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Home My WebLink AboutMiles of Excavating 12/31/2018A\ I Commonwealth 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: TIMOTHY KONOWITZ Doing business as: MILES OF EXCAVATING 242 PARK STREET WRENTHAM MA 02093 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: 11 TRUCK REGISTRATION NUMBER(S): N79 901 BOARD OF HEALTH JWichaeC-%1cCCean, Chairman V 0 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application DATE: 2017 BUSINESS NAME: MILES OF EXCAVATING MAIL ADDRESS: 242 PARK STREET TOWN: WRENTHAM STATE: NAME OF OWNER: TIMOTHY KONOWITZ BUSINESS TELEPHONE: (508) 384-9590 LICENSE NUMBER: 11 MA ZIP CODE: 02093 CELL: (508) 726-8715 FAX: (508) 384-9590 E-mail: MILESOFEXCAVATING@YAHOO.COM Alt E-mail: FED ID/SS NO: 04-3458817 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): N79 901 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: I RUCKS 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 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 A = Acceptable Inspected by: 3 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 By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary or Federal Identycation 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 IndustrialAccidents u,p Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Legibly Business/Organization Address: `\Ras-k !-A-cecly kA A Cm-) -k Phone #:_ Are you an employer? Check the appropriate box; Business Type (required): 1, I am a employer withemployees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestataatibEar/Esting Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity, g ❑ Non-profit workers' comp. insurance regaired] 3. ❑ We are a corporation and its officers have exercised 4, ❑ Entertainment their right of exemption per c.152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.RR Other *Any applicant (hat checks box #I must also all out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation bas other employees, a workers' compensation policy is required and such an organization should chock box#1. I am an employer diat is Insurance Company Nor Insurer's Address: W City/State/zip: CAA U Policy # or Self -ins. Lie. Attach a copy of the wt workers' compensation insuranceformy employees.' .below Is thepollcy Information. Q5i In(p ExpitatlmDate• compensation pollcy 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 insurance coverage verification. I do and that ilte Official use only. Do not write In this area, to be completed by city or town offlctat. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other above Is true and correct 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office Contact MILEOFE-01 —__ CWOODSIDE ,4164 R CERTIFICATE OF LIABILITY INSURANCE D ) 08128/2017 08/28/2077 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 INSURERS) AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). PRODUCER License # 1780862 HUB International New England 600 Lon water Drive Norwell, MA 02061-9146 N CT Michelle Wolf PHONE FAX lac, Na, Ea1 : (508) 888-2183 lac, No):.,_ _ %- tss: michelle.wolf hubinternational.com _ INSURERIS)AFFORDINGCOVERAGE _ NAICA INSURERA:Nautilus Insurance Com an 17370 INSURED INSURER B:Commerce Insurance Comnagy 34754 INSURERC: Wesco Insurance Company 25011 Miles of Excavating Timothy Konowitz dba 242 Park Street Wrentham, MA 02093 __ _ INSURER D : — — INSURERE: _ INSURER F: COVERAGES CERTIFICATE NIIMRFP- REVISION nu uaoco. 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 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. INSR �__. TYPE OF INSURANCE A661 SUER _ POLICYNUMBER POLICY EFF POLICY EXP UNITS A I X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [X] OCCUR X NN770794 02/27/2017 02/27/2018 EACHOCCURRENCE $ 1,000,000 DAMAGE T AEAGEs EaENTED $ 100 0 00 -- MED E%P (Anv one oersan S 15,000 ---- -.. PERSONAL& A_DVINJURY_ 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ POLICY JECT El GENERALAGGREGATE $ 2,000,006 PRODUCTS-COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT $ 1,000,000 B OTHER: AUTOMOBILE LIABILITY BODILY INJURY Per arson S ANY AUTO AUTOS ONLY X AUTOSULED N.pWNEo X ALT OS ONLY X_ AUTOS ONLY MMBHDLXX 02/27/2017 0212712018 BODILY INJURY Peraccident --- $ PPeracccRjnt AMAGE �I I _ --- iS UMBRELLA LIAB OCCUR EACH OCCURRENCE § AGGREGATE § _- EXCESS LIAB CLAIMS -MADE PER OTH- STAT. TE ER I S C �WORKERSCOMPENSAIIION idescribe DED RETENTION$ ANDEMPLOYERSLIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE f-�� oFFI EWMEM EXCLUDED? M WFNatory In � j under DESCRIPTION OF OPERATIONS belov NIA WWC3291661 0812312017 08123/2018 -` E.LEACHACCIDEN7 _ $ 500,000 ELDISEASE_EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. W TBUC-ZUTD AL;UKU CUHPURATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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: J7 TRUCK LTC. NUMBER: Equipment QC1. Mobile Tank (securely mounted ou 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 Pr 4. Pumps (leak -proof) ,4( This vehicle is in mpliance with 310 CMR 15.50`. Person Interviewed (2017)