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Home My WebLink AboutA. Viera Disposal & Sanitation 12/31/2018Commonwealth 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: BRIAN VIERA & CHERYL VIERA Doing business as: A. VIERA DISPOSAL & SANITATION, INC. 329 TREMONT STREET REHOBOTH MA 02769 is hereby granted a SEPTAGE 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: 2 TRUCK REGISTRATION NUMBER(S): 80130 BOARD OF HEALTH Michael .McCCean, Chairman A Septage Pumpers Application DATE: 2017 LICENSE NUMBER: 2 BUSINESS NAME: A. VIERA DISPOSAL & SANITATION, INC. MAIL ADDRESS: 329 TREMONT STREET TOWN: REHOBOTH STATE: MA ZIP CODE: 02769 NANSE OF OWNER: BRIAN VIERA & CHERYL VIERA BUSINESS TELEPHONE: (888) 598-7274 CELL: (508).840-3253 FAX: (508) 223-3823 E-mail: .9:VIc-RA@GGlv1G NGT FED ID/SS NO: 20-1678847 REGISTRATION NUMBER(S): FEE PER TRUCK: $75.00 Please make appropriate chan� Board of Health, Town of Mansf Me TRUCKSI Alt E-mail: Chery l C t Ci l;-} y en e,5 ; of . ("'ram NUMBER OF TRUCK(S): 1 80130 i, date. aA enclose check payable to Town of Mansfield. Mail to: yParkow Mansfield, MA 02048.� DATE: /_ /6 ""1_�] 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 C..MR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.502 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: B. Venting of Mobile Tanks: ,Securely mounted on truck ,/Vent permits escape of gas, but not liquid Zatertight C. F/{0se: eak-proof cover �/ Suction or pressure hose in good repair Tight discharge tanks D. Pu ps: Maintained to prevent leaking of sewage A = Acceptable Inspected by: \\��.�V..1 NA Not Acceptable Inspected on: a� 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:�CorpoVfe 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 lndustrialAccidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: A. Viera Disposal & Sanitation Inc. Address: 329 Tremont St. City/State/Zip: Rehoboth, MA 02769 Are you an employer? Check the appropriate box: I. ❑ 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. El 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.] Phone #:888-598-7274 Business Type (required): 5. ❑ Retail 6. ❑Restaurant/BarMatingEstablishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 I.❑ Health Care 12.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. '*lf 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 insurancefor my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 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 i�sarancie coverage verification. under tlr sins nd penalt' s f perjriry that the information provided above is true and correct. —J„ / �. r,_`, c1 _ Hare. �o 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 ALSQUAL-01 CFERGUSON ,a►�RO CERTIFICATE OF LIABILITY INSURANCE DAT0104//201) 10104017 7 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 endorsement(s). PRODUCER C NTACT Provider Group 275 Promenade Street, Suite 135 Providence, RI 02908 PHONE FAX (A/c,No, Eat); (401) 762-0922 tAlc,No):(401) 769-2086 MEs: needhamr@providerig.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: Risk Placement Services Inc. INSURED INSURER 8 : INSURER C A. Viera Disposal & Sanitation, Inc. INSURER D: 329 Tremont Street Rehoboth, MA 02769 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER- RPVICInNI MHMRPR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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 LTR TYPE OF INSURANCE ADDL INSD SUER MD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR ENVP01049403 0713112017 0713112018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES IF. ...denee) $ 50,000 MED EXP An one arson $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENT X N AGGREGATE JELQT LIMIT APPLIES PER: POLICY ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,010 PRODUCTS-COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSWNEp AURTOS ONLY AUTOS ONLY COMBINEDSINGLE LIMIT $ BODILY INJURY Per arson $ BODILY INJURY Per accident $ POPE ldent AMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED?EDT (Mandatory In NHl If Dyyes, describe antler Dns, des I be under OPERATIONS below NIA PER OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES IACORD 101, Additional Remark. S.hodul., maybe aUt .h.d if ....pace 1. required) Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 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 AL,ur[U LD tLU'i O/Ud) (91908.2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD