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HomeMy WebLinkAboutClaude DuBord & Son 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 CLAUDE DUBORD & SON, INC. Doing business as: CLAUDE DUBORD & SON, INC. 45 MAE AVENUE BRIDGEWATER MA 02324 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: 5 TRUCK REGISTRATION NUMBER(S): MA G41-583, E69402 S53488 BOARD OF HEALTH MichaeC.McCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 LICENSE NUMBER: 5 BUSINESS NAME: CLAUDE DUBORD & SON. INC. MAIL ADDRESS: 45 MAE AVENUE TOWN: BRIDGEWATER STATE: MA ZIP CODE: 02324 NAME OF OWNER: CL.AUDE DUBORD & SON, INC. BUSINESS TELEPHONE: (508) 697-2621 CELL: FAX: (508) 697-8761 E-mail: CLAUDE@CLAUDEDUBORDANDSONS.COM Alt E-mail: FED ID/SS NO: 04-2603832 NUMBER OF TRR CK(S): 3 REGISTRATION NUMBER(S): , MA G4 3 E696kD2 5 J 3AI ' FEE PER TRUCK: $75.00 Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: c ,ard of Health, Town of Man�spfrel_d,/&aPrkow Mansfield, MA 02048 SIGNATURE ( " _ U ✓L v DATE: 4 I< /I ..............................................................t... _ _.... 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 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: 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. L 6,1 0 ci t &0 _T'(. JX�z2 "( Signature of Indivim, d or Corporate Name ByVorfforate Micer (Mandatory, ifAppiicable) 04 Z&o 3%3Z.- "Social Security No. (Voluntary) or Federal Ident Ration 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 wiv)v.n:ass.gov/dia Workers' Compensation Insurance Affidavit; General Businesses Business/Organization Name: Ci Ara ou an employer? Check to appropriate box! I.,I am a employer with �0_ employees (full and/ or part-time).+ 2. ❑ 1 am it sole proprietor or partnership and have no employees working for me in any capacity, [No workers' comp. insurance required) 3. ❑ We are a corporation and its officers have exercised their right of exemption per a 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 reg.l one # Business Type (required): 5. ❑ Retail 6, ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. Non-profit 9. Entertainment 10,E Manufacturing 11 Health Care 120 Other lv *Any applicant thatoheoks box #1 must also fill out the section below showing their workers' compcnsat Ion policy information. 901f the eotporateo@icers have exempted themselves, but the corporation his other employees, a workers' compensation policy is required and such an or&aniaatlon should check box #I. 1 am an employer that is providing workers' compensation Insurance for my employees. Below is the policy informalton. Insurance CompanyName:-- A 1. M 11"lu+UAQ iqS ez) Insurer's City/stale/zip: Policy # or Self.ins, Lic. # idW C L31 D —301, 4 Expiration Date: .J -495 ^/ 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 MOL 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 maybe forwarded to the Office of rm..fi nednne-P.L-TIA I- ! _ __ . I do hereby cerik uVjf the pains 'perjury that tlse tnforniation provided above Official use only. Do not write in this area, to be cc nip toted by city or toivn officlaI,, City or Town; Issuing Authority (circle one); 1, Board of Health 2. Building Department 6, Other Contact Permit/License true and correct, 3. City/Town Clerk 4, Licensing Board 5, selectmen's Office www.mass.gov/dia Phone A� IQRO® CERTIFICATE OF LIABILITY INSURANCE DAT9/15/20/YYYY) ,A)'�'�' 0/15/2017 'INIS'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). PRCDUCER CONTACT NAME: Kern Maguire ESTABROOK & CHAMBERLAIN INSURANCE uc° N Eat: (508) 697-6963 A/C No) ADDRESS: kmaguire@estabrookohamberlain.com INSURERHAFFORDINGCOVERAOE NAICN .45 MAIN ST INSURER A: AIM MUTUAL INS CO 33758 BRIDGEWATER MA 02324 INSURED INSURER a : ,Q .4 tgDE DUBORD & SONS INC INSURERC: CILAUDE DUBORD & SON INC INSURERD: INSURER E : 4S MAS'AVENUE "BAbbitWATER MA 02324 1 INSURERF: ' C V 'G ES CERTIFICATE NUMBER: 192486 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 IADICATED. 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. I R. TYPE OF INSURANCE ADDL SUSHI WVQPOLICY NUMBER MMA101YYYY POLICY LIMITS i COMMERCIAL GENERAL LIABILITY EACHOCCUftRENCE § CLAIMS -MADE O OCCUR PREMISES Ea .... occueanw § MD EXP (Any one poraon) § ,) PERSONAL B ADV INJURY § h+ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE § 'Nl [,)'4 , POLICY❑PE° TOO PRODUCTS - COMP/OP AGG 8 § I� A?.' OTHER.] q Ay T O OBILELIABILITY M COMBINED SINGLE LIMIT § , Ea aede L BODILY INJURY (Per po am) § AA ft i i i' IANYAUTO �C,i�I :P AUTOSNED SCHEDULED NIA BODILY INJURY (Par auddent) § ( HIRED AUTOS AUTOS AUTOS PROPERTY DAMAGE Par. ieenl § § UMBRELLAUAB OCCUR EACH OCCURRENCE § EXCESS LIAR CLAIMS -MADE N/A AGGREGATE $ DIED RETENTION § _ WORKERS COMPENSATION I AND EMPLOYERS' LIABILITY YfNANYPROPRIETORWARTNERAEX /� STATUTE ER E.L. EACH ACCIDENT § 1,000,000 A OFFCERR EMEREXCUDED?ECUTIME NIA NIA N/A AWC40070263102017A 05/25/2017 05/25/201$',: (Mandatary In NH) E.L. DISEASE - EA EMPLOYEE § 1,000,000 If yea, dreorno under E.L. DISEASE -POLICY LIMB 1 § 1, 000,000 DESCRIPTION OF OPERATIONS below NIA OBSCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACOR0101, AddRlanel Remark. 