The URL can be used to link to this page

Home My WebLink AboutBay State Sewage Disposal 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. RICHARD & MARGARET CHAVES Doing business as: BAY STATE SEWAGE DISPOSAL 105 KINGMAN AVENUE LAKEVILLE MA 02347 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: 3 TRUCK REGISTRATION NUMBER(S): 98205 86514 BOARD OF HEALTH Nichae(NcCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 -rt�Ns>=-Nt-Inns �P-3 BUSINESS NAME: BAY STATE SEWAGE DISPOSAL MAIL ADDRESS: 105 KINGMAN AVENUE TOWN: LAKEVILLE STATE: MA ZIP CODE: 02347 NAME OF OWNER: RICHARD —P MARGARET CHAVES 5a' qy'-00Z(o BUSINESS TELEPHONE: (�a08}S'z2fi8 CELL: FAX: (508)-822-0766-" (5vs-) (o E-mail: JOELLENS@BAYSTATESEWAGE.COM Alt E-mail: JENNC@BAYSTATESEWAGE.COM FED ID/SS NO: 04-3015431 NUMBER OF TRUCK(S): 2 REGISTRATION NUMBER(S): 98205 86514 FEE PER TRUCK: $75.00 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE:- - ...... DATE: 11 7_/201 % 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. 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: Securely mounted on truck Watertight Leak -proof cover Tight discharge tanks AAcceptable 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: TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and - belie£ have filed all state tax returns and paid -all state taxes required under law. of Individual or Corp9ate Name By: Corporate Officer (Mandatory, ifAppiicable) oq-3b)-5 ] **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 IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 wo nnvip.nwss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: BAY STATE SEWAGE DISPOSAL, INC. Address 105 KINGMAN STREET City/State/Zip: LAKEVILLE, MA 02347 Phone #: 508-947-2636 Are you an employer? Check the appropriate box: Business Type (required): I. ❑✓ I am a employer with 23 employees (full and/ 5. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment 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. S. ❑ Non-profit 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ElManufacturing no employees. [No workers' comp. insurance required]* 11. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑✓ Other SERVICE with no employees. [No workers' comp. insurance req.] *Any applicant that checks box HI must also fill out the section below showing their workers' compensation polioy 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 Rl. I am an employer iliat is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ACADIA INSURANCE COMPANY Insurer's Address: P.O. BOX 59143 City/State/Zip: MINNEAPOLIS, MN 55459-0143 Policy # or Self -ins. Lie. # MAARP301685 Expiration Date: 06/15/2018 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. 1 do hereby qrtfy, raider the pains and penahies ofperjury 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 wway.mass.gov/cta ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/27/2017 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 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 CONTACT NAME: Carla Grosvenor FBINSURE LLC f`HAuc.NNr. Exth 508 824-8666 ac No: E�AIL AUDRESS: C msveno fbinsure.com INSURERS AFFORDING COVERAGE NAICM 128 DEAN ST INSURER A: ACADIA INS CO 31325 TAUNTON MA 02780 INSURED INSURER B: INSURER C: BAYSTATE SEWAGE DISPOSAL INC INSURER D: INSURER E : PO BOX 886 INSURER F: LAKEVILLE MA 02347 COVERAGES CERTIFICATE NUMBER: 168639 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. INSR LTR TYPE OF INSURANCE ADDL DIED SUBR POLICYNUMBER POLICY EFF MMIDO/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCUILGENERALLIABILDY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCURPREMISES A E(RENTED PREMISESSEa occurrence) $ MED EXP (Anyone person) $ PERSONAL &ADV INJURY $ N/A AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ GENT POLICY❑JE'CT- LOD PRODUCTS - COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINEDBINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO ALL AUTOS OWNED AUTOS UTOS N/A BODILY INJURY(Peleccidenl) $ NON -OWNED HIREDAUTOS AUTOS PROPERTYDAMAGE Per accident $ UMSRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE