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HomeMy WebLinkAboutPump Grump - 12/31/20201 t Too of Mansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FDG Haulers Applieatiou DATE: LICENSE NUMBER: BUSINESS NAME: P,Mq &,� MAIL ADDRESS: 1'O C30� cJ4 cal TOWN: t301-`IrM STATE: (" ft ZIP CODE: NAME OF OWNER: Neo Ri&-j BUSINESS TELEPHONE: S2b l„9$,4\c>l CELL: SF'rmE, FAX: EMAIL: Q&1C-nCe&,:yDte e Crx'K'C1. , r�Li ALT EMAIL: FED ID/SS NO: Ok-i'lS3'3Q608 NUMBER OF TRUCK(S): FEE PER TRUCK: kN 1®O ................................. SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:00AM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9:,As,of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: G�atrJ`g�� DATE: Truck Registration number: 'T 15 1lo - Circle one: Septa a FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG ................................. SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:00AM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9:,As,of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: G�atrJ`g�� DATE: TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) OH ;33_zq 1S 2s "Social Security No. (Voluntary) or Federal Identification Nunsber *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. Ct\Users\Ileite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc _ — - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: Po VjOX -�lqc�, City/State/Zip: Are you an employer? Check the appropriate box: L I am a employer with _ employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 31 We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. tN'o-Workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 122`6ther 3en4g�_ *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: (Y" wm �U Pthce.6 CO— Comte Insurer's Address: L uco 1 City/State/Zip:�ereV�SCx�� Policy # or Self -ins. Lie. # UDC ©QMC-:�T Expiration Date: ,� fT0 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage •asrequired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.inass.gov/dia