtrue and correct. Signature .,��� Date pw Phone #• R n i S37i i 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 #: �rom:Nicole 9oudreau FaodD: Page 2 of 2 Date:3262021 02:15 PM Page:2 of 2 RAGGS-1 DATE(MMIDDIYYYY) 03/26/2021 ACoiro" CERTIFICATE OF LIABILITY INSURANCE �'- 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 WANED, 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 603-890-6439 Santo Ins & Financial Sam LLC Salem 224 Main Street Suite 2A CO ACT Jason M Mlocek PHONE 603$90-6439 Fax 603-890.6521 AIC No EM: AIC No: E+AAIL .JasonLmsantoinsurance.COm Salem, NH 03079 Jason M MIOCek INSURER AFFORDING COVERAGE NAIC N iNsugeg A, Merchants Insurance 23329 NSURED aggs Septic Service Inc. EA Comeau PO Box 1027 INSURER B: INSURER D Concord, MA 01742 INSURER E : INSURER F rnvoonr•_cc OCOTIC'ICATR ul xacumo• PP1AQIrVJ MIIMRFR• 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 TYPEOFINSURANCE ADDL INSD SUB Wye POLICYNUMBER POLICY EFF ammelPOLICY Yy LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR CMP9165268 02122/2021 02/22/2022 CURRENCE S 1,000,000 TO RPREMISES ENTED $ 100,000 6'000AL An ene erson & ADV INJURY 1,000,000GENT AGGREGATE L@IMIT APPLIES PER: � JET LOC L AGGREGATE S 2,000,000POLICY :AMNNTE TS-COMP/OP AGO 21000,000OTHERA AUTOMOBILE LIABILITY AUTO SSCHESULED AUTOS ONLY UTI.I WNEp MRS ONLY X ACTO1 ONLY Pollution MCA0000131 02/22/2021 02/2212022 D SINGLE LIMIT S 1,000,000ANY JURY Per ersonOWNED JURY Per eccidenl X pp pPe�ecu�ent AMAGE S X A X UMBRELLA LIAR EXCESS LAB X OCCUR cLAIM"ADE CUP9148089 02122/2021 02122/2022 EACH OCCURRENCE 41000,000 AGGREGATE g 4,000,000 DED I X I RETENTION $ 10000 A WORKERS COMPENSATION AND ROPRIEE RIPARTILITV �ICERIMEMBER EXXCCLNI�EDEXECUTNE � (Mandatory In NH) Myer, describe under DESCRIPTION OF OPERATIONS be. NIA WCA9099892 3A: MA 02122/2021 0212212022 X PER OTH. E.L. EACH ACCIDENT $ 600,000 E.L. DISEASE - EA EMPLOYE 5001000 E.L. DISSEASE- POLICY LIMB 600,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1011 AddlOonal Remarks Schedule, maybe anschad it more space is required) jdoucette@mansfieldma.com CERTIFICATE HOLDER r.Aiunm I ATInki SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Mansfield Board of Health 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048,^� ACORD 25 (2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD