The URL can be used to link to this page

Home My WebLink AboutDumont Pumping Service 12/31/2018qND 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: ALEC RICH Doing business as: DUMONT PUMPING SERVICE P.O. BOX 292 NORTON MA 02766 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: 7 TRUCK REGISTRATION NUMBER(S): 518408 T15768 BOARD OF HEALTH MichaeCMcCCean, Chairman DATE: 2017 LICENSE NUMBER: 7 BUSINESS NAME: DUMONT PUMPING SERVICE MAIL ADDRESS: P.O. BOX 292 TOWN: NORTON STATE: MA ZIP CODE: 02766 NAME OF OWNER: ALEC RICH BUSINESS TELEPHONE: (508) 285-7783 CELL: FAX: (508) 821-4474 E-mail: ADVANCEDGROUP@COMCAST. NET Alt E-mail: FED ID/SS NO: 04-3339518 NUMBER OF TRUCK(S): 1 REGISTRATIONNUMBER(S):..- TN63 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 Ma re Six ark Row Mansfield, MA 02048 SIGNATURE: /� (L/ 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. 15,902 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents. i b.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: 501 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 P1�� & t-}Yy- \ (1 LICENSE NUMBER: 7 BUSINESS NAME: '1 VICE —7 � �� 1p 00 MAIL ADDRESS: P.O. BOX 292 1 TOWN: NORTON STATE: MA ZIP CODE: 02766 _._ NAME OF OWNER: ALEC RICH BUSINESS TELEPHONE: (508) 285-7783 CELL: FAX: (508) 821-4474 E-mail: ADVANCEDGROUP@COMCAST.NET Alt E-mail: FED ID/SS NO: 04-3339518 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): 3 �,La 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 Ma ie , Six ark Row, Mansfield, MA 02048. SIGNATURE..... DATE �Q ?(-) .-- 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. . 1b.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 Watertight C. Hose: Leak -proof cover Suction or pressure hose in good repair Tight discharge tanks D. Pumps: Maintained to prevent leaking of sewage A = Acceptable Inspected by: NA = Not Acceptable '--- - 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. Signature of Individual or Corporate Name C)Lk "3�: 3 q�10f9 **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. \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite I00 Boston, MA 02II4-20I7 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE RLED WITH THE PER➢UTTING AUTHORITY. City/State/Zip: --T Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 1 am a employer with employees (full and/ 5. ❑ Retail ,�r part-time).* 6. [IRestaurant/Bar/Bafing Establishment 2., i am a sole proprietor or partnership and have no g ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working forme in any capacity. [No workers' comp, insurance required] 8. ❑ Non-profit 3, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per e. 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.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted thcrosclvos, but the corporation has uthcr employees, a workers compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for 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 in�qrance coverage verification. I do hereby certify, under egrl;Zrs a . penalties ofperjury [hatthe information provided above is true and correct Signature: v � irate• 1�' l"I�I� 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 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 COMPANYNAME: � m_ d gv�w ADDRESS: TELEPHONE#: OPERATOR: TANK CAPACITY: TRUCK LIC. NUMBER: Egq u!ipment EYip 1. Mobile Tank (securely mounted on trucks, watertight, necessary oilor controls, leak -proof cover, tight discharge valves) a,V, 22.. Venting (gas) of Mobile Tank (properly constructed) 0/3uction or Pressure Hose in good repair ❑ .umps (leak -proof) is in con iance with 310 CMR 1; (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 Fiest Tri-Town Lispection Day COMPANY'NAME- (/ ► ADDRESS: TELEPHONE#: OPERATOR: TANK CAPACITY: 7 ( ✓ TRUCKLIC. NUMBER: �Egquipment t qi'1 1. Mobile Tank (securely mounted on trucks, watertight, necessary odor controls, leak -proof t! cover, tight discharge valves) ( 2. Venting (gas) of Mobile Tank (properly constructed) 3. Suction or Pressure Hose in good repair jk 4. Pumps (leak -proof) This cle is in compliance with 310 CMR 15.505, Inspector (2017)