HomeMy WebLinkAboutBoston Cremation - 4/30/20205
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Funeral Home Permit l
Permit Number: 00-3
This is to certify that: VICTOR BUONFIGLIO, PAUL BUONFIGLIO
115 NORTH MAIN STREET
Is hereby granted a BOSTON CREMATION
permit for
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expire Thursday, April 30, 2020 unless sooner suspended or revoked.
Fee : $50.00
BOARD OF HEALTH
.MichaeCHeaCey, Chairman
Town of Town of Mansfield - Board of Health 6 Park Rowansffeld
Mansfield, MA 02048
Application for Funeral Home Permit
Id�:IViI� r,fn�ra7 ail
I hereby make application for a FUNERAL HOME PERMIT which expires on April 30th of each year.
NAME OF BUSINESS: 6
11 00-w� C(e'vvict b' 01/1 Q
ADDRESS OF OWNER: vMC,4-) S�rZC� "�1 «E�t VIA 2- 99
rt
OWNER: �\C � oov,+(31( 0
BUSINESS PHONE:
BUSINESS FAX:
EMAIL ADDRESS:
FEDERAL ID/SS NUMBER: 9-_ ) b S9 t Z V
FEE: $ 25.00 1
SIGNATURE:
DATE:
i certify
belief, l
under la
1 , I
Signature of In
*This licenses
by the applica
** Your social
tax pays
request is made urt
Chapter 62C, sectia
Are�V{ou an employer? Cht
I.1/y I am a employer With
�� ll or part-time).#.......:
2.0 1 am a sole. proprietor
cnrployces working fl
[No workers' comp. i
3. ❑ Wo are a corporation.
thoir right of ZXOI P61
no employees. [No w
4. ❑ We aro a non-profit o.
wdth no employees. It
'Av applicant that chocks box.01 nn
if foe wpo office" Savo"
l mn an employer that 4r prom+
f nsurance Company Namc:_ }
insurer's Address: t -j
City/statclzipt Mt�
policy S or Sclf--iru, V-.#•U 3�
Afl3ch a copy of the Workers'
Failfuo to secure coycrage as. rep
fine up io $1,500,00 and/or one-
ofup to $250.00 a day against tl
investigations of the DIA for im
I do hereby certify, under the P
10f refal use o/rly, Do not wale
City or Town:
Issaing Authority (clrcia one):
t, Board of Health 2,. BW)dlug
6, Other
Contact Person:
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017
617-727-4900 — http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
UB-9M313365-18-42-G 12-06-18 TO 12-06-19
POLICY NUMBER EFFECTIVE DATES
PETER LATTANZI INS AGCY 166 WINTHROP AVE
REVERE, MA 02151
NAME OF INSURANCE AGENT ADDRESS PHONE #
BOSTON CREMATION LLC 115 N MAIN ST
MANSFIELD
MA 02048
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the heating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury, In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL. ADDRESS
W20P1G15 TO BE POSTED BY EMPLOYER