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SEPTIC HAULERS 2007DATE PRINTED: 08/23/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000049 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 LOCATED AT: Septic Haulers Sam's Transportation P.O. Box 241 GEOREGETOWN SALEM, MA 01970 1 Kimberley Drisooll Mayor MA 01833-0341 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0601 Aug 23, 2007 Dec 31, 2007 $50.00 Reg.# 11-85962 Dump Truck 2007 Mac Total Fees: $50.00 PERMIT EXPIRES jDecember 31, 2007 Board of Health Page 1 of 1 Rug 21 07 09:20a Kimberley Driscoll Mayor Jeanne Scott Salem ROH 978 745 0343 p.2 CITY OF SALEM, MASSACHUSETTS BOARD `oF HEALTH 120 WASHINGTON tiTRE41, 4TM RLOOR SALEM, MA 01970 TEL. 978-7a.1 -1.800 FAx 978.747-0343 JOANNE ScoYT, MPH, R5, CHO HEALTH AGENT APPLICATION FOK A PERMIT TO TRANSPORT OPEENSI%k. SU STANCES FLE: 1W Per VCnIClc PayaUle to The City of Salejm No Cash NAME OF APPLICAN1:� NAME OF COMPANY' ADDRESS: TYPE OF VEHICLE TEL H GROSS WEIGHT—p' YEAR OF MAKE REG. # SUBSTANCE(S ) HAULED ROUTE OF TRAVEL_.— (nnst be completed) --- ---- SCHEDULE OF TRAVEL --__ ---- — -- I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." 1 HAVE HAI) THE' oPPOR'rUNITY TO ASK QUESTIONS REGARDING THOSE RFGULATL'IONS..I UNDERSTAND THEM, AGREF-•rO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TOW SO MAY RESULT IN REVOCATION OF MY PERMITTO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGI- C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BFs'r KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL, STATE TAXES REQUIRED -ON ER THE LAW, Signature ' Uate Social Sccw'uy of Fuleral ID # --------------- ---------------------- -- ------------ - --- Pernlil # Check # Check Data: (Revised I U25/02 offpcntt.ins ) RECEIVED AG 2 2 2001 CITY OF SALE=M BOARD OF HEAL(H .J Commonwealth of Massachusetts I City of Salem vwo; Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 08/23/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000049 LOCATED AT: Sam's Transportation P.O. Box 241 GEOREGETOWN SALEM, MA 01970 MA 01833-0341 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0600 Aug 23, 2007 Dec 31, 2007 $50.00 Reg#. 11-82866 Dump Truck 2007 East Total Fees: $50.00 PERMIT EXPIRES 1December 31, 2007 Board of Health Page 1 of 1 r Aug 21 07 OS:20a � e Kimberley DriscGll Mayor APPLICA`ITIOi NAME OF APPLICAN'r ADDRESS: Q Joanne Scott Sa1emBOH S78 745 0343 CITY OF SALEM, MASSACHUSETTS ?Abs - BOARD •OF HEALTH 120 WASHINGTON STREII, 4TH FLOOR SALEM. MA 01970 TEL. 978-74 1- 1.600 FAA 976-745-V343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT FEE: $50 per vehicle payable to The City of Salem No Cash NAME OF COMPANY:— TEL k _, ADDRESS:__ —.— —'—"-- TYPE OF VEHICLE GROSS WEIIGHTc_ — REG. # ff– YEAR OF MAKE --a24 pno'7ZL,i_�.— SUBSTANCE(S) HAULED ROUTE OF TRAVEL�P�L (must be completed) -- — — — — SCHEDULE OF TRAVEL__ -- — —' I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." 1 HAVE HAD THL CIRPORTUNITY T'0 ASK QUESTIONS REGARDING THOSE RFGULAL'IONS. I UNDF..RSTAND THEM, AGREF. TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE To DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGI, CG2C,'S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BFsT KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL, STATE TAXES REQUIRED DER THE -LAW. t41 � SigL n 4Jale Social Security or Federal ID # Permit #_ Check # (Revised I t/25/02 offpcnit.ims ) Check Date: AUG 2 21007 CITY O`- SA! _EM BOARD OF HEALTH P-2 -�_ Commonwealth of Massachusetts City of Salem sr Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 08/23/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000049 LOCATED AT: Sam's Transportation P.O. Box 241 GEOREGETOWN SALEM, MA 01970 MA 01833-0341 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0599 Aug 23, 2007 Dec 31, 2007 $50.00 Reg.#11-82314 Dump Truck 2007 Mac PERMIT EXPIRES Total Fees: $50.00 31.2007 Board of Health Page 1 of 1 Aug 21 07 09:20a ISirnberley Driscoll Mayor Joanne Scott Salem BOH 97B 745 0343 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREt1, 4TH FLOOR SALEM, MA 01970 TEL. 978-7a 1-1600 FAX 970.740-0343 JOANNE SCOTT, MPH,. RS. CHO HEALTH AGENT P.2 APPLICATION FOR A I'EAMIT TO TRANSPORT OFFENSI ESU STANCES FEE: $50 per Vehicle payable to The City Of S No Cash NAME OF APPLICANT: ADDRESS: TEL NAME OF COMPANY: ADDRESS: — _ TEL TYPE OF VEHICLE GROSS WEIGHT_/. — REG. # _ —_ YEAR OF MAKE 2,&-D 7 �. SUBSTANCE(S) HAULED ROUTE OF TRAVEL (mus[ be cOntpleted) _ _— ---- SCHEDULE OI' TRAVEL__ — ---- — I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAV THE ol'POR•rUNITY TO ASK QUESTIONS REGARDING THOSE RFGULAI•IONS. I 11NDF..RSTAND THEM, AGREF-'r0 ABIDE- BY THFM, AND UNDERSTAND THAT FAILURE TO.DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFF N51VF SUBSTANCES. PURSUANT TO MGI, CG2C, S49A, I CERTIFY UNDER TIIF, PENALTIES OF PERJURY THAT 1, TO MY BF.sT KNOWLEDGE AND BELIEF, .HAVE. FILED ALL STATE TAX RETURNS AND PAID ALL. STATE TAXES REQUI U llLR THE 1 Sig` � Ua[e Svciul Sccw.rty or F4daral 117 # ------------- ----•- ---' Permit #_- - Check # Check Date: (Revised 11/25/02 offpcnnins ) IAUG 22.2001 CITY GI SALEM BOARD OF HEALTH r•�. i Commonwealth of Massachusetts City of Salem i ! Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 08/23/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000049 LOCATED AT: Sam's Transportation P.O. Box 241 GEOREGETOWN SALEM, MA 01970 MA 01833-0341 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0597 Aug 23, 2007 Dec 31, 2007 $50.00 Reg.# 12-62519 Dump Truck 2005 Mac Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of t Fug_21 07 08:20a Joanne Scott Salem BOH S78 745 0343 p-2 Kimberley Driscoll Mayor CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON :+TFEE 1, 4TH FLOOR SALEM. MA 01970 TEL. 978 -7a1 -I BOO FAA 978.747-0:343 JOANNE 5COTT. MPH, R5, CHO HEALTH AGENT '0!V 4156 APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SU ST'ANCLS FEE: 450 per vehicle payable to The City of Salcm >NoGash NAME OF APPLICANT: 01 TEL # ADDRESS: NAME OF COMPANY ADDRESS: TYPE OF VEHICLE GROSS WEIGHT_ REG. N—. -- TEL # YEAR UYMArF SUBSTANCES ) HAULED ROUTE OF TRAVEL_. (must be completed) SCHED[1LLOFTRAVEL — I HAVE READ THE BOARD OF HEALTH REGULATION. "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES," I HAVE HAI) THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE RFGULAnoNS. I UNDERSTAND THEM, AGREE TO ABIDE- BY THEM, AND [INDF.RS'rAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. BFRr KNOWLSUANT EDGE AND BELIEF,ICERTIFYHAVE FILED ALL STATE AX THE RETQl�URNSAND PAID ALL. S"AJURY THAT 1. TO T1E TAXES REQUIRED UNll THE LAW. Sigmuure ' Y Uare Social Sccm'icy or Federal ID # -------------- ------- Permil # Check # -------------- ------ Check Darc: ,�%a�l,b� (Revised 11125102 offperllt.ins ) 6 REC;IIV® VG 2 2 2001 CITE' OF SAtLE.fwl BOARD OF HEALTH �7 Commonwealth of Massachusetts City of Salem t Board of Health 120 Washington Street, 4th Floor Kimberley Driscoll Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 08/23/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000049 LOCATED AT: Sam's Transportation P.O. Box 241 GEOREGETOWN SALEM, MA 01970 MA 01833-0341 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0598 Aug 23, 2007 Dec 31, 2007 $50.00 Reg.#11-82107 Dump Truck 2007 Mac Total Fees: $50.00 PERMIT EXPIRES 2007 Board of Health 5 Page 1 of 1 .'. 1; 21 07 09:20a Kimberley Driscoll Mayor Joanne ScottSalem BOH 978 745 0343 CITY OF SALEM, MASSACHUSETTS BOARR 'OF HEALTH 120 WASHINGTON BTREhl, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1. e00 FAx 970.747-US43 NAME OF APPLICANT:, ADDRESS: NAME OF COMPANY ADDRESS: TYPE OF VEHICLE GROSS WEIGHT_ REG, # _�"��. SUBSTANCES) HAULED JOANNE SCOTT. MPH, R5, CHO HEATH AGENT FEE: $50 per Vehicle payable to The City of Salem jocX3 TEL N446 �:_ TEL # YbAK Ur mnnc--,2C,��.— ROUTE OF TRAVEL_:;4;. --- — S -- -- (must be completed)—" -- SCHEDULE OF TRAVEL _ __------- — — J HAVE READ THE BOARD OF HEALTH RFGUI,ATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." 1 HAVE HAL) THF OPPOR'T'UNITY TO ASK QIJL•'STIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREF TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO.DO SO MAY RESULT IN REVOCA'T'ION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGI. C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1, TO MY BEs,r KNOWLEDGE D111yyyRRRBEI.fEI- .HAVE. FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXSIRED THE LAW. — Signature Date SoSccw'ity or Federal ID # ------------------------------------------ -------------- Pernik Check # Check Data: (Revised I U25102 offpcnn.ins ) F.2 RECEIVED AUG 2 2 2001 CITY OF SA'_ErA BOARD OF HEALTH DATE PRINTED: 08/14/2007 ESTABLISHMENT NAME: File Number: BHF -2007-000037 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 LOCATED AT: Septic Haulers Kimberley Driscoll Mayor Stewarts Septic Service J & S Development 58 So. Kimball Street BRADFORD MA 01835 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0593 Aug 14, 2007 Dec 31, 2007 $50.00 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health l Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 RECEIVED' TEL. 978-741-1800 ` FAX 978-745-0343 UG 1 2009 JOANNE SCOTT, MPH, RS, CHO !1 U L I Kimberley Driscoll HEALTH AGENT CITY CF SA; -EM Mayor BOARD OF HEALTH APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT: ADDRESS: ISG C0/�/C/ /y`/�q//[C/ /Vy /ft. TEL# NAME OF COMPANY: �c J I,�QAj4�21`p�Qi�jpP'IF �/%�i� ADDRESS: z- � JYI'LIULC-oa Y, l / k&iW - TEL # TYPE OF VEHICLEA �//� GROSS WEIGHT �1�t� REG. # CO YEAR OF MAKE U^�U[�i SUBSTANCE(S ) HAULED ROUTE OF TRA (must be complett SCHEDULE OF I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." 1 HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 REQ��IR UNDER THE LAW. l i III 0,7 ; �, i %Zn ,x 2 fIL� 9�7 Permit # (Revised 11/25/02 offperm. ins) Check # Social Security or Federal ID # Check Date: 50 I a:. • —w Commonwealth of Massachusetts City of Salem i ! Board of Health Kimbefley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 08/14/2007 ESTABLISHMENT NAME: File Number BHF -2002-000002 LOCATED AT: Rooter Man P.O. Box 471 Peabody MA 01960 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0592 Aug 14, 2007 Dec 31, 2007 $50.00 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health �c4 Page 1 of 1 a CITY OF SALEM, MASSACHUSETTS BOARD HEALTH 120 WASHINGTON STREET, 4TH FLOOR RECEIVED SALEM, MA 01970 TEL. 978-741-1800 'AUG 132007 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO CITY OF G;LL_F_idl Kimberley Driscoll HEALTH AGENT BOARD OF HEALTH Mayor APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES n / FEE: $50 per VehiJcle payable to The City of Salem No Cash NAME OF APPLICANT: / {� 6 ),5 p /I (TRfY1✓�)QQN ADDRESS: /yy/ )% 7 &/L�O� TEL# 47,' -.SD -y7 VY NAME OF COMPANY: //�%D�t,— /Yl ADDRESS: po (� �2� 141bll TEL # TYPE OF VEHICLE &qC� K —rrUN V -- GROSS WEIG/HT/��i_q!J / REG. # /4 I d %/ YEAR OF MAKE SUBSTANCE(S ) HAULED E-rlverll� ROUTE OF TRAVEL 0 ✓T cADO— Llyn 17-S (must be completed) SCHEDULE OF TRAVELffq I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 Uygt-R,T-LA V. Signature Date Social Security or Federal ID --------------------------------------------------------- ------------ Permit # Check # g ~%� Check Date: (Revised 11/25/02 offperm.ins) _ IPAPORTAINT MESSAGE FOR A DATE 6 -'5;7'6 -70 TIME . -m \A P.M_ M AREA COIDE NUMBER EXTENSION G FAX ❑ MOBILE AREA CODE NI pWBER TIME TO CALL "TELEPHONED PLEASE ALL �---^ WILL CALL AGAIN CAME TO SEE YOU WANTS TO SEE YOU RUSH'..,. RETURNED YOUR CALL WILL FAX TO YOU MESSAGE 10 MIM FOR TIME M. OF PHONE AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE N MBER TIME TO CALL TELEPHONED PLEASE GALL CAME TO SEE YOU '.. WILL CALL AGAIN' WANTS TO SEE YOU '.. RUSH. RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED qmD FORM ■ s MADE IN te tr-ice-o6 gC vh eel l( r 971?- a-3 3 i PHONE ��.h-�.�i .5 AREA COL�iE-� N M R EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU 7 . i'• ��pp jr .,::+ „ . •:- wmmuuwrauu vL irwasaCnusecca art wat w 4 z^ r fir# ti #2 rt a', '§„' . v.�, • 3i - .,:�.. _ ,,City of Salem Board of Health Klmbe 120 Wasdey Driscoll hington Street, 4th Floor ri Mrley SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/09/2007 File Number: BHF -2002-000006 LOCATED AT: Boraczek Septic Drain 4 Hazel Drive HAMSTEAD NH 01830 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0374 Jan 8, 2007 Dec 31, 2007 $50.00 Vehicle: 1986 Mack Reg: 2807 -AR Total Fees: $50.00 PERMIT EXPIRES "December 31, 2007 Board of Health Page 1 of 1 a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH - • • 120 WASHINGTON STREET, 4TH FLOOR ¢ SALEM, MA 01970 ` may.IV���+++:a�C 9 TEL. 978-741-1800 FAX 978-745-0343 -- - JOANNE SCOTT,. MPH, RS, CHO Kimberley Driscoll HEALTH AGENT Mayor APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT: c3G1rne.-S (2t)oM C a kL Y\l`�—I r !r_y� ADDRESS: {��wJC�(i��(n 1 �ID m TEL ACC L n p D'Y ! I-Sa3(,0 NAME OF COMPANY:IJSI.W\ ADDRESS: "1 i CA DR [ MR� 14�EELt#� TYPE OF VEHICLE �� &t: 6— Ip1`� / GROSS WEIGHT y� /'qq REG. # Z%o%' 6/qYEAR OF MAKE i /o'er SUBSTANCE(S ) HAULED I ROUTE OF TRAVEL (must be completed) SCHEDULE OF TRA I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 THE LAW. y 0 Date Social Security or Federal ID # Permit # Check # Check Date: (Revised 11/25/02 offperm.ins ) w 'JAN - 8 2001 CITY OF SALEM BOARD OF HEALTH •a'v pr, �,4T is �'�3u�tr9L°_'+ed8ro .. .e aY .. '1tg < Ugh '"�: �'� ;' " R yv. sr ti CI•.+ of Salem �. +ta- . J F� 9r {7 ,,Board of Health IGmbmlley Dnscoh 120 Washington Street, 4th Floor ``s.• `MWyt)r SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/09/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000006 LOCATED AT: Boraczek Septic Drain 4 Hazel Drive - HAMSTEAD NH 01830 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0375 Jan 8, 2007 Dec 31, 2007 $50.00 Vehicle peterbuilt 1999 Reg: 2808 AR Total Fees: $50.00 PERMIT EXPIRES 31, 2007 Board of Health. Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-741-1800 A tt: � FAX 978-745-03 i.af 1%� I*- 1-, 0 "!il, JOANNE SCOTT, MPH, IRS, CHO Kimberley Driscoll HEALTH AGENT Mayor APPLICATION OFFENSIVE SUBSTANCES A PERMIT TO TRANSPORT OF FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF,4PPLICA-NT'-:' 30A6 QsoIzrr-La A DbRES S TEL /C4qQ%-(jj9- NAME -0 F, CO P -,c: t= .1� R'S pp G ADDRESS 11TEL# PE OF VEHICLE GROSS WEIGHT REG. YEAR OF MAKE ----------- SUBSTANCE(S ) HAULED .(must be i completes) I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND IONS FOR TRANSPORTIIY.G OFFEN$IVE'SUBSTANCES)""I HAVE HAD TILE OPPORTUNITY TO ASK QUESTIONS ABIDEREGARDING`THOSE' REGULATIONS d UNDERSTAND THEM; AGREE TO BY -THEM, AND UI�DERSTAND,THATFAILURE TO,DO SO MAY RESULT IN REVOCATION OF Y PERMIT TO PURSUANT TO;MGL C62C S49A I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1,40 MY ALUSTATE D PAID niT .6' ND E::::::: 7-1f'stYtw 1 ------------- k 3e +S i e , Diie, Social Securit�'or'Fedeial IDA 'Q. li",�t��-jj�i- . 14. C� z.� tJ. - -------------------------------Z--� ----------------- ----- -- -------- Permit'# Check # ----------------------- Check Date: Revised 11/25102 lfperm.i ........ . . .......... RECEIVE[). OF SALEM CITY BOARD ()F HEALTH DATE PRINTED: 01/02/2007 IDRI N:1t30RV,ITAIDQW- 0.1161X File Number: BHF -1999-000002 LOCATED AT: Septic Haulers Danvers Cesspool 32 Walter Road Danvers MA 01923 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0252 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 1983 Mack, REGISTRATION #: MA L 19910 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 4 CITY OF SALEM, MASSACHUSETTS csk): BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR RECEIVED� SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 DEC 4 2006 JOANNE SCOTT, MPH, RS, CHO Kimberley Driscoll HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Mayor APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT: TEL# 77SL-S( 45 - NAM[ TEL # 9JJ- 7 TYPE OF VEHICLE GROSS WEIGHT lJO nnG REG. # 4 "910' YEAR OF MAKE / 9 YJ? ) HAULED ROUTE OF'TRAVEL— (must be completed) SCHEDULE OF TRAVEL_ I HAVE READ THE BOARD OF HEALTH REGULATION, 'RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 THE LAW. Signature Date Permit # Check # 6) O (Revised 11/25/02 offperm.ins ) e; Social Security or Federal ID # Check Date: 1 a f V— tf� 'Board o Health r F� 120 Washington Street, 4th DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -2004-000250 LOCATED AT: SALEM, MA 01970 Septic Haulers James H. Currier Construction Co. Inc 131 Forest Street Middleton MA 01949 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0253 Jan 2, 2007 Dec 31, 2007 $50.00 /VEHICLE TYPE: Autocar, REGISTRATION #: MA H 70406 Total Fees: $50.00 PERMIT EXPIRES !December 31, 2007 1 Board of Health A 0 Page 2 of 4 Kimberley Driscoll Mayor CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH Ipe(t x"— 120 WASHINGTON STREET, 4TH FLOOR ECEM=® SALEM, MA 01970 TEL. 978-741-1800 DEC 19 2006 FAX 978-745-0343 JOANNE SCOTT, MPH, RCITY OF SALEM HEALS, CHO BOARD OF HEALTH APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT: NAME OF COMPANY:tZ—�7 f irr-,g i �nSl�_ Off �c TYPE OF VEHICLE—kj mar" TEL# TEL# GROSS WEIGHT//�� ' / n p REG. # z 9d lDLo YEAR OF MAKE 7 / SUBSTANCE(S ) HAULED ROUTE OF TRAVEL_ (must be completed) -- SCHEDULE SCHEDULE OF TRAVEL I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND BELJ'F, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE. TAXES RE IRED 'vN 1E2 �ro� h - c;onan Date Social Security or Federal ID # Permit # Check # /Syaz (Revised 11/25/02 offperm.ins ) Check Date: Department of lndustrialAccidents cw ce oflnvesakadons 600 Washington Street Boston, MA 02111 ww .ma-vsgov/dia WorkerCompensation Insurance Affidavit: General Businesses s' Please: Business/organization Name: City/State/Zip:, �rgPhone #: Are you an employer? Check the appropriate box: 1. I am a employes with Y—employees (full and/ or part-time)'e 2. ❑ lama sole XWnetor or pa mership and have no employees workiagfor me in any capacity. [No workers' comp. insurance required] g ❑ We are a eorp01736011 and its officers Nave exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp- insurance required)' 4. ❑ We are a non-pmft organization staffed by voom req' with no employees. [No workers' comp• r Basinen Type (required): 5. Qi Retail 6. [] Restauram/Bar/Eating Establishment 7. 0 Office and/or Sales (incl_ real estate, aato, etc.) 8. ❑ Non-taofit 9_ [] Entertainment" lo.n Mamtfacturing 11.0 Health Care} 12.M Ogler L >pny applicant that ehecksirox #t mast atw . out the seationbdow showing may wore:ee> --W-- r-•-, ----- ted themselves. but the cryo+anon bss other "'WZYM,s a workers' con p,,8. ionp li y is nq i -d and sada an =•Ffthe corporate ot5arshave excmp organization should check box #I- e sx r nr rerfnrnranon. -- fhQt lS.,pwQrJ!ers'CQmpeQSQtion lnSr�tr.Q�n•�C•¢J(rr my 0nptoyOa ie..... ., =...•r--.___- IQin an [:IlrplOyer Y""`••".i%m- .... Caty/Statelzip: Policy # or Sdf-i-LiE- # - a en ole declarateon page (showing the policy namber and expiration date). Attach a copy of the workers' compensate Policy Failure to $adore coverage as required under Section 25A ofMGL C. 152 can lead to the imposition oftaiminal penalties of a of a STOP WORK ORDER and a fine fine up to $1,500.00 and/or one-year imptisonmenl as well as civil penalties in the form oftip to $250.00 a day agailmike violator. Be advised that a copy of Ibis smemeutmay be forwarded to the Office of Imresti ns or meLu>.,w.,,�.,_..._..-....-_-a_ . l do hereby cert+fy, ihepans o1 popuryihQt the it farQtationprovided shovels trrseQnd correax Date: ' Sia Phone #: ®ff,[ecial use only. Do nor write in this areas to be completed 0 uty or town oQieiad City or Town: PermitiLecense # Issuing Autbority,(cirde one): 1. Board of Health 2. BuildingDeparienent 3. CS{y/Pown Clerk 4.I fceaseng Board 5. $etedmen's Office 6. Other Phone #: Contact Person:. www.ieassgov/dia,. -- _ E MIFIC T LI BIT�TW-5.1161. I SIC Ali E PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER -I E A STEVENS CO INC ONLY AND CONFERS NO RIGHTS UPON HOLDER. THIS CERTIFICATE DOES NOT AB ALTER THE COVERAGE AFFORDED BY THE 389 MAIN ST BOX 188 MALDEN MA 021485076 CoMPANY A —� INSURED COMPANY JAMES CURRIER CONSTRUCTION CO B COMPANY 131 FOREST ST _ MIDDLETON MA 019491911 ', COMPANY I D 12/08/06 AFFORDING COVERAGE INS CO AIM MUTUAL EXTENDOR-- 7E%FLOW.'-' 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. CO-PypE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE (POLICY EXPIRATION LIMITSLTR i DATE (MMJDDJYY) DATE (NIM/DDJYY) 1, GENERAL LIABILITY 9885121 7/01/06 7/01/07 GENERAL AGGREGATE $1,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGO $1 , 0 00 0 CO.. CLAIMS MADE ` XOCCUR j I Ii PERSONAL&ADV INJURY $1,000,000 OWNER'S & CONTRACTOR'S PROT I EACH OCCURRENCE $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEIIICLFS/SPECIAL ITEMS TOWN OF SALEM BOARD OF HEALTH 120 WASHINGTON ST 4TH FLOOR SALEM MA 01970 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE' EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR IRMAIL. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THIEFT,' BUT FAILURE TO MAIL SUCH NOTICE SHALE IMPOSE NO OBLIGATION ORAABILMY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVE& AUTHORIZED REPRESENTATIVE F.M. CLIFFORD, JR. CPCU, KN_A_" j FIRE DAMAGE (Ay onefire) $ 100,000 MED ESP (Any are person) I 5,000 =. AUTOMOBILE LIABILITY j 9885830 7/01/06 7/01/071/ 000, 000' COMBINED SINGLE LIMIT S ANY AUTO X ALL OWNED AUTOS i SCHEDULED AUTOS I N.on) INJURY $ (PerBODILY (Pe[pers HIRED ALTOS � I NON -OWNED AUTOS j BODILY INJURY S (ver a¢iacnp I PROPERTY DAMAGE 4 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY: EACH ACCR)EN( S AGGREGATE S i j _. EXCESS LIABILITY 9887430 X UMBRELLA FORM 7/01/06 7/01/07 I EACH OCCURRENCE $5,000,000 AGGREGATE $5, 000, OQO- S OTHERTHAN UMBRELLA FORM WORKERS COMPENSATION ANO AWC7O16989O1Z OO EMPLOYERS' LIABILITY 9/25/06 9 25/07 X TORWC T TITATu-S ERR EL EACH ACCIDENT $1,000,000 EL DISEASE -POLICY LIMIT $1,000,000 '- THE PROPRIETOR! INCL 'i PARTNERl XECUTIVE OFFICERS ARE: EXCL j EL DISEASE -EA EMPIAYEE 81 , O 0(),000 - I OTHER I - DESCRIPTION OF OPERATIONS/LOCATIONSNEIIICLFS/SPECIAL ITEMS TOWN OF SALEM BOARD OF HEALTH 120 WASHINGTON ST 4TH FLOOR SALEM MA 01970 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE' EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR IRMAIL. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THIEFT,' BUT FAILURE TO MAIL SUCH NOTICE SHALE IMPOSE NO OBLIGATION ORAABILMY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVE& AUTHORIZED REPRESENTATIVE F.M. CLIFFORD, JR. CPCU, KN_A_" tw'�y/�M'� r s $�. = C7a1 ♦ ...,, g �Ym,�Y4. ? y ( # City of Salem .y'Y✓ PE h !v Y S RR § L+4 �Y�y, 4h Q�. y Yl 1� �.s _,�, TF e a..:.4 4>m dtF.}i3(b iF•tuQ"�p Board of Health ?,,120 Washington Street, 4th Floor F i SALEM, MA 01970 DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -1999-000003 LOCATED AT: Septic Haulers Service Pumping & Drain Co. Inc. 5 Hallberg Park N Reading MA 01864 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0254 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Mack 2004, REGISTRATION #: 60148 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR �������® a I SALEM, MA01970 TEL. 978-741-1800 . . FAX 978-745-0343 DEC - 8 2006 JOANNE SCOTT, MPH, RS, CHO Kimberley Driscoll HEALTH AGENT C1 i Y OF SALEM Mayor BOARD OF.HEAU H APPLICATION FOR A PERMIT $50 RANer SPlORT OFFENSIVE The City of SUBSTalem ANCES oCas ES NAME OF APPLICANT:_ Service Pumping and Drain Co., Inc. TEL # ADDRESS: 5 Hallberg Park N. Reading, MA 01864 NAME OF COMPANY:_ ,— TEL # TYPE OF VEHICLE c2 —9` � C - GROSS WEIGHT S 000 REG. # (,-) Q i Li' R YEAR OF MAKE a�7� SUBSTANCE(S ) HAULED ROUTE OF TRA (must be complett SCHEDULE OF I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGULATIONS.REGARDING THOSE I UNDERSTAND THEM, ABIDE UNDERSTAND THAT FAILURE TO DOO MAY RESULT REVOCATION OF MY PERMIT TOND CARRY OFFENSIVE SUBSTANCES. MY BEST ANT TOEDGELAND , S49A,,IHAVE FCERTIF ILED ALLUNDESTATESTATE TAX RETURNS THE PENALTIES OF AND AID ALL STATHAT 1, TE ATE TAXES REQUIRED UNDER THE LAW. ;6. CH -OLq I a`ZO Date Social Security or Federal ID # --------------------------------------------------------- - - - --- --------- --------- ------- Permit # Check # Check Date: / (Revised 11/25/02 offperm.ins ) V \ 0 Board of Health } r fli #ftp x' 120 Washington Street 4th Floor t . �mflCrley D�SO011 .. r .,- �• Mayor -; SALEM, MA 01970 DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -1999-000003 LOCATED AT: Septic Haulers Service Pumping & Drain Co. Inc. 5 Hallberg Park N Reading MA 01864 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0255 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Mack 2005, REGISTRATION #: 63769 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH �^ 120 WASHINGTON STREET, 4TH FLOOR ��i/,}�(/�„ EIVED 9 e SALEM, MA 01970 TEL. 978-741-1800 DEC - 8 2006 FAX 978-745-0343 JOANNE SCOTT, MPH, ,RS, CHO CITY OF SALEM Kimberley Driscoll HEALTH AGENT g0ARD OF HEALTH Mayor APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT:_ Service Pumping and Drain Co., TEL # (q`7$)o21 to - 0124 ADDRESS: Inc. NAME OF COMPANY:5 Hallberg Park — N. Reading, MA 01864 ADDRESS: TEL # TYPE OF VEHICLE aCb'S GROSS WEIGHT f)o0 REG. # (g (4 C1 YEAR OF MAKE a-QoS SUBSTANCE(S ) HAULED S o Oki�4 r G ROUTE OF TRAVEL (must be completed) SCHEDULE OF TRAVEL I HAVE READ THE BOARD OF HEALTH REGULATION, "RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 THE LAW. '%2+&%jC14 7X;ii" r. lalt,i ori- ani ao9'1 Signature Date Social Security or Federal ID # Permit # Check # /a -Sq (Revised 11/25/02 offperm.ins ) tea. Check Date: /'�/7 - AV 410 Board of I Dnst 11 ��12OWaihinet�nStre�t4ihtPiou 5; r Mayor SALEM, MA 01970 DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000006 LOCATED AT: Septic Haulers Waynes Drains P.O. Box 298 WILMINGTON MA 01887 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0257 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 1998 International REGISTRATION: L45276 Total Fees: $50.00 PERMIT EXPIRES December 31,2007 Board of Health Page 1 of 1 'JoanneScott'Salem BOH 978 745 0143 - CITY OF SALEM, MASSACHUSETTS BOARO OF HI".ALTH 120 WASHINGTON STQCET, 4TH FLOOk SALEM, MA U 197o TEL. 578-741-1800 r. i -FAX 978-745.0343 ` CZ, JP. JOANNE SCOTT, MPH, P5,•CHO. - HEALTH AGENT APPI ICS:'ION FOR A, PERMIT TO TRANSPOR t3T_ ENSIVE SUBSTANCES _ FBF: $16 per Vehicle ppy;tblc to The Chy Of .' :,icm Nn C'1911 s ,.F. OF AP('L1C'.4N'T; :! ADDRFti;: AvnRL55:_>, \ o.X 0' �3 .�.� TSL #9 1 '�9 077% . ,HOF VFIIiCI, _ 5L'�-- '�",<,Lc)✓Yl �. .. WEIGHch�--_'k :11y[)C)© --- p, .: 7. N _� ti.L �.. d u- YEAR. OF MAKI.. DU11 O' TPAVEi,--_C�Qf11-:--_i��`3_M— _. '.N%E'READ THL HOARD OF HEALTH REGULATION, "RULES AND REGULA i,I.INS FOR '"1SPDP.Tt' i; O1 P G?4SI\'ESUASTANCES." ? HA\'F. HAD'I"HL OP?ORTI I ,I I : ' _ , `,1 Qi!ES1I'I^S '-i-,RDlN(_; 'HOML REGULATIONS. I UNDERSTAND THIiM, ACRS:❑'!'O 14, P.ND FAILURE TU DO SO MAY RESUCC ?N kEVUCATW` Cil h:` f%Ei2Vll"I 'I'0 tY I IV= N'UBS'I'ANCES.. UANT TO 1r.;-,_ Co?C, 549A, I CF,RTIFY UNDER THE PENAI.I'I..I'S Of FFR 'i.':"I itAI L '^;i N1Y - i KNTM DGE s,ND BELIEF, HAVE FILED ALL ST,A IT: TA \ RETUk.I`4 _^ kEGI_iiRED UNDER THE I.AW. Smial Sem tv , i :::d 1 nit N _ Check H L55d O, ?heck Date.: used 12/3?rJl eFtpa!a.in�s) RECrr EIVE 0 OU 2 3 2006 CITY OF SALEM BOARD OF HEALTH DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000006 1 11611W.74 NA BY-" Septic Haulers Waynes.Drains P.O. Box 298 WILMINGTON MA 01887 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0256 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE; Peterbuilt 2006 REGISTRATION: L41738 Total Fees: $50.00 PERMIT EXPIRES December -31,2007 Board of Health Page 1 of 1 SALEM, MA 01970 DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000006 1 11611W.74 NA BY-" Septic Haulers Waynes.Drains P.O. Box 298 WILMINGTON MA 01887 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0256 Jan 2, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE; Peterbuilt 2006 REGISTRATION: L41738 Total Fees: $50.00 PERMIT EXPIRES December -31,2007 Board of Health Page 1 of 1 63:33p Joanne Scott Salem BOH 978 745 r''443 xi.2 CITY OF SALEM, MASSACHUSL,T T S �= BCARD OF 1-4i2nLTH �\ 120 W4SHihcTON STREET, ,srn rLOOh Sn [M, 't/iA CJI87U TFL- D78,141-1800 ., Fix 979-745-C347 -,H JOANNE SGo7r, MPH. R5, ci-lo HEAL7, ACF_N] APPL ICATL®NFOR A PERMIT TO 7 RANSPL'OR01 VENSIVE SLTBSTANC&,S T FEF: $06 per Vehicle payapble to The City of 'i dQ— N6 C:tsii t OF APPLICANT:__lLC7S-Q�.�.\ -�l_. _ :;L Dz ti; ---a rL�m�� i-�- --- --- -- i I-(9 °�' _t� 'l D.- "E. OF CONIPANY:��k�(� �y-Z.P-LLQ -1._. r.� ' pp, ADDRESS: --_-2-0-6D) — 0— f.Uvki 1(�lOn TEL -1i ^_4 _9 _4�. 6-0-'©777 OF VEHICLE Q V ,,s WEI Hh-Snnyzop©a _ d _ Ly �''—I •J 0. YEAR OF N1Ah:L...._�---.,....-------- .' rANC `(S ) HAULED rE OF TR.AVL''L,-dS.A2P�s__I_..5.�1_ ��r------------ ----------_ cautpletcd) tU[, OFTRAVFI._ _pp ;"E READ THE BOARD CT }i.FALTH RL) ' iLATION, "RULES AND REG'UI A P INS FUR Pn: INE 01 PENSIVE St!BSTaP)CLS_' I HAVE HAD '1'H,7 OPPO7 I'U dt I : S6" '!ESCt iA':i 9,2D(PiG -£'HOSE REGULATIONS. C1:'JU'ECiSTAfiD TH L=Ni. .4GRBF: TD Ac81�.!l. `s1 THF+ MA, AND ?ERS T AND THAT FAILURE TO DO SO MAY RESULT tN REVOCATION 01-1 -N., PBRNiCf TO ot,rerlslvssliBs±Aicl:�. .,rl.;,Iv _ ,..J b..a _tiiC, 549A, Y C$RTlY1' UNDEK TNb FF'J:NI�CIIS CiP Pi at. ttY )-ii,h"[ I, To rn. BELTIF-T, PA_VL ALL, S` ATF TAX RETURdINS h i) P -I L:' Sl r.'1'C PEQUIRED UNDERTHE LAP;. Social `ceut•ity n- N- ::_-sl i! , nii ft Check !l j db C'hc�K Date: G/� JZO� ed 12l3l101 ('ffperm,iris) RECEIVED OCT 2 32003 CITy OF SALEM BC,AFI iJ QF .l -i; .ALTI-1 SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: File Number: BHF -2006-000006 LOCATED AT: Waynes Drains P.O. Box 298 WILMINGTON MA 01887 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0258 Jan 2, 2007 Dec 31, 2007 $50.00 Vehicle: Inertational Make: 2000 Reg: M13-610 Total Fees: $50.00 PERMIT EXPIRES !December 31, 2007 Board of Health Page 1 of 1 33n, .Joanne:Soott.;Salem BOH .978 745 0343 CITY OF SALEM, MASSA61-lust -l--q BOARO'OF HI ALTH " J> 1; O WASHINCTON STnEET, 4TH FLOOR ' n g Ix !!(per SALEM, MD, 619/u - '�`a TEL. 978741-1800 i l i i ✓ .,. F;:x 978--145-0 343 \ JOANNE SCOTT, MPH R5, CHO .77 �? HHEALTH Acr_N) _ .'i APPLICATION_ FOR A PERMIT TO 'T1ZA_I�T PCb Z t3�; ''_EINWE SUBSTANCES FFF: j141 per Vehicle payable to The Cit} of 'r;icm No Cash OF APPLICANT: Q per, ADDRESS:._Q �` p. ((�l��i 4 � 1 TEL �11��. 0-p_'©77 'F'OFVLIIiCL13. WEIGH I' YEAR OF NlAK --- '-51'A?QC'L(S I ,'.T LED --- Dc com io[w) ul.r OF TRAVEL— VE READ THE BOARD OF HEAI: H REGULATION, "RULESAND Rl;(W!_'AL i iix !=i Il? I13.PORTIi4i7O?*1";N.SIVF.SI'BSTAP7CGS."!HAVF.HAD'I'HEOPPGR'1`1)Nt .''�:'.,`C ... LARDING ''nOS: REGULATIONS. 1 UNDERSTA\ND.THLN1, AGRGG TO Au1 .'. [Y CHEM, AAD ERS,'AND THAT FAILURE TO DO SO MAY RESULT IN REVOCATIO' OF PFR,N11T 1'0 ;,V O 1 cvsn F. SuBsrANcis. 't i!ANT t0Nis JL C62C, 5490., 1 CERTIFI' UNDER THF.. PFNALIIiS OF PI'12,.- :' 9 i1'{i' I,"'J b!ti - ' AND BELIEF. HAVE. 1-i: L'? ALL STATE TAX. R1 PTiPNS i�! RE(G ;ieED U\lll !: THE. I,A1'. . Cnure. Dat Soi.l.tl Seetuiry � � �_-..! IL, .lit # Check Chock Raw: RECEIVED OU 2 3 2006 CITY OF SALEM BOARD OF HEALTH 09,14�2000 7.9:11 FAX 17819448,304 . 1 he LOrr monweattn o1 tvaassacnusrrts Aepartinent of Industrial Accidents pffece of Investigations 600 Washington Sired Poston, ALA 0211I www.mass.gOvIdia Workers' Compensation IjLsurance Affidavit. General Rnsinessi's VlAqvp A1141ass Insurance T3nsiTic,ss/Qrgatization Name: - Address: ci.tylstatalzip Are got n employer? Check the appropriate box: employees (full and/ i 1 am a employer with M po•tme).4and have 2. ❑ 1. am a soie proprietor or pain any ip no eltipioyeos working tor in any capacity. [No workers' come ivsarance regvuedj ]TI VJe arc a corporation and Its ai6cers have and lsed have their tight of exemption per o. t 52, § 1, )- no employees. (No workers" comp. insurance regvi=S q, 0 st,'c arc a non-profit org��on. staffed by volunteers, k leo insurance req.] Yhone U002 Business Type (required): 5. ❑ Retail 6, © P Staurant/Sar/fiating Establishment 7- Office and/or Sala (incl_ roa) Mate, ate' etc.) 8. ❑ Non-pro51 9. ❑ Entertainment 10-[] Mauufaeturiog 11.0 Health Care with no cmployoes. [No wor HE tenon nuc iafmuwuon• 3 mu.t 9Fa 5a act U,e section bolow sbowin tlfa+rwerkefi' comp P SotiM o5c 51, pmd w8 such an '.4ny eppiirxnt Ehnl alleckat,ax,= c cxc d jbcrosalvice, titin W� e %Porttibn bso oiL!* emptoyac�, a wpT):cY aompcn P •mtt'InI COY(OTdif. O}ttGllM 110"mike f ant an employer chat rs,Provirlirzg work rs' rnmp�sdtion insurance for my em ogees o lusnrance Uzapany Name_ � 1i7NiCT'S A _ t o, cily/Wty-zif< as p7 policy * or Self -ins. Lic. i f V 110.G1-11(rn:�.l-`�-tato Facpirationl7ate: Attach a copy of the workers' compensation policy declaration page (shoRing the policy number and expiration date . a Fa lure to recuse coverage as requ rod under Section 25A of MGL e. 152 can lead m the iaxpos tion otcrimmal penalties of fl nn P to S1, 09 a day agatnst the violatoY.S Be d•isad that oscopy of thilustalementFolie for.oaraedGto ttz offiEepof a fine Invcrpg8tions of the I71A for insurance coverage vtxi£reatio». -.. - . �� do herrly ..^Kifj�, under Chapains and penattfer of perjratry ehaf Aale, Si azure' wictai use only. po not wr& in this area ro be completed by city or town affrcial above is true a karunit/►.icense tf city or Zssusng Authority�h Zr e-0,0 n ➢e arfrtvcnt„ 3. CRYTowtl'Cferk '4: k iediusing l iisard 5 Selectmen's Office 9, $oard.ot,i� 8.... p b. other Phone#r ' pyyN',}n[sry,raeldia OU 2 312006 CITY OF SALEM BOARD OF HEALTH .. s • y} x .< s'�Fx.I c.•y dM'`, + Board of Health lQmberiey Driscoll.,° 120 Washington Street.Ath Floor ~ SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0307 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2002 Mack, REGISTRATION #: 54357 SEPTIC HAULER BHP -2007-0306 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #: H80752 SEPTIC HAULER BHP -2007-0305 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2002 Sterling, REGISTRATION #: 53767 SEPTIC HAULER BHP -2007-0304 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Sterling 2003 REGISTRATION #: 60750 SEPTIC HAULER BHP -2007-0303 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Mack, REGISTRATION #: H78352 SEPTIC HAULER BHP -2007-0302 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #: H 86627 SEPTIC HAULER BHP -2007-0301 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Mack2001, REGISTRATION #: H86639 SEPTIC HAULER BHP -2007-0300 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #: J18594 PERMIT EXPIRES jDecember 31, 2007 Board of Health Page 1 of 2 s' r ': Board of Health Wmbetley Dnsooll 120 Washington Street, 4th Floor Mayor. SALEM, MA 01970 DATE PRINTED: 01/04/2007 Septic Haulers Total Fees: $400.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 2 of 2 "F' .."` `. 3' wM ,r: 4- �'nu� w"�`'•,c+R >City of Salem t^� � '�i'v�sT -� � '� �Uaw. " '� o �� � a% Board of Health 120 Washington Street, 4th Floor; IGrnhetley 1 1 _ _, „' , . , - L ba.; Mayor. SALEM, MA 01970 DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Septic Haulers Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0306 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #: H80752 PERMIT EXPIRES Total Fees: $50.00 31, 2007 Board of Health Page 1 of 1 DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: JALGIYI, 1tlA UIY/U - Septic Haulers Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0305 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2002 Sterling, REGISTRATION #: 53767 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 1 •Y+t,' 4 th, .� k- �.w 1" City of Salem r r nIft4.."x^. bM�wP. r : Board of Health I�trll>elley DnSooll 120 Washington Street, 4th Floor NOW Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0304 Jan 4, 2007 Dee 31, 2007 $50.00 / VEHICLE TYPE: Sterling 2003 . REGISTRATION #: 60750 Total Fees: $50.00 PERMIT EXPIRES 'December 31, 2007 Board of Health t Page 1 of 1 Board of Health t ac„.i IGnlbCtl@y DnsC011 i120 Washington Street' 4th Floor G�� ' Y ;Q,. SALEM, MA 01970. DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Septic Haulers Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0303 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: Mack, 2001 REGISTRATION #: H78352 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 1 w ` % , �`` �* * �aCommonwealth of Massachusetts �� M r �'^" 1 yf.'h4 V i ,. s • t `.:: ' , 'Board of Health � ';.' - {:, t n .. s t � t. °` ' , .120 Washiagton'Street, 4th Floor ; IGmbedey Onscoll , .