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Home My WebLink AboutUnited Rentals NA, Inc. DBA Reliable Onsite Serv. - 12/31/2022� 06 31 � - 16 0'® ��U ansfield 'own of `Mansfield - Board of He 2 AUG 5 Zi6 Par d, MA 02048 Septage/FOG Haulers Application - DATE: 7122/2021 LICENSE NUMBER: 16 BUSINESS, NAME: United Rentals (North America), Inc. DBA Reliable Onsite Services MAIL ADDRESS: 791 East 64th Ave TOWN Denver STATE: CO NAME OF OWNER: United Rentals (North America), Inc. BUSINESS TELEPHONE: 856-305-6625 CELL: 856-305-6626 ZIP CODE: 80229 FAX: EMAIL: jwalker5@ur.com ALT EMAIL: environmental@ur.com FED ID/SS NO: 86-0933835 NUMBER OF TRUCK(S): 2 I y d ` G� p er 1 FEE PER TRUCK: $100 x 2 = $200 -rd vt 1 e��t J 2NP2HM6X3NM781662 d ro( Circle Septage FOG Truck Registration number: one: Truck Registration number:)-< 2NP2FIMbXbNM781632 Circle one: SeptageFOG 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: 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. SepticlFOG 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. SIGNATURE: DATE: 0 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. Signature of Individual or Corporate Name 86-0933835 "Social Security No. (Voluntary) or Federal Identification Number Vice President 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:\UsemWeite\Desktop\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: United Rentals (North America), Inc. Address: 100 First Stamford Place, Suite 700 City/State/Zip: Stamford, CT 06902 Phone #: 844-873-4948 Are you an employer? Check the appropriate box: Business Type (required): 1.❑✓ I am a employer with /(,(, V employees (full and/ 5. ❑ Retail or part-time).* NATICH W toC 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.❑ 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.] 12Q Other Equipment/Portable Toilet Rentals *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 isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ACE Property & Casualty Insurance Co. Insurer's Address: One Liberty Plaza - 165 Broadway, Suite 3201 City/State/Zip: New York, NY 10006 Policy # or Self -ins. Lie. # 20699 Expiration Date: 10/1 /2021 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certt&, undq Oe pains and pengkips of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone CERTIFICATE OF LIABILITY INSURANCE DATo`o02"YYY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Ann Risk Services Northeast, Inc. New York NV Office CONTACT PH WC. FAX .ExU: (966) 283-]122 N6 (800) 363-0105 �MAESS: One Liberty Plaza 165 Broadway, Suite 3201 INSURER($) AFFORDING COVERAGE NAIC# New York NY 10006 USA INSURED United Rentals (North America), Inc. United Rentals Inc. & Subsidiaries 100 First Stamford Place, Suite 700 Stamford CT 06902 USA INSURERA: ACE Property & Casualty Insurance Co. 20699 INSURER B: ACE American Insurance Company Z2667 INSURER Cu Indemnity Insurance Co of North America 43575 INSURER D: ACE Fire Underwriters Insurance Co. 20702 INSURER E: North American Capacity Ins CO 25038 INSURER F: nnamoAGES CFRTIFICATF MIIMRFR• 5700HHF40902 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. Limits shown are as requested man LB TYPE OF INSURANCE JHsD W D POLICYNUMBER MM/DD YY MNDIVYYffRR. LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [X]OCCUR XSLG 1 SIR applies per policy ter s & condi ions$2,000,000 ENCE $3,000,000 occurrenceX $2,000,000SIR nepemon) Excluded DV INJURY $3,000,005 GEN'LAGGREGATE LIMITAPPLIES PER REGATE $6,000,000 AGO $6,000,000 POLICY ❑PRO ❑LOCOMP/OP ECT OTHER: B AUTOMOBILE LIABILITY Y Y ISA H25315182 10/01/202010/01/2021 CEOMBBIINED SINGLE LIMIT kfenil $5,000,000 BODILY INJURY (Per person) X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NO"WNED ONLY AUTOS ONLY BOOILY-INJURY (Par aceMent) PROPERTYDAMAGE Perawderd A X UMBRELLALIAB X OCCUR XEUG27905 97006 10 Ol 2020 10 Ol 2021 EACH OCCURRENCE $15,000,000 AGGREGATE $15,000,000 EXCESS LUIB CLAIMS -MADE IDED1 IRETENTION C WORKERS COMPENSATION AND WLRC67458527 10 0201010112021 X PER STATUTE 1 ETH RR B EMPLOYERS' LIABILITY ANY PROPRIETOR PARTNER/EXECUTIVE N OFFICEWMEMBEfl E%CLUOEDy EN (Mandatory In NH) N/A y WLRC67458564 AZ CA MA 10/01/2020 10/01/202, ELEACHACCIOENT $2,000,000 E.L. OISEASE-EA EMPLOYEE $2,000,000 Cyes, descnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $2,000,000 B Excess WC WC UC67458606 WA 10/03/2020 10/01/2021 EL Each delft EL Disease se - -Policy EL Disease - Ea Emp $2,000,000 $2,000,000 $2,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional RemarNs Schedule, may be attached if more space H required) ADDITIONAL INFORMATION ATTACHED. m w c m TJ m6 M O Z qN U t: V CERTIFICATE HOLDER CANCELLATION �+ 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 AUTHORIZED REPRESENTATIVE Attn: Jeff Walker 6 Park ROW Mansfield RO MA 02048 USA C.