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Home My WebLink AboutUnited Site Services 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: BRIAN TOMPKINS, OPERATIONS MANAGER Doing business as: UNITED SITE SERVICES, NORTHEAST, INC. 50 WASHINGTON STREET, SUITE 10 WESTBOROUGH MA 01581 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 III section 31A and expires December 31, 2018 unless sooner suspended or revoked. LICENSE NUMBER: 18 TRUCK REGISTRATION NUMBER(S): 574081MA BOARD OF HEALTH NichaeCMcCCean, Chairman r �r \,, LICENSE NUMBER: 18 B04SS NAME: UNITED SITE SERVICES, NORTHEAST, INC. MAIL ADDRESS: 1 \`3S TOWN: WESTBOROUGH STATE: MA ZIP CODE: 01581 NAME OF OWNER: BRIAN TOMPKINS, OPERATIONS MANAGER BUSINESS TELEPHONE: (800) 442-1286 _ CELL: (508) 250-3007 FAX: (508) 543-4573 Email: BRIAN,TOMPKINS@UNITEOSITESERVICES.COM Alt E-mall: AP@UNITEOSITESERVICES.00M FED IDISS NO: 04-2663022 NUMBER OF TRUCK(S): 1 REGISTRATION NUMBERS): .,'%�Wl k1A a0/) nter FEE PER TRUCK $75.00 Please make appropra c anrdes.-Sicdn, date. and enclose check payable to Town of Mansfield. Mall to: -- - - -- Board of Health, Town of Mansfield, Six ark Row, Mansfield, MA 02048. —7 SIGNATURE: �C�w C Xi1L 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 Sewa i5.5G2 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 Went 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; d Maintained to prevent leaking of sewage A =Acceptable NA = Not Acceptable -' . r Inspected by: t�vv v tic r. 3 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. **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 furrdshed 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. WAHP KV.nes Doonm WAIPERMrr APPLICATIONS\TAX CSRTIFICAVON FORM.doo The Commonwealth oflMl ssachusefts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Lelzibly Name (Business/Organization/Individual): United Site Services Northeast Inc Address: 118 Flanders Road Westborough, MA 01581 Phone #: 1-800-TOILETS Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2, ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c, 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition ME] Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.® Other Portable Sanitation *Any applicant that checks box 41 must also fill out the section below showing theirworkers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box. must attached an. additional sheet showing the nameof the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees; they must provide their workers' comp, policy number. I am an employer that isproviding wor/rers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name; Safety National Casualty Corp. Policy # or Self -ins. Lic. M LDS4047370 Expiration Date: 11 /03/2018 Job Site Address: all United Site Services projects City/State/Zip: various Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dare). 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 th_e_ DIA for insurance coverage verification. I do hereby e,&y`irnder the pains andpenalties ofperjury that the information provided above is true and correct. Offacial 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector b. Other Contact Person: Phone #:. A� o& CERTIFICATE OF LIABILITY INSURANCE MMflD GATE 12017 YYYY) 111032017 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 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 Marsh USA Inc. One Towne Square, Suite 1100 Southfield, MI 48076 Attn: deVoit.certrequest@marsh.com CONTACT NAME: FAX INCPHONE,No Ext : All. No): E MAIL INSURERS AFFORDING COVERAGE NAIC# INSURER A: Safely National Casualty Coro. 15105 5212—GAWU-17-18 INSURED .United Site Services Northeast, Inc. INSURER B: XL Speclivity Insurance Compaq 37885 INSURER c : AIG Specialty Insurance Company 26883 31 East Belcher Road Foxboro, MA 02035 INSURER O: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-008823090-03 REVISION NUMBER: 0 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 LTR TYPE OF INSURANCE ADDL INSD SUBR MD POLICYNUMBER POLICY EFF fMMIDDffYYyI POLICY EXP MMIDDlYYYYI LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS MADE OCCUR GL4057787 11/0312017 1110312018 EACH OCCURRENCE $ 1,000,000 DAMAGISES( RENTED PREMES Ee occurrence) $ 1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: � LOG POLICY PEA OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGO $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY CAS4047369 11/0312017 11103/2018 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY(Peraccident) $ PROPERTY DAMAGE Per accident $ X UMBRELLALIAS EXCESS LIAR X OCCUR CLAIMS -MADE US00076933LI17A 11/0312017 11/03/2018 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DIED I X I RETENTION$ 10000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? FNJ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA LDS4047370 1110312017 11103/2018,. -- X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. pISEASE-POLICY LIMIT $ 1,000,000 C Pollution PLC 16214946 0811912015 0811912018 Each Pollution Incident Aggregate 1,000;000 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) United Site Services Northeast, Inc. 500 Washington St., Suite 100 Westborough, MA 01581 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 of Marsh USA Inc. John C Hurley @ 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD