Loading...
HomeMy WebLinkAboutHandy House/United Site Services - 12/31/2009Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that: Brian Tompkins, Operations Manager Doing business as: Handy House, Inc./United Site Services P.O Box 9131 Foxboro MA 02035 Town of Mansfield 6 Park Row Mansfield, MA 02048 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, 2009 unless sooner suspended or revoked. LICENSE NUMBER: 22 TRUCK REGISTRATION NUMBER(S): MA L94690 BOARD OF HEALTH Sr. Raymond Martin Chair an Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Septage Pumpers Application BUSINESS NAME: Handy House, Inc/it rt, 1edl J' /C 5cv V i G� 5 MAIL ADDRESS: P.O Box 9131 TOWN: Foxboro STATE: MA �Y A \) i0rn104;A6 NAME OF OWNER: tWark Rtrxtie, Operations Manager BUS TELEPHONE: (800) 442-1286 CELL: FED ID/SS No: 042563022 NUMBER OF TRUCK(S): REGISTRATION NUMBER(S): MA L`T 4l, 96 FEE PER TRUCK: $50.00 DATE: fenclo S LI ZIP CODE: FAX: (508)543-4573 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: December 2nd & 3rd, 2008 time: 8:00 am to NOON 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 cannot make these dates. FOR HEALTH AGENT'S USE ONLY 310 CMR: State Environmental Cdoe, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.19 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents (2) 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 j Leak -proof cover Tight discharge tanks I A = Acceptable NA = Not Acceptable B. Venting of Mobile Tanks: pp t� Vent permits escape of gas, but not liquid C. Hose: :Suction or pressure hose in good repare A D.Pumps: i 11-Maintained to prevent leaking of sewage y. i Inspected on: f 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) o yL '.qb 6 36-A D- " Social Security Number (Voluntary) or Federal�ntification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: P 1/) , 6e) Y Gl l4j, / > Phone#: Are you an employee? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating 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. 8• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have WE] 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.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: I / It) eP-S / JF Ali) City/State/Zip: I0 o-s r t✓ i In el - Policy # or Self -ins. Lie. #_ WA % 6cl U g3,5r3 3 W� GI [ R Expiration Date: 1 I h 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. I do hereby certify, under the pains and penahies ofperjary that the information provided above is true and correct ' y} Sienature: � � I„ �.« �'i, 7 ,l �-------�_ Date: / Official 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.mass.gov/dia ACORD,M CERTIFICATE OF LIABILITY INSURANCE DAT/20/OE(MM/D8 YYYY) ilB PRODUCER 1-212-295-8000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Integro USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE dba Integro Insurance Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1 State Street Plaza ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 9th Floor New York, NY 10004 INSURED HANDY HOUSE, INC. BOX 9131 MA 02035 VUvaR uCD INSURERS AFFORDING COVERAGE INSURERA: Liberty Mut Fire Ins Cc INSURER B: American Guarantee & Liabil INSURER C: Liberty Ina Corp INSURERD: NAIC # 23035 26247 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR %DD'I NSF TYPED INSURANCE POLICYNUMBER POLICYEFFECTIVE DA E M IDDm POLICYEXPIRATION DATE MIODNY LIMITS A GENERALLIABILITY TB2-641-435338-028 11/03/08 11/03/09 _ EACHOCCURRENCE $1,000,000 X COMMERCIALGENERAL LIABILITY CLAIMSMADE lxj OCCUR DAMAGETORENIM PREMISES Ea occurence $ 100,000 MED EXP(My one person) $10,000 PERSONAL&ADV INJURY $ 11000,000 GENERALAGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIESPER: PRODUCTS-COMPIOPAGG $2,000,000 X POLICY PRO JECT LOC A AUTOMOBILE X LIABILITY ANYAUTO AS2-641-435338-038 11/03/08 11/03/09 COMBINED SINGLE LIMIT (Ea accitlenl) $2,000,000 X ALLOWNEDAUTOB BCHEDULEDAUTOS BODILY INJURY (Parparson) $ X HIREDAUTOS NON-OWNEDAUTOS BODILYINJURY (Per acciden0 $ PROPERTYDAMAGE (Peraccidan0 $ GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHERTHAN EA ACC $ ANYAUTO $ AUTOONLV: AGG B EXCESSIUMBRELLA LIABILITY X OCCUR 11 CLAIMS MADE AUC 427541604 11/03/08 11/03/09 EACHOCCURRENCE 5 5,000,000 AGGREGATE $ 5, 000, 000 5 DEDUCTIBLE S RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PMb.mdR WA7-64D-435338-018 11/03/08 11/03/09 X I WCSTATU- OTH- TORYUMITS ER E.L. EACH ACCIDENT $1,000,000 EL.DISEASE -EA EMPLOYEE $1, 000, 000 ,ARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ffye..do E.L. DISEASE - POLICYLIMIT 51, 000, 000 SPECIALP Ounder SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS EVIDENCE OF INSURANCE FL 32805 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE ©ACORD CORF