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Home My WebLink AboutCroome Sanitation 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage Pumping and Transporting Permit This is to certify that: EARL T. P. CROOME, JR. Doing business as: CROOME SANITATION, INC. 26 HILLSIDE AVENUE 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: 6 TRUCK REGISTRATION NUMBER(S): MA 4938A, 41189 BOARD OF HEALTH Mlchae(MCC(ean, Chairman .�� ptiGiNC) �� tY ° Town of Mansfield a Town of Mansfield - Board ofIgth s Row ti Mansfield, MA 02048 v� ASAAyyW i4a' 71€ Septage Pumpers Application ------------- - - DATE: 2017 LICENSE NUMBER: 6 BUSINESS NAME: CROOME SANITATION, INC. MAIL ADDRESS: 26 HILLSIDE AVENUE TOWN: REHOBOTH STATE: MA ZIP CODE: 02769 NAME OF OWNER: EARL T. P. CROOME, JR. BUSINESS TELEPHONE: (508) 252-4668 CELL: FAX: (508) 252-5144 E-mail: CROOMESANITATION@COMCAST. NET Alt E-mail: FED ID/SS NO: 04-3131229 ✓4139A NUMBER OF TRUCK(S): 2 REGISTRATION NUMBER(S): MA 55543; 41189 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: 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 T ranSpor al on 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 I A = Acceptable 3 NA = Not Acceptable S. 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. Ob o vv\,e. JOJI Z -kk dyl T✓\L. Signature of Individual or Corporate Name 3131 as "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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. 0. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 B 01 16 Issuing Company: Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 6089473 - 14 Previous Policy No.: 6089473-13 1. Name Insured and Address Agency Name and Address 07431 Croome SanitatiX769 c (508) 824.8666 26 Hillside AvenFBinsure Rehoboth, MA 0 P.O. Box 509 \ Taunton, MA 02780 Other workplaces not shown above: Refer to Name and Location Schedule FEIN: 042472921 Risk ID No.: Bureau File No.: 000158630 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 04/06/2017 to 04/06/201812:01 AM Standard Time at the insured's mailing address. 3..,,A..,. Workers C the states Part One of the policy applies to the Workers Compensation Law of B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ . 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 01 B 0115 Includes copyrighted material of The National Council on Compensation Page 1 of 4 Insurance, with their permission. The Commonwealth of Massachusetts Department of Industrial. Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dla Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Croome Sanitation Inc 26 HIllside Ave. City/State/Zip: Rehoboth, MA 02769 Phone 4: 508-252-4668 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 6 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. Ej Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g, Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and the have 10.0 Manufacturing no employees. [No workers' comp, insurance required]* 11.❑ Health Care 4. El We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.) 12.00ther Septic ,Services *Any applicant that checks box Nl must also fill out the section below showing their workers' compensation policy information --It me cogrorate onrcers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box Nl. Iant an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Name: Acadia Insurance Insurer's 290 Donald J. Lynch Blvd. City/State/Zip: Marlborough, MA 01752-4710 Policy #or Self -ins. Lic. # WCA 5089473-1.4 Expiration Date: 4/6/1? 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 a 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigation of the DIA for insurance coverage verification. I do hereby certify, aadgr the palms and penalties of perjtuy that the information provided above is true and correct Signature: Date: �i l /17 508-252-4668 Earl T.P..Croome, Jr. — President FOther. only. Do trot write in this area, to be completed by elly at- torvrt official n: Pcrmit/Licensc tl _ hority (circle are): Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office rson: Phone a: wx%%v.fums.gov/dia 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: TRUCK LIC. NUMBER: Equipment elco li b GS D' d CP cc �S \�' OCR 2, L 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. Inspe r (2017) Town of Foxborough Town of Mansfield Town of Norton al""'310 CMR 15.505 it'SEPTAGE HAULERS INSPECTION REPORT 1 PERMIT#: Paid: Y or N COMPANY NAME: ADDRESS: TELEPHONE#: OPERATOR: TANK CAPACITY: TRUCK LIC. NUMBER: Equipment DATE: 11/9/2017 First Tri-Town lnsnectio NMI ❑ 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 (ieak-proof) ❑ This vehicle is in compliance with 310 CMR 15.505. Person Interviewed Inspector (2017) License Number: 2018-25 The Commonwealth of Massachusetts Town of Norton This is to Certify that Earl T.P. Croome Jr Doing Business As: Croome Sanitation Inc. Whose Place of business is: 26 Hillside Ave, Rehoboth, Ma 02769 IS HEREBY GRANTED A LICENSE $75.00 For: PUMPING AND HAULING SEPTAGE, GREASE OR SLUDGE IN THE TOWN OF NORTON. Registration Number: 4938A This License is granted in conformity with 310 C.M.R. 15,000 and the statutes and ordinances relating thereto and expires December 31, 2018. L Robert B. edeiros Chairman Vice-Ch irman William Hebard, Clerk Date Issued: 10/2/17 Town of Norton 310 CMR 15.505 SEPTAGE HAULERS INSPECTION REPORT PERMIT#: DATE: 111AS7'2017 Paid: Y or N First Tri-Town Inspection Day COMPANY NAME:y"�Qr7%� ADDRESS:�� TELEPHONE#:"// OPERATOR: /r/�� j r�ar)4r 91v TANK CAPACITY: T CX/'✓ TRUCK LIC. NUMBER: Equipment L Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof cover, tight discharge valves) 6Y 2, Venting (gas) of Mobile Tank (properly constructed) 0/3. Suction or Pressure Hose in good repair OV 4. Pumps (leak -proof) o' This vehicle is in compliance with 310 CMI tso Interviewed (2017)