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HomeMy WebLinkAboutCavalieri Cesspool Service 12/31/2018T 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: WILLIAM CAVALIERI Doing business as: CAVALIERI CESSPOOL SERVICE 61B COTTAGE STREET NORTH ATTLEBORO MA 02763 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 III section 31A and expires December 31, 2018 unless sooner suspended or revoked. LICENSE NUMBER: 4 TRUCK REGISTRATION NUMBER(S): J31-444 BOARD OF HEALTH MichaeCMcCCean, Chairman Septage Pumpers Application BUSINESS NAME:ZI MAIL ADDRESS: (p) B TOWN:/10(I(tI 97T I C(-0e,' STATE: fV1/ 5 S NAME OF OWNER: L, _), ( ( t t l�j 64Ott li'I %JLI� BUSINESS TELEPHONE:-j(S (oqS'- Cta 3C<-) CELL: ,Si�iSiG( DATE: 1419]AIM:IzIII N1 3 4 ZIP CODE: () d 76 . j 50S�-,?71 `3)3/7FAx: E-mail: Cwvgt:c '. II•'S j C yn� i, ccM Alt E-mail: FED IDISS NO: (} ,I - (f��(�C� NUMBER OF TRUCK(S): J 3000 REGISTRATION NUMBER(S):}�-L{ FEE PER TRUCK: Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town , f Mansfield, Six P .k-Row, Mansfield, MA 02048 SIGNATURE: Liziy DATE: .............................................................................................................................................................. . TRUCKS INSPECTIONS: DATE: TIME: PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO. MAIN STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THESE DATES 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 A = Acceptable 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: 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) 03 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Address: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.9 I am a sole proprietor or partnership and have no ?, ❑ 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box NI must also till 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 t11. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Y Insurer's Address: 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 insurance coverage verification. I do hereby certify, tamer the pains and penyhfus-gfpoury 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 Person: Phone www.mass.gov/dia 3,;73% CAVAW01 OP ID: SD ACORO 16- CERTIFICATE OF LIABILITY INSURANCE -DATE 1 10124/2017 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 Phone:508-695.0314 R.A. Reinbold Ins. Agency Inc. 860 Landry Ave Fax: 508-699-2583 P.G. BOX 68 N. Attleboro, MA 02761- _ CONTACT NAME: PHONE---- A/c No Exit, LyNo): EMAIL ADDREss: Douglas J. Reinbold INSURER(S) AFFORDING COVERAGE NAIC# _ INSURER A: Safety Insurance Co. INSURED William P. Cavalied 61 B COTTAGE ST NORTH ATTLEBORO, MA 02760 INSURER B: INSURER C: INSURER D: INSURER 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. ILTNI TYPE OF INSURANCE OB SUR POLICY NUMBER MM/DO/YYVVV MM/ODY/YEYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) _ $ PERSONAL B ADV INJURY $ GENERAL AGGREGATE GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOG PRODUCTS-COMPIOP AGG $ — $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS 6238583 06/23/2017 05/23/2018 COMBINED SINGLE LIMIT Ea accident $ 1,000,08 BODILY INJURY (Per person) _ $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ LIAB FEXCESSB OCCUR LAADAGGREGATE EACH OCCURRENCE $ $ RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERS,LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (MandatoryinNH) If yes, describe under DESCRIPTION OF OPERATIONS be. N /A I WC STATU- OTH- TCRY LIMITS E ._ E.L. EACH ACCIDENT $ E. L. DISEASE - EA EMPLOYEE ------ $ E.L. DISEASE -POLICY LIMIT -- $ DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace is required) 2002 EREI 1FVHBXAK12HK26403 CERTIFICATE HOLDER CANCELLATION MANSFIE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Douglas J. Reinbold J ACORD 25 (2010/05) ©1988-2010 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: C 00jo'\ \Q k \ ADDRESS: VD CyNe.c N A\ TELEPHONE#: (��US OPERATOR: C) TANK CAPACITY: zc 'o C ) TRUCK LIC. NUMBER:' V1� 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 kA. Pumps (leak -proof) i This vehicle is in compliance with 310 CMR 15.505. erson 4tervkied Inspect (2017)