HomeMy WebLinkAboutCanoe River Campground - 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Campground Permit
This is to certify that: GONSALVES FAMILY: STARLIN, INC.
Is hereby granted a CANOE RIVER CAMPGROUND
permit for:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
137 MILL STREET, MANSFIELD, MA 02048
250 SITES
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires December31, 2o1s unless sooner suspended or revoked.
Fee : $75.00 plus $1.00 per site Total Fee: $325.00
Permit Number: 1
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Campground Permit
I hereby make application for a CAMPGROUND PERMIT, which expires on December 31st of each year.
NAME OF BUSINESS:
ADDRESS OF OWNER:
OWNER:
BUSINESS PHONE:
BUSINESS FAX:
E-MAIL:
ALT E-MAIL:
CANOE RIVER CAMPGROUND
137 MILL STREET, MANSFIELD, MA 02048
GONSALVES FAMILY: STARLIN, INC.
(508) 339-6462
(508)339-5237
MARK@CANOERIVER.COM
FEDERAL ID/SS NUMBER: 04-2375571
NUMBER OF SITES: 250
FEE: $75.00 Plus $1.00 Per Site
PERMIT NUMBER: 1
TOTAL FEE: $325.00
SIGNATURE:
DATE: l �l /I 7
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
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.
ST/4/�c !•a, /Vc
Signature of Individual or Corporate Name
01/-D375ss 7i
**Social Security No. (Voluntary) or Federal
Identification Number
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.