(Wy/dlA (✓/J(/l /c/-Y c/A// ✓Y' 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AUUIIIUNAL K Aon Risk services Northeast, Inc. POLICYNUMBER See certificate Number: 570088540902 see certificate Number: S70088540902 AGENCY CUSTOMER ID: 570000086099 LOC #: K' b(iP7CUULC United Rentals (North America), Inc. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance 11 INSURER(S) AFFORDING COVERAGE I NAIC f#] Page _ of _ ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPEOFINSURANCE ADDL INSD SUER wvD POLICYWNIBER POLICY EFFECTIVE DATE POLICY EWIRATION DATE LIMITS (NIM/DO/YYYY) (MhMD/YYYY) WORKERS COMPENSATION D N/A SCFC67458643 10/01/2020 10/01/2021 WI OTHER E MiSC Liab cvg EEG000036706 10/01/2020 10/01/2021 CSL/TOT/IND/ $5,000, 000 The ACORD name and Iqgo are registered marks of ACORD AGENCY CUSTOMER ID: 570000086099 LOC #: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk services Northeast, Inc. NAMEDINSURED United Rentals (North America), Inc. POLICY NUMBER See Certificate Number: 570088540902 CARRIER See Certificate Number: 570088540902 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance CERTIFICATE CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CONT RE: ALL OPERATIONS PERFORMED FOR THE CERTIFICATE HOLDER. CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IN ACCORDANCE WITH THE POLICY PROVISIONS OF THE GENERAL LIABILITY AND AUTO LIABILITY POLICIES. A WAIVER OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER IN ACCORDANCE WITH THE POLICY PROVISIONS OF THE GENERAL LIABILITY, AUTO LIABILITY AND WORKERS COMPENSATION POLICIES. A WAIVER OF SUBROGATION IS GRANTED IN FAVOR OF CERTIFICATE HOLDER IN ACCORDANCE WITH THE POLICY PROVISIONS OF THE EMPLOYERS LIABILITY POLICY FOR KENTUCKY, MISSOURI, NEW HAMPSHIRE, & NEW JERSEY. GENERAL LIABILITY AND AUTO LIABILITY EVIDENCED HEREIN IS PRIMARY AND NON-CONTRIBUTORY TO OTHER INSURANCE AVAILABLE TO AN ADDITIONAL INSURED, BUT ONLY IN ACCORDANCE WITH THE POLICY'S PROVISIONS. CONTRACTUAL LIABILITY, BROAD FORM PROPERTY DAMAGE COVERAGE, INDEPENDENT CONTRACTORS COVERAGE IS PROVIDED IN ACCORDANCE WITH THE POLICY PROVISIONS OF THE GENERAL LIABILITY POLICY. THERE IS NO SPECIFIC "XCU" EXCLUSIONS AND COVERAGE IN ACCORDANCE WITH POLICY'S GENERAL LIABILITY TERMS AND CONDITIONS. GENERAL LIABILITY POLICY INCLUDES THE FOLLOWING ENDORSEMENT FORMS IN ACCORDANCE WITH THE POLICY PROVISIONS: ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - COMPLETED OPERATIONS. ALL OTHER STATES (AOS) INCLUDES: ITEM 3 A . WORKERS' COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS' COMPENSATION LAW OF THE STATES LISTED HERE: AK, AL, AR, CO, CT, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT, INC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SO, TN, UT, VA, VT, WV. ACORD 101 ,,,n PbvnV um,ro anu ,naV ,v, fin.... n,a.--nr Annual Collaborative Septic Hauler Inspection Day (In accordance with 310 CMR 15.505) INSPECTION REPORT Participating Health Departments: Avon, Foxborough, Mansfield, North Attleboro, Norton, Plainville, Sharon, Stoughton, Walpole Company Name: C&\C_ Address: —1 �cs,Sk un N"Q Telephone #:5 Operator at Inspection: C(�A �'o=, Tank Capacity: A \ o ' c Truck License #: Registration Exp. Date: Truck Inspection Mobile Tank (securely mounted on truck, watertight, necessary odor controls, leak -proof cover, tight discharge valves) Venting available to allow the escape of gas on Mobile Tanks (properly constructed) Suction or Pressure Hose in good repair Pumps (leak proof) Operator at Inspection 4nsp4ectorL2--��c Date (Updated: September 2018)