HomeMy WebLinkAboutRiccio Builders - 12/31/2020LICENSE NUMBER:
APPLICANT:
BUSINESS NAME:
MAIL ADDRESS:
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048-
Disposal Works Installer Application
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CITY/TOWN: �VVN { \g_LAIJ) STATE:` A/A
BUSINESS PHONE: 56F6 _2 "" �"'2.� BUSINESS CELL:
BUSINESS FAX:
E-mail:
Alt E-mail:
ID/SS NUMBER:
ZIP CODE: O2J) 5
LICENSE HELD: Town LT" A-r-� ,; " �) Year Licensed
LICENSE HELD: Town %O
LICENSE HELD: Town
Year Licensed
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 31 st yearly.
FEE: $ 100.00
SIGNATURE:
DATE:
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
The Commonwealth of Massachusetts
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: ��
City/State/Zip: �.A � 1S 1 rz l '� (2 Phone #: `36S
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a em to ith employees (full and/
5. ❑ Retail
or - toe).*
6. ElRestaurant/Bar/Eating Establishment
2. m a sole proprietor or partnership and have no
I, ❑ 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
10.❑ Manufacturing
no employees. [No workers' comp, insurance required]*
I I.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
1
121-1 Other
with no employees. [No workers' comp. insurance req.]
* n..., .,..eI i—I eb.t aka " hnv a I mnct al cn
**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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. #_
Expiration
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 D Ai�foInsurance coverage verification.
I do hereby certify,
that the information provided above is true and correct.
nat,- I Z I-,� I I�
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Contact
www.mass.gov/ma
Phone
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 C rporate Name By: Corporate Officer (Mandatonj, if Applicable)
�9 2 Z L I b 1
**Social Security No. (Voluntanj) 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.
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