HomeMy WebLinkAboutAmici Funeral Home, Inc. - 4/30/2019e
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
q �
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Funeral Horne Permit
Permit Number: 00-1
This is to certify that. MICHAEL A. BOLEA
115 NORTH MAIN STREET
Is hereby granted a AMICI FUNERAL HOME, INC.
permit for.
This permit is granted in conformity with the Statutes and Ordinances relating thereto,
and expires on Tuesday, April 30, 2019 unless sooner suspended or revoked.
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Fee : $25.00 6 �r
BOARD OF HEALTH
.rlichaeCMcCCean, Chairman
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Ar 4
Application for Funeral Home Permit
PERMIT NUMBER: 00-1
I hereby make application for a FUNERAL HOME PERMIT which expires on April 30th of each year.
NAME OF BUSINESS
ADDRESS OF OWNER:
OWNER:
BUSINESS PHONE
BUSINESS FAX:
AMICI FUNERAL HOME, INC.
115 NORTH MAIN STREET
MICHAEL A. BOLEA
(508) 339-7595
(508) 339-7597
EMAIL ADDRESS:
FEDERAL ID/SS NUMBER: 04-3128766
FEE: $ 25.00
SIGNATURE: 'k
DATE:
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.
11 ( nuc. i�cme
Signature of Individual or Corporate Name
**Social Security No. (Voluntary) 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.
R.\HmIth\J=e's D0c=euts\PERMIT APPLICATIONS\TAX CERTIFICATION FORMAoe
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\ The Commonwealth of Massachusetts
Department of IndustrialAecidents
7 Congress Street, Suite 100
Boston, MA 02114-2017
r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED RTPH THE PERAffTTINGAUTHORITY.
Business/Organization
Address:
City/State/Zip
Are you an emplo ? Che
1.❑
2, El
3.x
4. F]
VYl 1 G I
the appropriate box:
I am a employer with employees (full and/
or part-time).*
I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
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]`
We are a non-profit organization, staffed by volunteers,
with no employees. jNo workers' comp. insurance req.]
#`rte' �t-75�
Business Type (required):
5. ❑ Retail
6. Restaurant/Bar/EatingEstablishment
7. ❑Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
I0. ❑ Manufacturing
I I-F1Health care `,
12.(JOther E— eta r✓l0-
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
**If the corporate officer; have exempted themselves, but the corporation has other employees, a worker compensation polity is required and such an
organization should check box #1.
Lam an employer that is providing workers' compensation insurance for my employees. Below it the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy# or Self -ins. Lic. #- Expiration Date:
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 maybe forwarded to the Office of
Investigations of kee DIA for insurance coverage verification.
I do hereby
ofperjury thatthe information provided above q true and correct
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
Contact Person
Permit/License
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral of written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, orthe
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to constru ct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. Tf an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Tndustrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit sbould be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Sbould you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below, Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/l icense applications in any given year, need only submit one affidavit indicating current
policy information (if neces'sary). A copy of the affidavit that has beesofficially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i,e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit
The Department's address, telephone and fax number;
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or I-877-NLUSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15