8pbeeole, may be eRecbed if man apace la squired) ,YYyy riters'tCompensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay C ruins for benefits to employees in slates 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 "issVe 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 atwwrr.mass,gov/lwd/workem-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS, B_ Park Road AUTHORIZED REPRESENTATIVE ,J f`'�/S_ Mansfield MA 02048 t4 n Ier I u - � Daniel tilt' Daniel M. Cr y, CPCU, Vice President —Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. -A&l)kD 25 (2014101) The ACORD name and logo are registered marks of ACORD ) T t is ;' i DUBOR-1 OP ID: KM �••�` �pRO° DATE (MMIDOAMN) CERTIFICATE OF LIABILITY INSURANCE 0711412017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS _[ICERTIFICATE 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 oi(RPPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) 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 endorsements . PRODUCER Estabrook & Chamberlain Ins .;:0: Box 277 CON NAME; Thomas T. Chamberlain PHONE FAX Arc No Ex : 608-697.6963 ac Ho: FAX-697-5809 _ ' ADDRESS, Bridgewater, MA 02324.9986 Thomas T. Chamberlain INSURER(Sl AFFORDING COVERAGE NAIC i INSURERA: New Hampshire Insurance Co. INSURED Claude Dubord & Sons, Inc. INSURERS: American International Co. 45 Mae Avenue Bridgewater, MA 02324 INSURER C : INSURER D: INSURER E : • INSURER F: ' COVE. �bGE§� CERTIFICATE NUMBER: REVISION NUMBER: =T IS -TO -CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD " INDICATIEO. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 06RTIFICATE 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. L R TYPE OF INSURANCE POLICYNUMBER MMIDO MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 Jr' CLAIMS -MADE a OCCUR 01 •LX-059312766-0 05/14/2017 05114/2018 PREMISES ea o current. $ 100,000 MED EXP (Any one person) $ 5,000 Blkt addl CG2003 PERSONAL &ADV INJURY $ 1,000,00 X AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,00 tl - GEN'L POLICY ❑PECT D LOC PRODUCTS - COMP/OP AGO $ 2,000,00 $ OTHER AUTOMOBILE LIABILITYEe e©IN�EDISINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) s A �ANYAUTO 01-CA-069969546-0 05/14/2017 05114/2018 ,',',11•!. ~''`1'X i.. AA(ILNO VJNED X AIROS HEDULED 11 WNED I111RED AUTOS X AUT BODILY INJURY (Per accident)$ PereccaY DAMAGE $ $ )( U,MBRELLAUAB X OCCUR EACH OCCURRENCE It 2,OOQOO �. i EXCESS LIAR CLAIMS-M40E 29•UD•066146793.0 05/14/2017 05/14/2018 AGGREGATE $ 2,000,00 DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORiPARTNERiEXECUBVE ❑N/A OFFICER/MEMBER EXCLUDED? (Mandatory In NH) PER OTR STATUTE ER E. L EACHACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ II yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIr $ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Addidonal Remark. Schedule, maybe attached If more spec. le required) CERTIFICATE HOLDER CANCELLATION MANSFI6 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE . ;v, :I�'. �iL4i'laa� C��1aL•rX�t.�4v�t.+'7 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ! i Town of Foxborou Town of Town c fie Norton _ OF c�c� Cv 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 1y-\y Cx'> --k�)'Jb u r g T .S(Y� t✓C ADDRESS: L15 rA ne 6 ,e TELEPHONE#:7 OPERATOR: TANK CAPACITY: 7 7 Q 6 TRUCK LIC. NUMBER: Equipment 1. Mobile Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof cover, tight discharge valves) X Venting (gas) of Mobile Tank (properly constructed) . Suction or Pressure Hose in good repair Al 4. Pumps (leak -proof) �a This vehicle is in compliance with 310 CMR 15.505. r Person Inte iewed Inspector od- (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 i jv1.�A tti�n h First Tri-Town Inspection Day COMPANY NAME: ADDRESS: TELEPHONE#: OPERATOR: TANK CAPACITY: `> () (` TRUCKLIC. NUMPER: Enuuipment ' 1. Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof / cover, tight discharge valves) ta2. Venting (gas) of Mobile Tank (properly constructed) q�3/. %Suction or Pressure Hose in good repair . 4. Pumps (leak -proof) SN This vehicle is in compliance with 310 CMR 15.505. ersok'Intet viewed Spector (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: C Vxuc)Q- vvx)c 3 ADDRESS: TELEPHONE#: h,09, c, C' l OPERATOR c,yav� t a�A�sc� TANK CAPACITY: Sc)c) TRUCK LTC. NUMBER:-5'A<G%' _ 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. C, Person Interviewed Insp�c or (2017) Town of Foxborough Town of Mansfield Town of Norton 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT PERMIT#: Paid: Y or N COMPANY NAME: ADDRESS: TELEPHONE#: OPERATOR: DATE: 11/9/2017 First Tri-Town Inspectiot TANK CAPACITY: TRUCK LIC. NUMBER: I IJ ! /I E ui ent 1. Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 4/2./ Venting (gas) of Mobile Tank (properly constructed) oV 3 Suction or Pressure Hose in good repair 7 Pinups (leak -proof] tY This vehicle is in a fiance with 310 CMR 15.5 P n rviewed (2017)