2013 SEPTIC HAULER-WIND RIVER ENVIRONMENTAL Commonwealth of Massachusetts
s r
City of Salem
Board of Health Kimbedey Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Septic Haulers Permit
DATE PRINTED: 06/25/2013
ESTABLISHMENT IITANLE: iiad River Environmental'LLC-
` a.' < +:_, f
Ft��r�wna�:sttF-zoo2�aana� 577 Mam Street Suite 114 g:
JI
LOCATED AT:
fi SALEM, MA. 01970 E
��� .. � � 3._ � � _�^�n n •. � �- �' �' =�`?�' tom. � `� :r� �.'°�',. ''&` � ��'fx '� +� �t a£
b Pernut 1`ype� Permit NO.� Permit Issued Pest E�rires Fee.Restrictions 1 Notes
SEPTIC HAULER = BHP-ZOi3-0483 } 1
Jan 1,Z013 'Dec 31 2013 $105 00:Make&Year Mack 2002 Re
-° .,_. zt- fir. '' 'ems.s"t`hx
2 SEPTIC IiAULER` BHP -Q48Z ��,ai 1,2013 -Dec 31,2013 $105 OD-IvIAKE&YEAR Sterling 2003 4IV
b n-REC 10 2G93• �
F
� SEPTIC HAULER � BHP:Z013-0481 Jan 1y 2013 Dec 3 ,2013 :: $105 00's`7EHICI E TYFE 20Q 1 Mack.
7E6!`4.'M90196� 71,k
_- TYYs P1013 $105 00 VEHICLE TP..;Ea' a 2`.�0 01 Mr e�SEPTIC HAULERS' BHO41 _, J $ _
.M90195 « a r` EPTICIAgRB -Z093479U 2013 E 200 .`•�_�
,
.3 ' ;SEPTIC HAULERet
BHP-2013 0478 _Jan 12013 , Dec 31,2013' $105 00 YEI ICLE TYPE 200 Macic
t ,ItEG# T6680� � 4g ',
�A z
SEPTIC HAULER BHP!41340417 Jan 1,^2613 Dec 31,2013 4 _ $105 00`VEHICLE TYFE 2003'Sterling {
a A a '
Reg...79954# -
Y
.=+FOtalFees. •� .: - �>
PERMIT EXPIRES ecemlaer 31, 2013
Board of Health
Page 1
I I
b
WCA-
�?� CITY OF SALEM, MASSACHUSE
DEC
BOARD OF HEALTH
L6/
120 WASHINGTON STREET,4 FLCMR t 3 2n'Z ou Prevent, Health
TEL. (978)741-1800 FAx(978)749� UFSq�EM Promote.Protect.
KIMBERLEY DRISCOLL lraindin0a7salem.com H
RY RA1l4llIN,RSf Rl-'HS,CIIO,CP-LDS
MAYOR HE,1I.rlI AGENT
APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES
FEE: $105 Per Vehicle payable to the City of Salem No Cash
Name of Applicant: c6awd) N L_t-C,
Address: S1? (Y a t y1 5- 4 LJ AS6 r\ N� ..C)! `Z _Tel#:�c Z$ �+ l rU C)u
Name of Company: \� r�1CC1 L-L-C _
Address: '51 MCL( l '5'V ��Jc�Sc�;n , (VIA- CS l'Z.Lt C _Tel#: ,SoGcD
Type of Vehicle
Gross Weight z `
Reg.#
Substance(s)Hauled
Route of Travel_ _ 2� f
(must be completed)
Schedule of Travel L4 -�Ic Y1�S ptN (Y wA �A
I HAVE READ THE BOARD OF HEALTH REGULATIONS,"RULES AND E
SUBSTANCES."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS
UNDERSTAND THEM;AGREE TO ABIDE BY THEM AND UNDERSTAN ___ ______ _-.
REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES.
PURSUANT TO HGL C62C, S49A I CERTIFY UNDER THE PENALITIES 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 hate SS #or Federal ID#
--------------------- --------r------------------------------------------------ ------------ may�---------------------------------------------- -------------------- ---
Permit# U7!D�qjCheck# Check Date
Updated 5/23/11
A�® CERTIFICATE OF LIABILITY INSURANCE 7/3/2012"'
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((es)must 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 NAME 1e al Stolberg
Bearence Management Group PHONN.E . (651)379-7800 Fi4AlX No:(6511379-1001
2010 Centre Pointe Blvd AD DRESS:astolberg@bearence.com
P ODUC RSLU IQMEBp0008671
Mendota Heights MN 55120 INSURE S AFFORDING COVERAGE NAICN
INSURED INSURERA:Starr Indemnity 6 Liability 8318
INSURERB.Ins. Company of State of PA 19429
Wind River Environmental LLC INSURERC:
577 Main Street INSURERD:
INSURER E:
Hudson MA 01749 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL1262917209 REVISION NUMBER:
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.
NTRT TYPE OF INSURANCE POLICY NUMBER ADMISUBRI MM/DDYIYYri MMIDDIYYYICY Y LIMITS
LTR'
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY PR M rre $
CLAIMS-MADE OCCUR MED EXP Any one person $
PERSONAL&ADV INJURY 5
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $
POLICY PRO I LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS
BODILY INJURY(Per accident) $
SCHEDULEDAUTOS
PROPERTY DAMAGE $
HIRED AUTOS (Peraccident)
NON-OWNED AUTOS $
$
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 15,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $ 15,000,000
DEDUCTIBLE $
A X RETENTION $ 0 SISCCCLO1832812 6/30/2012 6/30/2013 $
B WORKERS COMPENSATION X I STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY
OFFICER/MEIMBER
/PARTNERI EXECUTIVE� NIA E.L.EACH ACCIDENT $ 500,000
EXCLUDE(Mandatory in NH) 25889555 6/30/2012 6/30/2013 E.L.DISEASE-EA EMPLOYEq$ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT J$ 500,00
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Blanket Waiver of subrogation with respect to workers compensation, applies where required by contract. Certificate
holder is listed as additional insured with respects to the umbrella liability policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Wind River Environmental, LLC ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
A Stolberg/ERIKEY
ACORD 25(2009109) C 1988-2009 ACORD CORPORATION. All rights reserved.
INS025(200909) The ACORD name and logo are registered marks of ACORD
T7—
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A 02111
M
wwwmass.govIdia
Workers' Compensatiou Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApRlicant Information Please Print LegibL,
Name (Business/OrganizatiorAndividual)l,:V 6A\/VonKY%,6mN 44,
Address: 20
City/State/zip: Phone#: 0M i N 5-600
A u an employer?Check the appropriate box: Type of project(required).
1.71 am a employer with I go 4. (:] I am a general contractor and 1 6. El New construction
employees(full and/or part-time).* have hired the sub-contractors
2.[1 1 am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling
ship and have no employees These sub-contractors have 8. []Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp.insurance.)
required.] 5. E] We are a corporation and its 10.0 Electrical, repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.[:]Plumbing repairs or additions
myself.-[No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.) t C. 152,§1(4),and we have no 13.VOthersgb�1Cw0k%,
employees. [No workers'
comp.insurance required.) L
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 name of 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ c
Policy#or Self-ins.Lic.#: Expiration Date: (o 1 —30 t�
Job Site Address: M 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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenallies ofperjury that the information provided above is true and correct.
Si nature: -- Date:
C 9N- -'511 3
V7
Phone#:
�
Official use only. Do not write in this area,to be co leted 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: Phone#:
Information and histructiouts
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially,stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 e.xt 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
0 0 0 0 0 0 0
m o0 0o ao 00 00 00
Y O
O
N M
H in
m m m ^O n m
Un O O O N N
lD O O O O O O
M H H � N N N
m U U U U U U
Y O O O O O O
n n n n n n
¢ NNN N N
= 0_ 0_ 0_ 0_ 0_ 0_
N N N N N N
N 2
y 0 00 00 00
Ln 00 00 00
lW LOO W
CD top l00 00C
0D
C
Y i U U U U U V
41
N G G G G G
m 1-4 r-I T-1 N N N
aea,k 0 0 0 0 0 0 0
m to Ln
r Ln N O
N O O
a � tD rl r,
Q' a 0 0 0 a a nz
a ¢ U U U ¢ ¢ ¢
E E E 'E E E E
u d d a m a a
Y' Y Y Y' Y Y �C
U U U U U U U
pggsea L L L L L L
sn;e;S a a a ¢ a a s
z z z z z z z
y3ueJB z z z z z z z
;lun U a a a a a a
L 'J