N/A DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDEDI N/A N/A N/A MAARP301685 06/15/2017 0611512018. PER Eol X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe aMached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts If the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at WWW.Mass.90V/Iwd/workers-compensatiordinvestigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield - Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row - 1 st Fir AUTHORIZED REPRESENTATIVE Mansfield MA 02048—�"� Daniel M. Crgw y, CPCU, Vice President — Residual Market— WCRIBMA n 19RR-9n1d ACnRn r.nRPnRATInN All rinhfa rnann.nd ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD BAYSTAT-02 LBROWN a►il Ro CERTIFICATE OF LIABILITY INSURANCE DATE 06/28/2017 ) osr2arzo17 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 CONTNAMFACT Loretta Brown FBinsure, LLC 128 Dean Street Taunton, MA 02780 PHONE FA% bar No, E,d : (508 824-8666 1240 wc, No : ADDRESS. LBrown@fbinsure.com INSURERS AFFORDING COVERAGE NAIC # INSURERA: Selective Ins CO of Southeast 39926 INSURED INSURER B: Selective Ins Co Of SC 19259 INSURER C: Baystate Sewage Disposal Inc INSURER D: PO Box 886 Lakeville, MA 02347 NSURER 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 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. INSR TYPE OF INSURANCE ADOLNsp SUER Wen POLICY NUMBER POLICY EFF POLICY E%PLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-;,71 OCCUR S2056663 01/18/2017 01/18/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES dEns occurrence $ 500,000 X MED EXP May one arson 15,000 Blkt Add'llns X I Blkt Waiver PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑X PRO nLOC GENERAL AGGREGATE $ 3,000,000 PRODUCTS -P 3,000,00 $ OTHER: B AUTOMOBILE LIABILITY CeMBINtlEDi SINGLE LIMIT $ 1,000,000 X BODILY INJURY (Per arson $ ANY AUTO A9098990 01118/2017 01/18/2018 BODILY INJURY Peraecid.rn $ OWNED SCHEDULED AUTOS ONLY AUTOB X PROPERTY DAMAGE Per axMiam S HIRED NON -OWNED AUTOS ONLY PUTOBONLY [MIS Poll Transit B X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 3,000,000 AGGREGATE 31000,000 EXCESS LIPS CLAIMS -MADE S2056663 01/18/2017 01/18/2018 DED XI RETENTION$ O $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN MY PROPRIETORIPARTNER/EXECUTIVE WandaRIME, NHJ EXCLUDED? If yes, describe under NIA PER OTH- STATUTE FOR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ B Equipment Floater S2056885 01118/2017 01/1812018 Leased Equipment 50,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Adtl#ional Remarks Schedule, maybe aaeched ifmore space is required) Septic Tank Cleaning & Repair Contractor. Automobile Liability policy Includes Pollution Transit Liability coverage. Leased Equipment coverage is Actual Cash Value -Special Form with $1,000 Deductible. Town of Mansfield Health Department Town Hall 6 Park Row • 1st Fir 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 REPRESENTATIVE 0 off. SA&W , ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Foxborough Town of Mansfield Town of Norton 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT PERMIT#: DATE: 11/9/2017 Paid: Y or N First Tri-Town Inspection Day COMPANY NAME:', ADDRESS: I Li✓ 1` l Y7J �i a�L 1' 7 ?` TELEPHONE#: OPERATOR: ✓/ Q ��. !/)✓7 C L 7 TANIZ CAPACITY: TRUCK LTC. NUMBER: r EE in ent 1. N bile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof cover, tight discharge valves) Venting (gas) of Mobile Tank (properly constructed) 3. /Suction or Pressure Hose in good repair fig 4. Pumps (teal( -proof) pia' This vehicle is in compliance with 310 CMR I (2017) Town of Foxborough Town of Mansfield Town of Norton 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT PERMIT#: DATE: 11/9/2017 Paid: Y or N First Tri-Town Inspection Day COMPANY NAME: \ ADDRESS: TELEPHONE#: OPERATOR: TANK CAPACITY: S 1 o C) TRUCK LIC. NUMBER: c(i (01: \ l Equipment t 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) 1� 3. Suction or Pressure Hose in good repair 4. Pumps (leak -proof) This vehicle is in compliance with 310 CMR 15.505. �nsper lwite ".4 AJ2, Person Interviewed (2017)