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Home My WebLink AboutWInd River Environmental 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: WIND RIVER ENVIRONMENTAL, LLC Doing business as: WIND RIVER ENVIRONMENTAL, LLC 46 LIZOTTE DRIVE MARLBORO MA 01752 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: 19 TRUCK REGISTRATION NUMBER(S): 93124 90223 89714 BOARD OF HEALTH .7MichaeCMcCCean, Chairman tc�fo,n of Mansfield Town of Mansfield - Board o �7ealth 6 P k Row CICT 3 0, Z014 7afield, MA ozoaa kiG Septage Pumpers Application DATE: 2017 LICENSE NUMBER: 19 BUSINESS NAME: WIND RIVER ENVIRONMENTAL, LLC MAIL ADDRESS: 46 LIZOTTE DRIVE TOWN: MARLBORO STATE: MA ZIP CODE: 01752 NAME OF OWNER: WIND RIVER ENVIRONMENTAL, LLC BUSINESS TELEPHONE: (978) 562-4500 CELL: FAX: (978) 562-7255 {{ } E-mail: ACREEDON@WRENVIRONMENTAL.COM Alt E-mail: tZJt�rr; 2.yt�z. WY"e.tlVi i/'GS✓4 n'12Y47Ca.) Clo(y\ FED ID/SS NO: 04-3487677 � //NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): 931N 90223 89714 95769 92933 FEE PER TRUCK: $75.00 � € t Please make appropriate changes. Sign, date. and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. »,. F SIGNATURE: { - 'r— �r� _. DATE: r�$G f 4 ................................................................................................................................................................... •.......... 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 C.MR: 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 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. W;nclzV2Crttj Signature of Individual or Corporate Name M-3g8-4G-7_4 **Social Security No. Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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. m a Water Solutions Group, Inc. 35 Mozwjfte Blvd, Tauntoi4 MA 509,890.9012 hguatY 1 k 2017 Anna Crtedoin Wind River FAIVkoMjlgnW 46 LiZotte t)rjvq: Suite,1006 Marlboro, ,MA01752. in do restdotiods and c6breceive septage and anywhere, W$Q is W,11109 to cQn6rklW tPOONIng 9OPtage from WA-E provided that you maintain your City of Taunton septag"mWer's, Vern , uts, Your current per . Mi I ts I will expire Docewlaq:31, 2017' We thar-k You fOtYbdrbUs-meMandifYoU:Aodl4*e4hyR itther4uesao6s,plepse coduetmel. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations b 1 Congress Street, Suite 100 e Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: GeneralBusinesses Applicant Information please Print Leaibly Business/Organization 46 Lizotte Dr Wind River Environmental LLC MA 01762 Are you an employer? Check the appropriate box: 1.9 I am a employer with 500+ 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, §(4), and we have no employees. [No workers' comp. insurance required]' 4,0 We are a non-profit organization, staffed by volunteers, Phone #: *Any applicant that checks box #1 must also fill out the section bclow showing thei "If the corporate officers have exempted themselves, but the corporation has other organization should check box #L. Business Type (required); 5. n Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl.real estate, auto, etc.) 8, ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 1 I.❑ Health Care 11E] Other _ required and 'such -an l am an empioyerthat is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Federated Mutual Insurance Company Insurer's Address: PO Box 328 City/State/Zip: Owatonna, MN 55060 Policy # or Self -ins, Lic. # 6047563 Expiration Date: 6/30/18 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 $250,00 a day 'against the violator. Be advised that a copy of this statement may be" forwarded to the Office of Investigations of the DIA for insurance coverage verification, Signaturec._.....�_._-c-_."