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HomeMy WebLinkAboutCroome Sanitation, Inc. - 12/31/2021BUSINESS NAME: c-g-o0nnE 511t4 t TA T t o .l MAIL ADDRESS: TOWN: Vo &X % STATE: MA NAME OF OWNER: RE t-( o 60 Tti EA41_ •T C2o0&�t S'(? BUSINESS TELEPHONE: ';Og - U6 6 X CELL: EMAIL: C rjvvtC 15" tTft-Tt6rJ (5' CoMC-FAST, ISET FED ID/SS NO: G � - 3) 31 Z-2-9 ALT EMAIL: - - . r -t -- LICENSE NUMBER: G ZIP CODE: 0-�l76 FAX: FEE PER TRUCK: $100 NUMBER OF TRUCK(S): Truck Registration number: Circle one: Zag FOG Truck Registration number: b/ 9 3 S A V Circle one: 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: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 ...................................................................................... _................................-----------.-•---.................................--- 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. 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. /d 12 � 12-() 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. C9-oome 5Ar4e I Rla.s Zi1C Signature of Individual or Corporate Name ©' -- 3 t _3 l 2^2 9 "Social Security No. (Voluntary) or Federal Identification Nunnber 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;\Usem\.sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts FAA Department oflndu.snialAceidents Office oflnvesligatiorr.s 600 Washington Street Boston, 11IA 02111 IV tnrplik rnass.go n/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: czoowr i NC: 0_ Box 5 City/State/Zip: Re,1A t) e Are you an employer? Check the appropriate box: L Q I am a employer with 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.] one #: 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 11.❑ Health Car 12.R1 Other Q 4-I e SCE Y t 1-es "Airy applicant [list checks box #] 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 mid such an organization should check box #1. I arrr mr employer tlial is provirlirrg workers' comrpensation insurarrce,for ray employees. Below is the policy information. Insurance Company Name: R LfA o l A ZtJ S s1 oz 10 K C-E Insurer's City/State/Zip: v2gO ®ntAt D Lyta L1-t D (&r p 1-1 52..- `f%/ 0 Policy # or Self -ins. Lic. # U%� g (� 3 1 ! Expiration Date: q / 6 121 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 cerdfp, raider the pains and penalties of perjury that the information provided above is true and correct. --_ --- /o /2-8 )2-o runahue­---C = Date: Of use only. Do not write in this area, to be completed by city or torvrr 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 #: tvww.nmss.,goc;dia COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5089473 - 17 Previous Policy No.: 5089473-16 07431 1. Name Insured and Address Croome Sanitation, Inc. P o ")( 6-q Rehoboth, MA U2769 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 042472921 Risk ID No.: Bureau File No.: 000158630 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 04/06/2020 to 04/06/2021 12:01 AM Standard Time at the insured's mailing address COVERAGE 1 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident $ Bodily Injury by Disease $ Bodily Injury by Disease $ 500,000 each accident 500,000 policy limit 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 01 A 0711 Includes copyrighted material of The National Council on Compensation Page 1 of 5 Insurance, with their permission.