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Home My WebLink AboutAll Seasons Septice Service 12/31/2018\ 4Y Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health __ Septage Pumping and Transporting Permit This is to certify that: KEVIN ORLANDO Doing business as: ALL SEASONS SEPTIC SERVICE, INC. 200 CUSHING STREET, SUITE 7 STOUGHTON MA 02072 is hereby granted a SEPTA GE PUMPING AND TRANSPORTING PERMIT to engage in the pumping or transporting of the contents of privies, cesspools, septic tanks and other offensive substances. This permit is granted in conformity with the STATE ENVIRONMENTAL CODE.' 310 CMR 15.02(2) and MGL chapter 111 section 31A and expires December 31, 2018 unless sooner suspended or revoked. LICENSE NUMBER: 1 TRUCK REGISTRATION NUMBER(S): J93012 BOARD OF HEALTH MichaeCwlcCCean, Chairman 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. of Ik iviqLal or Corporate 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. 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: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: MA 02072 All Seasons Septic Service, Inc. 200 Cushino St.. Ste. 7 Phone #: 866-822-6846 Are you an employer? Check the appropriate box: 1. 0 I am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.$ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition ME] Electrical repairs or additions I L EJ Plumbing repairs or additions 12.❑ Roof repairs 13.R Other *Any applicant that checks box #1 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 time 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 am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Utica National Insurance Group Policy # or Self -ins. Lic. #: 4101564 Expiration Date: 4/14/2018 Job Site Address: 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 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 $250.00 a day 'against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent' nd / )7AYP.[ atns and penalties ofperjury that the informatirovided a ove i tr and correct. ' 111 1i� Sianatnre• 866-822-6846 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A� o4b CERTIFICATE OF LIABILITY INSURANCE DATE(MWDINYYYY) 6/21/2017 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the poticy(les) must 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 ondorsemen s . PRODUCER A.E. Barnes t Co. Insurance Agency, IRO. 141 Pleasant Street P.O. Box 85 South Weymouth MA 02190 CAndrade NAME:ONT MariaAdd_ PHONE 4 (781) 335-1589 (ac.Ne): (791)340-0626 ADURE s: mandrade@aebarnes.aom INSURER(Sl AFFORDING COVERAGE NAIC9 INSURERA:Utica National Insurance INSURED All Seasons Septic Service, Ina, Orlando 5, Inc. 200 Cushing Street 67 Stoughton MA 02072 _Group_ INSURER B;Pil Lim Insurance Co. 21750 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:meter 2017-2018 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OFINSURANCE ADOL BUSH POLICY NUMBER POLICY EFF M POLICY EXP LIMITB A X COMMERCIAL GENERAL LIABILITY CLANSMADE 1XI OCCUR CRP4104867 2/12/2017 2/12/2018 EACH OCCURRENCE $ 1,000,000 PREMISES Ee otturtenee S 500,000 MED EXP(An9 one Pe ) $ 15,000 PERSONAL S ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: POLICY ❑LOC X JECT OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMP/OP AGO $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALLODINNEO X SCHEDULED OS NON OV,NED X HIRED AUTO 6 X AUTOS CSC00001001473 - 2/12/2017 2/12/2018 OMBI LE LIMIT $ 1,000,000 BODILY INJURY (Per persan) S BODILY INJURY(Per ecddWI) $ PROPERTY DAMAGE Per eccBenl $ Unkwmd mohM canbNed S 25/50 UMBRELLA UAB EXCESS DAB OCCUR CLAIM84MDE EACH OCCURRENCE S AGGREGATE S D D RETENTION $ A WORKERSCOMPENSATION AND EMPLOYERS- LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE YIN OFFICERIMEMBER EXCLUDE07 (M"wwcwyln NH) N yea. deaalbe wdK DESCRIPTION OF OPERATIONS W. NIA 4101564, d/14/2017 4/1q/2018 ' X TATUTE 'ER — E.L. EACH ACCIDENT $ 1,000,000 E.L.DISEASE-EA EMPLOYE S 1 000 000 E.L DISEASE- POLICY LIMB I S 11000,000 T1 - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached N Moro Space le Mquimdl PROOF OF INSURANCE 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 Hoffman/MAR "' '� -w- *iAN'_ M 1988.2014 ACORD CORPORATION. All rights ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS026 (201401) Town of Foxborough Town of Mansfield Town of Norton 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT FPai RMIT#: DATE: 11/9/2017 d: Y or N First Tri-Town Inspection Day COMPANY NAME;�� ADDRESS: TELEPHONE#: n-U OPERATOR: YkyAv'\ TANK CAPACITY: TRUCK LTC. NUMBER: Equipment 1. Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 2. Venting (gas) of Mobile Tank (properly constructed) 3. Suction or Pressure Hose in good repair 4. Pumps (leak -proof) This vehicle is in compliance with 310 CMR 15.505. �tor Person t erviewedTnsp (2017) Town of Mansfield Town of Mansfield -Board of Health (i Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 LICENSE NUMBER: 1 BUSINESS NAME: ALL SEASONS SEPTIC SERVICE, INC. MAIL ADDRESS: 200 CUSHING STREET, SUITE 7 TOWN: STOUGHTON STATE: MA ZIP CODE: 02072 NAME OF OWNER: KEVIN ORLANDO BUSINESS TELEPHONE: (866) 822-6846 CELL: FAX: (781) 344-5788 E-mail: ALLSEASONSOFFICE@YAHOO.COM Alt E-mail: FED ID/SS NO: 04-3497823 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): J93012 FEE PER TRUCK: $75.00 Niease make appropriate hanger. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town ansfield Six Park Row Mansfield, MA 02048 SIGNATURE. DATE: ...........I— ..........:.... t.l.........� -TRUCKS INSPECTIONS: DATE: THURSDAY NOVEMBER 9, 2017 TIME: 7:30 AM - 10:30 AM 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 FOR HEALTH AGENT'S USE ONLY 310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. ": 5.502 Transportation and Disposal of Privy. Cesspool, and Septic Tank Contents. 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. A. Mobile Tank: Securely mounted on truck Watertight Leak -proof cover Tight discharge tanks A = Acceptable i NA = Not Acceptable B. Venting of Mobile Tanks: Vent permits escape of gas, but not liquid C. Hose: Suction or pressure hose in good repair D. Pumps: Maintained to prevent leaking of sewage Inspected by: Inspected on: