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Home My WebLink AboutG. Horne Pumping 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: GARRY HORNE Doing business as: G. HORNE PUMPING • c•r_ MANSFIELD MA 02048 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 I I I section 31A and expires December 31, 2018 unless sooner suspended or revoked. LICENSE NUMBER: 9 TRUCK REGISTRATION NUMBER(S): MA 1803 BOARD OF HEALTH 'lichaeCMcCCean, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 LICENSE NUMBER: 9 BUSINESS NAME: G. HORNE PUMPING uTif_1TWT77T�� TOWN: MANSFIELD STATE: MA ZIP CODE: 02048 NAME OF OWNER: GARRY HORNE BUSINESS TELEPHONE: (508) 543-4511 CELL: FAX: (508) 285-3937 E-mail: Alt E-mail: FED ID/SS NO: 04-2868251 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): MA 1803 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: s _ DATE: S_ 1 ........................... .... ........ ........- ........- ........ ............ 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 FORTi'J I certify under the penalties of perjury that L to my best icnowledee az c" relief, have iiled afl state tax returns and paid all state taxes required antler taw. Si�rlature of l '�.ual or Corporate blame By; Corporate Officer (Mandatonj, if Applicable) mil_ �� 'Social Security No. (Noluntwy) or Federal Zdactifzcation 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 deliszquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. RAHcalthUam's DOcllII1 o\TAX CERTMICATION FORM.doo i i 7`Ate f";`tlrnttaCirzwetitlt: of �clssrer..faraseCt.€' ; epartment of tndrrsdruaLAeczdea€ts )2f ,-e ta,} j`fIVesFtgaa0sts Weston, MA 02114-2017 FV tV iE',rtEG?&,P, j', iJ3if(i9ff. Woorer s9 C sitapentaffor. insuranceAffidavit Gefaeriai Businesses ,kmk"at )ortrt Dare . _. _ � Please- I Brut Le tgv�aly Adds n: - Are you an emplo;, ex? Checir the appropriate box; I, C Z a_na a employer vihtit. mmernployees (fall and/ nr part-time)." 2.1,4i 1 ain a sole Proprietor or partnership and have ao employees working for me. in any Capacity, [No workers' comp, insurance required) 3, El We, are a corporation and its officers have exorcised their right of exemption per o, 152, § 1(4), and we have no emplovee,% [No workers' comp, insurance required! ?, E] We are a non-profit organization, staffed by volunteers with no employees, (No workers' comps insurance ten, Phone, Business Type (regnlred): S. ❑ Retail tv, 6. [1 RestatimmA/Bar/Bating Establisbarent 7, ❑ Office mud/or Sates (inol, real estate, auto, etc) 8. 0 Non-profit 9. ❑ Entertainment WE] Manufacturing I I.❑ rlsa th Care 110 Other V,fry opptlusat that ohcoiu 1:001 most 050 fill nut nit Amflon hdlow ahawingf0r—=rkrs' wrnpensntton pol{oy ina,m&hon, N '�°Jf the urrpmatc n�cees h®ve exempted ehcrosclves, but the corporation ben other dmpfoyeos, a workers' nnmpuuaflnn policy is required and zueh nn argnnizatinnshould clrectsbox Hi, I girl all eloPkyef that 1,911rovidi➢ g Workers' ConlpenSadon insurance for Pny e sphay ses, heron, iS the PORCy it amatiam insurance Company Insurer's Address: City/State/Zip: Policy # or Self -his. Lie, ir,, Expiration Attaeh a copy of the workers' enmpensation policy declaration page (showing tile policy number and expiration da(a), Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Into up to $1,500.00 and/or one-year imprisonment, as well as civil penalties ill the form of a STOP WORK ORDER acid a fine of'up to $250.00 a day against the violator, Be advised that a copy of this statement may be foty arded to the Office of Investigations of the DJA for insurance coverage verification I do hereby acrie, tinder Fisnnhrre�..M%"f '^,.s. that the information provided above is true and correct. Offtcird use only, Do not Write tit this area, to be, compieted by city or town off etat, City or Town:--Permit/License Issuing Authority (circle one): 1. hoard of health 2, Building (Department a, City/Town Clerk A. Licensing Hoard 5. Selectmen's Orfieo 6, Other .. Contact Person: —_.___ — Phone Town of Foxborough Town of Mansfield Town of Norton 310 CMM 15.505 SEPTAGE HAULERS INSPECTION REPORT PERMI�#; DATE: 11/9/2017 Pald/� Or N First Tri-Town Inspection Day r� l COMPANY NAME: // bZ (h 1 ADDRESS: �/'dl' TELEPHONE#: 5— — OPERATOR: TANK CAPACITY: TRUCK LIC. NUMBER: Equipment 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 k4. Pumps (leak -proof) is vehicle is in compliance with 310 CMR Person Interviewed (2017)