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Home My WebLink AboutDepco Enterprises, 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: RICHARD C. DEPPISCH Doing business as: DEPCO ENTERPRISES, INC. 60 HOLMAN STREET #2 ATTLEBORO MA 02703 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: 16 FEE $100.00 BOARD OF HEALTH MichaeCHeaCey, Chairman Town of Mansfield Town ofMansfield - Board of Health 6 Park Row Mansfield, MA 02048 LICENSE NUMBER: APPLICANT: -- cGuz G- rye i so `--- BUSINESS NAME: MAIL ADDRESS: Ut 1 I uwt CITY/TOWN: 1E�Lo� STATE: GEC ZIP CODE: d27°j BUSINESS PHONE: S�b " � '�� BUSINESS CELL: 9-'7 g 7-2 _ BUSINESS FAX: E-mail: i/`t e. FZ e o6we'v ewe. eo Alt E-mail: FEDERAL ID/SS NUMBER: 'jv�dCG 2S� LICENSE HELD: Town I" c _ - Year Licensed LICENSE HELD: Town l tl Cc Year Licensed LICENSE HELD: Town i44W a 16 / `Nr t -- Year Licensed 0 y. Sr 01- 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: 1012 911b? 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) ?oyoib,233 **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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Z�_kjoYOt X?4 � e - Address: Zd 1IW4"4- S 142 City/State/Zip: Aid /ehrl "t"t 02"7t>-3 Phone #: o Are you an employer? Check the appropriate box: Business Type (required): 1. [ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no ?, ❑ 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12:VWther 2jA--400tdt" *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: + rr-14, /V_ otwam,," Insurer's Address: %U ttil2a, U t �S` Gt�fj " 30' City/State/Zip: [ ,cam ItA E 4 vi v Policy # or Self -ins. Lic. If w we 333 3 3 e t 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 tip 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 pains and penalties of perjury that the information provided above is true and correct. � - x77 &W 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 #: Wesco Insurance Company A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ncci Code: 26135 Insured: DEPCO ENTERPRISES INC. 155 COMMONWEALTH AVE ATTLEBORO, MA 02703 Other workplaces not shown above: See Extension of Information Page Producer: INFORMATION PAGE Policy Number: W WC3333381 _Individual _Partnership X Corporation Federal Tax ID: 204066233 Risk Id: AmTrust North America, Inc. Renewal of: W WC3256423 c/o TPA Insurance Agency, Inc. 10 New England Business Center, Ste 303 Andover, MA 01810 2 The policy period is from 3/1712018 to3/1712019 12:01 a.m. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $100,000 each accident $500,000 policy limit $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM STATE ASSESSMENT TOTAL ESTIMATED COST Minimum Premium Deposit Premium Issue Date: 2/3/2018 Countersigned by: