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Home My WebLink AboutEveready Pumping Service - 12/31/2008COMMONWEALTH of MASSACHUSETTS TOWN of MANSFIELD BOARD of HEALTH, SIX PARK ROW SEPTAGE PUMPING AND TRANSPORTING PERMIT This is to certify that: Mark Peterson, President Mark Peterson Enterprises, Inc. Doing business as: dba Eveready Pumping Service 8 Short St. S. Easton, MA 02375 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 I I I section 31A and expires December 31, 2008 unless sooner suspended or revoked. LIC: 16 Truck Registration Number(s): H51-302 BOARD OF HEALTH Dr. Raymond Martin, Chai man TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD SEPTAGE PUMPERS APPLICATION Business Name: Mail Address: Town: State: Zip Code: Name of Owner: Bus Phone: Marls Peterson Enterprises, Inc. dba Eveready Pumping Service 8 Short St. S. Easton MA 02375 Fed ID/SS No.: Date: No. of Trucks: Registration Numbers: Fee: $50.00/Truck Mark Peterson, President 508-238-6241 Fax: 04-3542102 2007 1 truck H51-302 Signature: Please make appropriate changes. Sign, date and enclose checkpayable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Roue, Mansfield, MA 02048. TRUCK INSPECTIONS. December 4th & 5th, 8: 00am to NOON, at the Town Hall, adjacent to South Common, Park Row, So. Main St. Please be there or call (508) 261-7366 if you cannot make these dates. Thank you. __ : _ /CH9f��i/1flCI�Y7IJU�`I 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 privies, cesspools, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. A. Mo ile Tank Securely mounted on tank Watertight Leak -proof cover Tight discharge tanks B. Venting of Mobile Tanks _Vent permits escape of gas, but not liquid C. Hose /11 Suction or pressure hose in good repair D. Pumps Maintained to prevent leaking of sewage it A = Acceptable NA = Not Acceptable Inspected by `J Inspected on R WealthVane's Do unlenlsTER IT APPLICATIONSIPOMPERSAc TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. he Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **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. R:\Health\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street o Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: / ymw Address: 9r9 PVW44Fl9,0x Xvwg-tVV �2s2Q C� City/State/Zip: !�a &y A-0' ',44W Phone#: Are y an employer? Check the appropriate box: Business Type (required): 1. 1 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 10.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We by I L ❑ Health Care are a non-profit organization, staffed volunteers, V40 (✓�rWfrJi. with no employees. [No workers' comp. insurance req.] 12.[vjOther *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.' v **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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is lire policy information. Insurance Company Insurer's Address: /b �el� (*t�/Lr�4 ST P de A* ,�i City/State/Zip: fia�a!lsGfl ft� (?_:70 § dpG�m Policy # or Self -ins. Lic. # F,�- V iUGffLV Expiration Date: t�k 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 cerd , under the ains�and penalties jc perjury that the information provided above is true and correct. Sienature� 7�e &5f /A/' ;�i�e , /',Gf'(i.�.✓��6'.�� raatP. 1l1o?;71D% Phone #: 5-P Gtr �' iP 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 Phone www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE iiiosiz o ) PRODUCER (SOS),997-6061 FAX (508)990-2731 Southeastern Insurance Agency, Inc. 439 State Rd. P.O. Box 79398 N. Dartmouth, MA 02747 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Mark Peterson Enterprises, Inc., DBA: Eveready Pumping Services 8 Short Street S Easton, MA 02375 INSURERA: Ohio Casualty Group INSURERS: Utica National Insurance Croup. INSURERc: Guard Insurance INSURER D: INSURER E: COVERAGES 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 ADD'L TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE tMMIDD1YY1 POLICY EXPIRATION DATE IMMIDDNY) 06/04/2008 LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [fl OCCUR BHO(07)53218425 06/04/2007 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES IF, mcura,ce) $ 10,000 MED EXP (Any one person) $ 100,000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICYF_j PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BAC 4033002 03/24/2007 03/24/2008 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS be. EVWC802848 01/26/2007 01/26/200$ WCSTAT_jMU- OTH- E.L. EACH ACCIDENT $ lOO OOO E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCFI. I.ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of Mansfield 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Board of Health BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 6 Park Row OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Mansfield, MA 02048 AUTHORIZED REPRESEN VE Joanne Bretton ACORD 26 (2001/08) ©ACORD CORPORATION 1988 k� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 02/15/2008 PRODLJER (508)997-6061 FAX (508)990-2731 Southeastern Insurance Agency, Inc. 439 State Rd, P.O. Box 79398 N. Dartmouth, MA 02747 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Mark Peterson Enterprises, Inc., DBA: Eveready Pumping Services 8 Short Street S Easton, MA 02375 INSURER A: Ohio Casualty Group INSURERS: Utica National Insurance Group INSURERG: NorGuard Insurance Company INSURER D: INSURER E: COVERAGES 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 ADDT TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X] OCCUR BHO(08)53218425 06/04/2007 06/04/2008 EACHOCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 10,000 $ 100,000 MED EXP (Any one person) PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT PRO LOG PRODUCTS - COMP/OP AGG $ 2,000,000 B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BAC 4033002 03/24/2007 03/24/2008 COMBINED SINGLE LIMIT (EaaccidenU $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANYAUTO AUTO ONLY -EA ACCIDENT $ OTHERTHAN EAACC AUTO ONLY: AGO $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? IF yes, describe under SPECIAL PROVISIONS below EVWC904857 01/26/2008 01/26/2009 X WC STATU- OTH- E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT 1 $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CAMCFI I ATInNI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of Mansfield 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Board of Health BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 6 Park Row OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ,Joanne Bretton ACORD 25 (2001108) ©ACORD CORPORATION 1988 ACO/RD CERTIFICATE OF LIABILITY INSURANCE °ATE,MM/°D/Yo08 o7/zs/z PF0bUCER (508)997-6061 FAX (SO8)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. 439 State Rd. P.O. Box 79398 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIL# INSURED Mark Peterson Enterprises, Inc., INSURER A: Peerless Insurance 24198 DBA: Eveready Pumping Services INSURERS: Utica National Insurance Group 8 Short Street INSURERc: Guard Insurance S Easton, MA 0237S INSURER D: INSURER E: COVERAGES 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. INSRADD` TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [X] OCCUR BHOS3218425 06/04/2008 06/04/2009 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 10,00 MED EXP (Any one person) $ 100,000 PERSONAL 8 ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN. AGGREGATE LIMIT APPLIES PER POLICY PRO- ECT LOG PRODUCTS - COMP/OP AGG $ 2 QQQ,QQQ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BAC 4033002 03/24/2008 - 03/24/2009 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) $ GARAGE LIABILITY ANY AUTO - AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below EVWC904857 01/26/2008 01/26/2009 WC STATU- OTH- E.L. EACH ACCIDENT $ SOO,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.C. DISEASE =POLICYLIMIT $ 500;000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY THE INSURER. ITS AGENTS ACORD 25 (2001/08) 11 111 'V' w " """" � / j ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)