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HomeMy WebLinkAboutPatriot Services 12/31/2018me 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: KATHLEEN BLANCHARD Doing business as: PATRIOT SERVICES P.O. BOX 294 BRIDGEWATER MA 02324 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: 14 TRUCK REGISTRATION NUMBER(S): K81034 GREASE TRAPS ONLY BOARD OF HEALTH .MlchaeC.MCCCean, Chairman BUSINESS NAME: PATRIOT SERVICES MAIL ADDRESS: P.O. BOX 294 TOWN: BRIDGEWATER STATE: MA NAME OF OWNER: KATHLEEN BLANCHARD BUSINESS TELEPHONE: (508) 697-9565 CELL: E-mail: PATRIOTSER@COMCAST, NET Alt E-mail: ®9L\��41I1 LICENSE NUMBER: 14 ZIP CODE: 02324 FAX: (508) 697-9564 FED IDISS NO: 20-1256154 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBER(S): K81034 GREASE TRAPS ONLY 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 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: Securely mounted on truck r. _ 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: oh.\ -A\ A =Acceptable � NA. = Not Acceptable '` 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. zuof Individual or Corporate Name y: Corporate Officer (Mandatory, if Applicable) ')o -17, **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. 1 N The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 k1Vj www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERA f=G AUTHORITY. Business/Organization Name: r� `�c3L�I�ta� V—U I CP C Address: '-�b '-�Npo:�Yt� Areypa an employer? Check the appropriate box: I . , I am a employer with employees (full and/ or part-time).* 2: [_] 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 req.] Phone #: Business Type (required): 5. ❑Retail 6. ❑Restaurant/Bar/BafingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 111p,1t Health ((Cara 1 12, pry.Other ] L Sl v (usc rszT 0 o *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy Wormetion. �l **If the corporate officers have exempted themselves, but the corporation bas other employees, a workers' compensation policy is required and such an organization sbould check box N. I am an employer that is providing }porkers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: C) G--C-u�l City/State/Zip: 7'..p- 0.. \`4s" a�!y� Policy # or Self -ins. Lie, # L,� �d t'�, ti Expiration Date: C T� 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 e. 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 hereby ce fifl,llnder the pains and penalties ofperjury thatthe Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License is a and correct 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 w .mass.gov/dia Phone #: ACORO® CERTIFICATE OF LIABILITY INSURANCE `a DATE(MM)D/YYYY) 10/25/2017 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Matisse Lima D'Agostino Insurance Agency °a"c° No EXt: (508) 586-0414 ac Nq: (508) 584-7432 E-MAIL ADDRESS: mlima@rfdinsurance.com 7 ChristY 's Dr. Suite 2 INSURER(S) AFFORDING COVERAGE NAICIf INSURERA: TRAVELERS IND CO OF AMER 25666 Brockton MA 02301 INSURED INSURER B: TRAVELERS CAS INS CO OF AMER 19046 _ INSURERC: TRAVELERS INSURANCE 25658 PATRIOT SERVICES INC INSURERD: TRAVELERS IND CO OF CT 25682 115 HAYWARD PL INSURER E : 1 INSURER F: BRIDGEWATER MA 02324 COVERAGES CERTIFICATE NUMBER: 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 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. ILTR TYPE OF INSURANCE ADDIL I D D POLICY NUMBER MWDDY� MU`DDY)YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 6807C436024 02/25/2017 02/25/2018 EACH OCCURRENCE $ 1,000,000 PREMISES Ewa oNccurtence $ 300,000_ _ MED C(P(Any one person) $ 5,000 PERSONAL a ADV INJURY $ 12000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY PRO LOG ECT OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS X AUTOS NON.WNED X HIREDAUTOS X AUTOS BA7C434006 02/25/2017 02/25/2016 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY parson) $ BODILY INJURY Per actltlent ( ) $ PROPERTY DAMAGE Per accident $ G X UMBRELLA LIAB EXCESS LIAB_ X OCCUR CLAIMS -MADE CUP7C751811 02/25/2017 02/25/2018 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED RETENTION $ PR/COMP OPS AGG $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (MandatoryinNH) Use describe under DESCRIPTION OF OPERATIONS below NIA U88C48634A 02/25/2017 '02/2512018.- PER OTH- X STATUTE ER EL EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE — --- $ 1,000,000 E.L DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it mare space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Patriot Services 115 Hayward PL AUTHORIZED REPRESENTATIVE Bridgewater Me 02324 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD October 12. 2017 Patriot Services Inc. 940 Plymouth Street fIalifax Ma 02338 Waste Water Services Inc 1997 Bedford Street Bridgexa ater Ma 02324 W. W.S.1. is a toll -service wastewater transportation and disposal company. We have extensive experience in managing the transportation and disposal of liquid wastes in Nety England. W- W.S.1. is constantly in contact with disposal facilities throughout New England to insure our customers ahvays have options. W.W.S.I. has received approval to dispose of your waste at Earth Source in Raynham Ma as well as several organic digesters. W.W.S.1 understands the operations of Multi Tank Systems. Selvage Treatment plants. large or small. W.W.S.1 can service all your septic and setter system needs 1AI. W.S.1 will provide 24-hour Emergency sen ice. Waste Water Services Inc. Pumps. Transports and disposes of Patriot Services Inc. Tight Tank grease at your facility on 940 Plymouth Street Halifax Ma 02338. PROPOSAL: Pump, transport and dispose of Tight Tank Grease COST: $0 20 per gallon Sincerely,- - aame�s Baird