�"' Date: / J Ag v y9q- / &8 Official use only. Do; not wn7e in this area, to he completed by city or torten official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6.Other Contact'Persont:. Copy - farts and fQTMt may vary from ai4 nal DOES NOT: AFFIRMATIVELY I OF; INSURANCEDOES NOT COMPANY WIND RIVER ENVIRONMENTAL LLC 46. LIZOTTEDR MARLBOROUGH, MA 01752 policies may require an mdomemenL A OR - -- nw�mvn ngmxlc. I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RERUIREMENT, TERM OR CONDITION OF. ANY CONTRACT- OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CE - FIOATE:MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THEPOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH: POLICIES. LIMITS SHOWN MAY FU+VE BEEN REDUCED BY PAID CLAIMS. E OF INSVRANGEIL UBRR:Y NUMBER L E F-.POLCY MP➢E ❑pCCUR VOL LIMIT&A40ENERAI„LIABILITV ENTEbPa "It"* tEENCE DY INJURY TEUpMIT APPUESPER mE I" RECATE OMPIOP AOO AUTQMOBILE "ABILITY ANY AUTO OWNED AUTOS ONLY SCHEDULED HIRED. AUTOS ONLY NONOWNBD Os - AUi080NLY OMBI EQ SINGLE I, edb14YINJURY i@prpendry BCDILY INJURY rae0ldeRl} OPE AMA DE UMBRELLA LIAR EXOE$B.LIAe OCCUR CLAIMSMADE EACH OCCURRENCE' 'AOOREOATE DED RETENTION A WORKERSCOMPENSATION AND EMPLOYERS'LIABILITY -Yl ANY PROPRIETOP ?ARTNERIEXECVTIVE OFFICERIMEMEER EXCLUDED? Imyeenddwy lnN) IIEStA4iFTION �Sx DE OF OPERATIONS.Lalaw NIA N 60g7563 06/30/2g17 OB/30/2018 - X PER STATUTfi OER �. E.L. EACH ACCIDENT s1'Oi}0'000 Ex. DISEASE +EA EMPLOYEE $1,000,0gO F:L DISEASE +P041CY LIMIT 31,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VENN:LES (ACOR4 f01, AddlSerel0.ematke SggdSe, m.y N aDeded if moreaPiwli rteulreO) THIS COPY IS NOT Tp BEREPRODUCED FOR ISSUANFE OF CERTIFICATES. 01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION -DATE THEREOF, NOTICE WILL ISE ,DELIVERED IN A. CERTIFICATE. HAS BEEN FILED WITH EACH OF YOUR CERTIFICATE AC®ORDANCE MTH THE POLICY PROVISIONS. HOLDERS, _ — ACCORD 25 (20I0A73) Tile ACORD"tjaiRe and logo are registered marks of ACORO CERTIFICATE OF LIABILITY INSURANCE KTEND OR ALTER THE. COVEI A CONTRACTBETWEEN THE THE POWDERHORN AGENCY INC. 3$3 CANDLEWOOD LAKE Rb, BROOKFIELD, CT 06804 WIND RIVER ENVIRONMENTAL LLG 46 LIZOTTE DRIVE MARLBORO, MA 01752 THIS' INDICATED, CER71fl EXCLUSIONS ILT�GR I TO CERTIFY THAT THE -P0 ICIES NOTWITHSTANDING ANY REOUIREMENT, CATE MAY BE ISSUED OR MAY AND: CONDITIONS OF SUCH TYPE Of INSURANCE OF INSURANCE PERTAIN, POLICIES. 1 9fi. D LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY THEPOLICIES pLIMITS SHOWN MAY HAVE BEEN REDUCED POLICY NUMBER ISSUED TO CONTRACT BY PAID mpg 6/30/17 6/30/17 $/30/17 THE INSURED OR OTHER DOCUMENT DESCRIBED yCLAIMS. . MM � E rtCVIDIVN NUMbtK: NAMED ABO E FOR HE WITH RESPECT HEREIN IS SUBJECT TO. UNITSA IOD POLICY'PERTIS TO WHIH CH ALL THE TERMS, A B cERERALUASIUTv X COMMERCIALGENERAL LIABILITY' CLAIMS -MADE X1OCCUR Y Y NIA Y Y 01-LX-011394068-2 01-CA-069970467-0 COLLISSION DED:;5;000 COMP. DED: 5,000 29-UD•016697456-2 6/30/18 6130/18 6130/18 EACH OCCURRENCE' $ 1,000,000 S I •slEaEw�,LRenDe $ - - 100 000 MED.EXPAnyone parmh) $ 5000 PERSONAL&ADVINJURY $ 1-000000 GENERAI.AGGRE"TE $ 2;000,000 GEN - ghouoBlLEUgsiUTY X X, LAGGREGATE.LIMppIT� APPLIES PER;. POLICY jM LOC ANYAUTO ANOS ED X A6VO ULEO N WHEO HIRED AUTO$ X A.. UMBRELLAUAs X OCCUR E%CESS.LIAB CLAIMS -MADE PRQOUCTS-COMPIOPAGG. $ 2-000000' Ea -50 $ . IT 1,000,000 BODILVINJURYIPer Dersdn) - $ BODILY IWURY(Per acddent) $ .a aW eAt .$ FACHpOCURRENCE $ 5:000,000 AGGREGATE $ 5.000,000; DED RETENTION$10,000. WDR RS CpMpENBATION AGULOYBR$' I. IAB)LM YIN ANVPBOppRIETORNARTNEWEXECUTIVB'—1 (Man E"IIn H EXCLUOIi.00 L�� Ryy%ds$g76p undet. -0E �RIPTI NOF0 TIONS tI _ 79RYJ.IM •. $ E.L EACHACCIOENT' $ ELDISEASE-EA EMPLOYE $ E.I. DISEASE -POLICY LIMIT' ONCRIPYIONOFQPERATIONSI LOCATIONSIVEHICLE6(Aaach ACOR07ai, gadlNPAal RanlarNa Schedule)if more space lei J aQtiireN) EVIDENCE OF INSURANCE WIND RIVER ENVIRONMENTAL LLC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE.CANCELLED BEFORE 577 MAIN STREET THE FXPIRATIIONCE DATE P THEREOF,ICY NOTICE WILL: BE pBLryERED IN. HUDSON, MA 01749 AUTHORIZED REPRESENTATIVE g 01988-2010ACORD CORPORATION. All rights reserve ACORD,2B (2010/05) The ACORD name and logo am registered marks of ACORD