HomeMy WebLinkAboutDumont Pumping - 12/31/2020OCT z 6 201
Town of Maq'sfield
LICENSE NUMBER:
- Board of Health
Disposal Works Installer Application
APPLICANT: 1 \ec Q>Ch -----
BUSINESS NAME:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
MAIL ADDRESS: \ _O Q6X- 8nc_�, _
CITYITOWN: _ _ STATE: MC' ZIP CODE: C)a'1L.0(0
BUSINESS PHONE:S05.�ke5'11$3 BUSINESS CELL: 3R. mC-_
BUSINESS FAX:
E-mail:0.cv000cx�@CLi c1C4LJI , he's
Alt E-mail:
ID/SS NUMBER: C),-A nA Qr> 1
LICENSE HELD: Town _QX�Cco Year Licensed cid1�
LICENSE HELD: Town 1__) - — Year Licensed _-o��
LICENSE HELD: Town Year Licensed
I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage".
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires` December 31st yearly.
FEE: $ 100.00
SIGNATURE:
DATE: -la�,� "1------- -
Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield.
Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
N-�G s1$
"Social, Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Userslitc\Desktop\Scott's Docninents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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_ 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: Drcrs,+
Address: Po 60-y-,
City/State/Zip: 1,�,-kt CC)B Phone #:
Are yop an employer? Check the appropriate box:
Business Type (required):
1.
I am a employer with _�employees (full and/
5. ❑ Retail
or part-time).*
2. ❑ 1
6. ❑Restaurant/Bar/Eating Establishment
am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑Non-profit
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
100 Manufacturing
no employees. (N`o.yVorkers' comp. insurance required]*
4.❑ We -profit organization, by
1 L❑ Health Care
anon staffed volunteers,
12.[2`6ther
with no employees. [No workers' comp. insurance req.]
Any applicant that checks box # 1 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
aganization should check box #1.
am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy information.
nsurance Company Name: ``C wc% 5\5:u-} (3w_ri CIOL &CQx1P
usurer's Address: LA (00I
:ity/State/Zip: I� l� [Z__
r) C\l��'1�5" \\P il►
'olicy # or Self -ins. Lic. #� �� ���� Expiration Date: �J
-TT
Utach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
,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
nvestigations of the DIA for insurance coverage verification.
do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Offrcial 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.mass.gov/dia