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2013 SEPTIC HAULER-STEWART'S SEPTIC SERVICE Commonwealth of Massachusetts City of Salem Board of Health .Kimberley Driscoll 120 Washington Street,_4th Floor Mayor SALEM,MA 01970 Septic maulers Permit DATE PRINTED- 12110/2012 a ESTABLISHMENT-NAME:'.',.-.',. -StewartsSeptk Service File Number.BHF 2007-000037 J&S Development = 58 So.--Kimball Street BRADFORD MA.,�01835 LOCATED AT: SALEW MA- 01970 - Permit Type- -Permit No. Permit Issued Permit Expires Fee Reskrictions/`Notes SEPTIC HAULER BHP-2413-0100 Jan 11013 ` Dec 319-2013 $105.00_VEHICLE TYPE: Vacum Pump TrucicReg#64963 Total Fees: $105.00 PERMIT EXPIRES IDecember 31, 2013 Board of Health`` Page 7 m � - •d . CITY OF SALEM, IVIASSACHUSETTS " BOARD OP HEALTH HINC7T0N STREET 4'11 FLOOR PublicHeatth CW Prevent.Promote.Protect. 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL r� lramdin a.salem.corn L:1RRY Ri1MDIN,RS/1tLIIS,CE IO,Ci'-1 S MAYOR ®�� HE,,.\j,—n I AGENT �pF APPLICA FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES FEE: $105 Per Vehicle payable to the City of Salem No Cash Name of Applicant: ✓ i n ce c -)-Oh nvinre19"2719 Address: ff!m 0'1 4�;/d0A- 01705 Tel#: 97Y37,? W 71 Name of Company: J and -a 1 b- A c5 h- )2 r Address: I rn LrC L� T�/1� Tel#: �") M 15-$-/ Type of Vehicle �(U-l)m— /[ Gross Weight 80 L Reg.# Q�96.3 _ Year of Make: RICO5 PEJer Substance(s)Hauled - �e�,r£' j G Route of Travel E 1 (must be completed) Schedule of Travel I HAVE READ THE BOARD OF HEALTH REGULATIONS,"RULES AND REGULATIONS FOR TRANSPORTIING OFFENSIVE SUBSTANCES."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I UNDERSTAND THEM;AGREE TO ABIDE BY THEM AND UNDERSTAN THAT FAILURE TO DO SO MAY RESULT IN 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. D MCM24) L/ iQ97�1315 Signature Date SS #or Federal ID# ---------------------------------------------------------------------------------------------------------------------------------------------------------------°----------------------------- Permit# Check# Check Dat lJ Updated 5/23/11 Circle K store (was a Blue Canoe): 323 Highland Ave Salem ma Home owner-Nigro @ 48 old farm road Salem "Also upon customer request t.; TV Y, uw n ear J and S Development Corp• dba STFWAR7'S SEPTIC SERVICES 58 South Kimball Street • Haverhill MA 01835-7532 •Tel: (978) 372-7471 • Fax: (978)373-6611 To Whom It May Concern: All waste is disposed of at our own treatment plant located @ 20 South Mill St Bradford Ma 01835 Our Discharge permit No._PTX-017 2875-01 Expiration Date:April 2,2015 Questions please call us 978.372.7471 j�` a•o a. a.v•.e.•w•o.r a-ae.e.e vJ auuuas a-renua-ceu Department of Industrial Accidents Office of Investigations 600 Washington.Street _ Bosion, MA 02111 www.mass.govldia Workers' Compensation insurance Affidavit: General businesses Applicant Information Please Print Lc ibl ter! 1 Business/Orbaiiization Name: nddressl _ -- — 7 City/State/zip: f'I�one#: - kre,you an employer?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 Z.❑ I am a sole proprictor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Nom-profit 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 no employees. [No workers' comp.-insurance required]* 11.0 Health Care �.❑ We are a non-profit organization,staffed b volunteers, P - with no employees. [No workers' comp. insurance req.] 12.�Other �h , ��) Uy applicant that cheeks box li I niust also till out the section below showing their workers'compensation policy inrormation. l I the corporate oniccrs have exempted themselves,bill the corporation hiLS other employees,a workers'compensation policy is required and such an _aniration should check box if 1. am an emplqper that is providing workers'compensation insurance for my employees. Below is the polio y information. lsurance Company Name: lsurcr's Address: _ � - L' ity/State/7.ip: Aicy{i or Self-ins. Lic. I ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). :lill.lre to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ile 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 line f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lvestigations of the Din ibr insurance coverage verification. do hereby certijy,under th(e,pauls and penalties of perjury that the information provided above is true and correct. i mature: }iL }�` 1(.aCi 1..., .� Date: ) x- hone t1• �-77 7/ Official use only. Do not write in this area,to he 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.nhass.gov/dill massDOT CERTIFICATE OF REGISTRATION RMv Division + M.G.L.Chapter 90 Section 240 nukes it a crime to alter this Certificate VU TE TYPE RATIOR IAIMBER RJEWRATION TYPE OFWM DkTE rm ITRUMMMNUMM APN 70609 APPORTIONED 07/01/12S"Not;vl:aw 06 13 02218070170112 MPRB MOOS.YEAR r Mono. soot axon dal F WI OHT�UM 1996 TRB CONVEN TRACT RED uredBegist wRE OR TRAM YJ CU WMFICAnMW B M O WAW i7:F NMBM MGM MB61OF 1XP5LBOX7TN402884 GREAT DIVIDE INS AT170839 ,�q/ ,PASSEKWIS mow 062000 WOOS)of OMRIER(S)AM AWUNG Aop1E88 FEES J AND S DEVELOPMENT CORP aeasTRATrow 0.00 58 S KIMBALL ST ME 0.00 BRADFORD, MA 01835-7532 ME=KAM 0.00 ETA 0.00 TOTAL 0.00 MASSACHUSETTS DEPARTMENT OF TRANSPORTATION REGISTRY OF MOTOR VEHICLES DIIViSION The rewo of the RM11 database constlhite the offldal status d the vehicle mglstrwion, EgALMMUM CNAROEaFAXFM IF THIS VEHICLE IS NEWLY ACQUIRED, IT MUST BE INSPECTED WITHIN SEVEN (7) DAYS SnWADOM OF REGISTRATION. CITY.STATE ZIP CODE Important Information for Vehicle Owners .Every person operating a motor vehicle shall have the Certifi- Return the registration plates to the RMV Immediately if: cate of Registration for the motor vehicle and for the trailer,if any,and his/her license to operate,upon his/her person or in -The vehicle has been sold or junked and the registration is not the'vehicle,in some easily accessible place. going to be transferred to another vehicle.Keep a copy of the Bill of Sale,7711e, and completed Reassignment of 77de for ur .By law,you must report any change of address to the RMV within records to document the transfer. 30 days in writing.Address changes can be made on the RMV -You move to another state and you register the vehicle In that state. website:www.mass.ggov/rmv or by mail to:RMV,P.O.Box 55889, Boston,MA 02205-5589.Once you have reported the address .The Insurance policy is not renewed or is cancelled and there is change to the RMV,please write corrected address in box no plan to obtain a new policy. provided above. Transferrim8:Your Plates: Massachusetts law (M.G.L. Chapter 90, Section 2) allows you to transfer valid registration plates from this vehicle to a newly acquired new or used motor vehicle or trailer while you obtain Insurance and a new registration.AD of the following must be met: 1.You are at least 18 years of age and you own the motor vehicle or trailer Identified on this Registration Certificate,2.You transfer ownership of this vehicle to another person or permanently lose possession of it(such as through repossession,etc.);3.The newly acquired vehicle Is of the same vehicle type(passenger vehicle to passenger vehicle,trailer to trailer,etc.);the same registration type (passenger to passenger,commercial to commercial); and has the same number of wheels;and,4.The self and buyer properly complete the Assignment of the Certificate of Title(for the newly acquired"used"vehicle)or Certificate of Origin(if a'new"vehicle). If an of the above are met,you may operate the newly acquired vehicle with the transferred plates up to 5.00 pm of the 7th calendar day following the date of transfer(or loss of possession). The day of transfer or loss Is day 11. During those 7 days,you must carry the Bill of Sale (or the dealer's Purchase Contract)for the newly acquired vehicle and this Registration Certificate when operating the vehicle. See FA&About the Seven-Day Registration Transfer Law on the RMV's webslte at www.mass.gm1rmv. No Insurance Card Regialyed:Massachusetts's law does not require an insurance card. The law,M.G.L.Chapter 90, Section 34A and Chapter 175, Section 113A requires the vehicle's owner to maintain a compulsory motor vehicle liability Insurance policy or bond for bodily Injury coverage and property damage Insurance. If an Insurer is identified on the face of this Registration Certificate, it Is required by law to electronically notify the RMV(Registry of Motor Vehicles)If coverage lapses.The vehicle owner is then notified by the RMV to obtain new Insurance within 10 days or the registration will be revoked.Bonds are filed with the State Treasurer 4 office. BE FIRST IN LINE BY GOING ONLINE AT WWW.MASS.GOV/RMV Schedule a Road Test Request a Duplicate Title NEED TO VISIT AN RMV OFFICE? Renew Your Driver's License Request a Duplicate Registration Renew Your Registration Change Your Address SAVE TIME Pay Citations/Court Hearing Fee Cancel My Plate/Registration Complete Your Replace Your Driver's License Order a Special Plate Application Online! VISIT OUR WEBSITE FOR A FULL LIST OF AVAILABLE TRANSACTIONS BFLMT BAn1 s ® DATE(MMIDD/YYYY) A C40R EP CERTIFICATE OF LIABILITY INSURANCE 10/25/2012 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(ies) 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: Linda Murray MTM Insurance Associates PHONEM. (978)681-5700 FAX/C No (978)681-5777 575 Chickering Rd EMAIL .lindam@mtminsure.com INSURER S AFFORDING COVERAGE NAIC tl North Andover MA 01845 INSURERA:Nautllus Insurance Company INSURED INSURER B:Great Divide Insurance Company J & S Development Corporation, INSURERC.We8CO Insurance Com an DBA: Stewart Septic System INSURERD: 58 South Kimball Street INSURERE: Bradford MA 01835 INSURER F: COVERAGES CERTIFICATE NUMBER:11-12 Master 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. INSR ODLISUBRPOLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYY MM/DD/YYYY GENERAL LIABILITY EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY A 100,000 R E occurrence $ A CLAIMS-MADE OCCUR CP01520613-11 9/26/2012 9/26/2013 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000, GEN'LAGGRE GATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY F PRO LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ 1 000,000 B ALL OWNED X SCHEDULED 1523931-11 9/26/2012 9/26/2013 BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED ROPERTY DAMAGE $ Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ RDEXCESS LIAB HCLAIMS-MADE AGGREGATE $ ED I I RETENTION$ $ C WORKERS COMPENSATION WC STATU- O R AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y[ N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? 9/26/2012 9/26/2013 C3045821 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 1,000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 707,Additional Remarks Schedule,If mores pace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SALEM BOARD OF HEALTH " 120 WASHINGTON STRET 4TH FLOOR SALEM, MA 01970 AUTHORI7,.ED RESENTAT E M Hol and-De y/MAR ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights i4served. INS025(201005).01 The ACORD name and logo are registered marks of ACORD