+» _.:... , �.,• ."' .- � ..,.._� ___ - _ .. Mayor . -_ SALEM, MA 01970 DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: B14F-2002-000007 LOCATED AT: Septic Haulers Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0302 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #: H 86627 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page i of 1 g�- y, zy.•- .;�` --y _ .':'.x�" n.�&,t"�,tt. CityofSalem., Board of Health w "3ifey Driscoll a IGmbe 120 Washington Street, 4th Floor r •,=, MByI)f SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0301 Jan 4, 2007 Dec 31, 2007 $50.00 /VEHICLE TYPE: Maek2001, REGISTRATION #: H86639 Total Fees: $50.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 1 of 1 i° x (;Ity Of yi' +[' n Board of Health R r t,. %, IGmbelley Driscoll 120 Washington'Street, 4th Floor Mayor SALEM, MA 01970 Septic Haulers DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0300 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2001 Mack, REGISTRATION #:118594 Total Fees: $50.00 PERMIT EXPIRES ;December 31, 2007 Board of Health Page 1 of 1 fs- . City a 9 r . �, �2 Ci of Salem ,'�� Board of Health _' l(imberiey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2002-000007 LOCATED AT: Septic Haulers Wind River Environmental, LLC 577 Main Street Suite 110 Hudson MA 01749 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes SEPTIC HAULER BHP -2007-0307 Jan 4, 2007 Dec 31, 2007 $50.00 / VEHICLE TYPE: 2002 Mack, REGISTRATION #: 54357 Total Fees: $50.00 PERMIT EXPIRES iDecember 31, 2007 Board of Health Page 1 of 1 CITY OF SALEM, MASSACHUSETTS a BOARD OF HEALTH a , 120 WASHINGTON STREET, 4TH FLOOR ����IpJ9�® SALEM, MA 01 970 ilii TEL. 978-741-1800 l�� gLOOr FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM Kimberley Driscoll HEALTH AGENT BOARD OF HEALTH Mayor APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $50 per Vehicle payable to The City of Salem No Cash NAME OF APPLICANT:: fin' ,1-- 1` WO `E— yin �/� (� �j p _ ADDRESS: I51 --A 1,`� `S �L&N�iN1�t,�TyT��p STEL# )�p�(�2q NAME OF COMPANY: (JVM�,6 n VQ 1I t W V''J"t ( � ADDRESS: Jt�Jl 1 l — TEL # TYPE OF VEHICLE GROSS WEIGHT REG. # YEAR OF MAKE SUBSTANCE(S ) HAULED ROUTE OF TRAVEL_ (must be completed) SCHEDULE OF TRAVEL I HAVE READ THE BOARD OF HEALTH REGULATION, 'RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM, AND UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES. PURSUANT TO MGL C62C, S49A, 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 THE LAW. � Z l Date Social Security or Federal ID # Permit # Check #.p 3(o i�(ot) Check Date: 41-ao.OU (Revised 11/25/02 offperm.ins) Branch Unit Type Year Make Model VIN TankSize Plate State NENO C11 Combo truck 2003 Sterling Heil combo 2FZHATAK73AK69576 3300/300y60750 MA NENO C17 Combo truck 2002 Sterling Progress combo 2FZHATAK33AK69574 3300/300$53767 MA NENO P10 Pump truck 2001 Mack Heil 1M2P270C41M060140 4800 v/H80752 MA NENO P24 Pump truck 2001 Mack Progress iM2P270Ci1MO60130 4800 v H78352 MA NENO P26 Pump truck 2001 Mack Progress 1M2P270C51M060132 4800 c- H86639 MA NENO P27 Pump truck 2001 Mack Progress 1M2P2570C32M062270 4800 H86627 MA NENO P43 Pump truck 2001 Mack Kary-Mor 1M2P270C81M060174 4800 m J18594 MA NENO P44 Pump truck 2002 Mack Kary-Mor 1M2P270C72M062272 4800 54357 MA LU C= c L w LU s LU M C I. _ W LL O O o 0 Q _� a UO pyr+d m The Commonwealth of Massachusetts Department of Industrial Accidents RECEIVED Office oflnvesdgations 600 Washington Street 'JAN 3 2007 Boston MA 02111 ' CITY OF SALEM www.mass gov/ilia BOARD OF HEALTH Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lea y Name (Business/Organization/Individual): WY)A U rAU�„y , Address:511 _"Ian 1 S� I � City/State/Zip: 4W.M1 M DIA9 Phone #: v6 1 p "lp2`My Ar you an employer? Check the appropriate box: 1. I am a employer with4. I am a general contractor and I El Type of project (required): -S� 6. ❑ New constructionemployees (full and/or part-time}. * 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet # '7, Remodeling ❑ g ship and have no employees These subcontractors have 8. ❑ Demolition working for mem any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 5. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. _ c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] 1 employees. [No workers' 13.E] Other comp. insurance required.] •Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Y Homeowners who submit this affidavit indicating they aro 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 name of the sub•contiactors and their workers' comp. policy information I am an employer that isproviding workers' compensation insurance for my employees. Below is thepo/icy and job site information. . r Insurance Company Policy # or Self -ins. Lic. #: /11 C 63 2 Expiration Job Site City/State/Zip: 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 st_atenlent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties ofperjury that the information provided above isst2true /annd correct. Signature: �, Date: 12-- (J `LJ Official use only. Do not trite 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: ACORD CERTIFICATE OF LIABILITY INSURANCE CSR A8 DATE(MMSDONY•/Y) WINDR-2 07/07/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NUK 7R ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rosenbloom. S Rosenbloom, Inc, 111 3rd Ave S, Suite 400 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PaLwYkFi,E�Ve DATE (NIMMOPM Minneapolis NTT 55401 Phone:612-436-5600 Fax:612-436-5601 INSURERS AFFORDING COVERAGE_ HAIC III INSURED INSURER& The Hartford 22357 Wind River Environmental, LLC et al 57177 main Street INSURER 8: National Union (AIG Group) INSURER C:(REVISED) INSURER D' NSURER E: A 