HomeMy WebLinkAboutB-P Trucking - 12/31/2020T z.wn- of-�l ani fidd - Board of Health
Hai der's Application
BUSINESS NAME: B -P Trucking, Inc.
BUSINESS ADDRESS: P.O. Box 386
TOWN / STATE / ZIP: Ashland, MA 0 17 21
NAME OF OWNER: Stephen DePaolo
TELEPHONE NO: 508-231-1000
CELL NO: 774-279-0906
FAX NO: 508-881-6123
E-mail:sales@bptrucking.com
Alt E-mail:
FED ID/SS NO: 042595703
REGISTRATION NO: T92006
T92007
NO OF TRUCK(S): 2
FEE PER TRUCK: $75.00
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SIGNATURE:
*Oq�)_S�1+7_
Town of Mansfield
6 Park Row
Mansfield, MA 02048
PERMIT NUMBER:
TOTAL FEE: $150.00
Permit Expires December 31st yearly.
DATE: Z-/
2
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.
The Comntoinvealth of Massachusetts
Department oflndustrialAceidents
Office of In Vestigations
600 Washington Street
Boston, MA 02111
wivw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le ibl
Business/Organization Name: B—P Trucking Inc
Address: 47-65 Nickerson Road, Ashland, MA 01721
City/State/Zip: Ashland, MA )1721 Phone:
* ,tn
,-
Are
you an employer? Check the appropriate box:
1. t am an employer with ]employees (FT
and/or PT.)*
2. 1 am a sole proprietor or partnership and have no employees
working for me in any capacity.
1. We are a corporation and its officers have exercised
their right of exemption per c.152, § 1(4), and we have
no employees (no workers 'comp. insurance required.)**
4. We are a non-profit organization, staffed byManufacturing
volunteers, with no employees (no workers' comp.
insurance required,)**
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Business Type (required):
Retail
Restaurant/Bar/Eating Establishment
Office and/or Sales (including real estate, auto, etc.)
Non -Profit
Entertainment
Healthcare
Other (please specify):Soil irl Wante Removal
X
nn�inonl
X
Out- --, -r•----•- -• •-• ..
—ten ,.. mu,, o„u .,�, u, u,c soeavn below snowing 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 ant an employer that is providing workers' compensation insarancefor my employees. Below is the policy information
Insurance Company Name: '% ,q v N L N 2 ZrS' Al D E Ni il(t 7 �/ C co
Insurer's Address:
City/State/Zip:
Policy # or Self -Ins. Lie. #: 47 /-1 U 8 0 y (2 p 6,S -Q i Q Expiration Date:_ 1— Q 1 — Q p ,_� c,
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
S 1,500.00 andfor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine up to 5250.00 a day
against the violator. Be advised that the copy of this statement may be ronvarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: _ Date:
Phone N: 508-231-1000
Oficial 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): .._„_...�,.�.
Board of Health Building Department City/Town Clerk
Licensing Board Selectmen's Office Other:
Contact Person: 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.
Sign re of Individual or Corporate Name
04-2595703
""Social Security No. (Voluntary) or Federal
Identification Number
Stephen DePaolo, VP
By: Corporate Officer (Mandatory, if Applicable)
"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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