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Home My WebLink AboutPump Grump 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: ALEC RICH Doing business as: PUMP GRUMP P.O. BOX 528 TAUNTON MA 02780 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: 15 TRUCK REGISTRATION NUMBER(S): T15768 BOARD OF HEALTH MichaeCMcCCean, Chairman JUL d " 209wnof Mansfield Town of Mansfield - Board of'Hea#h 6 Park Row Mansfield, MA 02048 Septage Pampers Application DATE: LICENSE NUMBER: BUSINESS NAME: '?p Ggxv— AD MAIL ADDRESS: PO Q�b'x 6a? TOWN: �k STATE: tY>t:�r ZIP CODE: 0a-7 NAME OF OWNER:(.'}VC, Q�r BUSINESS TELEPHONE: 50$ ,�M gipi CELL: 5 FAX: E-mail: txclvasteec?sc�(ta V(� CUr oor, i'1Gk Alt E-mail: FED ID/SS NO: 61-A3-N3CA51i, $ NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): j t5i la L FEE PER TRUCK: 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: _a±�J ." DATE: TRUCKS INSPECTIONS: DATE: TIME: PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO. MAIN STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THESE DATES FOR HEALTH AGENTS 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: Section or pressure hose in good repair D. Pumps: 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, havefiled all state tax returns and paid all state taxes required under law. S gnature of Individual or Corporate Name g51? "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, IfApplicaloO *This I!censewiII not be issued unless this certification clauseissigned by the applicant. "Your sod al 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. C:NUsers\slcite\Desktop\Scott's DmumenOFood Establishments-Temp\TAX CERTIFICATION FORMAM The Commonwealth of Massachusetts Department of Industrial Accidents OffieeofInvestigations 600 Washington Street Boston, MA 02111 www.mass,gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: t�� Txtis 4c r Nep aich dvy--L Utnrc.tRyrtp,a1) Address: 2r) G 6-74 �a V Phone #: b C iv9 ti Qt M I Are yoy.an employer? Check the appropriate box: Business Type (required): 1. [14 am a employer with t�-- employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales line I, real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' camp. insurance required] 3. ❑ We are a corporation and its officers have exercised 4. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 11.0Health Cara 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.U�Other e.CjV, C. Serer t? S -Any applicant that checks box NI must also till out the section below shoving their workers' compensation policy information **If the wrpormc onicers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing D o� Cxt workers' compensallonInsurance for my employees. Below Is the policy irrformatlon. Insurance Company �t�� Nyyame:^(Mfnnc-t �'1'_yPC'.�- Cxe6c-ae Insurer's Address ^ 'i'� 1-MLA City/State/Zip: V-P, nP,�%��t Policy # or Self -ins. Lie. Expiration Date: Ci 1 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 ofperjury that the information provided above is true and correct 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 www.masxgov/dia WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY —INFORMATION PAGE INSURER: MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 JACKSONVILLE, FL 32245-6000 REM 1. NAMED INSURED AND MAILING ADDRESS: ALEC RICH (SEE NAMED INSURED ENDT) PO BOX 528 TAUNTON MA 02780-0528 POLICY NO: WCO2972T NEW BUSINESS NCCI Company No: 27103 Account No: CACO2972T AGENCY NAME AND ADDRESS: TAYLOR INSURANCE AGENCY 448 TURNPIKE STREET SOUTH EASTON, MA 02375 AGENCY PHONE NO.: (508) 230-2244 AGENCY NO.: 201040 LEGAL ENTITY: INDIVIDUAL OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POLICY PERIOD: From: 03-07-2018 To: 03-07-2019 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OR, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 347 Annual Premium: $ 1,434 Audit Period: ANNUAL Date: 03-08-2018 Countersigned by _ WC 00 00 01 A CopyrigtA 1987 National Council on Campersatian Insurance INSURED COPY Policy Number WCO2 972T MAIN STREET AMERICA ASSURANCE COMPANY NCCI Carrier Code 27103 EXTENSION OF INFORMATION PAGE LOCATION SCHEDULE Named Insured ALEC RICH Agent Name TAYLOR INSURANCE AGENCY State: MASSACHUSETTS ALEC RICH DBA: bUMONT PUMPING & PUMP GRUMP ',. PO BOSS 528 'TAUNTON MA 02780-0528 LEGAL ENTITY: INDIVIDUAL FEIN: 04-3339518 tt EMP : 2 WC 00 00 01 A Effective Date: 03-07--2018 12:01 A.M., Standard Time Assent No. 201040 MURK COPY Policy Number WCO2972T EXTENSION OF INFORMATION PAGE Item 1. - SCHEDULE OF NAMED INSURED(S) MAIN STREET AMERICA ASSURANCE COMPANY Named Insured ALEC RICH Effective Date: 03-07-2018 Agent Name TAYLOR INSURANCE AGENCY 12:01 A.M„ Standard Time Aaent No.201040 64-1627 (CONT.) THE NAMED INSURED ON FORM 64-1627 IS AMENDED TO READ: ALEC RICH DBA DUMONT PUMPING 6 PUMP GRUMP WC 00 00 01 A INWRED COPY