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HomeMy WebLinkAboutSoares Pumping, Inc. - 12/31/2021*f166y 4V Town of Mansfield - Board of Health a Disposal Works Installer LICENSE NUMBER: Jr BUSINESS NAME: MAIL ADDRESS: Town of Mansfield 6 Park Row Mansfield, MA 02046 CITYITOWN;l,��C1 STATE: _ t I'� ZIP CODE: BUSINESS PHONE: 6DSS-'ZRL ©4'0_T BUSINESS CELL: BUSINESS FAX: 6c gat i ' 9 Lilaq E-mail:i:1_�CSC` �__Y.eSPUMQC1c�_CoM Alt E-mail: ID/SS NUMBER: ('y f.- LICENSE HELD:. Town LICENSE HELD: Town — LICENSE HELD: Town Year Licensed Year Licensed Year Licensed I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage". understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31 st yearly. FEE: $ 100.00 SIGNATURE: `? Cii�s.•' �l /\ _ DATE: 10 Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 Town of Mansfield 6 Park Aorv, Mansfield, Massadvisetts 02048 Health De ariment Any Donovan -Palmer, MPH, RS Health Agent October 13, 2020 Onsite Disposal Works` installer: Your current Disposal Works Installer Permit will expire on December 31, 2020. To renew your permit, please submit the following documents and payment to the Health Department. Please 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. Disposal Works Installer 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. Please contact the Health Department if we can be of any additional assistance. Sincerely, V Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Finailadpalmo@mansfielditra.com SOARSAN-02 PAMARAL ACORD° CERTIFICATE OF LIABILITY INSURANCE DAT116/2 OIYYYY) 1/6/2020 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 endorsements . PRODUCER License # 1780862 CONNAMTACT Megan Bodyul HUB International New England 222 Milliken Boulevard Fall River, MA 02721 PHONE Fax ac, No, E.O: (508) 235-2231 ,AX No : Si,%fflEss. megan.bodyul@hubinternational.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: Selective Insurance Company of South Carolina 19259 INSURED INSURER B: Selective INSURER C:IrcnshoreSpecialty Company 25445 Soares Pumping Inc INSURER D: 195 Thrasher Street Taunton, MA 02780 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER- REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE 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 ift TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIALGENERAL LIABILITY CLAIMS -MADE 52190987 11112020 1/112021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 600,000 MED EXP (Anyoneperson) 16,000 PERSONAL &ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY FAI YE RefLOC OTHER: GENERAL AGGREGATE 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 $ A AUTOMOBILE LIABILITY AUTO OWNED SCHFOULED AUTOS ONLY X AUTOS HIRED NON OWNED AUTOS ONLY X AUTOS ONLY A9100369 11112020 1/112021 COMBINED SINGLE LIMIT Ea ac t de 1,000,000 $ BODI LV INJURY Perperson) $ IxANY BODILY INJURY Peraccidenl $ P OPERTV DAMAGE er accident $ A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE S2190987 1/112020 1/1/2021 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 DED I I RETENTION$ S B WORKERS COMPENSATION YIN YIN ANY FICERI AREIMB R/E%CWEED?ECUTIVE ❑ (Mandatoryin NH) If yes, descdbe under DESCRIPTION OF OPERATIONS below NIA C9080203 1/23/2020 1/23/2021 X PER STATUTE DE E.L. EACH ACCIDENT 500,000 $ E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT 500,000 $ C Pollution I Environm 002617604 1/1/2020 111/2021 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 Applicant Information Please Print Le:ribly Business/Organization S�(l P�✓ Ye e J Address: ��j '� �(i`rG City/State/Zip:�nau (n I MR UM hone #: t. 77j • TaL4 • 0491 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with 1O 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] $• ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.aOther �P_] IC. j&pal r *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' cottipensation insurance for my employees. Below is the policy information. Insurance Company Name: "Pje� \i e_ mSL)r0_nC e Insurer's Address: City/State/Zip: Fw-voI2a t Mom. Policy # or Self -ins, Lic. # Expiration Date: I 10tis I C9 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 WORD 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 of perjuty 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 official. 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 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. Sca-yes �uM��cY�a Inc��zc-� Signature of Individual or Corpo tr2 e 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. C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc op eeexogkw - '� Town of Seekonk 100 Peck St, Seekonk,. MA` 771 508-336-2910 ar, as °""ewtuo Issued To: Robert Soares Jr. Mailing Address: 195 Thrasher St Taunton, MA 02780 License Number: Issued Date: Expiration Date: BOHP-A00034-2020 1/1/2021 12/31/2021 PROFESSIONAL LICENSE CERTIFICATE Seekonk Board of Health License Type: Board of Health Classification: Septic System Installer Fees Paid: $100.00 r";-.4 Wc srYy a(X 'n4 ealth Agent 11/23/2020 IWN OF EASTON Board of Health 136 Elm Street North Easton, MA 02356 Phone:$00-230-0620 NUMBER: DWI.21-0010 COMMONWEALTH OF MASSACHUSETTS Board Of Health FEE: $100 ( $100-Unibank ) DATE ISSUED: 11/2112020 4 Soares Pumping, Inc. 195 Thrasher Street, Taunton, MA, 0,2780 IS HEREBY GRANTED A DISPOSAL WORKS INSTALLER PERMIT This permit is granted In conformity with the Statutes and ordinances relating thereto, and expires 12/31/2021 unless sooner suspended or revoked. eo 41, Timothy Meyers For the Board of Health 10/15/2020 Marc Durocher Soares Pumping Inc. Permit No. DW-20-20 Town of North Attleborough, MA Board of Health 43 South Washington SL North Attleborough, MA 02760 508-699-0103 nattletwro.com IV PublicHealth Prevent. Promote. Protect. 195 Thrasher Street Taunton, MA 02780 THE COMMONWEALTH OF MASSACHUSETTS Town of North Attleborough, MA, Board of Health DISPOSAL WORKS INSTALLER LICENSE Fee: $100 Issue Date: October 15, 2020 This permit is issued in conformity with the authority granted to the Board of Health, by Chapter 111, Section 31A, of the Massachusetts General Laws, and amendments, and is subject to the provisions of the Town of North Attleborough, MA Ordinances, and upon such terms and conditions, and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health. Marc Durocher Soares Pumping Inc. Whose place of business is:195 Thrasher Street Taunton, MA 02780 Type of business and any restrictions: DISPOSAL WORKS To Install Disposal Works in: Town of North Attleborough, MA, Massachusetts Permit Expires: October 31, 2021 This is an e-pennit. To tram more, scan this bamode or visit mdhatlleboreughma.viewpointcloud.wml#te rds/52528 MON,,, 1/1