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Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Disposal Works Installer's Permit
This is to certify that: JOHN CAPONIGRO
Doing business as: CAPONIGRO CONSTRUCTION
P.O. BOX 2693
ATTLEBORO MA 02703
Town of Mansfield
6 Park Row
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: 44
FEE $100.00
BOARD OF HEALTH
Michae(HeaCey, Chairman
all Town of Mansfield - Board of Health
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APPLICANT:
BUSINESS NAME:
MAIL ADDRESS:
Disposal Works Installer Application
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Town of Mansfield
6 Park Row
Mansfield, MA 02048
CITY/TOWN: x " STATE: _ w ZIP CODE: e),� 03
BUSINESS PHONE: d,17 / BUSINESS CELL: 51047—A---
BUSINESS FAX:
E-mail: a /2 �✓�'f1 r1 �` %j%D �j7T✓�"/I/ C �' I
Alt E-mail:
ID/SS NUMBER: o<ti '—
LICENSE HELD: Town
LICENSE HELD: Town/r—r.
LICENSE HELD: Town .° "
Year Licensed /
Year Licensed /
Year Licensed L
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
FEE: $ 100.00
SIGNATURE:
DATE:
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.
of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
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"*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.
CAUsers\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
pplicant Information Please
Business/Organization�//�Nait
xme: �i� / � t
Address. Q
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a.2
11CY 6___
Are you an employer? Check the approp4ate box: Business Type (required):
I. ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.�L I am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑ Non-profit
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 volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #I 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
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 da gai he violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of t DI r insurance coverage verification.
I do hereby ceffy, ijdder the
the information provided above is true and correct.
Date• � 0 p`_li-_
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 Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone #:
www.mass.gov/dia