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HomeMy WebLinkAboutMr. Cesspool, Inc. 12/31/2018L9 Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: Doing business as: CHARLES LEONARD MR. CESSPOOL, INC. P.O. BOX 50027 NEW BEDFORD MA 02745 Town of Mansfield 6 Park Row 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 II I section 31A and expires December 31, 2018 unless sooner suspended or revoked. LICENSE NUMBER: 12 TRUCK REGISTRATION NUMBER(S): S16315 BOARD OF HEALTH Nichae(NeC(ean, Chairman �� � ykgM1hCOA.`� fpRsnu`� Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application BUSINESS NAME: MR. CESSPOOL, INC. MAIL ADDRESS: P.O. BOX 50027 TOWN: NEW BEDFORD STATE: - DATE: a LICENS NUMBER: Sol , MA _�.---ZIR-C--ODE: 02745 kd n =._.._.r.----- 2017 12 r,I.A_ME OF OVV,NER: CHARLES LEONARD BUSINESS TELEPHONE: (508) 985-0991 CELL: FAX:1 E-mail: mrcesspool@verizon.net Alt E-mail: FED ID/SS NO: 46-4276914 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): S16315 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 sfiel Six Park Row, Mansfield, MA 02048. j 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 '10 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: B. Venting of Mobile Tanks: k Securely mounted on truck _ A Vent permits escape of gas, but not liquid ''t Watertight C. Hose: Leak -proof cover '�, Suction or pressure hose in good repair Tight discharge tanks D. Pumps: N Maintained to prevent leaking of sewage A = Acceptable _....1 Inspected by: NA =Not Acceptable J Inspected 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. Alr��Twlt�lhc__ Signature of Individual Kr Corporate Name By: Corporate Officer (Mandatory, ifApplicable) Y6 ~Yd,764=/ "*Social Security No. (Voluntary) or Federal Identification 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 1 Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PER&IITTIIv'G AUTHORITY. pplicant InformationPl Business/Organization City/State/Zip: Are y Tr an employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part-time),* 2: Q 1 am a 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 c. 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 rN.] )n #: Business Type (required): 5, El Retail 6,nRestaurar:t/Bar/BatingEstablishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10, ❑ Manufacturing 11. ❑ Health Care. ii *Any applicant that cheoPs box #1 nnsst also fill out the section below showing their W miotn' compensation policy ioformation. **If the corporateoflicers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such m miranization should check box M. I am an employer that is proi4ding Insurance Company Name: Insurer's Cityistate zip; my is Policy# or Self -ins, Lic. #X� � 57�wz Expiration Date: 1, aI/Id` Attach a copy of the workers' compensation policy declaration page (showiner an g the policy numbd 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 feria of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Official use only. Do not write fn 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/Towa Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone #: ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(/13/201MM/ 2017l �� 12 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 PRODUCER Southeastern Insurance Agency, Inc. 439 State Rd. P.O. Box 79398 North Dartmouth MA 02747 INSURED P O Karen Bernier xtj (508)997-6061. _. i FAX 1(AIC, No):.(506) 990-2731.__ _. kbernier@southeasternins.com e Co. l New Bedford MA 02745 (INSURER F: COVERAGES CERTIFICATE NUMBER-CL1731303566 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 W)TH 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, lADDL SUBR'- - POLICY EFFr POLICY EXP ILTR TYPE OF INSURANCE POLICYNUMBER MWDO/YYYY MMIDDNYW LIMITS X COMMERCIAL GENERAL LIABILITY EACH $ 1, 000, 000 I A CLAIMS MADE X �''� OCCUR TO h DAMAGE TO RENTED 4 PREMISEUEa occmmrce)_ I $ 300, 000 BKS57844348 3/?/201? 3/7/2018 MED EXP (Any one person) $ 15,000 _ PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. ( GENERAL AGGREGATE I$ 2,000,000 I X 'i POLICY PRO- ( I LOG � JECT ' PRODUCTS, CONFIDE AGO ( $ 2,000, 000 OTHER: $ AUTOMOBILE LIABILITY _ (Ed acddent51NGLE LIMIT ) $ 1,000,000 A ANY AUTO BODILY INJURY person) P LS TALL OWNED SCHEDULED BAS57844348 3/7/2017 3/7/2018 BODILY INJURY (Per mukenn $ AUTOS AUTOS NON -OWNED X I HIRED AUTOS X AUTOS PROPERTY DAMAGE (Per accident) _ I$ included Uninsured motorist combined $ 300, 000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE L$ 1, 000, 000 B EXCESS LIAB CIAIMS MADE( - AGGREGATE $ 1,000,000 X DIED RETENTION$ 101000 US057844348 3/7/2017 3/7/2018 $ WORKERS COMPENSATION X PER X OTH STATUTE_1 AND EMPLOYERS' LIABILITY YIN( -I IER I$ .ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? I N C NIA ELEACH ACCIDENT 500,000 T In (MandatoDESCRIPTION IXW057894398 3/7/2017 3/7/2018- EL DISEASE EMPLOYE $ 500, 000 Oantler yes,deunder II OF OPERATIONS below I El DISEASE - POLICY LIMIT It 500,000 I 1 i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Com Town of Mansfield Town Hall 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Bernier/KAB "T J� Jot -I ©1988-2014 ACORD CORPORATION. All ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401)