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. NUK 7R N8 TYPE OF INSURANCE POLICY NUMBER PaLwYkFi,E�Ve DATE (NIMMOPM PO DATE MMO LIMITS I. A 0 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES Eeocc r nce) $ 300,000 A X COMMERCIAL GENERAL LABILITY 41UUNAX6631 06/30/46 06/30/07 CLAIMS MADE FX I OCCUR MED ENP (Any we person) $ 10,000 PERSONAL 6 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP Ar G $2,000,000 POLICY X JJEECT 7 LOC A AUTOMOBILE X LIABILITY ANY AUTO 41WPDP4367 06/30/06 06/30/07 COMBINED SINGLE LIMIT (EaacWderd) $1,000,000 BODILY INJURY IPer Pef9on) $ ALL OWNED AUTOS SCHEDULED AUTOS- BODILY INJURY (Per eaadeR) $ X X HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Peraccidert) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $5,000,000 8 X7 OCCUR F cawsMADE 885616762 06/30/06 06/30/07 AGGREGATE $5,000,000 t $- DEDUCTIBLE $ X RETENTION $10.000 WORKERS COMPENSATION AND - X TORYLIMITS I I ER A EMPLOYERSLWBIUTY ANY PROPRIETORIPARTNER/EXECUTIVE 41WBRC6329 06/30/06 06/30/07 E. L. EACH ACCIDENT $500,000 - E.L. DISEASE -EA EMPLOYEE $500,000 OFFICERIMEMBEREXCLUDED? Vys,dunder SPCIHL PROVISION belm E.L. DISEASE -POLICY LIMIT 1 $500 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION BLANX01 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 TD OD SO SHALL Evidence of Insurance IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE NSURER, ITS AGENTS OR REPRESENTATIVES. I. A 0 ACORD 25 (2001108) ® ACORD CORPORATION 1888 CITY OF SALEM BOARD OF HEALTH REGULATION # 9 Adopted June 20, 1995 RULES AND REGULATIONS FOR TRANSPORTING OFFENSIVE SUBSTANCES SECTION I - GENERAL The Board of Health, City of Salem, Massachusetts, acting under the authority of Section 31B, Chapter 111, of the Massachusetts General Laws and amendments and additions thereto, and by any other power thereto enabling, has adopted the following rules and regulations in the interest of and for the preservation of the public health. The effective date shall be June 30, 1995. SECTION II - DEFINITIONS 2.0 BOARD OF HEALTH - the legally designated health authority of the City. 2.1 DEPARTMENT - the City of Salem Health Department. 2.2 FUME - any gasses or aerosol resulting from chemical reaction, distillation or sublimation. 2.3 HEALTH AGENT - the legally designated representative of the Board of Health. 2.4 ODOR - that property of gaseous liquid or solid materials that elicits a physiologic response by the human sense of smell. 2.5 OFFENSIVE SUBSTANCE - shall mean any substance(s) deemed by the Board of Health to potentially affect the general public's health, safety and welfare and/or create a public health nuisance. Examples of such substances include, but are not limited to, offal, septic sewage, sewage sludge, or any by-products of its treatment. 2.6 PERSON - an individual, partnership, association, firm, syndicate, company, trust, corporation, city department, bureau, agency, or any other entity recognized by law as the subject of rights and duties. 2.7 NUISANCE - everything that endangers life or health, gives offense to senses, violates law of decency or obstructs reasonable or comfortable use of property. 2.8 VAPOR - the gaseous state of certain substances that can exist in equilibrium with their solid or liquid states under standard conditions. 2.9 VEHICLE - equipment for hauling, storing, moving or transporting offensive substances defined in Section 2.5 herein. SECTION III - REGULATED OND T 3.0 No person shall remove or transport any offensive substance(s) through or across any street of the City, to the extent possible under the General Laws of the Commonwealth of Massachusetts, without first obtaining a permit from the Board of Health or its Agent. 3.1 Application for a permit shall be made on form(s) provided by the Department. 3.2 The fee for such permit shall be $50.00 per vehicle, except that the fee may be waived for vehicles owned by the City of Salem and for vehicles owned by third parties performing contract services for the City of Salem. 3.3 The permit shall expire at the end of the calendar year in which it is issued. 3.4 The Board of Health or its Agent may place reasonable restrictions, including route and scheduling of travel, upon any permit issued. 3.5 All persons obtaining a permit to remove or transport offensive substances shall use closed vehicles in good repair with adequate means of containment which prevent leakage and/or spillage of liquids, solids, vapors, odors, or fumes of any kind. Such containment means may include a pressure relief valve to enable the discharge of fumes generated therein. The vehicles and their containment areas shall be kept in a clean condition satisfactory to the Board of Health or its Agent. 3.5 Any person(s) transporting an offensive substance(s), within the City under such permit, shall have the permit in their possession for inspection by any Salem Health Department personnel or police officer. SECTION IV - VARIANCES 4.0 The Board of Health or its authorized Agent may vary the application of any provision of these regulations with respect to any particular case, when, in its opinion, the enforcement thereof would do manifest injustice provided that the decision of the Board of Health is not in conflict with the spirit of these standards. 5.0 Each part of these regulations is construed as separate to the end that if any section, item, sentence, clause or phrase is held invalid for any reason, the remainder of these regulations shall continue in full force and effect. 6.0 Any person(s) who violates the regulation shall be punished by a fine of not more than $300.00 (M.G.L., Chapter 111, Section 31B) City of Salem Board of Health 9 North Street Salem, MA 01970 Joanne Scott, Health Agent George H. Levesque, Chairman Martin Fair Owen Meegan Irving Ingraham, MD Mary Madore Leonard Milaszewski Peter Saindon Barbara A. Sirois, Clerk of the Board Published in the Salem Evening News on June 30, 1995 After a vote of the Board, _6_ affirmative, _0_ negative and abstaining the following signature is authorized. George H. Levesque, Chairman