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Home My WebLink AboutG. Horne Pumping - 12/31/2019mil Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that GARRY HORNE Doing business as: G. HORNE PUMPING 46 BURT STREET NORTON MA 02766 Town of Mansfield 6 Park Row Mansfield, MA 02048 is hereby granted a SEPTA GE PUMPING AND TRANSPORTING PERMIT to engage in the pumping or transporting of the contents of privies, cesspools, septic tanks and other offensive substances. This permit is granted in conformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and MGL chapter III section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 9 TRUCK REGISTRATION NUMBER(S): MA 1803 BOARD OF HEALTH Michael3HeaCey, Chairman z Dec.12.2018 2:39PM No.0670 P. 4 oof Mansfield > Town of Mansfield -Boar P k Row $9 ; ' 2tri �,lylallofleld, MA atone bo Septage Pumpers Applicatlon BUSINESS NAME: L , 1.3-. —"— '7*" � '" h e �� MAIL ADDRESS: t-Lc�, •��Alt- !�;'A-- TOWN: STATE: vva/s NAME OF OWNER; t1l°'_^'4? BUSINESS TELEPHONE:fe)1b1 '- CELL: DATE: l-�- \t' _1-V r� LICENSE NUMBER: E-mail; Alt E-mall; FED ID/SS N0: C�)�tv`1 S ( NUMBER OF TRUCK(S): REGISTRATIONNUMBER(S): L m FEE PER TRUCK: ZIP CODE: G C' FAX: '5 0 `t, ')-b S "!:,A-S ) Please make appropriate changes. Sign, date, and enclose check payable to Town of Mansfield. Mall to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02046, SIGNATURE: .DATE 11 i 2uLiL> ........................................................................................................................................,, TRUCKS INSPECTIONS: DATE: TIME: PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO, MAIN STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261.7366, IF YOU CAN NOT MAKE THESE DATES FOR HEALTH AGENT'S USE ONLY 310 CMR; Slate Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitery Sewage. 15.502 Transporlatlon and Disposal of Privy, Cesspool, and Septic Tank Contents. 15.505 Equipment; No person shall use equipment to remove or transport the contents of prives, Cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. A. While Tankt Securely mounted on truck Watertight Leak-prwr cover Tight discharge tanks A Acceptable NA N= Not Acceptable ' _ J H. Venting Of Mobile Tanks! Vent permits escape or gas, but not liquid C. Have; Suction or pressure hose In good repair M pumps; Maintained to prevent leaking orsewage Inspected by: Inspected on: Dec, 12, 2010 2:40PM No.00'70 P. 5 'TAX CERTIFICATION FORM I certify tinder the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. 4 Sigre�ivi4l dual or Corporate Name "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. CAUsarAsleilo\DoskwplScoi Ps Doaumonts\Food Ustahlishmorn- Tamp\TAX CERTIFICATION FOR Kdoe The Commonwealth of Massachusetts Department of Ittilush'ial Aceldenls i 1 Congress Street, Suite 100 a Boston, MA 02114-2017 ivivtumass,govIdia Worlcers' Compensation Insurance Affidavit: General Businesses, TO BE RILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaibiy Business/Organization Name; Address: Ifw BOR % 3-{ , City/State/Zip: IVORTO /0 MY1 0) ,74hone #: ,SUS- e 5 -3137 Are you an employer? Cheelt the appropriate box: i, ❑ I am a employer with employees (full and/ or part-time),* 2. C4 I am a sole proprietor or partnership and have no employees working for me in any capacity, [No workers' comp. insurance required] 3. [,] 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 by volunteers, with no employees, [No workers' comp, insurance req,l Business Type (required): 5, ❑ Retail 6. n Restaurant/Bat/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. n Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 121R Other ,Sc euaLC *Any applicant Mot checks box 01 musl also fill oat the scotion below showing their workers' compensation policy iufarmatioa, **If the corporate ofacers Love exempted themselves, but thecorporotloo has other employees, a workers' compensation policy is required sad such an organization should ebeek box 111. I alto all enrplover drat is providing Ivorhers' compensation insu ance for my employees. Below is floe policy inforrnatloa, Insurance Company Insurer's City/State/Zip: 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, under the pabis and peyallies afpejytny foal the inforatation provhled above is true pied correct. Official nse only. Do not write in iMs area, to be completed by city or town offlelol City or Town: Permit/License Issuing Authority (circle one): I, Board of Health 2. Building Department 3. City/Town Cleric 4, Licensing Board 5, Selectmen's Office 6, Other Contact Person: Phone Collaborative Septic H Inspection Dav (In accordance with 310 CMR 15.505) INSPECTION REPORT Which Towns are you currently licensed with? (check all that apply) ❑ Foxborough ❑ Ma Company Name: Address: Telephone##: Operator at Inspection: Tank Capacity: Truck License f#: Registration Exp. Date: Truck Inspection Mobile Tank (securely mounted on track, watertight, necessary odor controls, leak -proof cover, tight discharge valves) t1d Venting available to allow the escape of gas on Mobile Tanlcs (properly constructed) ❑ Suction or Pressure Hose in good repair 1f El -pumps (leak proof) Operator at Inspection I Date (Updated: September 2013)