HomeMy WebLinkAboutUS General Contractors, Inc. - 12/31/2019Commonwealth 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: SEAN BOSWELL
Doing business as: US GENERAL CONTRACTORS, INC.
430 SCHOOL STREET
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 : 39
FEE $100.00
BOARD OF HEALTH
MichaeC -CeaCey, Chairman
Town of Mansfield
oivii ol amifiel - Board t#'Health s Park Row
Mansfield, MA 02048
Disposal Works Installer Application
LICENSE NUMBER:
APPLICANT: Sean Boswell
BUSINESS NAME: US General, Inc
MAIL ADDRESS: 430 School St
CITYITOWN: Mansfield
BUSINESS PHONE:
508-339-0464
BUSINESS FAX:
97'- 2018
E-mail:
Sean@usgenco.net
Alt E-mail:
ID/SS NUMBER: 462657092
LICENSE HELD: Town Norton
DEC j i,% 1,18
STATE: MA ZIP CODE: 02048
BUSINESS CELL: 508-967-4177 -
Year Licensed 97'- 2018
LICENSE HELD: Town
Taunton
Year Licensed
97'- 2018
LICENSE HELD: Town
No.Attlboro
Year Licensed
97'-2018
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 31st yearly.
FEE: $ 100.00
SIGNATURE:
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
The Commonwealth of Massachusetts
Department oflntdua'trial Accidents
Office ofInvestigations
600 Washington Street
_ — Boston, MA 02111
nowminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
Phone
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑
I am a employer with .. employees (full and/
5. ❑ Retail
or parttime).*
6. ❑ Restaurant/BarMating Establishment
2
CC
I am a sole proprietor or partnership and have no
7. E] Office and/or Sales (incl real estate, auto, etc.)
employees wonting for me in any capacity.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1 (4), and we have
10.❑ Manufacturing
no employees. [No workers' comp, insurance required]
11.❑ Health Care
4. ❑
We are a non-profit organization, staffed by vohmteers,
with no employees. [No workers' comp. insurance req.]
121-1 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' compensation insurance for my eorplo}'ees. Below is the policy it f trtlmtion.
Insurance Company Name:
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
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 dayaga}r }st the violator. Be advised that a copy of this statement may be forwarded to the Office of
ons
Investigatiofthe DI,PGfbr insurance coverage verification.
I no hereby certify,,*(nder the pt&ns and penalties ofperjury that the information provided above is trite and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone
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.
Signature of Individual or Corporate Name
"Social Security No. (14011/111111y) or Federal
Ideatiifieatimi 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.
C:\Users\steite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doe