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HomeMy WebLinkAboutWaste Management of MA, Inc. - 12/31/2020kv Town' of Mansfield - Board of Health Hauler's Application 4t-c)o/43?06q_� PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 TOTAL FEE: o, 6tio BUSINESS NAME: BUSINESS ADDRESS: and TOWN/STATE/ZIP: /�1 �� �'c/ �`�16v NAME OF OWNER: TELEPHONE NO:/ CELL NO: /J� % �� 3� `l FAX NO: 97 407� E-mail: �ToEele,-,"0a Alt E-mail: FED ID/SS NO: UV ,�/S yJ 06 3 REGISTRATION NO: NO OF TRUCK(S): Q FEE PER TRUCK: $75.00 Permit Expires December 31st yearly. SIGNATURE: ` DATE: )) Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. 1 TAX CERTIFICATION FORM ill s . , 114u II i.., 1h , if, If xlnil I [1 IIIII I]I J 11 1e 11 f , I I .i�6�. „ .... . 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. o�1-d5-9Ste(_? **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. C:\Users\sleite\I)esktop\Scolds Doctanents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Print Form Department of Industrial Accidents h Office of Investigations I Congress Street, Suite 700 Boston, MA 02114-2017 - www.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le0bly Business/Organization Name: Address: //JV City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): L K] 1 am a employer with/4G r employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. [No workers' comp. insurance required] 8. ❑ Non-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 WE Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑ Health Care _ with no employees. [No workers' comp. insurance req.] 12.© Other Jyo«s C' 9' pep /. tt7.ae-( r/ lle m,e, *Any applicant that checks box k 1 must also fill out (lie section below showing their workers' compensation policy infornw ' m. **If the empointe oliceis have exempled themselves, bit( the eorponnion lilts other employees, it workers' conipensntion policy is mquircd and such an organization should check box N 1. I antian employer that is prov. /ink workers' compensation insurance for tiny employees., BeLnv is the policy inforueation. Insurance Company Name: / fLf /y '/ i CG!! l 1�%� ((Y f�"7� `�� UW17 Insurer's City/State/Zip:___ Policy k or Self -ins. Lic. N t/,' L� �C� %'r:� ��'LJ v Expiration Date: / !> Attach a copy of the workers' compensation policy declaration page (showing the policy numbiSr . nd 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, ul(der the pains and penalties of perjury that tree infornnetion provided above is true and correct. Phone ft: _oCK (e C, % < 0 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit7License 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: www.mass.gov/me Phone