HomeMy WebLinkAboutRiccio Builders - 12/31/2019I
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Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Disposal Works Installer's Permit
This is to certify that: JOHN RICCIO
Doing business as: RICCIO BUILDERS
P.O. BOX 807
MANSFIELD MA 02048
is hereby granted a DISPOSAL WORKS INSTALLER PERMIT to construct, alter, install, or
repair individual sewage disposal systems. This permit is granted inconformity with the STATE
ENVIRONMENTAL CODE: 310 CMR 15.02(2) and expires December 31, 2019 unless sooner
suspended or revoked.
LICENSE NUMBER: 34
FEE $100.00
BOARD OF HEALTH
AichaeCHealey, Chairman
The Commonwealth ofMassachusetts
Depailt4ter'rt of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.niass.gov1(la
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: PKC—,� �Imll
Address:___ ''0 g
City/State/Zip:—
122-04 - Phone #: SViO$' L'�2, I - i52--Z-'7
Are you an emplo er? Check the appropriate box:
1. ❑ I am ployer with employees (fill and/
art -time).*
2. 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.]
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
1 I.❑ Health Care
12.❑ Other
"Any applicant that checks box #1 most also fill out the section below showing their workers' compensation policy information.
* s I f the corporate ofliceis have exempted themselves, but the corporation has other employces, a workers' compensation policy is required and such an
organization should check box If 1.
/ air. an employer that is provitliitg workers' compensation insurtntee for my employees. Beloty is the policy in%brmatiorr.
Insurance Company
Insurer's Address:
City/State/Zip:
Policy // or Self -ins. Lie.
Expiration
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
tine 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 oft A for insurance coverage verification.
/ do lrerehy cert fp, tWerte anti pgnalties ofpeijury that the information provided above is trueandcorrect.
'. Date, 101
aI'
Official use
City or Town:
Do not write in this area, to be completer) nv cite or town q%ficial.
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/din
Phone #:
Town of Mansfield
Town of Mansfield - Board of Health s Park Row
Mansfield, MA 02048
Disposal Works Installer Application
LICENSE NUMBER: <nJN
APPLICANT: _ O(F�tl
BUSINESS NAME: o ar�1o____lc�iN �
MAIL ADDRESS: v I g
CITY/TOWN: «Gd� STATE: lMl�__ ZIP CODE:
BUSINESS PHONE: �>o�''fi�('8737 BUSINESS CELL: ,5G F5' i �( 7� 7
BUSINESS FAX:
E-mail: G�laCo co ' IGiz I
Alt E-mail:
ERAL ID/SS NUMBER:
LICENSE HELD: Town
LICENSE HELD: Town H 0 f0U3_
LICENSE HELD: Town Motk:I
Year Licensed q 90 S
Year Licensed 1 C60
Year Licensed �dt KV S
I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires December 31 st yearly.
FEE: $ 100.00
SIGNATURE:
DATE: V
f,g
Please make appropriate changes. Sign, date, and enclose check for $100.00 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
r
Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Nronber
*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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